PSEUDOSEIZURES OR SOMATOFORM SPELLS; HYSTEROEPILEPSY OR SOMATOFORM SPELL DISORDER

VERNON M NEPPE MD, Ph.D

The aphorism "the number of medications used for this condition attests to nothing working" may be applied at times to terminology: Psychogenic seizure, Nonepileptic seizure, Pseudoseizure, Hysterical epilepsy, Hysteroepilepsy, Hysterical seizures, Conversion fits, Pseudo-attacks, Doxogenic seizures, Paroxysmal somatoform disorder.

What is an appropriate non-prejudicial term for patients who have phenomena that resemble epileptic seizures but which are in reality psychogenically induced? This is an active area of debate in neuropsychiatry and epileptology. The number of terms suggested for such a phenomenon is indicative of the difficult status of such events in conventional medical terminology.

Two decades ago, clinicians were calling these events hysterical epilepsy, hysteroepilepsy or hysterical seizures. The term hysteria then went out of favour in psychiatry and with it hysterical seizures. Most common today is pseudoseizures raising a new area of debate as to its appropriateness. The events are not seizures hence the pseudo component. However, they are not pseudo in that they are extremely real episodes and pseudo implies a disparaging element to the events. We agree with Trimble on the pejorative inference on the nature of these episodes. Patients feel badly, guilty, distressed or resentful that their condition is perceived in a pseudo-artificially -sense and that they are being actively accused of causing it. Whereas this may or may not be true this perception is unhealthy and inappropriate. Moreover Slavney emphasizes the active role of the experient in the pseudoseizure - they are doing it to themselves, its not happening to them - in this way it is pseudo but it has implications in primary and secondary gains such as sick role and attention. Moreover, such events are generally not consciously motivated: the patient is not malingering his illness nor is it consciously performed but for no apparent environmental gain - factitious. Nonepileptic seizure followed but this attempt to be neutral in connotation and acceptable in denotation (Gates and Erdahl) fails because of the inherent paradox in the terms. Psychogenic seizurebecomes an alternative - again the term seizure is controversial, although the psychogenic nature of the event is emphasized. The term psychogenic in psychiatry has become almost as unfashionable as hysterical. Camouflage terms reflecting more non-prejudicial frameworks yet emphasizing the connection with the body has led to the whole area of Somatoform disorders being studied. Merskey has suggested several other alternatives. He emphasizes the conversion nature of the events and suggests conversion fits - the problem is it is inaccurate: whereas conversion phenomena do occur, dissociative elements exist as well. Moreover, we often refer to conversion in the context of negative events - paralysis, mutism and these are classically positive activities. Merskey also suggests Doxogenic seizures. This introduces the esoteric term, doxogenic, implying the patients own mental conceptions and, in fact, Merskey has also used the term in the multiple personality disorder implying a common theme which is unproven and probably unlikely - the two conditions do not appear to markedly co-exist.

Can terms like epilepsy and seizures be linked with pseudo or hysterical of somatoform or conversion or some other equivalent? Not easily: These events are not seizures so that the term is inaccurate (Slavney). One cannot broaden the term seizure to imply other paroxysmal events without compromising the essential character of epileptic firing in the brain. If it so broadened such events as syncope and pain which involve non-epileptic short-lived episodes of impaired consciousness, sensory perception discomfort, or motor movements would be so incorporated.

This then restarts the debate on the nature of seizures - whether we ought ot be limiting the term to epileptic firing . Merskey alternatively raised pseudo-attacks . This brings the debate on pseudo back to the forefront and introduces a new source of prejudice namely the attack. Is a pseudoseizure an attack - if it's psychologically induced is the patient the victim of the attack or the cause of the action? Attack seems as prejudicial as seizure. What terms can be used? We feel badly about adding to this debate new terms but clearly the old ones are unacceptable.

There is a need for a term describing short-lived episodic phenomena of concern to the patient or those around him - the term spell accurately describes this. We feel the term ought to be non-prejudicial for the patient, not reflect episodic firing in the brain, allow for the fact that numerous patients labelled pseudoseizures actually turn out to have real though atypical seizures on depth telemetry, and that real seizures commonly co-exist in patients with pseudoseizures. We want to emphasize the essential episodic nature of the events which are usually sudden and have onsets over seconds and usually last short time - generally seconds or minutes occasionally hours or days. Consequently they are paroxysmal. We and others have used the term spell for a nonprejudicial way to describe such paroxysmal attacks of altered or impaired consciousness, behavior, emotions, perceptions or motoric movements. We need to replace seizure with something and spell seems more logical than somatoform seizure for example. There is a major advantage to using the term spell. Clusters of events can easily be combined into a disorder or syndrome encompassing the paroxysmal disorders. Spell is defined is paroxysmal and delineates the episodic nature of the illness and is particularly valuable considering our other suggested related classification of Paroxysmal Neurobehavioural Disorder. Spells imply that these are happening as single discrete episodes in time and moreover a series of spells of may ultimately lead to a diagnosis of a syndrome or disorder cluster e.g. Paroxysmal Somatoform Disorder (Blumer) which may include also bodily episodes such as faints or episodic pain or headache. Spells are non-prejudicial. They do not imply seizure phenomena and yet do not connote conversion, dissociation, hypochondriasis or hysteroid behavior either.

Moreover, we want to link with conventional DSM and ICD nomenclature, now and in the future. We need to reflect conscious or unconscious behavior of episodic bodily or mental kind non-prejudicially and it would be worth having a term such as somatoform - resembling bodily symptoms recently introduced into psychiatric classifications. Indeed, one of us (DB) has already suggested paroxysmal somatoform disorder as a possibility.

The Somatoform element we believe to be useful because it emphasizes the bodily symptoms elements e.g. many of these patients have pain syndromes such as headaches. Hence, Somatoform Spells which would allow differentiation from syncopal or pain episodes. People who have repetitive somatoform spells would have SSD or Somatoform Spell Disorder. We respectfully, therefore, add to the tumult of terms this one.