Clinical features, prodromal symptoms cognitions and outcome in patients with dissociative (psychogenic non-epileptic) seizures
| Prodromal symptoms | ||||||||
|---|---|---|---|---|---|---|---|---|
| Age/sex | Type of attack | Duration* | Diagnosis | Main comorbidities | Somatic symptoms | Cognitions | Wilful submission | Outcome |
| 17F | Sudden motionless unresponsiveness, 60–120 s | 8 months, 1–2× day | Clinician witnessed attacks | Anxiety | Rising sensory disturbance, chest tightness, breathlessness, palpitations | ‘There but not there’, ‘Horrible’ | ‘Just want the attack to happen to get rid of the feeling’ | Attack free for 2 years, with minor recurrence, working |
| 17F | Motionless unresponsive episodes evolving to four limbs jerking, arching and self-slapping-preserved awareness on occasions. 60–600 s | 10 months, up ×20 day | Clinician witnessed attacks | Low mood | Taste in mouth, fluttering in abdomen, arms and legs go heavy, band-like sensation round head | Prodrome very unpleasant . ‘I know its going to happen’ | Can dissociate at will. Did so at clinic to demonstrate (with left arm jerking). Despite this was upset at psychological formulation as thought that equated with ‘making it up’ | Attack free for 4 months, return to normal school activities. |
| 21F | Falls to ground, lies in flexed posture then a pause followed by leg and arm jerking. 60–300 s, | 10 years, approx 1× week | EEG confirmed | Anxiety, low mood, irritability, intermittent self-harm. | Occasional ‘vision closing in’ | Becomes unusually irritable and ‘disliking almost everyone’. Prodrome highly unpleasant. | Acknowledged that can prevent seizures but sometimes brings them on deliberately as it is ‘easier’. | Significantly improved but with intermittent seizures. Trying to return to college. |
| 24F | Generalised twitching, falls, unaware, 5–60 min | 12 months, 0–5× day | Clinical Diagnosis—able to avert attacks | Complex regional pain syndrome | Increasing pain from CRPS<AQ: Please provide full form of CRPS>, hot, sweaty, funny taste | ‘Not there’, ‘Pain unbearable’ | ‘Its like your body wants to do it to make the pain better’ | Attacks continue, not working |
| 29F | Motionless unresponsiveness, eyes roll, 60–600 s | 24 months, 3–4× month | Clinical diagnosis—able to avert attacks | Anxiety | Chest heaviness, heat, headache, tingling right arm | ‘Not there’ ‘out of it’, shouts ‘its coming’ but can't remember doing so. | I don't have the energy to fight the attack—just want it to hurry up and come along | Attacks reduced and confined to evenings, working |
| 30F | Motionless unresponsiveness, 30 s | 14 months, 3–4× month | Clinical diagnosis—able to avert attacks | Anxiety, globus | Palpitations, | ‘Not there’ | ‘Feel like I want it to happen so the feeling goes away’ | Attacks largely gone, working |
| 30F | Generalised shaking retained awareness, falls 60–600 s | 6 months, 2–3× day | Clinical diagnosis | Pain, fatigue | Grinding sensation in teeth and chest as if being pulled underwater | ‘Frightening’, ‘Horrible’ | Doesn't feel well until she allows herself to ‘go through it’. Like trying to hold poisonous gas in her mouth | Attacks continue unchanged, not working |
| 32F | Generalised shaking, falls, sometimes with preserved awareness, 180–240 s | 3 months, ∼10×/month | Clinical diagnosis—retained awareness | Tremor, weakness, fatigue | Queasy, ‘as if I have spun round,’ arms shaking, sweaty hot, ‘breathing goes funny’ | ‘Horrible’, ‘frightened’ feeling escalating over 180–240 s | Wishes that she would blackout to get rid of the feeling | Attacks ceased following consultation, not working |
| 36M | Loses consciousness, jerking, 120–900 s | 4 years, 0–20 week | EEG confirmed | Anxiety, fatigue, widespread joint and muscle pain. | Initially denied but later admitted to cardiorespiratory somatic of panic and said they were highly unpleasant | Increasing sense of irritability. ‘highly unpleasant’ | Averted two seizures at prodromal stage l but effortful and exhausting Acknowledged in past he had brought seizures on in these circumstances | Improved, no seizures in over 2 months but frequent anxiety attacks. Beginning to return to some normal function |
| 39F | Bilateral limb shaking, eyes roll backwards, protruding tongue, can't speak, preserved awareness, duration minutes to 1 h | 18 months, 1–2/week | Clinical diagnosis—retained awareness | Phobic anxiety, hyperventilation | Malaise, shaking in left leg then right leg | Anxious cognitions that if prodrome was prolonged that she may damage herself and ‘never come out of it’ | Acknowledged that she brought on seizures as she was anxious about long term damage (signalled by prodrome symptoms) if she did not | With explanation that the attack is not physiologically harmful- has diminished intensity attacks presenting more like typical panic |
| 54F | Goes blank, arms and legs jerk, unaware, doesn't fall 30–60 s | 30 months, 1–2× day | EEG confirmed | Depression, pain, anxiety, bladder symptoms | None | ‘Horrible’ ‘frightening’; ‘Out of control’ ‘not there’. ‘there is nothing I can do’. Traumatic memory, 10 s | Later admitted tearfully that once the prodromal symptoms start she wants the attack to happen to take them away | Attacks continue unchanged, working |
*Duration of attacks from onset to discovery of wilful submission.
F, female; M, male.