21st June 2023

Non-epileptic seizures

One fifth of those referred to epilepsy specialist centres do not have epilepsy. The majority of these patients have non-epileptic seizures (NES), which are also known as dissociative seizures or attacks. NES is not due to aberrant electrical activity seen in epilepsy or any other neurological cause.

Risk factors

The risk factors for developing NES are:

• Female – 75% of patients with NES are women
• Trauma or acute stress, such as the loss of a loved one, bullying, a history of abuse, or adverse experiences in childhood or adolescence, etc.
• Family history of epilepsy or psychiatric diagnoses
• Comorbid disorders:
  • Another functional disorder – a history of previous medically unexplained symptoms is present in 80% of patients
  • Epilepsy – 10-30% of those with non-epileptic seizures also have epilepsy.
  • Head injury
  • Sleep disorders
  • Cognitive problems
  • Migraine
  • Asthma
  • Depression – the most common psychiatric comorbidity in children and adolescents
  • Anxiety
  • Post-traumatic stress disorder
  • Personality disorder

Features of non-epileptic seizures

When giving the diagnosis of NES to a patient and their carer, the following are key points to discuss :

1. Reasons for concluding they do not have epilepsy – results of tests and what they mean, etc.
2. What they do have (describe what dissociation is and why it can develop)
3. Validating their experiences and reassurance that they are not ‘putting it on’ – one of the primary fears/judgments of patients with dissociative or functional disorders feel
4. The triggering “stress(es)” might not be clear
5. The aetiological factors in their case
6. Maintaining factors
7. Caution that if on an AED that its withdrawal should be done gradually
8. Describe psychological treatment

Treatment

The mainstay of current NES treatment is cognitive behavioural therapy (CBT). This will allow one to learn coping techniques to deal with the NES and hopefully improve them over time. Part of treatment is learning the warning sign of an attack, as this will help the patient regain control of the attacks. One way to regain control and avert an attack is by the patient challenging and answering their anxious thoughts, such as will they injure themself, will it be embarrassing, or will they die. Another way is for the patient to distract themselves, by doing things like counting, talking to someone or playing a game, or by grounding where they pay attention to each of their senses and what they are experiencing in the present. The indications that the treatment is working are that the patient will start to have more warnings, the warnings will be less anxiety-provoking for them, the warning symptoms will be longer, they will be conscious and aware during some of their episodes, and eventually they can avert some of the attacks.