Delivering the diagnosis of psychogenic pseudoseizures: should the neurologist or the psychiatrist be responsible?
CONTROVERSIES IN EPILEPSY AND BEHAVIOR
Delivering the Diagnosis of Psychogenic
Pseudoseizures: Should the Neurologist
or the Psychiatrist Be Responsible?
Dieter Schmidt, M.D.Cynthia L. Harden, M.D.,* and Stephen J. Ferrando, M.D.†,1
*Comprehensive Epilepsy Center and †Psychiatric Consultation-Liaison Service,
New York-Presbyterian Hospital–Weill Medical College of Cornell University,
New York, New York 10021
Received and accepted for publication October 8, 2001
The evaluation and treatment of patients with psychogenic
pseudoseizures requires a joint collaborative
effort of neurologists and psychiatrists. Such is not the
case in many instances, however. Once the diagnosis
of psychogenic pseudoseizures is made, neurologists
and psychiatrists are often unsure how to best proceed.
This phenomenon was clearly exemplified at a
meeting held in New York City in March 2001 called
Psychogenic Pseudoseizures, Dissociative Disorders
and Brain Stimulation in Neuropsychiatry: Meeting
the Diagnostic and Management Challenges, which
was attended by approximately 120 physicians, evenly
divided between neurologists and psychiatrists. Over
the course of this meeting, we sought to uncover the
perceptions of both groups of specialists about psychogenic
pseudoseizures to then find ways of improving
communication between the two medical disciplines
so that patients could be more effectively
treated. Participants were asked their specialty and
then the following three multiple-choice questions:
1. Patients with psychogenic pseudoseizures are accurately
diagnosed using video-EEG monitoring: (a)
most of the time, (b) some of the time, (c) almost never.
1 Department of Psychiatry, Payne Whitney Clinic, New York-
Presbyterian Hospital, 525 East 68th Street, Box 181, New York, NY
10021. Fax: (212) 746-5946. E-mail: email@example.com.
2. In addition to telling patients their diagnosis, the
best treatment for psychogenic pseudoseizures is: (a)
psychotherapy, (b) family therapy, (c) hypnosis, (d)
behavioral therapy, (e) depends on the psychiatric
diagnosis, (f) none, (g) other.
3. The main reason that patients with psychogenic
pseudoseizures often "fall through the cracks" is due
to: (a) doctors "dropping the ball," (b) patients' own
psychopathology interferes with treatment, (c) medical
The results were statistically analyzed as a function
of specialty. Significant differences in answers between
neurologists and psychiatrists were found for
two of the three questions. Neurologists thought that
video-EEG monitoring accurately diagnosed pseudoseizures
most of the time, whereas psychiatrists
thought that this diagnostic method was accurate only
some or none of the time. In response to the third
question, neurologists answered that patients "fall
through the cracks" due to their own psychopathology,
whereas psychiatrists thought that doctors were
"dropping the ball." There was no interspecialty difference
for the second question; most physicians said
the best treatment depends on the psychiatric diagnosis.
Perhaps these differences in perception are not surprising.
However, the results identify potential problems
in managing patients with psychogenic pseudoseizures,
since the two main disciplines involved in
their care appear to have very different views of the
patients and the diagnostic process.
© 2001 Elsevier Science
All rights reserved.
In this article, we present a discussion of yet another
potential controversy that may arise in the management
of patients with psychogenic pseudoseizures.
Who should present the diagnosis to the patient once
it is established by video-EEG monitoring: the neurologist,
the psychiatrist, or both?
THE NEUROLOGIST SHOULD PRESENT
THE DIAGNOSIS OF PSYCHOGENIC
Cynthia L. Harden, M.D.
When the diagnosis of psychogenic pseudoseizures
is presented to the patient for the first time, the ensuing
discussion between patient and physician is critical.
It marks a turning point in the treatment process,
heralding a new course of therapy that involves psychiatric
evaluation and follow-up. During this initial
discussion, the neurologist must introduce the idea
that the episodes under evaluation may have a psychiatric
basis. The discussion should clearly convey
the message that the behaviors in question support a
diagnosis of nonepileptic seizures of presumed psychological
origin, for which a psychiatrist is needed to
identify the underlying psychological mechanisms.
Thus the psychiatric cause must be presented as presumptive,
as it can be established only when the patient
undergoes a psychiatric evaluation.
Often, neither patient nor physician expected that
the diagnostic testing would yield this conclusion. The
discussion of psychiatrically related problems can
therefore lead patients to ask questions that may be
difficult for the neurologist to answer. Nonetheless, I
believe that the treating neurologist should present
the diagnosis to the patient based on the principle of
the therapeutic alliance, the “psychic glue” that binds
neurologists to their patients.
The Therapeutic Alliance
The therapeutic alliance is defined as a contract
between physician and patient whereby they agree to
work together for the patient's therapeutic benefit. The
physician brings to this relationship professional
knowledge and experience, and provides the assurance
that the patient will be helped. The patient expects
that the physician will provide a framework for
relief of his or her symptoms. In the context of this
relationship, patients are also educated on reasonable
expectations of their care.
The answer to the question of who should initially
discuss the diagnosis of psychogenic pseudoseizures
is an empirical, not a theoretical one, and is based on
the following argument. The physician who has developed
a therapeutic alliance with the patient should
be the one to outline a framework for the treatment
plan. Further, the physician initially presenting the
new diagnosis to the patient must be the person with
whom the patient already has developed a trusting
relationship. Since it is the neurologist, and not the
psychiatrist, who evaluates abnormal episodic behaviors
with EEG monitoring, it is therefore the neurologist
who must initially discuss this diagnosis with the
The therapeutic alliance is typically discussed in the
context of the collaborative bond between a psychotherapist
and his or her patient, based on mutual
respect, trust, and commitment to the work of treatment
(1, 2). Yet this concept applies to any doctor–
patient therapeutic relationship, including the diagnostic
process associated with psychogenic pseudoseizures.
Kossoy and Wilner (3) and others have
identified the characteristics of a therapeutic alliance
that contribute to a beneficial treatment outcome.
- A consistent relationship, providing continuous
and predictable contact
- A commitment to mutual trust
- A warm and empathetic medical provider
- Respect for the input of patients, which then leads
to the patients' having a sense of some control
over their treatment
- Effective communication between clinician and
Challenges to Maintaining the Therapeutic
Alliance after the Diagnosis of Psychogenic
Following the diagnosis of psychogenic pseudoseizures,
there may be a shift in the goals of therapy. This
is not without risks! For example, if the neurologist
had not anticipated the diagnosis of psychogenic
pseudoseizures, he or she might essentially abandon
the patient, assuming that someone else will continue
the care of the patient.
Such a negative reaction is probably more a reflection
of the physician’s attitude and internal conflicts
than the patient’s psychiatric condition, in my opinion.
Patients with psychogenic pseudoseizures are
complicated and sometimes difficult to work with.
© 2001 Elsevier Science
All rights reserved.
|Controversies in Epilepsy & Behavior
Their psychiatric problems may include depression,
dissociative disorders such as posttraumatic stress disorder,
and somatization disorder, including conversion
disorder (4–6), often in the setting of a personality
disorder (7). Therefore it is not surprising that a
physician unaccustomed to dealing with such patients
may hesitate to assume responsibility for presenting
the diagnosis and directing the initial management.
Further, neurologists are not specifically trained to
manage their own feelings of anger, frustration, or
even disgust that may result from working with patients
with psychogenic pseudoseizures. Such feelings
could lead to anger, frustration, or apathy being directed
at the patient. Yet, if neurologists are to present
the diagnosis of pseudoseizures, they must consciously
anticipate the occurrence of such feelings
(which are often unconscious), so they do not inadvertently
fracture the doctor–patient relationship and
therapeutic treatment alliance.
Physicians' negative reactions to patients are mediated
by the phenomenon of countertransference. A
physician’s countertransference leads to illogical attitudes
or feelings toward the patient as a result of the
physician’s psychological conflicts (8). For example,
patients with eating disorders are known to engender
therapeutically unhelpful responses from their physicians
including rescue fantasies and feelings of rage
and frustration when the patients consistently exhibit
self-destructive behavior (9). In the specific case of
psychogenic pseudoseizures, physicians may react
with anger and defensiveness toward patients because
they may believe the patients are malingering or seeking
their attention, irrespective of whether the pseudoseizures
result from a conversion or dissociative disorder
and are hence unconscious (10). Further, because
patients with psychogenic pseudoseizures often
have personality disorders (11), the psychiatrically
naı¨ve physician can be manipulated by the patient and
eventually become enraged, without understanding
why this has occurred.
Clearly, neurologists and psychiatrists have to deal
with a variety of difficult issues when interacting with
patients with psychogenic pseudoseizure. Neurologists
must consciously work to maintain the doctor–
patient relationship even when the goals of treatment
have changed. While the psychiatrist may question
whether neurological illness has been adequately excluded
when the diagnosis of psychogenic pseudoseizures
is made (unlike the neurologist), he or she is
better trained to foster a beneficial therapeutic alliance
with the patient.
In conclusion, the neurologist should be the physician
to present the patient with the diagnosis of psychogenic
pseudoseizures. He or she should be consciously
aware of the negative feelings that may arise
from working with such patients and stay focused on
the therapeutic goals, even as they change. A positive
therapeutic alliance should be maintained, as it will
enable the neurologist to guide the patient toward
appropriate psychiatric treatment.
THE PSYCHIATRIST SHOULD BE
Stephen J. Ferrando, M.D.
The evaluation and management of patients with
psychogenic pseudoseizures create a major challenge
for both the treating neurologist and psychiatrist.
There are the obvious implications that psychopathological
factors are involved. Additionally, many patients
with pseudoseizures also have true epileptic
seizures, and no psychiatric diagnosis is pathognomonic
for this condition, from the psychiatric perspective.
The psychiatric literature discusses the genesis of
pseudoseizures as related to unconscious conflicts
such as aggression, dissociation, somatoform disorders,
depression, character pathology, and early childhood
trauma. This heterogeneity may lead to diagnostic
quandaries for the neurologist and may evoke
strong (countertransference) feelings of frustration,
helplessness, and even repulsion, leading to a desire to
withdraw from and abandon the patient.
Dr. Harden has stressed the importance of the therapeutic
alliance between the patient with psychogenic
pseudoseizures and the neurologist. This would dictate
that the neurologist be involved primarily in delivering
the diagnosis of pseudoseizures and making a
referral for a psychological and psychiatric assessment
and treatment. I have no debate with this. However, I
take issue with the timing of psychiatric involvement.
My thesis is that the psychiatrist should become involved
early, before the diagnosis of psychogenic
pseudoseizures is made and conveyed to the patient.
The reasoning for this is severalfold:
First, I maintain that every patient who presents
with seizures should undergo psychiatric screening.
This is justified by data that suggest up to 55% of
patients with epilepsy present with major depressive
disorder (12), which may be a manifestation of the
underlying brain pathology or a reaction to the diagnosis
© 2001 Elsevier Science
All rights reserved.
Second, certain psychopathological features and elements
of the psychiatric history may be predictive of
the diagnosis of pseudoseizures, and early psychiatric
diagnosis may increase diagnostic clarity and the
quality of care. Eisendrath and Valan (13) identified
factors that helped to prospectively identify patients
subsequently diagnosed with psychogenic pseudoseizures.
These included a psychiatric diagnosis of
somatization or personality disorder, the presence of
childhood loss, and the presence of a model for seizure
Third, the involvement of the psychiatrist prior to
the delivery of the diagnosis of pseudoseizures to the
patient serves to normalize the integration of psychiatric
and neurological care. Thus, a team approach is
emphasized in the care of any patient that presents
with seizure-like activity, especially patients found to
have psychiatric comorbidity. This integration of neurological
and psychiatric management of patients at
the outset and over time not only enhances the diagnosis
of psychogenic pseudoseizures, but also allows
for identification and discussion of important countertransference
reactions that inevitably arise and impede
Even though it may not be practical to have every
patient who presents for video-EEG monitoring undergo
psychiatric evaluation, it may be useful to request
a psychiatric consultation for those patients who
are suspected of having psychogenic seizures. In this
manner, the psychiatrist can present him- or herself as
a member of an integrated team evaluating the patient’s
problem. Once epileptic seizure activity has
been ruled out, the neurologist and psychiatrist can
then confer on the best way to deliver the diagnosis to
It is important to note that no single approach suits
all patients because of the their multifaceted expression
of psychopathology. There are three general therapeutic
approaches to patients with somatoform disorders
such as psychogenic pseudoseizures that may
apply to different patients based on their willingness
to accept a psychological explanation for their symptoms
(14). Such approaches may be useful for both the
neurologist and the psychiatrist in their management
of the patient’s condition. For the patient who is willing
to accept the link between her or his physical and
psychological symptoms, a reattribution approach (15)
can be used. In this approach, a three-step process
links psychological stressors (e.g., anxiety) to underlying
physiological mechanisms (e.g., autonomic activation)
to the genesis of physical symptoms (seizurelike
activity). A psychotherapeutic approach can be employed
by the psychiatrist seeing a patient with
pseudoseizures during the initial contacts (16). In this
approach, the psychiatrist attempts to establish a
trusting relationship with the patient that is based on
taking a neutral approach to the verity of the patient’s
seizure symptoms. This, it is hoped, will allow for
subsequent engagement in an insight-oriented psychiatric
treatment. For patients who present as hostile
and rejecting of psychological factors impacting their
"seizure" presentation (generally those patients with
significant character pathology), a more directive medical
model approach may be used (17). Such patients
may reject a priori the involvement of a psychiatrist in
their management and may be followed up individually
by the neurologist on a regular basis. During these
medically oriented visits, the neurologist addresses a
review of the patient’s symptoms and initiates a
workup of symptoms that appear to have a legitimate
physiological basis. Such consistent follow-up may
serve to minimize the use of emergency services and
general health care utilization. Importantly, it also
serves to minimize polypharmacy, as many of these
patients will seek sedative and opiate medications for
their somatic complains. Even those patients who are
initially quite negativistic and rejecting of psychiatric
interventions, may accept this notion over time when
they perceive that their neurologist is taking them
seriously and not abandoning them. However, unfortunately,
psychiatric involvement will need to be mandated
for some patients who persistently refuse.
Whatever the nature of the ongoing management of
these patients, it is of utmost importance for the neurologist
and psychiatrist to be in close communication
so as to coordinate care. Thus, inherent in all of these
approaches is that the neurologist continues to follow-
up with the patient on some regular basis, while
the psychiatric care is initiated and underway. This
ongoing relationship between the neurologist and the
patient mitigates the patient’s concerns about overlooked
neurological symptoms and assuages fears of
abandonment and rejection. Simultaneously, the psychiatrist
attempts to forge an alliance with the patient
and begins to establish a dialogue with them about the
impact of psychological and social factors on their life
and, ultimately, on their neurological presentation.
There are some interventions that are not helpful for
patients with psychogenic pseudoseizures or other
somatoform disorders. For instance, reassurance may
increase the expression of symptoms because the patient
perceives the physician as unconcerned. In addition,
direct confrontation is generally not useful (18,
19). Lazare (19) advises against confronting patients
© 2001 Elsevier Science
All rights reserved.
|Controversies in Epilepsy & Behavior
with the information that the symptom is psychological
in origin. It is more useful to work indirectly in
inquiring about the patient’s life situation and social
supports, being mindful of detecting underlying conflict,
symbolic meanings of symptoms, and distressing
affects against which the symptom serves as a defense.
It is also important that both neurologist and psychiatrist
convey to the patient that they see the symptoms
as “real” and not something that is “all in her or
his head.” This notion is reinforced by the consistent
and regular presence of the neurologist and psychiatrist
working together along with the patient. Further,
the increasingly recognized connection between mind
and body can be reinforced to the patient based on an
overall holistic integrated approach to care.
In conclusion, the early integration of psychiatric
evaluation and management approaches into the care
of the patient with psychogenic pseudoseizures is
likely to be the optimal approach. Psychiatric screening
may assist in identifying patients who are at risk
for psychogenic pseudoseizures, as well as diagnosing
such potential risk factors as somatization disorder,
personality disorder, a history of significant loss, and
the presence of symptom models. However, most importantly,
such early involvement conveys to the patient
the importance of an integrated approach to his
or her symptoms regardless of etiology. This may
make the diagnosis of pseudoseizures more understandable
and acceptable to the patient, and it may be
more likely to encourage psychiatric follow-up subsequent
to the diagnosis.
The authors thank Dr. Stefan P. Stein for his kind review of this
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