Page 197 - ILAE_Lectures_2015

Table 3. Predisposing, precipitating and maintaining factors in dissociative seizures.

Predisposing Psychological Social

Perception of childhood Adverse (abusive) experiences in
experience as adverse childhood

Somatising trait Poor family functioning

Dissociative trait Traumatic experiences in
Avoidant coping style adulthood
Personality disorder
Modelling of attacks on others
with epilepsy

Mood disorder

Precipitating Perception of life events as Adverse life events
negative/unexpected

Acute panic attack/syncope

Maintaining Perception of symptoms as Angry/confused/anxious reaction
being outwith personal of carers
control/due to disease
Fear of responsibilities of being
Agoraphobia: avoidant and well/benefits of being ill
safety behaviour

Angry/confused/anxious
reaction to diagnosis

There is no evidence at present for biological factors which are therefore not listed in the table.
However, there may be genetic influences on relevant personality attributes, coping styles and traits.
(Adapted from Binzer et al45)

abnormal personality in DS49,50 may be an effect of adverse experiences at a stage of
development when personality attributes are formed. None of these features, however, is
unique to patients with DS; they are seen in patients with other psychiatric disorders,
including somatoform presentations other than DS47,51. Why some children exposed to
grossly abnormal experiences develop psychiatric disorder later in life but others do not, and
what determines the form the illness takes, is not understood. Further studies of coping styles,
putative dissociative and somatising traits, and how these are related to childhood traumatic
experiences will help tease apart the undoubtedly complex individual/environmental
interactions involved.

One study has presented evidence of adverse events in the year prior to onset of DS which
might be regarded as precipitating factors for the disorder45. Once the disorder is established
a number of maintaining factors may operate. Agoraphobic avoidance is more common in
patients with DS than in epilepsy and serves to heighten anxiety about having seizures which
in turn makes seizures more likely66. Anxiety about the seizures will also be fuelled by
conflicting diagnoses and advice received from the numerous contacts patients have with
doctors, paramedics, accident and emergency staff as well as friends, support groups and the
internet. Finally, for some individuals at least, the benefits of the sick role may provide an