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Neuropsychiatric Disorders > Dissociative Seizures > Flashcards

Dissociative Seizures Flashcards

1
Q

What are the main differential diagnoses of “funny turns”?

A
  1. Normal behaviour (e.g., tantrums in children)
  2. Medical (e.g., syncope, paroxysmal neurological disorders, metabolic)
  3. Psychogenic (e.g., dissociative seizures, factitious, other psychiatric presentations
  4. Malingering
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2
Q

What evidence is there for the unconscious nature of dissociative seizures?

A

▪️ Experienced clinicians judgement
▪️ Compliance with AEDs
▪️ Telemetry
▪️ Poor imitation of epilepsy

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3
Q

What is the main demographic for DS?

A

▪️ Female
▪️ Onset in teens/early 20s
▪️ Diagnosis often missed for years

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4
Q

What are the main issues associated with misdiagnosis of DS?

A

▪️ Missed opportunity for treatment - much better prognosis!
▪️ Multiple trials of anticonvulsants
▪️ Anticonvulsant toxicity (e.g., teratogenic
▪️ Dangerous if treated like “status epilepticus” (e.g., put in ICU)

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5
Q

What can we use to differentiate DS from epilepsy?

A
  1. Clinical judgement (most important!)
  2. Inter-ictal EEG
  3. Telemetry/EEG with provocation
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6
Q

What signs are common in dissociative seizures but rare in epileptic seizures?

A

▪️ Duration over 2 minutes
▪️ Eyes closed
▪️ Fluctuating course
▪️ Asynchronous movements
▪️ Aware but unresponsive
▪️ Pelvic thrusting and head side to side

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7
Q

What features are common to epilepsy but rarely seen in DS?

A

▪️ Post-ictal stertorous breathing (noisy)
▪️ Post-ictal confusion
▪️ Automatisms

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8
Q

Why are major injuries seen more rarely with DS compared to epilepsy?

A

Some level of protective subconscious control

(BUT minor injuries more common in DS?)

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9
Q

Can dissociative seizures arise from sleep?

A

Not really, although may seem that way if they arise from slight states of wakefulness in the night

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10
Q

Why might hyperventilation be more common in DS than epilepsy?

A

Association with anxiety

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11
Q

What can you look for on examination to differentiate DS from epilepsy?

A

▪️ Non-clonic movements
▪️ Eyes closed
▪️ Avoidance/resistance (particularly to eye opening)

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12
Q

What psychiatric phenomenology are commonly described with DS?

A

“Panic attacks without panic”:
▪️ Derealisation/detachment
▪️ Somatic symptoms of arousal (e.g., sweating, hyperventilation, palpitations)
▪️ Lack of ictal fear
▪️ Posy-ictal motional “relief”
▪️ Agoraphobia

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13
Q

What clinical features may be supportive of a diagnosis of DS but cannot be used alone?

A

▪️ Failed response to multiple AEDs
▪️ Absence of risk factors for epilepsy
▪️ Risk factors for DS

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14
Q

What are thought to be the main risk factors for DS?

A

▪️ Previous MUS
▪️ Childhood trauma
▪️ Past psychiatric history
▪️ Possibly family history of epilepsy or personal history of BI?

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15
Q

How does accuracy of diagnosing epilepsy correct compare to diagnosing DS?

A

Very similar and reasonably accurate (70-80%)

BUT significantly less accurate correct diagnosis of DS by referring doctors

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16
Q

How useful is routine (inter-ictal) EEG for diagnosing DS?

A

Not very

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17
Q

How would EEG be used ideally to differentiate DS and epilepsy?

A

▪️ Video-EEG
▪️ With provocation so aim is to capture a seizure
▪️ Can also do sleep EEG

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18
Q

What sign on video-EEG telemetry is diagnostic of DS?

A

Preserved alpha rhythm during apparent impaired consciousness

(Alert although appearing not to be)

19
Q

What signs on video-EEG telemetry would be diagnostic of epilepsy?

A

▪️ Ictal epileptiform discharges (spike and wave)
▪️ Post-ictal slowing

20
Q

What are the main problems with using video-EEG telemetry to diagnose DS?

A

▪️ Can be difficult to capture a seizure, either if they are infrequent or someone has multiple types
▪️ False positives from movement (can look like epileptiform spikes)
▪️ False negatives from simple partial seizures or frontal lobe seizures (could be alert so looks like DS)

21
Q

What can you do if you want to record a seizure of someone who has them infrequently?

A

Seizure “provocation” with several methods (e.g., hypnosis, tuning fork, IV saline, suggestion)

Need eyewitness to verify seizure is habitual!

22
Q

How might serum prolactin be used to differentiate seizure types?

A

Idea is that lactate in blood increases with increased movement with seizure.

More likely to get a greater increase in epilepsy than DS

BUT rarely done in practice

23
Q

What should you consider in the psychiatric assessment of someone with possible DS?

A
  1. Is there a primary psychiatric disorder mistaken for epilepsy?
  2. Is there an associated psychiatric disorder?
  3. Evidence of deliberate simulation?
  4. Possible predisposing, precipitating, and maintaining factors?
24
Q

How does ictal anxiety in partial seizures differ from panic attacks?

A

▪️ Often shorter
▪️ More circumscribed
▪️ Tends to come out of nowhere
▪️ Described as tangibly different from anxiety but can’t describe how

25
Q

What psychiatric disorders are most commonly associated with DS?

A

▪️ Personality disorder
▪️ Somatoform disorder
▪️ Depression
▪️ Anxiety
▪️ PTSD

26
Q

What evidence might suggest seizures are deliberately simulated?

A

▪️ History of medical deceptions
▪️ No corroborative history available
▪️ Non-compliance with AEDs
▪️ “Pseudologia fantastica”

27
Q

What social factors may predispose DS?

A

▪️ Traumatic experiences, particularly sexual abuse
▪️ Poor family functioning
▪️ Modelling of symptoms

28
Q

What psychological and biological factors may predispose DS?

A

▪️ Somatising trait
▪️ Dissociative trait
▪️ Avoidant coping style
▪️ Emotional instability
▪️ Mood disorder
▪️ Epilepsy

29
Q

What biological factors may precipitate DS?

A

▪️ Acute panic attack
▪️ Syncope

30
Q

What social factors may precipitate DS?

A

Adverse life event

31
Q

What psychological and biological factors may maintain DS?

A

▪️ Illness belief
▪️ Agoraphobia
▪️ Reaction to diagnosis
▪️ Negative cognitive distortions (expectations)

32
Q

What social factors may maintain DS?

A

▪️ Carers attitudes
▪️ Sick role

33
Q

What is the psychological model for dissociative seizures?

A

A dissociative response to emotional arousal (not just negative)

Interpretation of physiological response

“Panic without panic”

34
Q

How can an arousal model of DS be useful?

A

▪️ Explains the condition to the patients
▪️ Can give targets for CBT - how can we give people another outlet to that extreme state of arousal?

35
Q

What is the integrative model of DS?

A

▪️ Seizure scaffold shaped by factors such as seizure models from others, experiences misinterpreted as seizure, prior illness
▪️ Elevated arousal may activate seizure scaffold, aided by anticipated onset, threat perception, and internal/external cues
▪️ Inhibitory processing may be compromised by chronic stress, arousal or other factors
▪️ DS then reduces arousal bringing back to seizure scaffold

36
Q

What has been shown about the emotional awareness of individuals with DS?

A

Typically much less aware of own internal state, both cognitive and emotional

(Shown with Libet’s task for measuring action awareness)

37
Q

What are the four steps to diagnosing DS?

A
  1. Explain what it is (and what its not)
  2. Reassure them its real and recognised
  3. Explain what dissociative seizures are including model, possible causes and maintenance factors
  4. Treatment
38
Q

What treatment can be offered after diagnosis?

A

▪️ DS often improves spontaneously with correct diagnosis and self-management strategies
▪️ Gradually withdraw AEDs if not needed
▪️ Limited role for other psychotropic meds
▪️ Further information
▪️ Psychology referral

39
Q

If someone has had a seizure, who should be alerted?

A

DVLA

40
Q

Why must you be careful taking someone of AEDs upon DS diagnosis?

A

▪️ May need them for comorbid epilepsy or neurological conditions
▪️ Withdrawal can make seizures worse so must be withdrawn slowly and gradually

41
Q

When is AED withdrawal safe to do?

A
  1. If unlikely to have comorbid epilepsy (all seizure types NES, no history of childhood seizures, no epileptiform abnormalities on EEG)
  2. AED withdrawal is gradual
42
Q

What can you do in clinic following DS diagnosis?

A

▪️ Help them to understand and accept (including further information)
▪️ AED withdrawal
▪️ Distraction (grounding) techniques
▪️ Managing anxiety/anger/stress
▪️ Damage limitation (e.g., carry note explaining nature of seizures to prevent being brought to A&E)

43
Q

What factors are associated with poorer DS prognosis?

A

▪️ Later diagnosis
▪️ Psychiatric comorbidity

Neuropsychiatric Disorders (30 decks)

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