Nonepileptic seizures are classified as a conversion disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Conversion disorder is included in the broader category of somatoform disorders. Essentially, the patient presents with symptoms suggestive of a neurologic or other general medical condition, preceded by conflicts or other stressors. The symptom is not feigned, and appropriate investigations fail to reveal evidence of a causative organic condition. The symptoms cause significant distress and interfere with the patient's general functioning.
In some patients, NESs are part of a symptom complex subsumed under the rubric somatization disorder. In this condition, the patient has a pattern of recurring multiple and significant somatic complaints beginning under the age of 30 and extending for a prolonged period, sometimes many years.
Patients with NESs also suffer from associated psychiatric disorders. More than one condition is often present. Anxiety disorders are commonly encountered, often unrecognized by patient or physician. In particular, many patients fulfill DSM-IV diagnostic criteria for panic disorder, with or without agoraphobia. The symptom complex of NESs may be due solely to panic attacks, or the attacks may coexist with NESs. Careful inquiry is essential in order to establish the diagnosis.
Depression is often seen in patients with NESs. In some, it has been proposed that the pain of depression has been unrecognized or unaddressed by family or others. As a result, the development of NESs may constitute a mechanism of bringing the patient's problems to the attention of the medical profession.
Psychotic disorders such as schizophrenia are considered uncommon accompaniments of NESs, although they may be seen.
Other conditions that are even less common include malingering and factitious disorder.
A detailed psychiatric interview will usually bring out any associated psychiatric disorders. In some cases, however, application of the Structured Clinical Interview for DSM-IV (SCID) may be required to determine the number and extent of the patient's problems.
Reviewed and revised February 2004 by Orrin Devinsky, MD, New York University
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