| Description |
- Background:
One of the most challenging groups of patients seen by neurologists today are those experiencing convulsive, seizure-like episodes – but in whom no abnormal neurologic activity is found. Psychogenic non-epileptic seizures sit at the fraught intersection between physical and mental illness: a psychiatric condition that presents as a neurologic one. The gold-standard diagnostic method is simultaneous videotape and electroencephalographic monitoring (video-EEG), which first became available in the early 1980s. But despite neurologists’ expectation that the diagnostic precision provided by video-EEG would shortly lead to treatment breakthroughs, the prognosis of psychogenic seizures remains poor today: even after psychotherapy, few patients achieve symptom remission. We examined the history of psychogenic non-epileptic seizures from the 1960s to the 2010s to determine how etiological theories have changed over time, why treatment is still so challenging, and why psychogenic seizures have remained an orphan condition, viewed by neurologists, psychologists, and psychiatrists alike as not quite within their purview.
Methods:
We relied on medical literature and popular media sources published between 1958 and 2023, as well as an anthology of 105 patient narratives published in 2018.
Results:
Convulsive “fits” were one of the central features of hysteria, a disease that fascinated neurologists in the late nineteenth century and served as the archetypal disorder of psychoanalysis. But by the mid-twentieth century, the diagnosis of hysteria was rarely made, and only occasionally did neurologists question whether convulsive episodes might not be epileptic in nature. The development of video-EEG monitoring in the 1980s revealed that non-epileptic seizures were much more common than previously believed, spurring a renaissance of interest among neurologists. The search was on for an explanatory model, and the 1980s saw the rise of a proposed association between childhood sexual trauma and psychogenic seizures, put forward by psychoanalysts eager to reassert the value of Freudian ideas. Although this theory was prominent in the popular press, by the 1990s neurologists had shifted towards attempting to classify patients into subgroups, capturing the key fact that trauma was an important predisposing factor for some patients, but not all. However, after recognizing that these classification schemes were incompatible with the psychiatric Diagnostic and Statistical Manual, in the 2010s neurologists tried to construct a single etiological model common to all patients with psychogenic seizures. But though they hoped that this integrative model would guide clinical trials and point the way towards evidence-based treatment, fragmentation and skepticism among mental health providers complicated these research and treatment efforts.
Conclusions:
Even after video-EEG monitoring could definitively show that a patient’s seizures were psychogenic rather than epileptic, psychiatrists hesitated to treat non-epileptic seizures as a psychiatric symptom. This was in large part because post-psychoanalytic psychiatry had reoriented around prescribing pharmacotherapy rather than administering psychotherapy, an approach ill-suited for treating psychogenic seizures. The psychiatric disinterest in non-epileptic seizures and lack of participation in research has hindered progress in developing new diagnostic categories and etiological models; conceiving of new therapeutic possibilities; and conducting clinical trials to assess those therapies. Although patients benefit from interdisciplinary neurologic-psychiatric care, disparate reimbursement systems for mental health versus medical care present an additional barrier to clinical collaboration. The path to freeing patients from their non-epileptic seizures is not yet clear, but new directions are only likely to emerge if the social and structural barriers between the disciplines of the brain and the mind can be overcome.
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