Spells 101

Within the fields of neurology and psychiatry, there is an entire subset of symptoms that come and go in various patterns. For lack of a better word, they are referred to as spells. I’ve found some patients have marked reactions to the use of this word, likely harkening back to childhood when their family dismissed a feeling, belief, or symptom as “just a spell”. However, in neurology and psychiatry, spells are some of the most extreme symptoms where we consider some of the most dangerous conditions. The sudden onset, “brief focal neurologic spell” is a Transient Ischemic Attack (a blood clot that nearly caused a stroke until it dissolved) until proven otherwise. 

A good way to understand how spells are taught to neurologists, especially to prepare you for the myriad of questions about the events, is to consider different spells of arm numbness. Sudden onset arm numbness should be treated as a possible stroke. If it escalates over time, stroke is less likely. If it starts in the fingers of one hand, moving up the arm and to the face, the way to tell what caused it is usually the time course. If it moved up to the arm over the course of 20 seconds or less, it may be a seizure. If it takes 20 minutes to go from the fingers to the shoulder it could be migraine associated. If it moves up the arm over the course of a few days to a week, it is more worrisome for inflammation of the brain or spinal cord. If it typically happens in both hands at the same time, it is usually a medical problem like low blood sugar or low carbon dioxide from breathing too quickly.

It isn’t always the quality of the symptom that helps determine what it could be, but the other features. How did it start, and how does it change over the course of the spell? Is it always the same? What are the differences between the spells? How often are the spells occurring? What other symptoms occur with the main symptom? Do other symptoms occur just before the spell, or just after? Are there any triggers that typically occur within the day prior to the spell? Can anything make it worse or better? Did the spells change at all after any medication changes or changes to routines or habits? These are the ways to tell if a headache is migraine, tumor, tension, or nerve irritation, often more so than the pain’s quality or severity.

It is also very important to consider any previous symptom spells that came and went when you were younger. Often a diagnosis is made based on prior spells. I’ve had more than a few patients who were told by a neurologist that they only had a couple of spots on their MRI, but because they didn’t have symptoms they didn’t have Multiple Sclerosis. When I meet them, with a little prodding they admit to a weird buzzing in their left leg for two months in highschool, and a couple of months in college where their right arm felt very heavy and a little numb. They didn’t think of it until I asked, but those details dramatically change how often I want to examine a patient and which drugs they should be on to reduce brain inflammation. 

Psychiatry is no different in this respect, and it is one of the worst consequences in the arbitrary division of neurologic and psychiatric disorders as the two fields split 80 some odd years ago. Some of the most difficult, complex, and distressing symptoms are often neglected because neurologists and psychiatrists don’t coordinate well. Episodes of confusion, panic, fainting, and shaking can occur with many different neurologic and psychiatric disorders as well as conditions typically evaluated by cardiologists, endocrinologists, and other specialists. I’ve had patients who were treated for panic attacks for years before I diagnosed seizure, seizure treated for years until I diagnosed PTSD, and panic associated with fainting treated for years before I convinced a cardiologist to place an implantable monitor to identify a heart rhythm as the underlying cause.

These unfortunate spells fall between the cracks because of poor cross training and communication between the fields, often leading to inappropriate diagnoses that stick with the patient. There has been a recent surge in the diagnosis Non-Epileptic Seizure, as a reaction to the previous model of “ruling out Epilepsy” but not making a diagnosis. However, I’ve now met many patients with very classic panic attacks, PTSD associated dissociative spells, and even one who had a medication side effect who were diagnosed as having “Psychogenic Non-Epileptic Seizures” simply because the spell didn’t match changes on an EEG. I would rather doctors start diagnosing Non-Epileptic cardiac arrhythmias since the cardiologist would just ignore the addition. However, the treatment protocols for non-epileptic seizures is very different from the dissociative spells of PTSD and the diagnosis could confuse psychiatric providers and therapists or worse make them refuse the referral if they don’t feel comfortable treating non-epileptic seizures.

So whether your problem involves weakness, panic, hallucinations, or loss of consciousness, the main goal is to gather as much information as possible about the events, any associated features, and not worrying about what might be irrelevant. Then discuss the symptom with your PCP and let them decide if it is an emergency, safe to monitor, or justifies referral. If the specialist diagnoses you with “Non-”anything, consider it an appropriate working diagnosis that might change when you see a different provider. Non-cardiac syncope may change to panic attack as much as Non-epileptic seizure might change to PTSD dissociative event. 

Below find a list of common spells to consider that could have a final diagnosis in multiple fields. Each of them has very benign causes, very distressing causes, and even life threatening causes. Read the symptom hub to learn about some of the fascinating spells that come from the brain along with their medical names like Palinopsia, Prosopometamorphopsia, and others! If you’d like to discuss your spells with an expert, request a consult today. 

Altered awareness

• Confusion

• Exhaustion

• Loss of consciousness

• Drowsiness

• Disorientation

Perceptual disturbance

• Hallucination

• Visual or auditory distortions

• Double vision

• Blurred vision

• Phantom smells/tastes

• Dizziness

Somatic disturbance

• Heart racing

• Chest pain or tightness

• Shortness of breath

• Abdominal discomfort

• Texture/color changes to the skin

• Fever or sweats

• Chills 

Behavioral disturbance

• Agitation

• Compulsions

• Impulses

• Aggression

• Pacing

• Overall reduced activity

• Freezing

• Staring

• Twitching

• Shaking

 Mood disturbance

• Sadness

• Excitedness

• Rage

• Anxiety

• Fear

Thought disturbance

• Worry

• Obsession

• Delusion

• Paranoia

• Suicidality