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acceptable alternative to the responsibilities of healthy life52, and carers, unwittingly or
otherwise, may play an important role in perpetuating disability. The stigma attached to
mental illness undoubtedly has an important role in shaping the medical presentation of
somatoform disorders and contributes to the reluctance many patients have in accepting
psychiatric treatment.

Management

An approach to discussing the diagnosis with patients
The way in which the diagnosis of DS is presented to the patient is possibly the single most
important factor determining outcome (Table 4). A clear explanation of the reasons for
concluding the patient does not have epilepsy should cover both clinical features and
investigation findings. It is important that patients are not left with the impression that
investigations alone hold the key to diagnosis; a quest for further tests might otherwise ensue.
Once the patient understands that epilepsy and other ‘medical’ causes have been excluded
they will often be extremely sensitive about being accused of putting on their attacks. The
clinician should put aside any prejudices they may have in this respect, suspend disbelief if
necessary, and reassure the patient that their attacks are real, disabling and involuntary.

Next, an intelligible explanation of what the patient does have is required. The concept of
dissociation can be explained as involuntary episodes of ‘switching off’ or going into a
‘trance’. Examples of selective attention (mental absorption – not hearing one’s name called
when reading) and divided attention (travelling home from work and remembering nothing
of the journey) can be used to illustrate the involuntary, unconscious nature of dissociative
phenomena and how we can all be unaware, or have no memory of, sensory experience or
complex activities despite perfectly normal neurological function.

Table 4. Presenting the diagnosis of dissociative seizures.
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The discussion should cover:

1. Explanation of the diagnosis
• Reasons for concluding they don’t have epilepsy
• What they do have (describe dissociation)

2. Reassurance
• They are not suspected of ‘putting on’ the attacks
• The disorder is very common

3. Causes of the disorder
• Triggering ‘stresses’ may not be immediately apparent
• Relevance of aetiological factors in their case
• Maintaining factors

4. Treatment
• DS may improve simply following correct diagnosis
• Caution that AED withdrawal should be gradual
• Describe psychological treatment

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