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non-epileptic seizures

Non-epileptic seizures (NES) or dissociative seizures are different from epilepsy as they have a different cause.  If you, or someone you know, has been diagnosed with non-epileptic seizures it may be helpful for you to identify the type of seizures that are relevant to you and how you feel about them.

Describing dissociative seizures

There are several different types of seizures, and they can happen for many different reasons. Seizures that are not due to epilepsy are sometimes called 'non-epileptic seizures'. They can have a physical cause such as low blood sugar (hypoglycaemia) or something related to the way the heart is working.

Or non-epileptic seizures may have a psychological cause. Other names for non-epileptic seizures with a psychological cause include 'non-epileptic attack disorder' and 'dissociative seizures'. We mostly use the term 'non-epileptic seizure' because it is a widely used term.

What causes epileptic seizures?

Epileptic seizures are caused by a disturbance in the electrical activity of the brain (and so they always start in the brain). Our brain controls the way we think, move and feel, by passing electrical messages from one brain cell to another. If these messages are disrupted, or too many messages are sent at once, this causes an epileptic seizures.

What happens to the person during the seizure depends on where in the brain the seizure activity happens.

Around 1 in 5 people (20%) diagnosed with epilepsy who are then assessed at specialist epilepsy centres are found to have non-epileptic seizures (NES). This may be partly because epilepsy and NES can look very similar, and can affect people in similar ways. However, the difference between epileptic and non-epileptic seizures is their cause.

Non-epileptic seizures

Non-epileptic seizures (NES) are not caused by disrupted electrical activity in the brain and so are different from epilepsy. They can have a number of different causes.

What causes non-epileptic seizures?

Types of NES

Non-epileptic seizures (NES) can be divided into two types: organic non-epileptic seizures and psychogenic seizures.

Organic NES

These seizures have a physical cause (relating to the body). They include fainting (syncope) and metabolic (biochemical processes in the body) causes such as diabetes.

Because organic NES have a physical cause, they may be relatively easy to diagnose and the underlying cause can be found. For example, a faint may be diagnosed as being caused by a physical problem in the heart. In these cases, if the underlying cause can be treated the seizures will stop.

Psychogenic NES

Some NES are called ‘psychogenic seizures’. 'Psychogenic' means they are caused by mental or emotional processes, rather than by how the brain and nervous system functions (a neurological cause). Psychogenic seizures may happen when someone's reaction to painful or difficult thoughts and feelings affects them physically.

Psychogenic seizures include different types:

  • Dissociative seizures happen unconsciously, which means that the person has no control over them and they are not ‘put on’. This is the most common type of NES. 
  • Panic attacks can happen in frightening situations, when remembering previous frightening experiences or in a situation that the person expects to be frightening. Panic attacks can cause sweating, palpitations (being able to feel your heart beat), trembling and difficulty breathing. The person may also lose consciousness and may shake (convulse).
  • Factitious seizures means that the person has some level of conscious control over them. An example of this is when seizures form part of Münchausen’s Syndrome, a rare psychiatric condition where a person is driven by a need to have medical investigations and treatments.

Other names for non-epileptic seizures

Non-epileptic seizures are sometimes known as non-epileptic attacks. People who have non-epileptic seizures may be described as having 'non-epileptic attack disorder' (NEAD).

These terms are not always helpful because they describe the condition by saying what it is not rather than by saying what it is.

NES used to be called 'pseudoseizures’ but this name is unhelpful because it sounds like the person is not having 'real' seizures or their seizures are deliberately 'put on'.

A newer name for non-epileptic seizures is 'dissociative seizures'. This is helpful because it does not describe seizures in terms of epilepsy. It is also recognised by the World Health Organization (this means that it is included in the International Classification of Diseases: a list of all known diseases and conditions).

Dissociative seizures

We all react to frightening or stressful situations differently. When we are frightened we might feel physical symptoms such as a racing heartbeat or feeling sweaty. When we feel sad, we might cry. So how we feel emotionally can sometimes cause a physical reaction.

An extremely frightening or upsetting experience may be so emotionally difficult for some people to think about that they cannot consciously cope with how this makes them feel.

In some cases, they will unconsciously hide or 'repress' the memory of these events. These memories may always remain hidden and the person may never remember the events that happened.

For some people, the memories of these painful past events can suddenly come back or 'intrude' in to their thoughts or awareness. This might happen during an emotional or stressful situation, or when there is something in the environment that unconsciously triggers a distressing memory.

Dissociative seizures can happen as a cut-off mechanism to stop bad memories from being re-lived. The person splits off (or 'dissociates') from their feelings about the experience because it is too difficult to cope with. The seizure happens because their emotional reaction causes a physical effect.

These seizures are an unconscious reaction so they are not deliberate and the person has no control over them.

One way to describe this is by comparing it to 'domestic deafness'. This is the experience of concentrating so hard on something that we don't realise when someone is talking to us. It can feel like 'turning the volume down' to drown out what is happening around you so you can concentrate. Dissociative seizures are like the body's way of 'drowning out' a frightening or painful memory so that it doesn't enter into our thoughts.

What causes dissociative seizures (DS)?

Any experiences that we have, whether good or bad, can have a deep and long-lasting effect on us, and everyone has their own way of dealing with them. Dissociative seizures (DS) are often caused by traumatic events such as:

  • major accidents
  • severe emotional upset (such as the death of a loved one)
  • psychological stress (such as a divorce)
  • difficult relationships
  • physical or sexual abuse
  • being bullied.

It can be hard to find the cause of someone’s DS. For some, they start shortly after a specific event. For others, they may not start until years later or they may start suddenly for no apparent reason. Once DS have started, they might be triggered or brought on when the person is stressed or frightened. Or they might happen spontaneously in situations that are not stressful or frightening. Sometimes, even the fear of having a seizure can, in itself, trigger a seizure.

Finding the original event that caused the DS to start might help to find a way to treat the seizures. But this is not always possible and it can be hard to talk about traumatic or difficult events.

Seizures caused by a delayed response to a very stressful event or situation, for example, being in a war or a disaster, are a response to past events. These seizures may be part of a post-traumatic stress disorder (PTSD) - a condition that sometimes starts after a traumatic event. During the seizure the person may cry, scream or have flashbacks (sudden, vivid memories of the event). They may not remember the seizure afterwards.

What are the symptoms?

Although DS start as an emotional reaction they cause a physical effect. Features of the seizures can include palpitations (being able to feel your heart beat), sweating,a dry mouth and hyperventilation (over-breathing).

Some features of DS are very similar to epileptic seizures. These physical features include loss of awareness, loss of sensation, and loss of control over bodily movement (which may include having convulsions).

Who has dissociative seizures (DS)?

DS can happen to anyone, at any age, although some factors make DS more likely. DS are:

  • more common in women
  • more likely to start in young adults
  • more likely to happen to people who have had an injury or disease, severe emotional upset or stressful life events
  • more common in people with other psychiatric conditions (such as depression, anxiety, personality disorders or people who self-harm).

How are non-epileptic seizures diagnosed?

If you have seizures, your GP will usually refer you to a specialist for diagnosis. This will usually be a neurologist to see if the seizures are epileptic. Or you may be referred to a psychiatrist or psychologist (as NES are usually classified as a psychiatric condition).

It may be easier for doctors to try and rule out possible physical causes first, including epilepsy. This will influence the types of tests you might have.

NES can be difficult to diagnose because they can appear similar to epileptic seizures. There are no symptoms that will definitely tell NES from epileptic seizures.

Taking a personal history

Tests used to find the cause of seizures cannot, on their own, confirm a diagnosis. However, taking a ‘personal history’ can help to find the cause of your seizures. This includes looking at:

  • your neurological history (about your brain and nervous system and its development)
  • your psychological development and mental health, including whether you have had depression or other psychiatric conditions, or have been subject to stress and trauma in the past
  • whether there is a family history of depression or other conditions
  • the history of your seizures, such as when they first started and when they happen
  • whether you have been diagnosed with epilepsy but your seizures have never been controlled with anti-epileptic drugs. 

What happens during the seizure

Asking you about what happens during a seizure can be helpful to find the cause. If you don’t remember your seizures, you might like to bring someone to the appointment who has seen your seizures. See our guide to recording what happens during a seizure

The specialist might ask you about:

  • when your seizures happen
  • whether you get any warning before a seizure happens
  • what happens to you during the seizure (if you don’t remember, a witness could help describe what happens to you)
  • how long the seizures last
  • what you remember, if anything, about the seizure afterwards
  • how you feel afterwards and how long it takes you to recover. 

Medical tests

Some tests are used to rule out other causes of seizures, including epilepsy.

  • Medical examinations and blood tests can be used to check your overall health and see if your seizures have a physical cause such as diabetes.
  • Brain scans such as CT (computerised tomography) or MRI (magnetic resonance imaging) are used to form a picture of your brain. This may show a physical cause for epileptic seizures, but would not usually be helpful in diagnosing NES.
  • An EEG (electroencephalogram) records the electrical activity of the brain. It is often used to see if seizures are caused by disrupted brain activity, which helps to diagnose epilepsy. NES are not caused by changes in brain activity.
  • Video telemetry involves having an EEG and being filmed at the same time. This compares what a person is doing with what is happening in their brain during the seizure, and can often show the difference between epileptic and non-epileptic seizures. This can help to diagnose epilepsy (if, during a seizure, your brain activity changes) or diagnose NES (if, during a seizure, your brain activity does not change).

If the tests show no neurological or physical cause for your seizures, and your specialist thinks it might be NES you may be referred to a psychiatrist or a psychologist for diagnosis.

Treatment options

Treatment may depend on the cause of your seizures, and your medical history. Your specialist may talk to you about what treatment options might be helpful.

Medication

If you have seizures that are not epileptic they will not respond to anti-epileptic drugs (AEDs).

If you already take AEDs, for example if you were previously diagnosed with epilepsy, your specialist may suggest you gradually reduce them. If you have NES and epilepsy, you will usually continue to take AEDs for your epileptic seizures.

If you also have anxiety or depression, your specialist might talk to you about whether other medication, such as anti-depressants, might be helpful.

Other forms of treatment

Psychotherapy is the recommended treatment for NES. Psychotherapy is the name for a group of different ‘talking’ therapies (treatments).

Mental health professionals, including psychiatrists and psychologists, are trained in different forms of psychotherapy.

Cognitive behavioural therapy (CBT) is often recommended for NES. CBT looks at how you think about things, how this affects you physically and emotionally and how it affects what you do (your behaviour). By changing the way you think about yourself, other people and the world around you, this may change the way that you behave. CBT tends to focus on how things are affecting you in the present, and ways to help you to view current situations more positively and cope with stressful events.

CBT can take several months or longer as it may take time for you to feel comfortable talking about your experiences and feelings.

Living with non-epileptic seizures

First aid

The general first aid guidelines for NES are the same as for epileptic seizures:

  • keep the person safe from injury or harm, and only move them if they are in danger
  • if they have fallen, put something soft under their head to protect it
  • allow the seizure to happen, don’t restrain or hold them down
  • stay with them until they have recovered.

Keeping a normal routine if possible

For some people, NES may disrupt their daily life or they may want to avoid activities in case they have a seizure. However, studies show that it can help to keep as normal a routine as possible, and try not to avoid activities or other people, which can lead to being isolated and more anxious, making seizures more likely.

Treatment for NES may work best when someone is active in life, including working, studying or other activities which are meaningful or satisfying.
If you are working, your employer has a responsibility to keep you and other employees safe at work. To do this, they need to know about any medical conditions that may affect you at work, including NES. Your employer may need to do a ‘risk assessment’ to see if your condition might affect safety at work.

Financial help

You may be able to apply for financial help, depending on how your seizures affect your daily life. Whatever the cause, seizures can affect different areas of life for some people.

Driving standards (regulations)

Driving standards for the UK are set by the Driver and Vehicle Licensing Agency (DVLA) (opens new window). You will need to stop driving, tell the DVLA that you have NES, and return your licence to them. Each case may be looked at individually, but you can apply for a new licence once your doctors confirm that your seizures have been 'satisfactorily controlled'.

These regulations are based on the possibility of having a seizure while driving and the risks this could bring.

Seizures and disability

The Equality Act 2010 (opens new window) aims to protect people against discrimination if they have certain characteristics, including having a disability. Someone has a disability if they have:

"a physical or mental impairment which has a substantial and long-term adverse effect on the ability to carry out normal day-to-day activities".
Equality Act 2010.

Here 'substantial' means it is difficult or time-consuming to do activities compared to someone without a disability, and 'long-term' means at least 12 months. 'Day-to-day activities' include being able to get around, hear, see, remember and concentrate.

The Equality Act does not include a list of every disability covered. Although epilepsy is listed as a physical disability, NES is not listed. To be covered by the Equality Act, you need to show that you meet the definition above.

How you feel about your diagnosis

Being diagnosed with any condition can cause different emotions, and may affect many parts of your life. You may be relieved to know what is causing your seizures. Or you may find it hard to come to terms with, particularly if you were previously diagnosed with epilepsy and have now been diagnosed with NES.

Being diagnosed can also feel quite scary or upsetting because of the stigma around how psychiatric conditions are sometimes viewed. Understanding that NES can be your body’s natural way of reacting to stressful situations might be helpful.

There is no ‘right’ way to feel about your diagnosis, but being able to accept it can be part of helping to improve your seizure control.

You might like to call our confidential helpline to talk about your diagnosis and how you feel about it. Or visit our forum to talk online with other people.

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