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Dissociation: what is it and why is it important?
  1. Jon Stone
  1. Consultant Neurologist and Honorary Senior Lecturer, Department of Clinical Neurosciences, Western General Hospital, Crewe Road, Edinburgh EH4 2XU, UK;

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    Dissociation is a mysterious and “woolly” area for many neurologists. In this article I will try to persuade you that it describes a common and interesting group of symptoms that many of our patients have—both with and without disease. I will suggest that it should be in the differential diagnosis for anyone presenting with dizziness or blank spells. Dissociative symptoms also occur in common neurological problems such as migraine, epilepsy, and syncope as well as in people with symptoms such as functional weakness, non-epileptic attacks, and depression. They may also occur in isolation but be mistaken for disease. Being able to recognise them, explain them, and perhaps even do something about them should lead to a happier patient and a happier neurologist. Let’s look at some cases from neurology outpatients:

    CASE 1

    A 34 year old woman was walking along with some friends when over a period of a minute or two she developed an intense and frightening feeling of “dizziness”. She felt hot and nauseous, had tingling on the left side of her face, and had to sit down on the path. It all resolved within 10 minutes but she was left feeling shaken by the experience. Later that week the feeling of dizziness recurred on two further occasions, just as unexpectedly, but less intensely. She found it hard to describe the dizziness but eventually said it was like “floating off or being not connected with the world somehow”. The same thing happened during a normal EEG recording. Although the family doctor had been concerned about epilepsy or a transient ischaemic attack, the diagnosis was dissociation, perhaps due to a panic attack.

    CASE 2

    A 26 year old student was referred to the clinic because of “blank spells” with a query about epilepsy. They came on gradually and faded away slowly, lasting about …

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