Functional/dissociative seizures in a single women’s rehabilitation center in Addis Ababa, Ethiopia: a single-center case series and thematic analysis of neuropsychiatric presentation, cultural meaning, and structural barriers to care

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Background: Functional/dissociative seizures (FDS; previously termed psychogenic non-epileptic seizures, PNES) are disabling functional neurological events associated with trauma, dissociation, psychiatric comorbidity, impaired functioning, and increased mortality. In sub-Saharan Africa, limited access to video-electroencephalography (video-EEG), limited specialist services, and culturally embedded explanatory models complicate recognition and treatment. To our knowledge, there are no published Ethiopian case-based studies of FDS employing structured clinical formulation and thematic analysis. Methods: We present six young women, aged 18-24 years (median 20), identified during routine care in a residential rehabilitation setting in Addis Ababa with clinically suspected FDS. Because video-EEG was unavailable, cases were formulated using positive seizure-like episode features, psychiatric assessment, trauma history, cultural attributions, applying the staged diagnostic framework proposed by LaFrance et al. Treatment response was recorded as a clinical outcome and was not used as diagnostic evidence. The de-identified case narratives were analyzed using framework-based thematic analysis informed by Braun and Clarke, organized around a multidisciplinary model spanning neurobiology, trauma and attachment, dissociation, cultural psychiatry, and structural violence. Results: Episodes exhibited features consistent with clinically suspected FDS: prolonged duration, irregular or asynchronous motor activity, forced eye closure or side-to-side head movements in some cases, preserved or fluctuating awareness, sensory prodrome in one case, limited recall, absence of postictal confusion, and emotional or interpersonal triggers. Psychiatric features included depression, anxiety, self-harm, substance use, khat-related arousal, nightmares, and suicidality. Trauma and attachment-related vulnerabilities included parental abandonment, maternal rejection, sexual abuse, family-arranged child marriage, homelessness, restricted socialization, estrangement, and separation from a child. Five overarching themes were identified: (1) neurological episode features; (2) betrayal and attachment disruption; (3) dissociation and functional shutdown; (4) psychiatric risk and comorbidity; and (5) culture, gender, and systemic invisibility. Conclusion: Clinically suspected FDS was identified in young women at a single Ethiopian rehabilitation center and may be under-recognized in comparable settings. These single-center observations are hypothesis-generating and require confirmation in larger studies with electrophysiological support. In settings where video-EEG is unavailable, culturally adapted screening, trauma-informed assessment, suicide risk evaluation, treatment of psychiatric comorbidity, and clear referral pathways are urgently needed.

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