May 1, 2009 -- When 46-year-old Jane Smith underwent marriage therapy with her husband, the sessions unlocked parts of Jane's memory that she said she repressed for over a decade -- memories with frightening powers.
"I began remembering witnessing my brother being abused... And I began to remember my own abuse," said Jane, who requested her real name not be used. She said she later realized that she was physically and sexually abused by family members starting at age 4.
Jane confronted her parents, saying she wanted to talk about it, but they did not want to.
"Two weeks later I got a letter from them saying, 'Don't contact us again,'" Jane said.
That was when her seizures began.
Trauma Related Seizures
"When her parents sent her a letter rejecting her, she suddenly had a seizure in our house," said her husband, 47-year-old John Smith (not his real name), said. "We were shocked. I thought she was just dying."
But Jane was not dying. Instead she was suffering what are known as psychogenic nonepileptic seizures (PNES), seizure-like episodes that can be brought on due to trauma as well as depression and anxiety.
Although such seizures are well characterized in medical literature, PNES are difficult to treat because the condition falls in the gray area between psychology and neurology -- a place where many doctors are unwilling to go.
"It's an incredible no man's land," John said.
But new research presented at the American Academy of Neurology this week may be a step towards identifying the link between the mind and the brain when it comes to PNES and towards improving treatment.
"There's more and more evidence that there's a bidirectional link between seizures and depression," said Dr. W. Curt LaFrance, an assistant professor of psychiatry, human behavior, and clinical neuroscience and Brown University and the lead author of the study. "If you treat those comorbidities, can you treat those nonepileptic seizures?"
PNES are not the result of irregular electrical activity in the brain, as is the case with epileptic seizures. Instead, PNES have underlying psychological or emotional causes, including post-traumatic stress, depression, anxiety, and chronic illnesses such as cardiac disease or chronic pain.
In his study, LaFrance examined 38 patients with nonepileptic seizures, half of whom were given a placebo drug and half of whom received antidepressants. He found that those treated for depression showed a 40 percent reduction in seizures. The data also showed that patients with more severe depression were less likely to improve after being treated with drugs.
Antidepressants as Therapy
Although LaFrance said he could not be certain that the overall results would not prove random after further trials, he pointed out that when the data was broken down by seizure type, significant seizure reduction occurred in the group that had underlying psychological problems. LaFrance said his results support proceeding with a larger trial on the use of antidepressant therapy on people with PNES.
Overall, experts in the field accept LaFrance's theory.
"People with psychogenic nonepileptic seizures can often have other psychological or psychogenic symptoms [like depression and trauma], and it is that comorbidity that people have been trying to sort out for a long time," said Dr. Martin Goldstein, director of cognitive neurology at the Mt. Sinai School of Medicine in New York.
"If you treat the comorbid, associated psychological symptoms of patients who have nonepileptic seizures, these patients do over time do better. They do have a reduction in frequency and severity of nonepileptic seizures."
Seizures are in fact a primitive way to express emotions or feelings that cannot be expressed verbally or in other ways, such as crying.
And seizures were a way for Jane Smith to express what had happened in her past. After more therapy, Jane realized that she had also had seizures during episodes of abuse as a child starting at age four, periods she described as "lost time."
"I remembered the first time I was being [sexually] abused and that I had a seizure," Jane said. "And then when I have had memories and flashbacks of it, that has caused seizures."
Jane said her seizures were likely a coping mechanism for her abuse. Eventually, as she took control of her body and her life as a teenager, Jane repressed memories of the abuse and the seizures stopped. Neither the memories nor the seizures surfaced again until she was 31 and received the letter in which her parents cut off contact.
Problems Seeking Treatment
Jane is unique in that she was able to identify the connection between her seizures and past trauma quickly. The Smiths run a resource Web site for people with nonepileptic seizures called The Nonepileptic Seizure Organization, and John said that most of the people who get in touch with him are clueless about what could be causing their condition.
"Nonepileptic seizure patients feel absolutely, totally neglected. They literally are desperate," John Smith said. "They want to believe it's a medical problem and they just don't make the [trauma] connection."
As a result, people with PNES are shunted back and forth between neurologists and psychologists as they attempt to classify and treat their condition.
"From a practical point of view, what else are we going to do?" said Dr. Selim Benbadis, a professor of neurology and director of the Comprehensive Epilepsy Program at the University of South Florida in Tampa.
The subtleties of classifying a severe physical problem, such as a seizure, that is brought on by intense emotional troubles and are difficult to treat with medication make doctors uncomfortable, according to Benbadis. He estimates the prevalence of nonepileptic seizures to be between 2 to 33 in 100,000 people.
Confounding the issue is that over 20 percent of people with epilepsy may also have PNES, which could lead to people with PNES being misdiagnosed with epilepsy and treated with drugs that prove ineffective. In addition, a small subgroup of patients who fake seizures for attention, for money, or other advantageous reasons -- known as malingering -- can bias treatment providers against people who don't know the cause of their seizures.
Mind Or Brain Or Both?
Because she identified the connection between her past trauma and her seizures, Jane could explore treatment options faster than others in her position. Most people with PNES average seven years before receiving proper diagnosis and treatment.
With therapy and antidepressant medication, Jane has been able to reduce the frequency and severity of her seizures to the point where she remains conscious, talking herself through them.
Coping With Trauma-Related Seizures
"I'm having some pretty severe memories that almost cause me to go into [a seizure]," said Jane. Instead of the paroxysms of a full seizure, her body now only clenches in feelings of helplessness.
"But then I remember I'm there for myself. The memory is of the child but the adult is there to pull me back into the now."