N onepileptic seizures and childhood sexual and physical abuse Kenneth Alper, MD; Orrin Devinsky, MD; Kenneth Perrine, PhD; Blanca Vazquez, MD; and Daniel Luciano, MD Article abstract-Nonepileptic seizures (NES) must be distinguished from epilepsy to avoid the adverse effects of unnecessary antiepileptic drugs and to initiate appropriate psychiatric treatment . A higher frequency of prior sexual abuse has been suspected in NES, although no prospective controlled study has compared patients with NES and epilepsy. A series of patients with conversion disorder presenting as epilepsy and 140 patients with complex partial epilepsy (CPE) without evidence of conversion were selected from a series of consecutive admissions to a comprehen- sive epilepsy center. The groups did not differ with respect to age, years of education, race , or marital status , but the percentage of women was greater in the conversion NES group (73.2%) than in the CPE control group ( 50 .7%; p < 0.002). The frequency of a history of sexua l or physical abuse was greater in the NES group (32.4%) than in the CPE controls (8.6%; p < 0.000). Severity of sexual but not physical abuse was significantly greater in the NES group re l ative to controls (p < 0.05). There was a trend for a closer relationship of the perpetrator of sexual abuse to the victim among the NES patients compared with CPE controls (p < 0.1). These results support the impression that childhood abuse is more common among patients with conversion NES than with epilepsy, and suggests that in some cases childhood abuse may be a contributory pathogenetic factor. . Nonepileptic seizures (NES) as a conversion disor- der is an important problem in clinical neurology. NES are common; across the five largest reported series of hysterical patients, NES are the second most common conversion symptom pattern. I The reported rate of NES ranges from 5% to 20% in out- patient populations presenting for evaluation of seizures. 2 In comprehensive epilepsy centers, the reported range is from 10% to 409P Identification of NES is critical to avoid poten- tially grave consequences that attend errors of either failing to recognize NES or mistaking true epileptic seizures for NES . Patients with unrecog- nized NES are liable to the iatrogenic hazards of inappropriate treatment with anti epileptic drugs (AEDs) and of intubation during pseudostatus epilepticus,3 and are at potential risk for invasive surgical procedures if coexisting epilepsy and NES are misinterpreted as refractory epilepsy. On the other hand, a patient in our center with definite complex partial epilepsy (ePE) has a history of true status epilepticus resulting from discontinuation of AEDs on the basis of an erroneous diagnosis of NES made in a general hospital emergency service. The diagnosis of NES ultimately rests on the clini- cal observation of an unambiguously non physiologic event that is typical of the patient's prior events. NEUROLOGY 1993;43:1950-1953 There are no behavioral correlates or historical antecedents of the disorder that discriminate NES from epilepsy with absolute certainty; however, some features appear to be more common in NES than in epilepsy. One such feature appears to be a history of childhood sexual abuse. Shen et al,4 in an article out- lining their approach to presenting the diagnosis of NES, noted a history of incestuous abuse or rape in six of eight patients with NES. Gross 5 described six cases of conversion NES with positive history of inces- tuous abuse, and postulated conversion NES as a pos- sible explanation for Navajo and Galenic folk beliefs connecting seizures and incest. Standage 6 noted two cases of incest in a series of 25 patients with conver- sion NES in a study limited by lack of a systematic effort to obtain a sexual history of all patients . While these studies tend to support the widely held clinical suspicion of an association of conversion NES and history of sexual abuse, there are no con- trolled prospective studies comparing the frequency of sexual and physical abuse in patients with NES and in a matched control group with true epilepsy. Preliminary evaluation of a subset of the present series of patients indicated a higher frequency of a history of childhood abuse in NES patients (unpub- lished). In the present study, we report on the fre- quency and severity of prior sexual and physical From th e Depa rtment s of Psychia try and Neur ology, New York Univers ity School of Medicine and the Hos pital for Joint Di seases , New York, NY. Recei ved Dece mber 24, 199 2. Acce pted for publication in final form March 11 , 1993. Address co rres pondence a nd re print reques ts to Dr. Orrin Devinsk y, De partment of Ne urology, Hospi tal for Joint Di seases , 301 E. 17th Stree t, New York, NY 10003. 1950 NE UROLOGY 43 October 1993