Psychodynamics and Psychiatric Diagnoses

of Pseudoseizure Subjects

Elizabeth S. Bowman, M.D., and Omkar N. Markand, M.D.

Objective: The goal ofthis study was to determine current and lifetime rates of DSM-III-R
disorders in patients with pseudoseizures and to ascertain whether trauma is associated with
the occurrence of pseudoseizures. Method: Adult pseudoseizure patients (N=45) were inter-
viewed regarding seizure course and life events, and they were given the Structured Clinical
Interview for DSM-III-R-Patient Version, the Structured Clinical Interview for DSM-III-R
Dissociative Disorders, the Dissociative Experiences Scale, and the Personality Diagnostic
Q uestionnaire-Revised. The pseudoseizures were diagnosed in a tertiary-care video-EEG
facility. Most ofthe subjects (78%) were female, and the mean age ofthe overall patient group
was 3 7.5 years (SD=9. 7). Results: The mean duration of the subjects ‘ seizure history was 8.3
years (SD=8.O). Common current psychiatric diagnoses included somatoform disorders
(89%), dissociative disorders (91 %), affective disorders (64%), personality disorders (62%),
posttraumatic stress disorder (PTSD) (49%), and other anxiety disorders (47%). The lifetime
occurrence of nonseizure conversion disorders was 82 % . The mean Dissociative Experiences
Scale score was 20.2 (SD=1 8.2). Trauma was reported by 84% of the subjects: sexual abuse
by 67%, physical abuse by 67%, and other traumas by 73%. Conclusions: Pseudoseizure
subjects have high rates of the psychiatric disorders found in traumatized groups; they closely
resemble patients with dissociative disorders. Reclassification of conversion seizures with the
dissociative disorders should be considered. Pseudoseizures often appear to express distress
related to abuse reports. Clinicians should screen pseudoseizure patients for adult and child-
hood trauma, dissociative disorders, depression, and PTSD.
(Am J Psychiatry 1996; 153:57-63)

P seudoseizures
resemble epileptic
are sudden
seizures
changes in behavior
but are without
that
organic
have had psychiatric
edge, there
treatment
have been no studies
(1, 2, 6). To our knowl-
of comprehensive as-
cause. Clinicians agree that psychological mechanisms sessment of clearly defined psychiatric diagnoses in
are responsible for pseudoseizures, but there have been pseudoseizure patients. One study (6) showed high
few studies of the specific diagnoses or life stresses as- rates of posttraumatic stress disorder (PTSD), affective
sociated with pseudoseizures. Compared to epileptic disorders, and dissociative disorders but did not sys-
subjects, pseudoseizure subjects have higher rates of de- tematically assess other diagnoses. Although most stud-
pression (1, 2) and personality disorders (3) but have no ies are limited by few subjects, unspecified diagnostic
characteristic personality style (4). Psychological test- criteria, unclean evaluation methods, and retrospective
ing studies comparing pseudoseizure and epileptic sub- design, some trends have emerged from case reports.
jects have yielded conflicting results (4, 5). A growing number of reports connect pseudoseizures
Psychiatric disturbance has been noted in more than with sexual conflicts and sexual abuse (6-9). One study
one-half of pseudoseizune subjects, and more than 80% (6) showed high rates of sexual and physical victimiza-
tion in pseudoseizune patients. Pseudoseizures have
been observed to resolve when sexual conflicts and
Received May 9, 1994; revisions received Nov. 3, 1994, and Feb.
7 and Aug. 1, 1995; accepted Sept. 8, 1995. From the Department of abuse are addressed in psychotherapy (8, 9). Another
Psychiatry and the Department of Neurology, Indiana University trend is the association of pseudoseizures with dissocia-
School of Medicine. Address reprint requests to Dr. Bowman, Depart-
tive disorders. In studies of dissociative disorders, inves-
ment ofPsychiatry, Indiana University School of Medicine, Rm. 291,
541 Clinical Dr., Indianapolis, IN 46202. tigators have noted pseudoseizures, other conversion
Supported in part by a grant from the Association for the Advance- symptoms (10, 11), and somatization disorder in 64%
ment of Mental Health Research and Education. (1 1 ). In case reports (12, 13) pseudoseizunes have been
The authors thank Amy Williams, Sandra Dreeson, A.C.S.W.,
Vicenta Salanova, M.D., Betty Maybuny, M.D., and K.K. Mohan,
described as dissociative symptoms. One study (6)
M.D., for assistance with data collection. showed a high rate of dissociative disorders among

Am] Psychiatry 153:l,January 1996 57

PSEUDOSEIZURES

pseudoseizure subjects and many similarities between in EEG, 3) nonsteneotypic nature ofthe events,and 4) motor phenom-
ena atypical for epileptic convulsions (e.g., rhythmic side-to-side head
them and patients with dissociative identity disorder.
motion, intense truncal arching, out-of-phase limb activity). In most
Beginning with Janet, dissociative disorders and cases, more than one of these criteria were used for the pseudoseizure
trauma have been linked to pseudoseizures and other diagnosis. In all cases, acquaintances confirmed that the videotaped
conversions. Citing this, Nemiah (14) argued that con- seizure was the subject’s typical seizure activity.

version disorders should be categorized with dissocia-

tive disorders. Significant associations have been found Psychiatric Diagnostic Instruments
among dissociation, abuse, and somatic complaints in
Before the research interview, each subject completed a personal,
patients with Bniquet’s syndrome (15).
family, and medical history form, a trauma experience checklist, the
This study was undertaken to assess the occurrence Dissociative Experiences Scale ( I 7), and the Personality Diagnostic
of a wide range of traumatic experiences and DSM-III- Q uestionnaire-Revised, a 140-item true/false questionnaire that is
R disorders in pseudoseizune patients, to provide diag- highly sensitive but only moderately specific for DSM-III-R personal-
nostic data to guide clinicians who assess these patients, ity disorders ( I 8). Scores below 20 on the Personality Diagnostic
Q uestionnaire-Revised indicate no personality disorder, scones
and to provide comparison data for others studying sei-
above 49 usually indicate a clinically significant disorder, and inter-
zures. To our knowledge, no study has comprehen- mediate scores indicate suspicion of a personality disorder. Axis II
sively assessed these patients’ psychiatric diagnoses by diagnoses were determined by considering scores on the Personality
using validated instruments and well-defined criteria. Diagnostic Questionnaire-Revised and 4 hours of interviewer obser-
vations of subjects and their descriptions of their relationships. The
Since the purpose of this study was to assess the occur-
interviewer formed conclusions about personality disorders before
rence of illnesses hitherto not studied in pseudoseizure scoring the Personality Diagnostic Questionnaire. The interviewer’s
patients, no comparison group of epileptic subjects was conclusions took precedence over questionnaire scores in the diagno-
used. We hypothesized that pseudoseizure subjects sis of a personality disorder when the clinical presentation and the
would have high rates of diagnoses associated with sex- questionnaire scones were markedly discordant. This method suffers
from interviewer bias but follows recommendations in the Personality
ual abuse.
Diagnostic Questionnaire for using supplemental interviews, and it
guards against false positive diagnoses from the questionnaire.
The subjects were interviewed by a psychiatrist (E.S.B.) trained in
METHOD reliable administration of the interviews. An unstructured interview
was used to gather personal history and details of trauma history and
to determine family dynamics and the relationship of seizures to life
Study Group
events. Axis I diagnoses were made by administering, in order, the
Structured Clinical Interview for DSM-III-R-Patient Version (SCID-
The subjects were patients olden than 1 7 years who were tested at P) ( 1 9), the SCID-P section for PTSD (20), and the Structured Clinical
a university EEG laboratory between May 1991 and December 1993 Interview for DSM-III-R Dissociative Disorders (SCID-D) (21 ). Non-
after referral by private and university physicians for evaluation of seizure conversion disorders are not included in the SCID-P. They were
seizures of unknown etiology. The inclusion criteria included normal
assessed by unstructured interview and review of medical records.
intelligence, EEG-confirmed pseudoseizunes, no neurologic surgery,
and no neurologic disease except epilepsy. Subjects were approached
for informed consent after they had been informed that their EEGs Statistical Analysis
indicated pseudoseizunes. Most subjects were contacted at the first
post-EEG visit at the university epilepsy clinic. Those who were fol- The occurrence of psychiatric diagnoses in the pseudoseizure
lowed by private physicians were contacted by telephone if they lived group was compared with the rates for the general U.S. population.
nearby. This eliminated some private patients, who likely had more Poisson’s test was used when the population occurrence was less than
economic means. 10%; otherwise, the binomial test was used. For the analysis of scores
Seventy-seven subjects were eligible during the study period, and on the Personality Diagnostic Questionnaire, SCID-D, and Dissocia-
45 were included. Of the 45 subjects, 35 (78%) were female, 41 were tive Experiences Scale, Student’s two-tailed t test was used to compare
Caucasian, three were African American, and one was Hispanic. The the means of different groups. For dichotomous categorical variables,
mean age was 37.5 years (SD=9.7, range=18-SS). Nine subjects were the chi-square test was employed, with the continuity correction of
employed, six were on leave, and 30 were not employed. Eighteen Yates when the expected number in each cell was at least 5. For cell
were receiving disability payments; in 13 cases the payments were for frequencies below 5, probability was determined by Fisher’s exact
seizures. The mean education level was 12.6 years (SD=2.32). Men test. For all statistical analyses, a p value less than 0.05 was consid-
and women were not significantly different demographically. ered statistically significant.
Of the 32 eligible subjects with pseudoseizures (18 women, 14
men) who were not studied, 1 1 patients declined to participate and
21 patients ( 14 women and seven men) were not studied because they
were missed or inaccessible. The proportion of women among the
RESULTS
patients not studied (56%) did not differ significantly from that of the
included subjects. Of those invited to participate in the study, signifi- Seizure History
cantly more men (seven of 17, 41%) than women (four of 39, 10%)
declined (X2=7.17, df=1, p<O.Ol). The mean ages ofthe subjects and The term “seizure” refers to any seizure activity (epi-
the group not studied did not differ significantly.
leptic on pseudoseizune). Five subjects had concomitant
Pseudoseizures were diagnosed by neurologists who observed or
videotaped seizures during EEG recordings in a video-EEG labora- epilepsy. The duration of anticonvulsant use and the
tory. EEGs were recorded for 1-8 hours by using the international characteristics, frequency, and duration of seizures did
10-20-electrode placement system with referential and bipolar mon- not differ significantly between men and women or be-
tages. Pseudoseizures were diagnosed by criteria (16) that included a
tween subjects without epilepsy and the entire group of
lack of EEG changes during a clinical event that involved alteration
of consciousness or bilateral motor/sensory phenomena; the diagno-
subjects. The mean age at seizure onset was 29. 1 years
sis was further supported by I ) presence of waking alpha rhythm (SD=1 1.0, median=28, range=8-S2). The mean time since
during the alteration in consciousness, 2) lack of postictal alteration onset was 8.3 years (SD=8.0 years, median=4 years,

58 AmJPsychiatry 153:1,January 1996

 ELIZABETH S. BOWMAN AND OMKAR N. MARKAND

range=1 month to 32 years). The mean current seizure TABLE 1. Psychiatric Diag noses of 45 Subjects With Pseudoseizures
frequency was 1 1 .5 pen week (SD=29.2, median=2.5). The
Current
median longest seizure-free period was 2 months. (past
Thirty-three of the 40 subjects without epilepsy had Lifetime month)
been treated with 85 trials of anticonvulsant medica-
Diagnosis N % N %
tions. The results had varied: the seizures resolved in
seven trials, improved in 30 trials, remained unchanged Affective disondersa
Any 44 98 29 64
in 28 trials, and worsened in 17 trials (the results of
Bipolar disorder I 2 1 2
three trials were not reported). Major depression 36 80 21 47
The clinical forms of the pseudoseizunes were purely Dysthymia _b b 6 13
generalized movements (N=24), purely localized move- Depressive disorder not otherwise
ments (N=14), falling on going limp (N=1O), localized specified 6 13 5 11
Organic affective disorder 3 7 0 0
movements with secondary generalization (N=9),
Any psychotic disordera 0 0 0 0
purely staring or absence of conscious awareness (N= Substance abuse on dependencea 19 42 5 11
8), and alterations of consciousness without movement Any 19 42 5 11
or amnesia (N=8). Twenty-four subjects had more than Alcohol abuse or dependence 13 29 0 0
Drug abuse or dependence 11 24 5 11
one form of pseudoseizune.
Anxiety disordersa
Any anxiety disorder except PTSD 23 51 21 47
Overall Psychiatric Diagnoses Panic disorder 12 27 9 20
Any phobic disorder 19 42 15 33
Table I shows the subjects’ psychiatric diagnoses. Generalized anxiety disorder b h
Obsessive-compulsive disorder 3 7 2 4
Current diagnoses include those present in the preced- Anxiety disorder not otherwise
ing month. The mean number of current axis I diagno- specified I 2 1 2
ses was 4.4 (SD=2.3, range=1-i0), and the mean num- PTSDC 26 58 22 49
ben of lifetime diagnoses was 6.0 (SD=2.6, range=2-1 1). Somatoform disordensa
Any 44 98 40 89
Common current axis I diagnoses were dissociative dis-
Somatization disorder 6 13 6 13
order not otherwise specified, PTSD, major depression, Somatoform pain disorder
h h 16
and phobias. The current and lifetime psychiatric ill- Undifferentiated somatoform
nesses of these pseudoseizure patients greatly exceed disorder 8 18 8 18
the U.S. population occurrences of major depression, Hypochondniasis I 2 1 2
Conversion disorder_seizunesd 40 89 35 78
PTSD, phobias, and dissociative disorders (22-26).
Conversion disordernonseizureC 37 82 2 4
Any eating disorder” 9 20 4 9
Somatoform Disorders and Symptoms Adjustment disorder’ 2 4 0 0
I)issociative disorders1
Any 42 93 41 91
Nineteen subjects (42%) and 38 subjects (84%), re-
Psychogenic amnesia 8 18 6 13
spectively, had current and lifetime somatoform disor- Psychogenic fugue 0 0 0 0
dens other than conversion seizures. Other forms of Depersonalization disorder 0 0 0 0
conversion (not occurring during seizures) with lifetime Dissociative identity disorder 7 16 7 16
Dissociative disorder not otherwise
occurrences were numbness (N=26, 58%), weakness
specified 28 62 28 62
(N=22, 49%), paralysis (N=19, 42%), fainting (N=16,
Any personality disorder’ 28 62
36%), staggering gait (N=1S, 33%), globus hystenicus
“Diagnosed by means of the Structured Clinical Interview for DSM-
(N=9, 20%), blindness (N=8, 18%), muteness (N=7,
III-R-Patient Version (SCID-P).
16%), deafness (N=6, 13%), and other visual distur- ‘Not assessed.
bances (N=i 1, 24%). Nonconvulsive conversion symp- cDiagnosed by means of the SCID-P section for PTSD.
toms were observed during the pseudoseizures of 18 dSee Method section for description of assessment.
eDiagnosed by unstructured interview and review of medical records.
subjects. Thirty-three subjects (73%) had severe unex-
1Diagnosed by means of the Structured Clinical Interview for DSM-
plained headaches. The physical forms and life contexts
III-R Dissociative Disorders.
of the pseudoseizures of 40 subjects met the DSM-III-R Diagiiosed by means of the Personality Diagnostic Questionnaire-
criteria for conversion disorder. Suspected seizures of Revised and 4 hours of interviewer observations of subjects and their
three subjects were purely trance states classified as dis- descriptions of their relationships.

sociative disorder not otherwise specified. In two sub-

jects, suspected seizures (alterations of consciousness,
other somatic complaints, no seizurelike movements) lation ( 1 7) and the median of 6-8 in epileptic persons
met the DSM-III-R criteria for undifferentiated somato- (27). The mean Dissociative Experiences Scale score
form disorder. was 20.2 (SD=18.2). This is significantly above the mean
of 10.8 (SD=10.2) in the general population (t=3.46,
Dissociative Disorders and Symptoms df=44, p<O.OO2; two-tailed t test) (28). Eleven scores
were above 30, indicating extensive dissociation (29).
The subjects’ median Dissociative Experiences Scale Table 2 shows SCID-D scores. They ranged from S to
score, 14.4, is above the median of 4 in the general popu- 20, with subscale symptom severity scores from I (ab-

Am J Psychiatry 1 53:1 , ]anuary 1996 59

PSEUDOSEIZURES

TABLE 2. Scores on the Structured Clinical Interview for DSM-Ill-R Dissociative Disorders score for the total group was 40.4
(SCID-D) for Pseudoseizure Subjects and Comparison Groups (SD=17.S, median=39, range=9-
Score 73). Personality disorders were di-
agnosed in 12 of 14 subjects with
Study by Steinberg et al. (21)
scores on the Personality Diagnos-
Outpatients With tic Questionnaire above 49 and 16
Outpatients With Nondissociative of22 subjects with scores of 20-49.
Pseudoseizune Dissociative Psychiatric
The mean scores for the subjects
Subjects (N=45) Disorders (N=18) Disorders (N=23)
with personality disorders (mean=
SCID-D Measure Mean SD Mean SD Mean SD 47.0, SD=15.3) and without per-
Total 14.33 4.20 17.28k’ 2.22 10o9h 4.73
sonality disorders (mean=29.6,
Subscales SD=1 5.9) differed significantly (t=
Psychogenic amnesia 3.53 0.69 3.56 0.86 2.30 1.15 3.54, df=43, p<O.OO1; two-tailed t
Depersonalization 3.13 1.06 3.56 0.70 2.26 1.10 test). Men and women did not differ
Derealization 2.38 1.34 2.94 1.12 1.70 0.93
significantly in score on the Person-
Identity confusion 2.56 1.41 3.56 0.51 1.87 1.14
Identity alteration 2.82 1.21 3.67 0.77 1.96 1.11 ality Diagnostic Questionnaire or
a5ignificantly higher than score of pseudoseizure subjects (t=3.62, df=61, p<O.OO1; two-tailed
in occurrence of a personality dis-
order.
test).
hSignificantly lower than score of pseudoseizure subjects (t=3.59, df=66, p’zO.OOI; two-tailed Among the subjects with person-
test. ality disorders, the interviewer ob-
served prominent maladaptive
traits of all DSM-III-R types, but
sent) to 4 (severe). To assess the resemblance of the avoidant, borderline, and histrionic styles occurred most
pseudoseizure subjects to patients with dissociative dis- often. The most common presentation was a confluence
orders and to general psychiatric outpatients, we corn- of maladaptive personality traits, rather than a single per-
pared our subjects’ SCID-D scores to the scores of sonality disorder. The scores on the Personality Diag-
groups studied by Steinberg et al. (21). The mean total nostic Questionnaire for individual personality disorder
SCID-D scone of our subjects was significantly higher diagnoses met the DSM-III-R criteria most often for the
than that of the psychiatric patients with nondissocia- paranoid (N=23), borderline (N=22), histrionic (N=18),
tive disorders, and it was significantly lower than the and avoidant (N=17) types. Despite their endorsement of
mean of the patients with dissociative disorders (table paranoid personality items, few subjects were clinically
2). Our subjects reported as much amnesia as did the paranoid, but many showed avoidant mistrust that they
dissociative disorder subjects, but they reported lower related to traumatic experiences.
levels of the other dissociative symptoms. The mean
scones of men and women on the SCID-D and the Dis- Trauma and Abuse Reports
sociative Experiences Scale did not differ significantly.
The pseudoseizunes frequently appeared to express Table 3 shows reported abuse and trauma. Pre-adult
dissociated distress about reported traumas. Twenty- abuse is abuse before age 18. Emotional abuse is fre-
nine subjects (64%) had alter personalities (N=7) or ego quent degrading interpersonal treatment. Spouse abuse
states (N=22) that often revealed that they caused refers to coerced sex or physical abuse sufficient to
pseudoseizures. The lifetime occurrences of some cause bruises. We did not seek to verify trauma reports.
nononganic dissociative symptoms were as follows: any Our findings support previous reports of high rates
amnesia (N=44, 98%), adulthood amnesia outside sei- of sexual abuse in pseudoseizure subjects. The subjects
zunes (N=37, 82%), childhood amnesia (N=33, 73%), reported nearly equal occurrences of sexual abuse,
intrainterview amnesia (N=20, 44%), fugues (N=16, physical abuse, and other traumas, describing lives with
36% ), depersonalization (N=39, 87% ), derealization multiple adversities. Other reported childhood traumas
(N=2S, 56%), any identity alteration (N=35, 78%), in- included neglect (N=10), violent homes (N=ii), and
ternal voice dialogues (N=18, 40%), and childlike emotional abuse (N=16). Ten subjects reported serious
states (N=17, 38%). Significantly more women (31 of accidents, and 1 7 reported other traumas, such as death
35) than men (three of 10) reported childhood amnesia threats, multiple bereavements, childhood abandon-
(x2=ll.4S df=1, p<O.OO1). ment, severe adulthood beatings, and witnessing trau-
matic deaths. The female subjects reported significantly
Personality Disorders more childhood sexual assault (69%) than was found
in women in the general population (38%) by a similar
The interviewer diagnosed personality disorders in 28 interview method (30) (X2=13.28, df=1, p<O.Oi) and
subjects. The total scores on the Personality Diagnostic significantly more adulthood and childhood sexual as-
Q uestionnaire-Revised for our subjects with and with- sault than was found in the Epidemiologic Catchment
out personality disorders did not differ significantly from Area studies: adulthood sexual assault, 10.5% (31)
the respective validation scores for psychiatric patients (p<O.Oi, binomial test); childhood sexual assault, 5.3%
with and without personality disorders (18). The mean (32) (p<O.O2, Poisson’s test). The rates of reported

60 Am] Psychiatry 153:1,January 1996

 ELIZABETH S. BOWMAN AND OMKAR N. MARKAND

abuse in our male and female subjects differ TABLE 3. Abuse and Trauma Reports of Female and Male Subjects With Pseudo-
little from the rates for corresponding groups seizures
of psychiatric patients (33, 34). The women All
reported significantly more physical abuse, Subjects Women Men Difference
Between
sexual abuse, and total trauma than the men. (N=45) (N=35) (N=10)
Sexes
For 3 1 subjects the pseudoseizures appeared Reported Event N % N % N 0/,,
(p)a
related to trauma.
Sexual abuse
Any 30 67 28 80 2 20 <0.01
Pre-adult 26 58 24 69 2 20 <0.05
DISCUSSION Adult
Any 16 36 16 46 0 0 <0.01
A major contribution of video-EEG moni- Spouse sexual abuse 9 20 9 26 0 0 n.s.
Rape by nonspouse 12 27 12 34 0 0 <0.05
toning has been differentiation of epileptic
Physical abuse
and psychogenic seizures. At our hospital, Any 30 67 27 77 3 30 0.01
one-third of the patients studied by video- Pre-adult 23 51 22 63 1 10 <0.01
EEG monitoring for characterization of the Spouse physical abuse 19 42 18 51 1 10 <0.05
Other traumas 33 73 29 83 4 40 <0.05
etiology of their episodes have pseudosei-
Any pre-adult abuse 30 67 26 74 4 40 n.s.
zures. Similarly, high frequencies (20%- Any adult abuse or trauma 27 60 24 69 3 30 n.s.
22%) of psychogenic seizures have been re- Anytrauma 38 84 34 97 4 40 <0.001
ported by others who studied patients with aFisher’s exact test.
medically intractable seizures by means of
video-EEG (35, 36).
An absence of ictal changes in the EEG during an epi- the Personality Diagnostic Questionnaire scores alone
sode is not, by itself, sufficient to diagnose pseudosei- suggest that one-third of pseudoseizure subjects have a
zures. In some complex partial seizures, particularly of high likelihood of having a personality disorder.
frontal lobe origin, and, more frequently, in simple pan- The lifetime diagnoses of nonseizure conversion dis-
tial seizures of unequivocal epileptic nature, EEG order were based on an unstructured interview and are
changes may not be recognizable or may be obscured also open to interviewer bias.Organic illness will likely
by ictal muscle artifacts (37). To further confound the eventually account for i0%-iS% of these diagnoses
issue, frontal lobe epileptic seizures often produce tonic (25). However, direct observation of ictal conversion
limb deviation or bizarre thrashing activity similar to symptoms (paralysis, weakness, numbness, etc.) in 18
that seen in pseudoseizures (37-39). Hence, it is possi- subjects supported the interview findings of high life-
ble that some of the subjects in this study may have had time rates of other conversion symptoms. These sub-
frontal lobe or simple partial seizures without surface jects’ multiple conversion symptoms suggest that
ictal EEG changes. However, this possibility is unlikely pseudoseizures may often be one of many conversion
since we applied multiple clinical and EEG criteria in symptoms oven years.
diagnosing pseudoseizures. The life narratives of our subjects revealed the con-
Generalization of our findings is limited by our terti- flicts over anger, sexuality, and dependency that Lazare
any-care population, in whom chronic disorders and noted (42). Five of the 35 women and six of the 10 men
lower socioeconomic status may be overrepresented. exhibited pseudoseizures that appeared to express an-
Men, more of whom refused psychiatric evaluation, gen. They exhibited a lifelong pattern of avoiding
were underrepresented in our study group. The men in awareness or expression of anger, and their seizures
the study group reported less abuse than the women, so had begun after adult frustrations. Most pseudosei-
having few male subjects may inflate the number of re- zures appeared to express sexual conflicts associated
ports of abuse. with reports of sexual trauma. Some of the subjects had
Self-report methods are vulnerable to both exaggena- already suspected such a link, and some of the alter
tion and denial. We did not substantiate reports of egos/personalities candidly associated pseudoseizures
trauma, so they must be viewed cautiously. When prior with distress about abuse.
medical records were available, we found that subjects Our findings support previous reports of an associa-
had denied or minimized psychiatric illness, so our re- tion between pseudoseizures and sexual abuse and sug-
port of lifetime psychiatric illnesses may be low. gest that the rate of trauma among pseudoseizure sub-
Axis II diagnoses are moderately reliable regardless jects may be higher than previously suspected. Multiple
of the evaluation method (40). Our method is open to kinds of trauma and recurrent trauma were associated
considerable error from interviewer bias, so the rate of with pseudoseizures that appeared to express distress
personality disorders could be inflated. It is also possi- about these events. The data confirmed our hypothesis
ble that our relatively chronically ill subjects had higher that subjects with pseudoseizures have high rates of di-
rates of personality disturbance than would subjects agnoses associated with sexual abuse (i.e., PTSD and
with recent onsets. Nevertheless, the rate of personality dissociative disorders). The rate of PTSD among our
disorders in our subjects is similar to that of subjects subjects is not significantly different from that of
with somatization disorder (60%) (41). At minimum, women who have sustained physical attack (24), lend-

Am] Psychiatry 153:1,]anuary 1996 61

PSEUDOSEIZURES

ing some support to our subjects’ reports of abuse. Our The diagnosis of these subjects’ pseudoseizures was
data suggest that sexual assault is less often associated not prompt, leading to years of anticonvulsant expo-
with pseudoseizures in men than in women, but studies sure and medical expenses. A higher index of suspicion
of more male subjects are needed. about pseudoseizures should exist for persons with
We found that contributory preceding life events were poorly explained seizure onset in adulthood (78% of
often remote in time (i.e., child abuse on rape). The psy- our study group), high or greatly fluctuating seizure fre-
chodynamic importance of precipitating events may be quency, and variable medication responses. Pseudo-
easily overlooked if a history of prior trauma is not seizure patients significantly exceed the general popula-
known. Examples of seizure-precipitating events related tion in rates of major depression, substance abuse, most
to occurrences in the past included seeing one’s rapist in anxiety disorders, PTSD, and dissociative disorders
public 2 years after the rape, renewed social contact with (22-26). They should be screened for these disorders,
a childhood abuser, an auto accident with minor injury other conversion symptoms, personality disorders, and
for a person who reported childhood beatings, gyne- trauma experiences.
cologic surgery for a person who reported childhood sex-
ual abuse, and the death or anniversary of the death of a
REFERENCES
reported abuser. Obvious precipitating events included
recent rape, entering on leaving abusive relationships, and
1. Lempert T, Schmidt E: Natural history and outcome of psycho-
adult physical assault. Significantly more women (24 of genic seizures: a clinical study in SO patients. J Neurol I 990; 237:
35) than men (one of 10) reported child abuse followed 35-38
by adult traumas and then onset of pseudoseizures 2. Roy A: Hysterical seizures. Arch Neurol 1979; 36:447
3. Gumnit RJ, Gates JR: Psychogenic seizures. Epilepsia 1986;
(x2 I 0.8 1 , df= 1 , p<O.Ol ). We strongly recommend that 27(suppl 2):S124-S 129
clinicians ask about remote and recent traumas when as- 4. Vanderzant CW, Giondani B, Benent 5, Dreifuss FE, Sackellares
sessing pseudoseizure patients. JC: Personality of patients with pseudoseizures. Neurology
As a group, subjects with pseudoseizures and pa- 1986; 36:664-668
tients with dissociative identity disorder are strikingly 5. Wilkus RJ, Dodnill CB: Factors affecting the outcome of MMPI
and neunopsychological assessments of psychogenic and epilep-
similar in their high rates of conversion symptoms and
tic seizure patients. Epilepsia 1989; 30:339-347
depression, rates of severe headaches, gender distnibu- 6. Bowman ES: Etiology and clinical course of pseudoseizunes: re-
tion, age at diagnosis, duration of symptoms before lationship to trauma, depression, and dissociation. Psychoso-
proper diagnosis, multiple psychiatric diagnoses, pen- matics 1993; 34:333-342
centage who report abuse, and percentage with overt 7. LaBanbera JD, Dozier JE: Hysterical seizures: the role of sexual
exploitation. Psychosomatics 1980; 2 1:897-903
alter personalities (6). Our SCID-D scores suggest that
8. Goodwin J, Sirnms M, Bergman R: Hysterical seizures: a sequel
pseudoseizure patients have more dissociative pathol- to incest. Am J Orthopsychiatry 1979; 49:698-703
ogy than do general psychiatric outpatients but are not 9. Gross M: Incestuous rape: a cause for hysterical seizures in four
simply a group of dissociative disorder patients seen in adolescent girls. Am J Orthopsychiatry 1979; 49:704-708
10. Putnam FW, GuroffJJ, Silberman EK, Barhan L, Post RM: The
the neurology clinic. We believe that pseudoseizune pa-
clinical phenomenology of multiple personality disorder: review
tients have lower SCID-D and Dissociative Expeni-
ences Scale scores
tity disorder because
than patients
pseudoseizune
with dissociative
patients represent
iden- .of 100 recent
1 1 Saxe GN, Chinman
cases. J Clin Psychiatry

J, van den Kolk BA: Somatization

G, Berkowitz
1986; 47:285-293
R, Hall K, Liebeng
in patients with
G, Schwartz
dissociative
a mixture of severe and mild dissociative disorders and disorders. ArnJ Psychiatry 1994; 151:1329-1334
12. Torern MS: Non-epileptic seizures as a dissociative disorder, in
because for some persons conversion is the sole disso-
Non-Epileptic Seizures. Edited by Rowan A, Gates JR. Boston,
ciative symptom. Butterworth-Heinman, 1993, pp 173-179
Our findings support Nemiah’s observation (14) that 13. Ramchandani D, Schindler B: Evaluation of pseudoseizures: a
convension, somatization, and dissociative disorders psychiatric perspective. Psychosornatics I 993; 34:70-79
14. Nemiah JC: Dissociation, conversion, and somatization, in
are connected and that conversion disorders should be
American Psychiatric Press Review of Psychiatry, vol 10. Edited
classified with dissociative disorders. The clinical pro- by Tasman A, Goldfinger SM. Washington, DC, American Psy-
file of pseudoseizune subjects is strikingly similar to that chiatnic Press, 1991, pp 248-260
of dissociative disorder populations, but it also resem- 15. Pnihor EF, Yutzy SH, Dean JT, Wetzel RD: Briquet’s syndrome,
bles the profiles of patients with somatization disorder, dissociation, and abuse. Am J Psychiatry 1993; 150:1507-1511
16. Shen W, Bowman ES, Markand ON: Presenting the diagnosis of
conversion disorder, and hypochondniasis in gender na-
psychogenic seizures. Neurology 1990; 40:756-759
tio and occurrence of depression and panic (43, 44). I 7. Bernstein EM, Putnam FW: Development, reliability, and valid-
Hypochondniasis subjects have also been found to have ity of a dissociation scale. J Nerv Ment Dis 1986; 174:727-735
high rates of sexual abuse (44). We suspect that pure I 8. Hyler SE, Skodol AE, Kellman HD, Oldham JM, Rosnick L: Va-
dissociative and somatization disorders may be the ends lidity of the Personality Diagnostic Questionnaire-Revised:
comparison with two structured interviews. Am J Psychiatry
of a spectrum of dissociative-somatic responses to
1990; 147:1043-1048
trauma. Pseudoseizure patients may be midway in such 19. WilliamsJBW, Gibbon M, First MB, Spitzer RL, Davies M, Bor-
a spectrum, consisting of persons whose dissociative usJ, Howes MJ, KaneJ, Pope HG, Rounsaville B, Wittchen H-U:
disorder is manifested first as conversion and persons The Structured Clinical Interview for DSM-III-R (SCID), II: mul-
tisite test-retest reliability. Arch Gen Psychiatry 1992; 49: 630-
who convey general emotional distress somatically.
636
More research is needed to clarify the relationship of 20. Kulka RA, Schlenger WE, Fairhank JA, Hough RL, Jordan BK,
these diagnostic categories. Marmar (;R, Weiss DS: Trauma and the Vietnam War Genera-

62 Am]Psychiatry 153:1,January 1996

 ELIZABETH S. BOWMAN AND OMKAR N. MARKAND

tion: Report of Findings From the National Vietnam Veterans 32. Siegel JM, Sorenson SB, Golding JM, Burnam MA, Stein JA: The
Readjustment Study. New York, Brunner/Mazel, 1990, pp 50- prevalence ofchildhood sexual assault: the Los Angeles Epidemi-

2 1 . 72
Steinberg
cal Interview
M, Rounsaville
for DSM-III-R
B, Cicchetti
Dissociative
DV: The Structured
Disorders: preliminary
Clini-
33.
ologic
1153
Catchment

Swett C Jr. Surrey J, Cohen

Area project. Am J Epidemiol

C: Sexual and physical

1987;

abuse
6:1141-

histo-
report on a new diagnostic instrument. Am J Psychiatry 1990; ries and psychiatric symptoms among male psychiatric outpa-
147:76-82 tients. AmJ Psychiatry 1990; 147:632-636
22. Regier DA, Farmer ME, Rae DS, Locke BZ, Keith SJ, Judd LL, 34. Bryer JB, Nelson BA, Miller JB, Knol PA: Childhood sexual and
Goodwin FK: Comorbidity of mental disorders with alcohol and physical abuse as factors in adult psychiatric illness. Am J Psy-
other drug abuse.JAMA 1990; 264:2511-2518 chiatry 1987; 144:1426-1430
23. Kessler RC, McGonagle KA, Shanyang Z, Nelson CB, Hughes 35. Mattson RH: Value of intensive monitoring, in Advances in Epi-
M, Eshleman 5, Wittchen H-U, Kendler KS: Lifetime and 12- leptology. Edited by Wada HA, Penny JK. New York, Raven
month prevalence of DSM-III-R psychiatric disorders in the Press, 1980, pp 43-51
United States. Arch Gen Psychiatry 1994; 51:8-19 36. GatesJR, Ramani V, Whalen 5, Lowenson R: Ictal characteristics
24. Helzer JE, Robins LN, McEvoy L: Post-traumatic stress disorder of psychogenic seizures. Arch Neurol I 985; 42: 1 1 83- 1 187
in the general population: findings of the Epidemiologic Catch- 37. Williamson PD, Spencer DD, Spencer 55, Novelly RA, Mattson
ment Area survey. N EnglJ Med 1987; 3 17:1630-1634 RH: Complex partial seizures of frontal lobe origin. Ann Neurol
25. Stefansson JG, Messina JA, Meyerowitz 5: Hysterical neurosis, 1985; 18:497-504
conversion type: clinical and epidemiological considerations. 38. Morris HH 3d, Dinner DS, Luders H, Wyllie E, Kramer R: Sup-
Acta Psychiatr Scand 1976; 53:119-138 plementary motor seizures: clinical and electroencephalographic
26. Ross CA: Epidemiology of multiple personality disorder and dis- findings. Neurology 1988; 38:1075-1082
sociation. Psychiatr Clin North Am 1991; 14:503-517 39. Kanner AM, Morris HH, Luders H, Dinner DS, Wyllie E, Mcd-
27. Loewenstein RJ, Putnam FW: A comparison study of dissociative endorp SV, Rowan AJ: Supplementary motor seizures mimick-
symptoms in patients with complex partial seizures, MPD, and ing pseudoseizures: some clinical differences. Neurology 1990;
posttraumatic stress disorder. Dissociation I 988; 1 : I 7-23 40:1404-1407
28. Ross CA, Joshi 5, Curnie R: Dissociative experiences in the gen- 40. Zimmerman M: Diagnosing personality disorders. Arch Gen
eral population. Am J Psychiatry 1990; 147:1547-1552 Psychiatry 1 994; 51:225-245
29. Carlson EB, Putnam FW, Ross CA, Torem M, Coons P, Dill DL, 41. Rost KM, Akins RN, Brown FW, Smith GR: The comorbidity of
Loewenstein RJ, Braun BG: Validity of the Dissociative Expeni- I)SM-III-R personality disorders in somatization disorder. Gen
ences Scale in screening for multiple personality disorder: a mul- Hosp Psychiatry 1992; 14:322-326
ticenter study. Am J Psychiatry 1993; 150:1030-1036 42. Lazare A: Conversion symptoms. N EnglJ Med 198 1; 305:745-
30. Russell DEH: The incidence and prevalence of intrafamilial and 748
extrafamilial sexual abuse of female children. Child Abuse NegI 43. Tomasson K, Kent D, Coryell W: Somatization and conversion
1983; 7:133-146 disorders: comorbidity and demographics at presentation. Acta
31. Sorenson SB, Stein JA, SiegelJM, GoldingJM, Burnam MA: The Psychiatr Scand 1991; 84:288-293
prevalence of adult sexual assault: the Los Angeles Epidemio- 44. Barsky AJ, Wool C, Barnett MC, Cleary P1): Histories of child-
logic Catchment Area project. AmJ Epidemiol 1987; 126:1154- hood trauma in adult hypochondriacal patients. Am J Psychiatry
I 164 1994; 151:397-401

Am J Psychiatry 153:1, January 1996 63