In `Psychodynamics and Psychotherapy of Pseudoseizures` Dalma Kalogjera-Sackellares has, at last, come out into the open and categorically stated that so-called psychotic disorders, such as undergoing pseudoseizures, defined as psychogenic non-epileptic states, can be successfully treated by psychotherapy rather than being suppressed by medical-drug intervention. The analysis of what constitutes the psychopathology of pseudoseizures should be essential reading for all medical, psychiatric and healthcare practitioners whose eyes should well and truly be opened by this admirable work.

Dalma Kalogjera-Sackellares classifies the cause of pseudoseizures as originating either from post-traumatic conditions, such as sexual trauma, serious head injury or traumatic life experience, and/or from inadequate psychosocial development which can result in psychological illness and over-dependence on others. Post-traumatic stress or impaired psychosocial development will indicate that the seeding incidents will not have been properly neurologically processed by the client who will remain in a state of overwhelm and may, thereby, exhibit symptoms of extreme dissociation, depression, anxiety, sexual inhibition, social withdrawal, intrusive imagery and cognitive inconsistency among others all of which are utilised as a coping-mechanism in the face of ongoing distress. 

Dalma Kalogjera-Sackellares explains in well researched and erudite detail the architecture of traumatic experience, which can result in the client's experience of pseudoseizure states, by drawing on psychoanalysis, object-relations theory and self psychology as well as including her own clinical observations and research into the nature of the pseudoseizure phenomenon. In `Psychodynamics and Psychotherapy of Pseudoseizures` Dalma Kalogjera-Sackellares reviews the research into the Freudian theory of complicated mourning, consisting of grief and inner conflict, which will manifest as a result of internalised traumatic experience of loss and disturbing relationships with significant others. Borderline syndrome and fusional attachment, taken from object-relations theory, and narcissistic injury and vulnerability, originating from self psychology, also come into the equation of the psychopathology of pseudoseizures. The author, furthermore, describes in depth the significance of the post-traumatic syndrome as an ecosystem consisting of projective identification, dissociation, uncontrollable anger, survivor guilt, intrusive recollection, perceived psychological entrapment and compulsive emotive outpouring. Finally, the phenomenon of initiative-inhibition contributes to the psychodynamic picture of pseudoseizures.

The treatment programme advocated by Dalma Kalogjera-Sackellares in `Psychodynamics and Psychotherapy of Pseudoseizure`s will allow the client to take personal responsibility for his recovery process rather than endeavouring to suppress or to avoid his symptom-pattern. The therapeutic practitioner then can assist the client to handle abreactive episodes, access the underlying cause, dissect the initiating traumatic experience, accept maternal deprivation, regain integrity, gain independence from his parents or carers, widen cognitive scope and reconstitute a fundamental belief in a safe and reliable world. 
Dalma Kalogjera-Sackellares concludes her impressive work with guidance for the psychotherapeutic practitioner who is advised to evaluate the client's chances of success by considering the prevalence of the post-traumatic syndrome in terms of complexity and chronicity, the persistence of pseudoseizure episodes, the extent of his traumatic experience and the presence of any co-morbid conditions. Armed with a history of the client's trauma and its nature in terms of loss, pervasive symptomatic regression, development crises, uncontrollable traumatic recollection, borderline syndrome, narcissistic injury and other clinical implications, the practitioner should be well equipped to proceed with empathetic understanding and clarity towards facilitating the client's successful resolution, restitution and recovery from the psychological damage he has previously sustained.

For psychologists, psychiatrists, neurologists, and others engaged in the diagnosis and treatment of patients with psychogenic pseudoseizures, a guide based on the author's 15 years of observing and treating such patients, many of them over a span of several years. Kalogjera-Sackellares (neuroscience, U. of Florida Health Science Center) describes a classification scheme of clinical syndromes; presents a framework for diagnosis; and discusses situations and problems commonly encountered among patients who present with psychogenic pseudoseizures. She draws on three major areas of psychodynamic theory to explain how trauma leads to the development of pseudoseizure syndromes: psychoanalytic theory, object-relations theory, and self-psychology.

Neurologists diagnose patients with psychogenic non-epileptic seizures (pseudoseizures), but generally do not understand the underlying psychopathology or treatment rationale. Psychodynamics and Psychotherapy of Pseudoseizures is a major contribution to the field. This remarkable treatise provides a theoretical framework to explain clinical presentations of patients with pseudoseizures and support therapeutic interventions.

” enjoyable and informative to read ....a useful guide to people who treat patients with not only pseudoseizures but other pseudo-neurological disorders."

Excellent ... an important work ... should be in every epilepsy library.

I approached this book with a degree of trepidation. Being a scientist-practitioner with a background in cognitive neuropsychology I am relatively unfamiliar with and unsocialised into the field of psychodynamic psychotherapy. As a clinician working in the field of neuropsychology, however, I have a practical experience with the complex and puzzling phenomena of somatisation disorders and so was keen to expand my knowledge of this field.

The foreword, written by a neurologist and neuroscientist, provides an excellent introduction to the phenomenon of pseudoseizures and the diagnostic process involved in identifying this disorder. It captures well the difficulties and uncertainty inherent in the process. It also provides a good introduction to and overview of the methodology of the author. The book is based on the author's experience of treating and assessing patients with a wide range of presentations over a number of years. Thus adding a valuable longitudinal perspective.

The first section of the book is reproduced from a previous publication, which serves as an introduction to the classification identified by the author of posttraumatic pseudoseizure syndrome (PTPS) and developmental pseudoseizure syndrome. The former is characterised as a variant of posttraumatic stress disorder (PTSD), while the latter is postulated to arise from difficulty in negotiating the difficult life tasks that accompany development. This seems a valuable distinction and it is disappointing therefore that it is apparently not maintained throughout the rest of the book, which concentrates solely on the PTPS. The first section ends with treatment of pseudoseizure syndromes, a valuable section dealing with practicalities of treatment. I found the section on reconceptualisation of the nature of pseudoseizures particularly helpful. It is aimed at three categories of patients with PTPS ” those who have suffered sexual trauma, those who have suffered head injury or post concussion syndrome and those who have suffered a chronic life course.

The second section presents a second framework for understanding pseudoseizures based within the psychodynamic tradition. This framework is based on three approaches; psychoanalytic theory, object relations theory and self-psychology. This is a challenging section for those not socialised into the idiosyncratic style of psychodynamic writing and I found the “Points of organisation' section rather confusing and unhelpful in setting out the aims. Despite these difficulties the discussion is elegantly constructed and at points very illuminating and thought-provoking. To mention just two, there are particularly insightful parallels drawn with the concept of complicated mourning and the authors view of pseudoseizures as an ecosystem captures well the complex nature of the disorder. Throughout, the points of technique are practical and valuable.

Section three sets out a model of posttraumatic disturbance likely to occur in pseudoseizure patients. While I would not describe this as a model in the strict sense of the word, it does provide a helpful synthesis and a drawing together of the strands of the discussion. It also provides a summary and some useful additions.

Understanding psychogenic pseudoseizures is a vast and formidable challenge. This book presents a first step at simplifying this task, by providing a framework for understanding the phenomenon and providing a rationale for an approach to treatment. The author, with her vast experience makes an invaluable contribution to the field and to clinicians involved in the treatment of these patients.

For some, however, the nature of the framework will be problematic. There is a tension between psychodynamic theory and neuroscience. This would seem to be as much in the style of writing as it is in the actual content of the writing. Throughout the book there are numerous unreferenced claims. One important one is that pseudoseizures are in some way a “solution' to the patient's trauma. While I can accept that a dissociative experience is in some way protective, this is very different from the claim that it may go some way to resolving the traumatic experience. The question of whether these experiences, whether they be pseudoseizures in people with PTPS or flashbacks in people with PTSD, are purely pathological or rather go some way to resolving the trauma is an important one. It is also one that is the current focus of debate generally in the field of psychiatry/psychology in the UK. This is one illustration of the tension. There may be some psychodynamic theory which states that pseudoseizures are functional in this way, but the author does not reference it or assumes that the reader is sufficiently fluent in psychodynamic theory to accept it.

Likewise, many questions are left unanswered: throughout the book I was asking what is it that makes one person develop pseudoseizures in relation to trauma and another person a different somatic symptom? This question was finally addressed on page 235. It was a long time to wait but the answer, that it is unimportant in approaching treatment, was helpful. It would have been helpful for me if this point had been made earlier. These points of critique generally relate to style. A psychodynamic style may well be perceived as rather inaccessible in mainstream psychology. However, in the case of this book it is worth persevering with.



In summary, therefore, the author achieves her aim of examining the influence of trauma in the genesis of pseudoseizures and presenting the implications of treatment and she does this extremely well. It is perhaps unfair to expect an explanation grounded in empirical study. The phenomenon of pseudoseizures is, at present, impervious to neuroscience. The author has tackled the subject head-on via one of the few approaches that can deal with it and she should be congratulated for it.