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Psychogenic Seizures
Perspective Psychogenic Seizures— Why Women? MILTON ROSENBAUM, M.D.
The only consistent finding in studies of psychogenic seizures is the approximately threefold higher incidence in women. Therefore, why women? Charcot and Freud emphasized the sexual aspects of the seizure as has the current interest in childhood sexual abuse. From case studies and review of the literature the author believes that psychogenic seizures in women express rage, fear, and helplessness against the dominant and abusive male rather than sexual conflicts. Emphasizing the aggressive component of seizures does not minimize the traumatic effects of sexual abuse but rather includes it as leading to rage and helplessness. (Psychosomatics 2000; 41:147–149)
I like a look of Agony, Because I know it’s true— Men do not sham Convulsion, Nor simulate, a Throe— Emily Dickinson
T
here has been renewed interest in psychogenic seizures (also called pseudoseizures, hysterical seizures, and nonepileptic seizures) in recent years. Some of the factors contributing to this growing interest include improved neurological diagnostic techniques (especially videotaped electroencephalograms), changes in seizure nomenclature and classification (especially those classified as complex partial seizures), refined surgical intervention, more psychiatry consultation-liaison services in university teaching hospitals, and the revived interest in dissociative disorders with the increased awareness of childhood/sexual abuse. Yet, despite this increased interest, the findings reported in the recent literature are inconsistent except for the approximately threefold higher incidence of psychogenic seizures in women. The incidence of childhood sexual abuse varies considerably (24%–86%), as does the incidence of cerebral pathology (8%–50%), the sexual coloring of the attack (4%–50%); the frequency of psychogenic seizures combined with epilepsy (5%–60%), the Psychosomatics 41:2, March-April 2000
number of patients with pseudoepilepsy who remain on anticonvulsive medication (50%–95%), the disparity of findings in long-term follow-up studies, and the marked diversity in the psychiatric diagnosis of patients with psychogenic seizures.1–7 This makes the finding of an approximately threefold higher incidence of psychogenic seizures in women remarkable. A review of all the case reports cited by Rowan and Gates in their book, Non-Epileptic Seizures showed that 84% of these cases were women.8 A report of psychogenic status epilepticus found 19 of the 20 patients were women (95%).5 The percentage of women in other studies ranged from 92% to 57%.4,9,10 In my series of 22 cases, 80% were women. Therefore, the main question is, Why women? For centuries hysteria was considered a disorder confined to women, and until modern times it was considered rare if not absent in men. Even today the term “hysterical” is associated with women. The term fainting applies to men as well as women but certainly the term swooning refers Received February 23, 1999; revised September 1, 1999; accepted September 15, 1999. From the Department of Psychiatry, University of New Mexico, 2400 Tucker NE, Albuquerque, New Mexico 87131–5326. Address reprint requests to Dr. Rosenbaum. Copyright 䉷 2000 The Academy of Psychosomatic Medicine.
147
Psychogenic Seizures to women (the example cited in Webster’s Collegiate Dictionary is “the ladies were swooning with joy”). A report on psychogenic epidemics, including seizures in the workplace, found that 90% of the workers were women.11 Certainly cultural factors are important in the behaviors of men and women, especially in the two areas related to psychogenic seizures, sex, and aggression. The role of sexuality in hysteria has been emphasized since ancient times, but it was Freud’s initial theory of the role of childhood sexual trauma in hysteria (including psychogenic seizures) or the “seduction theory” that brought the role of childhood sexual abuse to the attention of the medical and psychiatric community.12 Freud’s original theory was ridiculed and considered unbelievable. After he renounced this theory for the theory of “childhood sexual Oedipal fantasies,” most psychoanalysts and psychiatrists dropped the “seduction theory” and viewed most accounts of sexual abuse of children and rape in young women as fantasies. Interestingly, one exception was the high incidence of incest in the relatively few case reports of multiple personality.13 Although the frequency of childhood sexual and physical abuse in patients with psychogenic seizures varies considerably, there is general agreement of their significance in these patients. Alper et al.,1 in their prospective and controlled study of psychogenic seizures, emphasized the sexual aspects of the seizures but also mentioned bereavement and secondary gain from the sick role. After reviewing the literature and examining my own case material, I believe that psychogenic seizures in women express rage, fear, and helplessness, as Bowman and Devinsky noted,4,14 and the communication of these affects more often than sexual conflicts and sexual symbolism. Perhaps in grown women psychogenic seizures are similar to the temper tantrums of a young child, a type of behavior that expresses rage and aggression in those without physical power.15 Similarly, Perry noted that among the child survivors of the Koresh (Waco) tragedy, girls tended to use dissociative defenses, whereas boys acted out and became aggressive.16
Vignette 1
At the age of 16, a Hispanic woman was raped by her boyfriend while being held down by a friend of his. The patient was raised in a very religious family in which sex before marriage was forbidden. When the patient told her family of the rape they convinced the patient and her boyfriend to marry. The husband was violent toward his wife and left her after 2 years 148
of marriage. Shortly after she returned to live with her family she began to have seizures, but there were no abnormalities on neurological examination or on her EEG. The psychiatric consultant produced an attack by asking her to hyperventilate and by using strong suggestion. The patient admitted she felt hurt and angry with her husband but accepted her demeaned position because she felt guilty about the rape incident, as if she were responsible for it. The patient’s uncle had epilepsy and she had witnessed his attacks on several occasions.
Vignette 2
A 40-year-old divorced, white, chronic alcoholic man had several arrests for driving while intoxicated. Shortly before hospital admission, he was again arrested for driving without a license and sent to jail. The patient denied he had been drinking at the time of his arrest, but the arresting policeman recognized him and knew that he did not have a driver’s license. While in jail he began to have seizures and was admitted to the Neurology Service. The neurology workup, including video EEGs, was negative. The essential history from the patient and his older sister was that as a child he had temper outbursts that were worsened by physical abuse from his alcoholic father. During his temper outbursts he flailed his arms and stamped on the floor. As he grew up he continued to have occasional temper outbursts but there was no history of seizure activity. The patient had a cousin with epilepsy, and he had witnessed those seizures. In this case the psychogenic seizures not only expressed the patient’s helpless rage, but also, becoming “sick” allowed him to evade a serious punishment and loss of livelihood.
Bennet Simon in his book, Mind and Madness in Ancient Greece,17 while acknowledging the sexual factors of hysteria, particularly hysteroepilepsy, emphasizes the female resentment and rage toward the oppressive Greek male society and the women’s yearning for liberation from restraint. Chodoff18 believes that currently much of the behavior of women defined as hysteria is the product of cultural pressures. Simon17 viewed the baccharitic frenzies and hysterical outbursts as socially acceptable devices for expressing repressed (I would add suppressed) female feelings, the former sanctified by religion and the latter incorporated into the medical model of the times. He cites Dodds, who believes group experiences of dancing mania and ecstasy serve as expressions of protest and liberation by oppressed groups of which the most common are women. In considering the role of aggression in psychogenic seizures, it occurred to me that African American women could have a lower prevalence of psychogenic seizures than white Psychosomatics 41:2, March-April 2000
Rosenbaum
FIGURE 1.
Number of clinical sites that report more, equal, or fewer patients with psychogenic seizures than would be expected based on the base population of the same ethnicity at each clinical site. n ⴔ17 clinical sites reporting information for white women. n ⴔ20 clinical sites reporting information for African American women. Fisher’s exact test P ⬍0.002.
More
Number of Clinical Sites
Equal Fewer 12 10 8 6 4 2
women because traditionally African American women are more likely to openly express anger and assertiveness toward a dominating or violent African American man.19 Preliminary data (Figure 1) tending to confirm my hypothesis come from an ongoing study of 20 university-based epilepsy centers and C-L services equally distributed among catchment areas with high, average, and low African American populations. Emphasizing the aggressive component of psychogenic seizures is not meant to minimize the traumatic effects of childhood sexual abuse but rather to include it among those experiences that, as in ancient Greece and for most of the history of mankind until this very day, produced female resentment and rage toward oppressive male societies. In addition, focusing on suppressed and repressed anger and rage as important emotional etiological factors in psychogenic seizures can enhance the treatment outcome of various psychotherapeutic approaches.
0 African American women
White women
References
1. Alper K, Devinsky O, Perrine K, et al: Nonepileptic seizures and childhood sexual abuse. Neurology 1993; 43: 1950–1953 2. Merskey H, Buhrick N: Hysteria and organic brain disease. Br J Med Psychol 1975; 48:359–366 3. Lelliott PT, Fenwick P: Cerebral pathology in pseudoseizures. Acta Neurol Scand 1991; 83:129–132 4. Bowman ES: Etiology and clinical course of pseudoseizures: relationship to trauma, depression and dissociation. Psychomatics 1993; 34:333–342 5. Pakainis A, Drake ME, Phillips B: Neuropsychiatric aspects of psychogenic status epilepticus. Neurology 1991; 41:1104–1106 6. Snyder S, Rosenbaum D, Strain J: SCID diagnosis of panic disorders in psychogenic seizure patients. J Neuropsychiatry Clin Neurosci 1994; 6:261–266 7. Roy A (ed): Hysteria. New York, John Wiley & Sons, 1982, p 241 8. Rowan J, Gates J: Non-Epileptic Seizures. Boston, ButterworthHeinemann, 1993, pp 57–193 9. Mersky H, Trimble M: Personality, sexual adjustment, and brain lesions in patients with conversion symptoms. Am J Psychiatry 1979; 136:179–182 10. Ramchandani D, Schindler B: Evaluation of pseudoseizures: A psychiatric perspective. Psychosomatics 1993; 34:70–79
Psychosomatics 41:2, March-April 2000
11. Olkinuora M: Psychogenic epidemics and work. Scand J Work Environ Health 1984; 10:501–504 12. Freud S: The etiology of hysteria (1890a), in The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol. 3, translated and edited by Stroskey J. London, Hogarth, 1968, pp 187–221 13. Rosenbaum M: The role of the term schizophrenia in the decline of diagnoses of multiple personality. Arch Gen Psychiatry 1980; 37:1383–1385 14. Devinsky O: Nonepileptic psychogenic seizures: quagmires of pathophysiology, diagnoses, and treatment. Epilepsia 1998; 39:458–462 15. Leung AK: Temper tantrums. Am Fam Physician 1991; 44:559– 563 16. Perry B: quoted in Cody P: Child survivors of Koresh compound getting badly needed psychiatric help. Psychiatric News May 24, 1993, p 4 17. Simon B: Mind and Madness in Ancient Greece. New York, Cornell University Press, 1978, pp 238–268 18. Chodoff P: Hysteria and women. Am J Psychiatry 1982; 139:545– 551 19. Rosenbaum M: The role of depression in couples involved in murder-suicide and homicide. Am J Psychiatry 1990; 147:1036– 1039
149
The only consistent finding in studies of psychogenic seizures is the approximately threefold higher incidence in women. Therefore, why women? Charcot and Freud emphasized the sexual aspects of the seizure as has the current interest in childhood sexual abuse. From case studies and review of the literature the author believes that psychogenic seizures in women express rage, fear, and helplessness against the dominant and abusive male rather than sexual conflicts. Emphasizing the aggressive component of seizures does not minimize the traumatic effects of sexual abuse but rather includes it as leading to rage and helplessness. (Psychosomatics 2000; 41:147–149)
I like a look of Agony, Because I know it’s true— Men do not sham Convulsion, Nor simulate, a Throe— Emily Dickinson
T
here has been renewed interest in psychogenic seizures (also called pseudoseizures, hysterical seizures, and nonepileptic seizures) in recent years. Some of the factors contributing to this growing interest include improved neurological diagnostic techniques (especially videotaped electroencephalograms), changes in seizure nomenclature and classification (especially those classified as complex partial seizures), refined surgical intervention, more psychiatry consultation-liaison services in university teaching hospitals, and the revived interest in dissociative disorders with the increased awareness of childhood/sexual abuse. Yet, despite this increased interest, the findings reported in the recent literature are inconsistent except for the approximately threefold higher incidence of psychogenic seizures in women. The incidence of childhood sexual abuse varies considerably (24%–86%), as does the incidence of cerebral pathology (8%–50%), the sexual coloring of the attack (4%–50%); the frequency of psychogenic seizures combined with epilepsy (5%–60%), the Psychosomatics 41:2, March-April 2000
number of patients with pseudoepilepsy who remain on anticonvulsive medication (50%–95%), the disparity of findings in long-term follow-up studies, and the marked diversity in the psychiatric diagnosis of patients with psychogenic seizures.1–7 This makes the finding of an approximately threefold higher incidence of psychogenic seizures in women remarkable. A review of all the case reports cited by Rowan and Gates in their book, Non-Epileptic Seizures showed that 84% of these cases were women.8 A report of psychogenic status epilepticus found 19 of the 20 patients were women (95%).5 The percentage of women in other studies ranged from 92% to 57%.4,9,10 In my series of 22 cases, 80% were women. Therefore, the main question is, Why women? For centuries hysteria was considered a disorder confined to women, and until modern times it was considered rare if not absent in men. Even today the term “hysterical” is associated with women. The term fainting applies to men as well as women but certainly the term swooning refers Received February 23, 1999; revised September 1, 1999; accepted September 15, 1999. From the Department of Psychiatry, University of New Mexico, 2400 Tucker NE, Albuquerque, New Mexico 87131–5326. Address reprint requests to Dr. Rosenbaum. Copyright 䉷 2000 The Academy of Psychosomatic Medicine.
147
Psychogenic Seizures to women (the example cited in Webster’s Collegiate Dictionary is “the ladies were swooning with joy”). A report on psychogenic epidemics, including seizures in the workplace, found that 90% of the workers were women.11 Certainly cultural factors are important in the behaviors of men and women, especially in the two areas related to psychogenic seizures, sex, and aggression. The role of sexuality in hysteria has been emphasized since ancient times, but it was Freud’s initial theory of the role of childhood sexual trauma in hysteria (including psychogenic seizures) or the “seduction theory” that brought the role of childhood sexual abuse to the attention of the medical and psychiatric community.12 Freud’s original theory was ridiculed and considered unbelievable. After he renounced this theory for the theory of “childhood sexual Oedipal fantasies,” most psychoanalysts and psychiatrists dropped the “seduction theory” and viewed most accounts of sexual abuse of children and rape in young women as fantasies. Interestingly, one exception was the high incidence of incest in the relatively few case reports of multiple personality.13 Although the frequency of childhood sexual and physical abuse in patients with psychogenic seizures varies considerably, there is general agreement of their significance in these patients. Alper et al.,1 in their prospective and controlled study of psychogenic seizures, emphasized the sexual aspects of the seizures but also mentioned bereavement and secondary gain from the sick role. After reviewing the literature and examining my own case material, I believe that psychogenic seizures in women express rage, fear, and helplessness, as Bowman and Devinsky noted,4,14 and the communication of these affects more often than sexual conflicts and sexual symbolism. Perhaps in grown women psychogenic seizures are similar to the temper tantrums of a young child, a type of behavior that expresses rage and aggression in those without physical power.15 Similarly, Perry noted that among the child survivors of the Koresh (Waco) tragedy, girls tended to use dissociative defenses, whereas boys acted out and became aggressive.16
Vignette 1
At the age of 16, a Hispanic woman was raped by her boyfriend while being held down by a friend of his. The patient was raised in a very religious family in which sex before marriage was forbidden. When the patient told her family of the rape they convinced the patient and her boyfriend to marry. The husband was violent toward his wife and left her after 2 years 148
of marriage. Shortly after she returned to live with her family she began to have seizures, but there were no abnormalities on neurological examination or on her EEG. The psychiatric consultant produced an attack by asking her to hyperventilate and by using strong suggestion. The patient admitted she felt hurt and angry with her husband but accepted her demeaned position because she felt guilty about the rape incident, as if she were responsible for it. The patient’s uncle had epilepsy and she had witnessed his attacks on several occasions.
Vignette 2
A 40-year-old divorced, white, chronic alcoholic man had several arrests for driving while intoxicated. Shortly before hospital admission, he was again arrested for driving without a license and sent to jail. The patient denied he had been drinking at the time of his arrest, but the arresting policeman recognized him and knew that he did not have a driver’s license. While in jail he began to have seizures and was admitted to the Neurology Service. The neurology workup, including video EEGs, was negative. The essential history from the patient and his older sister was that as a child he had temper outbursts that were worsened by physical abuse from his alcoholic father. During his temper outbursts he flailed his arms and stamped on the floor. As he grew up he continued to have occasional temper outbursts but there was no history of seizure activity. The patient had a cousin with epilepsy, and he had witnessed those seizures. In this case the psychogenic seizures not only expressed the patient’s helpless rage, but also, becoming “sick” allowed him to evade a serious punishment and loss of livelihood.
Bennet Simon in his book, Mind and Madness in Ancient Greece,17 while acknowledging the sexual factors of hysteria, particularly hysteroepilepsy, emphasizes the female resentment and rage toward the oppressive Greek male society and the women’s yearning for liberation from restraint. Chodoff18 believes that currently much of the behavior of women defined as hysteria is the product of cultural pressures. Simon17 viewed the baccharitic frenzies and hysterical outbursts as socially acceptable devices for expressing repressed (I would add suppressed) female feelings, the former sanctified by religion and the latter incorporated into the medical model of the times. He cites Dodds, who believes group experiences of dancing mania and ecstasy serve as expressions of protest and liberation by oppressed groups of which the most common are women. In considering the role of aggression in psychogenic seizures, it occurred to me that African American women could have a lower prevalence of psychogenic seizures than white Psychosomatics 41:2, March-April 2000
Rosenbaum
FIGURE 1.
Number of clinical sites that report more, equal, or fewer patients with psychogenic seizures than would be expected based on the base population of the same ethnicity at each clinical site. n ⴔ17 clinical sites reporting information for white women. n ⴔ20 clinical sites reporting information for African American women. Fisher’s exact test P ⬍0.002.
More
Number of Clinical Sites
Equal Fewer 12 10 8 6 4 2
women because traditionally African American women are more likely to openly express anger and assertiveness toward a dominating or violent African American man.19 Preliminary data (Figure 1) tending to confirm my hypothesis come from an ongoing study of 20 university-based epilepsy centers and C-L services equally distributed among catchment areas with high, average, and low African American populations. Emphasizing the aggressive component of psychogenic seizures is not meant to minimize the traumatic effects of childhood sexual abuse but rather to include it among those experiences that, as in ancient Greece and for most of the history of mankind until this very day, produced female resentment and rage toward oppressive male societies. In addition, focusing on suppressed and repressed anger and rage as important emotional etiological factors in psychogenic seizures can enhance the treatment outcome of various psychotherapeutic approaches.
0 African American women
White women
References
1. Alper K, Devinsky O, Perrine K, et al: Nonepileptic seizures and childhood sexual abuse. Neurology 1993; 43: 1950–1953 2. Merskey H, Buhrick N: Hysteria and organic brain disease. Br J Med Psychol 1975; 48:359–366 3. Lelliott PT, Fenwick P: Cerebral pathology in pseudoseizures. Acta Neurol Scand 1991; 83:129–132 4. Bowman ES: Etiology and clinical course of pseudoseizures: relationship to trauma, depression and dissociation. Psychomatics 1993; 34:333–342 5. Pakainis A, Drake ME, Phillips B: Neuropsychiatric aspects of psychogenic status epilepticus. Neurology 1991; 41:1104–1106 6. Snyder S, Rosenbaum D, Strain J: SCID diagnosis of panic disorders in psychogenic seizure patients. J Neuropsychiatry Clin Neurosci 1994; 6:261–266 7. Roy A (ed): Hysteria. New York, John Wiley & Sons, 1982, p 241 8. Rowan J, Gates J: Non-Epileptic Seizures. Boston, ButterworthHeinemann, 1993, pp 57–193 9. Mersky H, Trimble M: Personality, sexual adjustment, and brain lesions in patients with conversion symptoms. Am J Psychiatry 1979; 136:179–182 10. Ramchandani D, Schindler B: Evaluation of pseudoseizures: A psychiatric perspective. Psychosomatics 1993; 34:70–79
Psychosomatics 41:2, March-April 2000
11. Olkinuora M: Psychogenic epidemics and work. Scand J Work Environ Health 1984; 10:501–504 12. Freud S: The etiology of hysteria (1890a), in The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol. 3, translated and edited by Stroskey J. London, Hogarth, 1968, pp 187–221 13. Rosenbaum M: The role of the term schizophrenia in the decline of diagnoses of multiple personality. Arch Gen Psychiatry 1980; 37:1383–1385 14. Devinsky O: Nonepileptic psychogenic seizures: quagmires of pathophysiology, diagnoses, and treatment. Epilepsia 1998; 39:458–462 15. Leung AK: Temper tantrums. Am Fam Physician 1991; 44:559– 563 16. Perry B: quoted in Cody P: Child survivors of Koresh compound getting badly needed psychiatric help. Psychiatric News May 24, 1993, p 4 17. Simon B: Mind and Madness in Ancient Greece. New York, Cornell University Press, 1978, pp 238–268 18. Chodoff P: Hysteria and women. Am J Psychiatry 1982; 139:545– 551 19. Rosenbaum M: The role of depression in couples involved in murder-suicide and homicide. Am J Psychiatry 1990; 147:1036– 1039
149