Starting Therapy for Dissociative Seizures
Barriers and Misconceptions
Last week, I introduced Nathan's story and outlined the mainstream understanding of functional neurological disorder (FND). This week, I'm focusing on what typically happens when someone with non-epileptic (dissociative) seizures begins therapy, and some of the common problems people can encounter.
Where do you begin?
Many people arrive for their first session worried that a medical cause has been missed. That’s entirely understandable. Most have already seen multiple professionals, often receiving conflicting explanations. Non-epileptic attacks can look similar to epilepsy, and if there's no clear stressful event leading up to the onset, it may not make immediate sense. It's no surprise that confusion persists.
Still, expectations must be clear and realistic from the outset. This way, the person stands the best chance of a good outcome, which is usually their primary reason for seeking help through a therapist.
Readiness for therapy
Most of us can name something we know would likely help to improve our health and wellbeing: exercising more, eating better, quitting smoking, or finally leaving that job you dread getting out of bed for. However, many people hold onto that awareness without ever taking action. This is commonly referred to as the precontemplation stage of change.1
Next is the contemplation stage. This is when we start weighing things up, but keep swinging between intention and avoidance. This is usually the most common point where people start thinking about therapy.
I do this sometimes as well. While I will happily sit in front of a psychotherapist any day of the week, try to get me to book a routine health check with my GP, and I'll spend weeks Googling symptoms. But if something doesn't go away on its own or starts interfering with daily life, then I prepare to act. Very soon, I’m at the action stage, on speed dial to a doctor.
Psychotherapy is similar. People often arrive after long periods of struggling. Something then tips them into action: relationship breakdown, pressure at work, or simply running out of options. Yet, motivation can then fade once therapy begins, especially if someone has been waiting a long time or the initial incentive for seeking help has eased. It can lead to cancellations, drop-outs, or sketchy engagement.
When this happens early in therapy, it’s usually a strong predictor of a poor outcome. There can be many reasons for this, but it’s essential to ensure that someone can dedicate time to both in-session and out-of-session work each week.
Acceptability of diagnosis
When I worked in the NHS, one of the biggest obstacles to progress was when someone didn't accept that their condition had a psychological component. This was especially common with dissociative seizures.
Scepticism itself isn't necessarily a big problem. It's healthy. Misdiagnosis happens, and no clinician gets it right every time. People also want to understand what’s going on, and that can take time for someone to grasp. But where someone remains quite fixed on finding a medical cause or explanation, despite multiple repeated investigations, it’s often an indicator that the symptoms are less likely to improve.
I appreciate that may sound harsh or as if I’m stripping away hope. It’s essential that people retain hope, and it's not for anyone, including a psychologist, to impose a diagnosis or way of thinking on someone. People’s decisions and choices need to be respected.
Sometimes, shame can also play a role, as can worry about how others will interpret the condition, particularly given the historical perspective on functional problems. Still, there is good evidence to suggest that one of the strongest predictors of non-recovery in FND generally is when the pursuit of medical explanations continues to dominate.2
That doesn't mean therapy is off the table entirely for someone unsure whether they buy the explanation, or perhaps not quite ready to start treatment. It simply means that to stand the best chance of improving the seizures, there has to be some willingness to explore the condition from a psychological perspective and to consent to committing to the process.
Prior experience with therapy
A lot of the people I see for treatment have usually seen a therapist before. Often, adopting widely used staple interventions.
Stress management techniques are commonly discussed across varied therapy models, but there’s often a tendency to take a “business as usual” approach. While they can be helpful, especially in the early stages of treatment, they're frequently not explained or fully considered in a way that fits the specific context of FND.
Seizures are also often described by well-meaning clinicians as being similar to a “type of panic attack”. While patients can experience high nervous system arousal, they often describe the sensation as being trapped or shut down in their bodies. Some say that the warning phase feels as if their body is “literally dying”. Many also describe an intense fear of embarrassment, particularly around the potential of seizures happening in social contexts. Overall, the experience is usually qualitatively different from panic disorder.
The analogy of panic, adapted to explain the brain's threat system, can make complete sense to clinicians, especially those familiar with Clark's (1986) cognitive model. My experience is that it often lands poorly with clients. More often than not, it can feel minimising and has left people feeling angry, upset, and less engaged, particularly those who have previously experienced panic disorder.
I’ve found it’s more collaborative to be guided by the language a person uses, or to rely on broader terms such as “threatening” or “disturbing” feelings when explaining what is happening. This tends to avoid alienating the person at the outset.
Misconceptions around trauma
Dissociative seizures are often treated using therapies associated with trauma reprocessing. Which makes sense when we consider that trauma-focused therapy aims to desensitise strong nervous system activation by integrating memory, thoughts, and emotions, while also supporting someone to stay in their “window of tolerance”.3
While trauma is frequently associated with FND, it isn’t universal. Yet, it’s common to hear patients saying that they have been previously told that they need to “treat the trauma causing the seizures”. Many arrive with the expectation that tracing the seizure activity to a specific event or memory will stop them. Very occasionally this can happen, but my experience is that it’s the exception, not the rule.
My typical advice?
Keep your hopes high and expectations low.
Even when clear traumatic events are present, therapy focused solely on reprocessing memory rarely results in seizures completely abating. Trauma work can help reduce associated triggers and remains important where relevant; however, it’s essential to keep things realistic. Otherwise, clients can feel discouraged when symptoms persist. I learned this the hard way.
The most common trajectory I see is a change in the seizures early in therapy; it can vary quite a bit from person to person, but initially often involves an increase in frequency but with lower severity. Longer-term improvement then tends to follow as therapy progresses.
Differences with dissociative seizures
Non-epileptic attacks often involve similar intense physical sensations that would be seen with any other type of treatment, but often with a delayed or reduced explicit internal awareness—sometimes referred to as alexithymia, or “emotional blindness”.
It’s not yet clear whether the process of dissociation mirrors that seen with trauma-related conditions such as PTSD or is more related to reduced awareness of emotion.4 At present, there is no firm consensus.
So why use the term dissociative seizures?
Although I write as a psychologist rather than a neurologist, research consistently points to links between emotional processes and functional neurological symptoms.
The prevailing view is that the person experiences an emotional trigger, the nervous system ramps up into hyperarousal, and the sensations are perceived as threatening in themselves, triggering an almost instant shift into hypoarousal. In effect, the system shuts down rather than staying with the surge of activation. Many people describe this sudden collapse of awareness as a "blackout" or “drop-seizure”. Almost like flicking a switch. Hence, managing dissociation while gradually exposing someone to strong emotion to help them increase their tolerance is often the tricky bit.
To explain this to clients, I often combine the window of tolerance with the reflex switch analogy, a concept frequently used by neurologists. This is not a strict scientific model, but it provides a practical way of framing the experience that my clients tend to find meaningful.
Losses not gains
Traditionally, there has been a professional tendency to think about functional problems in the context of “secondary gain”, whereby symptoms are viewed as a subconscious way of gaining attention and care.
While it is true that some people can seek care in unhelpful ways, this usually reflects early relational modelling. In my view, this relates more to personality-based problems and is not a general hallmark of functional neurological problems. Thankfully, contemporary thinking has moved away from a gains-based narrative. Certainly in the NHS services I have worked with, this would be considered outdated and unhelpful.
Most people have suffered significant loss. Many become afraid to leave the house. If they drive, their licence is often suspended, limiting their independence. Employment can be affected, beloved pets may have to be given up, and relationships frequently suffer. Friends and family often struggle to understand the condition, leaving the person feeling even more isolated.
Avoid trigger chasing
A common setback in the early stages of therapy is focusing too heavily on identifying situational triggers. Occasionally, there are clear triggers; a lot of my clients have said they notice increased symptoms around their menstrual cycle. But more often than not, triggers tend to be inconsistent. Sometimes they happen in public, other times when home alone. Seizures can occur due to fatigue, and sometimes when the person is feeling well. This is often one of the most frustrating aspects of the condition.
Treatment is typically more productive when we explore the finer details of the most recent seizure experience. Sometimes this will have happened live in the therapy room. Once we begin paying more attention to the emotional process, there is usually a brief warning stage before the onset of a seizure. Clients often describe this as feeling like a type of "aura".
Fatigue is pervasive, along with problems in memory and awareness following a seizure. Sometimes speech is temporarily affected. While frustrating and confusing, exploring the experiences that occur before and after seizures usually reveals more subtle, yet specific triggers and maintaining factors.
In essence, the detail lies in the internal experience rather than the external context.
Dissociative seizures can be frightening, and it often takes time to build trust in the therapeutic process. Early sessions typically focus on building regulation skills, enhancing emotional awareness and expression. We also examine social and relational factors, how people assume responsibility, how they ask for support or help, and their beliefs about illness. This can feel strange and confusing at first, but the reasons generally become clearer as things progress.
Next week, I will cover key points on collaborative formulation and creating a treatment roadmap, along with basic techniques for self-managing seizures, including cautions around Mindfulness.
Prochaska, J. O., & DiClemente, C. C. (1982). Transtheoretical therapy: Toward a more integrative model of change. Psychotherapy: theory, research & practice, 19(3), 276.
Carson, A., Lehn, A., Ludwig, L., & Stone, J. (2022). Predictors of outcome in functional neurological disorder: A systematic review. Journal of Neurology, Neurosurgery & Psychiatry, 93(9), 947–960.
Siegel, D. J. (1999). The Developing Mind: How Relationships and the Brain Interact to Shape Who We Are. Guilford Press.
Trobliger, R., Myers, L., Simpson, T., & Krámská, L. (2024). A comparison of patients with epileptic seizures (ES) versus those with psychogenic non-epileptic seizures (PNES) on a measure of alexithymia and mood. Seizure: European Journal of Epilepsy, 120, 33–40.