Psychosomatics 39:144-153, April 1998
© 1998 The Academy of Psychosomatic Medine
Pseudoseizures, Families, and Unspeakable Dilemmas
James L. Griffith, M.D.,
Alexis Polles, M.D., and
Melissa E. Griffith, M.S.N.
Received May 24, 1996; revised October 23, 1996; accepted June 6, 1997. From the Department of Psychiatry and Behavioral Sciences, The George Washington University Medical Center, Washington, DC; and the Mississippi State Hospital, Whitfield, Mississippi. Address reprint requests to Dr. Griffith, Department of Psychiatry and Behavioral Sciences AN8411, The George Washington University Medical Center, 2150 Pennsylvania Ave., N.W., Washington, DC 20037.
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ABSTRACT
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Fourteen videotaped family interviews of patients with diagnosed pseudoseizures were studied to determine the relationship of the symptoms to unspeakable dilemmas as forced choices imposed by family or social circumstances under conditions that also require the ensuing distress to be hidden. An unspeakable dilemma was evident in 13 of 14 interviews, with the patient the most silent family member in 13 interviews. In six cases, there was revealed a realistic threat of physical or sexual assault to a person involved in the problem, although not always the patient. These findings point to an important role for family therapy skills in the evaluation and treatment of pseudoseizures.
Key Words: Pseudoseizures • Family • Somatoform Disorders
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INTRODUCTION
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Medical anthropologists, drawing from cross-cultural studies of somatization, have proposed that somatoform symptoms can be understood as a bodily idiom of distress—a "language of the body"—that has come to dominate patient communications when verbal expressions have become suppressed or prohibited. This perspective suggests that somatoform symptoms represent disorders in which the important determining events are sociophysiological interactions between social, family, and cultural contexts and the patient's body. Such interactions are mediated by the patient's attributions of meaning to these interactions, a process that is structured by the categories and rules that the culture provides for interpreting personal experience.1–5
In treating somatoform disorders, we previously used a sociocultural perspective to describe the typical social context of a somatoform symptom as that of an unspeakable dilemma.6 In an unspeakable dilemma, a patient is distressed by family, social, religious, or political circumstances that have imposed forced choices in the patient's existence and consequent suffering must remain hidden from important persons involved in the situation. An unspeakable dilemma is thus experienced by a patient as entrapping, isolating, and demanding that suffering be camouflaged.
In this study, we examined 14 consecutive videotaped family interviews with patients referred for psychiatric evaluation of pseudoseizures. These cases largely fit the description of "psychogenic seizures," with few of the cases having neurological seizures, other neurological disorders, or other psychiatric disorders.7 Thus, they represented a patient sample well suited for the study of family and cultural factors in the generation of symptoms. We sought to determine what relationships may exist between unspeakable dilemmas and pseudoseizures and to delineate the salient features of these dilemmas.
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METHODS
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We conducted these interviews from 1990 to 1993. Fourteen patients referred for evaluation of pseudoseizures were videotaped together with family members during a clinical family interview that was a component of a requested psychiatric consultation. Each patient had been referred by community or medical center neurologists following a diagnosis of pseudoseizures. This diagnosis had been made for eight patients, according to clinical criteria, by using as criteria the observed form of paroxysmal behaviors, findings on neurological examination, and history of nonresponse to anticonvulsants. In six cases in which the diagnosis had been less certain, the clinical findings were supplemented by split-screen electroencephalogram monitoring. For two patients, neurological evaluation had not definitively ruled out co-occurrence of some neurological seizures in addition to pseudoseizures, and these patients continued to take carbamazepine as an anticonvulsant. The other 12 patients had been diagnosed as having solely pseudoseizures, and previously prescribed anticonvulsants had been discontinued. Psychiatric diagnoses listed in Table 1A and Table 1B were those provided by the psychiatric consultant based on clinical interviews with the patient.
A family interview was conducted that included each patient together with one or more family members. The choice as to who should be invited was made collaboratively with the patient, or the patient's mother in the pediatric cases, by discussing with them:6 "Who is involved in helping you with this problem? Who is concerned and worried about you? If we work on finding a solution for this problem, who would you want to be involved with you?"
The interviews were conducted in a manner intended to provide an atmosphere of respect, openness, and safety, so that family stories that otherwise might be difficult to speak about could be safely told.6 Thus, choices as to the order in which family members were addressed, how the interview was paced, and how spontaneous or structured the conversations were were guided by the interviewer's sense of what would sustain or shut down the openness required for the telling of important family stories. All family members gave permission beforehand for the videotaping of the interview, including an option to later rescind permission if they were to so choose, although none did so. If children were involved in the interview, they were permitted first to examine, maneuver, and use the remotely controlled cameras to videotape other family members to become comfortable with with clinicians and the interview format. The following general format was followed for the interviews.
A "joining phase" was conducted for 15 to 30 minutes, during which the interviewing clinician established rapport with each family member by inquiring how they had talked together as a family about the interview beforehand, what were any concerns about holding the meeting, what each family member regarded as his or her personal strengths and positive qualities, what they regarded as their strengths and positive qualities as a family, and what were aspects of their family not related to the patient's illness that the clinicians should first understand before proceeding. The purpose of the interview was explained as a wish expressed by the treatment team that the family members' observations and multiple points of view be included in the deliberations about how best to understand and to treat the patient's symptoms. Permission was given (as an "I pass" rule) not to answer any questions that might be experienced as inappropriate or intrusive.
Each family member was then invited to tell his or her account of the illness. The discussion began with whichever family member chose first to speak, with the interviewer facilitating subsequent participation by each of the others according to a sense of what order best fit that family's sense of social etiquette. If the patient had not spontaneously participated in the discussion by the conclusion of comments, he or she was specifically invited to comment agreement or disagreement with other family members' observations. Family members' responses to the neurologist's report of negative findings from the epilepsy evaluation were elicited and discussed. In response to queries about how such "spells" could occur if they were not seizures, the interviewer took a position of "therapeutic noncertainty" (reference 6, p 154), explaining that clinicians sometimes found seizure-like spells to occur in relation to stressful life circumstances even though the brain appeared to be normal and the processes through which such events occurred were not well understood. For example, the following interchange occurred between the interviewer and the patient's 14-year-old daughter in Case 9.
Case 9.
Daughter: I don't understand—if she was having seizures, and it was nerves, or stress, or something like that causing it—why would she also have pains in her stomach? If it was just stress, why would it do that? I don't understand that.
Clinician: Well, there may be a lot of mystery in that. There is a lot we don't know about how the mind and the body are connected together. Have you ever gotten upset by something, and it would affect your body?
Daughter: Well...When I get upset...It is like my stomach doesn't want to accept the food [rubbing abdomen]...It doesn't sit right, because I was upset...Or when I get mad, I don't want to eat anything.
Clinician: Your appetite really would go away?
Daughter: Yeah.
Clinician: That is probably as good an example as any I could pull out as an explanation, although we still don't exactly know how it is the two are connected.
A facilitated family discussion was then conducted in which each family member would be asked his or her opinion as to 1) what might have precipitated the seizures (either physical or emotional factors), 2) what might be maintaining their occurrence, and 3) what changes might need to ensue in order for the seizures to stop. It was emphasized that "opinions," not "facts," were requested to minimize the likelihood that comments would be experienced as disqualifying or blaming by the patient.
For pediatric cases, the interview was further segmented, with one section involving the full family interacting, another section with only the symptomatic child present, and another section with only the parents present.
Videotapes of each interview were reviewed by two clinicians to determine whether an unspeakable dilemma could be identified in association with onset of the pseudoseizures. An unspeakable dilemma was defined as a type of double-binding social situation8 in which: 1) a patient would reasonably expect an unacceptable degree of distress if he or she were to remain in the situation, 2) all obvious options for escaping the bind would pose the risk of even greater distress, and 3) revealing the extent of distress to others in the situation would be unacceptable, and 4) the patient opts to remain in the situation but suppresses external appearances of distress.6 An unspeakable dilemma was inferred when an account of the patient's experience of his or her social context at time of onset of pseudoseizures, drawn from the patient's and family members' comments and behaviors, included each of the listed elements.
Each unspeakable dilemma was further assessed to determine whether the silencing of expression was due to a realistic threat of physical harm or to psychological conflict (e.g., shame or guilt). For the former, potential victims of the threatened violence were identified.
Since a suppression of expression was hypothesized to be central to the process of symptom generation, individual family members, including the patient, were ranked according to their verbal expressivity during each interview.
Finally, it was determined for each unspeakable dilemma whether there was conscious awareness of its existence before the interview by either the patient or other family members.
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RESULTS
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The subjects consisted of 7 patients age 9–16 years (mean: 11.8) referred from the Pediatric Service, and 7 patients age 25–40 years (mean: 34.3) referred from the Adult Neurology Service of the University of Mississippi Medical Center. Each of the two groups consisted of six females and one male. Socioeconomically, six patients were lower class, two lower middle class, and six middle class, according to family income. Racially, nine were white, and five were African American.
Psychiatric diagnoses are listed in Table 1A and Table 1B. None of the patients had neurological impairments. The learning disabilities noted in Case 4 had not been considered to be of sufficient degree as to require special education classes.
Except for 2 pediatric patients whose seizures had been present for 3 and 2 years, respectively, the duration of symptoms since onset in the pediatric group had been only 3 months or less. In the adult group, however, the symptoms had been of brief duration (3 months) for only 1 patient, with symptom durations in the remaining cases for 3 to 20 years. In both groups, onset of seizures had occurred predominately during adolescence.
In the family interviews, all parents who were living in each child's home were present for the interview (three children with both parents, three with a single parent, and one with a foster parent). Five of the child interviews also included at least one sibling. All the adult patients were married, with all the spouses present for the interviews. In all four families of adult patients with children, the children were also present in the interview.
An unspeakable dilemma could be identified in 13 of 14 cases by both raters. Descriptions by the 2 raters were combined into summary narrative accounts in Table 1A and Table 1B. In the sole case (Case 6) in which an unspeakable dilemma was not delineated, the grandmother, in whose home the patient lived, seemed lacking in knowledge of many of the child's daily life experiences, and the biological mother, who had only recently reestablished contact with the child by visiting her in the hospital, did not appear for the interview. The videotaped interview did not sufficiently clarify what the child may have experienced or the extent to which she was expressing distress.
In 13 of 14 interviews (Case 8 excepted), the patient was the least verbally expressive person in the room. For example, it was later discovered that an 8-year-old girl with pseudoseizures (Case 2) was being physically abused and psychologically terrorized by an older brother. In the initial interview, other family members, including the brother, spoke in a friendly and relaxed manner. She, however, repeatedly covered her face with a pillow and refused to answer questions, such as the following.
Interviewer: "What sort of person is Jill? If I were to tell somebody who you had never met Jill who she is, what would you want me to tell them?"
Jill: [covering face with pillow] "There is no such person as me!"
In other cases, the patient often failed to answer questions or gave nondisclosing answers or nonverbal shrugs, whereas other family members elaborated detailed descriptions of the difficult circumstances they believed to patient to be struggling with.
Although each patient's dilemma was undoubtedly conditioned by social, religious, and political cultures in which it was embedded, the primary participants in the dilemma were all family members in 10 cases; in 3 cases, persons outside the family (a schoolteacher, a lover in an extramarital affair, the patients' teenage friends) were centrally involved. Religious beliefs and practices were integral aspects of the patient's dilemma in Case 9, in which the mother with pseudoseizures felt instructed by her God through dreams to take action against her child's abuser, yet she had not done so; and in case 10, in which the patient felt not only isolated from other persons in her struggle but also banished from her God's presence because of hatred she harbored against her mother.
In seven cases, the family was having difficulty coping with the stress from a psychiatrically ill family member other than the patient. Two patients feared physical assault and emotional abuse by a psychotic family member, with the patient the victim in Case 2 and the patient's mother the potential victim in Case 10. In Case 12, the wife had difficulty coping with stress entailed by living with her husband, who had recurrent exacerbations of schizophrenia. Two children with pseudoseizures were under threat of physical assault, one by an alcoholic father in Case 3, the other by a father with explosions of uncontrolled rage in Case 5. In Case 8, arguments with her husband appeared to be a factor in the generation of the patient's pseudoseizures; the husband was frequently hospitalized psychiatrically for chronic pain, substance abuse, and a personality disorder. In Case 9, the patient's daughters had been sexually abused by an uncle with chronic pedophilia. These cases suggest the importance of psychiatric comorbidity in families of patients with pseudoseizures.
In 6 of 14 cases, there was a realistic threat of physical or sexual assault to a person involved in the problem (2 of 7 adult cases, 4 of 7 child cases). An 11-year-old boy (Case 5), for example, suddenly began jerking, with an apparent loss of consciousness, during church services and had nearly daily occurrences of similar spells during the following weeks. In the family interview, he responded only with shrugs and silences. However, other family members—mother, aunt, and grandmother—began sharing speculations that "something had happened" between him and his stepfather, who in the past had beaten the mother. Near the end of the interview, the child confided his fears that his stepfather might kill him. The pseudoseizures subsequently stopped when the mother left the marriage.
As a contrasting case in which there was no threat of physical harm, the jerking spells of a 9-year-old girl (Case 4) were related to her struggle to perform as well in the classroom as had her older sister, despite having significant learning disabilities. The interview disclosed how she felt too ashamed to tolerate either receiving lower grades or requesting extra help. In this bind, she was too embarrassed to let her parents or teachers know her distress. Her pseudoseizures later stopped after open discussion of her dilemma and a restructuring of her school program.
In some cases, more than one member was at risk for harm (usually a mother and her child). The mother with pseudoseizures in Case 9 was not herself at risk for harm, but feared for the safety of her daughters. Both mother and son were are risk in Case 5; the patient's mother was at risk in Case 10.
In 9 of the 13 cases in which an unspeakable dilemma was evident, either the patient or other family members indicated a prior awareness that the dilemma existed. Indeed, there was seldom evidence that family members gained a new awareness as to what was the patient's dilemma in any of the interviews. Although usually aware of the patient's dilemma, family members typically had minimized the intensity of the patient's distress and sometimes had not associated the dilemma with onset of symptoms. A teenager (Case 1) moved with her widowed mother to live near her older sisters in a northern city far from their rural southern home after their house burned down. There she found new educational and career possibilities, excelled in school, and lived a more exciting urban lifestyle. Her mother, however, could not cope with either the new culture or the cold weather and wanted to return home. Her daughter made no protest during their return to the South, fearing that her elderly mother indeed might not have survived in the North. Back in her rural school, however, she began having blackout spells and jerking of her body, which were eventually diagnosed as pseudoseizures. When she told during the interview about her isolation, unhappiness, and shame that she was so unhappy, her mother and sisters each indicated their awareness of her bind. Each, however, stated that she had been unaware that the patient was experiencing it so severely.
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DISCUSSION
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Pseudoseizures occur in from 5% to 30% of patients among different epileptic populations,7 sometimes alone and sometimes comorbid with neurological seizures.7,9 Since the term "pseudoseizure" is negatively defined as paroxysmal behavior mimicking epilepsy, it has been applied to a collection of medical and psychiatric disorders that are often unrelated, including panic attacks, factitious disorders, and cardiac syncope. Pseudoseizures most commonly appear as somatoform symptoms, however.
Few studies have examined systematically the family and sociocultural contexts in which pseudoseizures arise. Most studies have examined either the role of intrapsychic conflict in the genesis of pseudoseizures or relationships between their occurrences and categorical or dimensional variables such as other psychiatric disorders,10 history of sexual abuse,11–14 Minnesota Multiphasic Personality Inventory-derived personality style,15 psychometric indicators of family dysfunction,16 or history of past brain injury.11 Bowman11 proposed four psychodynamic pathways through which pseudoseizures could be generated 1) dissociation of childhood abuse, expressed by alter egos as pseudoseizures; 2) symbolic expression of distress about adult rape; 3) an accumulation of life stresses that have overwhelmed defense mechanisms; and 4) panic attacks mistaken for pseudoseizures, with some patient histories fitting more than 1 pattern. While such studies provide an organized framework for studying the etiology of pseudoseizures, they are less useful for illuminating power relations within the patient's family and social world that provide a current social context for occurrences of pseudoseizures.
The cases here show how pseudoseizures can mark a patient's suppression of expression of distress. Case descriptions drawn from other studies have suggested similar findings. For example, LaBarbera and Dozier14 reported two cases in which an evaluation for pseudoseizures led to the discovery of current, ongoing sexual abuse, and two others in which the women, although not described as abused, expressed fear over aggressive sexual advances by men and were ashamed by their participation in the encounters. In each of these cases, the patients had been unable to disclose openly what had happened and its meanings until provided the safety of a psychotherapeutic relationship. Similarly, all the women among cases reported by Goodwin et al.13 had suffered sexual abuse as children. In 1 case, abuse by her father had occurred 2 weeks prior to onset of pseudoseizures; in another case, pseudoseizures were triggered by sexual intercourse that was not described as abusive. Standage,17 Ljungberg,18 and Wilkus et al.19 also reported frequent associations of family conflict and sexual abuse with onset of pseudoseizures. While the investigators in these studies noted the patients' ambivalence over sexual behavior, they did not inquire how the abuse had been specifically experienced by the patients, which is the focus of our inquiry.
Among our cases, as with those of Bowman,11 threats of harm involved not only sexual assault but also threats of physical violence. Moreover, it was another family member in 2 cases who was at serious risk for harm (patient's mother in Case 10, patient's daughters in Case 9), rather than the patient with pseudoseizures.
Previous studies of pseudoseizures have focused most on the impact of past trauma, and Cases 7, 8, 10, and 13 among our cases had suffered past familial sexual abuse. However, our findings more importantly point to the high prevalence of current, ongoing sexual or physical abuse that existed covertly until revealed during the pseudoseizure evaluation. Some past studies have made similar observations. Guberman20 and Bowman11 each divided their pseudoseizure patients into two distinct categories, one with longstanding pseudoseizures and severe psychopathology, and a second with little psychopathology for whom onset of pseudoseizures was related to recent emotional trauma. Among Bowman's patients, the onset of pseudoseizures was associated with at least 1 recent life stress in 85% of the cases. These investigators were not clear, however, whether recent traumas were solitary, isolated events or whether patients were enduring chronic abuse at the time of study.
The implications of this study are limited by its methodology: it was an uncontrolled study with nonblinded raters. In addition, pseudoseizures can occur with or without intermixed neurological seizures. Since the present study was conducted predominantly with the former, the findings may be most applicable to pseudoseizure patients who do not also have intermixed neurological seizures.7 As a mixed sample including both adults and children and both epileptic and nonepileptic pseudoseizure patients, these findings also may not discriminate between phenomena characteristic of all pseudoseizure patients and those limited to specific subgroups. The absence of neuropsychological and descriptive psychiatric data that might have been elicited through structured patient interviews limits the degree to which findings from this study can be integrated with other studies for which such investigations have been the primary focus of study.10 Finally, this patient sample is drawn from the southern United States, a region with unique social, political, and religious aspects in its culture that no doubt bear an influence on the form of such culture-sensitive symptoms as pseudoseizures.
This study suggests that an unspeakable dilemma is a commonly occurring psychosocial context within which pseudoseizures arise. However, it is not clear whether unspeakable dilemmas occur more commonly in the lives of pseudoseizure patients than among other epileptic patients, or whether pseudoseizure patients may have a greater vulnerability than others to the particular form of distress that an unspeakable dilemma brings.
These findings suggest several principles that can assist the diagnosis and treatment of patients with pseudoseizures. First, they suggest that an unspeakable dilemma, as a bind that can be neither acknowledged publicly nor escaped, can be identified in association with many cases of pseudoseizures. Discovery of such binding dilemmas requires the careful composition of a psychotherapeutic interview that enables stories of blame, shame, and threatened harm to be safely spoken. Such stories cannot be expected to emerge from interviews that are hurried, fail to convey respect for the patient's story of illness, or focus too intently on eliciting the details of symptom patterns.
Second, the unspeakable dilemmas of this study frequently concerned the patient and/or other family members living in current fear of physical or sexual assault. Whereas a relationship between past trauma and pseudoseizures has been emphasized in the literature, current threats of assault were notable among these cases. Among many of the cases, the occurrence of pseudoseizures appeared to represent family comorbidity related to inadequate psychiatric care for another psychiatrically ill family member.
Third, the patient's response to the psychosocial stress in nearly all our cases was characterized by suppressed expressions of distress, such that physical danger or severe emotional distress had been effectively camouflaged. This is worrisome because, absent awareness of the danger, other aspects of the patient's situation might have suggested secondary gain for the symptoms, as in "attention-seeking," leading to interventions that could have neglected an authentic source of the patient's distress.
Fourth, this suppression of distress was less often associated with a lack of awareness of the dilemma by family members and more often with their underestimation of how severely the patient was distressed by it. Among our cases, the nature of the unspeakable dilemma could be identified in nearly all cases when family members were included in the interview. In those cases not involving threats of danger, the family interviews were still useful by clearly delineating the dimensions of the patient's dilemma. This facilitated the subsequent engagement of the patient or family in a focused psychotherapy or family therapy for Cases 1, 4, 7, 8, 10, 12, 13, and 14, in which personal and relationship conflicts contributing to the dilemmas could then be addressed. Family therapy skills can thus play a specific role in consultation-liaison psychiatry.
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ABSTRACT
INTRODUCTION
