Functional Neurological Disorder (FND) : a patient's guide
including Functional/Dissociative (non-epileptic) Seizures, Functional Movement Disorder and other functional symptoms
Drop attacks often cause injury, especially to the knees and face
Many thanks to Nicola who agreed to let her picture be shown on this website.
A “Drop attack” is the medical term for a sudden fall to the ground without an obvious ‘blackout’. A typical drop attack is experienced when walking or standing and without any warning. Drop attacks are frightening and often lead to injuries, especially to knees, forearms and face.
There are many causes of drop attacks, such as simple falls, low blood pressure and epilepsy, but quite often, especially in people under the age of 65, it turns out that drop attacks are a type of functional neurological symptom. They are sometimes worth seeing as a form of very brief dissociative (non-epileptic attack)
Before reading this page, please check with your doctor that this information is relevant to you. If you have a diagnosis of ‘idiopathic drop attacks’ or ‘cryptogenic drop attacks’ then this information could be relevant. If your drop attacks are due to a known cause such as a heart condition or epilepsy then this information is not relevant
What are the typical features of drop attacks?
Over 90% of drop attacks, for reasons that are not understood at all, occur in women although men can develop the problem. The average age of onset is between 45 and 55 which is a bit older than some of the other symptoms on this website but they can happen at any age.
People with drop attacks often experience the following:
1. ‘I was just walking along minding my own business’. A drop attack is a sudden fall to the ground while standing or walking
2. ‘There was no reason for it’. There is usually no specific trigger although some patients do report drop attacks being more likely in certain situations, especially the tops of stairs and busy places like supermarkets. This may be something to do with ‘sensory overload’ that some people get in these situations (more on this below)
3. ‘One minute I was walking and the next I was on the ground. I don’t think I blacked out’. Patients with functional drop attacks normally can’t remember the fall itself but are aware of the impact on the ground (or within seconds of falling). This is different to a mechanical fall when people often do remember the fall (often in detail). Its also different to a dissociative attack (non-epileptic attack) where there is an actual ‘blackout’.
4. ‘I was able to get back up again quite quickly’. Unlike an epileptic seizure or a faint, people with drop attacks can usually get up again quite quickly
5. ‘I keep injuring myself’. Injury is a common consequence of drop attacks. In France the condition has been called ‘maladies de genius bleus’ (sickness of the blue knees) because patients with drop attacks so often fall down on their knees, bruising them in the process. Other common injuries include wrist and hand injuries as well as facial injuries. When drop attacks are witnessed, its often noticed that the person just crumples down to the ground rather than toppling over (like a faint)
6. ‘These falls have made me worried about going outside’. Its only natural when you’ve had some unexpected falls that you will worry about going outside. Not only can it be painful to fall down so unexpectedly but many patients report embarrassment, especially when others come to their aid. As with any other cause of sudden ‘attack, people with drop attacks often develop a fear of going outside on their own. This may be important to recognise as part of treatment
How do you diagnose Drop Attacks?
Drop attacks are actually a very characteristic problem. If someone has all the elements described above then its actually very unlikely there will be another cause such as epilepsy or a heart condition.
In older people, drop attacks can happen due to sudden lowering of blood pressure. Doctors sometimes use the terms syncope, vasovagal syncope or carotid sinus hypersensitivity to describe various types of fainting related to low blood pressure.
You may have a heart tracing (ECG) and possibly a longer heart tracing (24 hour or longer ECG) to try to capture an attack. If you don’t already have another form of epilepsy its extremely unusual for isolated drop attacks to be due to epilepsy.
Sometimes drop attacks happen because of knee or hip instability, or because the person keeps tripped over, although usually in these cases the person DOES remember the fall, often with a memory of the whole thing happening in slow motion
Will I come to serious harm?
Injuries are part and parcel of drop attacks. These can be as bad as broken bones or teeth, but more serious or life threatening injuries are not seen with functional drop attacks even in people having many attacks a day. This is different to epilepsy or even faints where serious injury does sometimes sadly happen. This is something to do with the nature of drop attacks not relating to a true loss of consciousness in which the body is completely unprotected. It's helpful to think of it more like a loss of AWARENESS, where the body is partially protected. This explains why people with drop attacks tend to crumple rather than topple, and sometimes (but not always) are able to avoid furniture and other obstacles when falling.
Why do drop attacks happen?
For information in general about how and why functional symptoms happen look on these pages.
There is still a lot we don’t understand about drop attacks. In some people they really are ‘cryptogenic’ (ie doctors really have no idea why they happen and there is no clear evidence that they are functional either).
But in other people its possible to see a pattern that fits quite well in to those seen in other functional disorders. Some evidence for this includes the following
•Some patients with dissociative (non-epileptic) attacks may develop drop attacks as they are getting better, or sometimes drop attacks turn in to dissociative (non-epileptic) attacks. For an example see the story by Mary on this website
•Some people with functional limb weakness have drop attacks which are triggered by the leg that is normally weak, ‘giving way’. Although these may be just described as falls, its often the case that the person feels a slight weakness and the next thing they know they are on the ground having fallen. This is more of a ‘drop attack’
•Many people with drop attacks feel strange when they come round. Sometimes this is a ‘spaced out’ ‘there but not there’ feeling which is called dissociation. (see page for more description). In some people this is a clue that dissociation is the reason for the drop attack in the first place.
•Some people with drop attacks only have them when they are outside of their house. If the attacks were due to a heart condition or epilepsy they would happen randomly
• Working with this “functional” model of drop attacks can also lead to successful treatment in some patients, although drop attacks are generally a hard problem to treat.
This is an example of a sequence of events that can lead to functional drop attacks
1.The person suffers a simple trip or fall, or faint – but gets a fright or shock which sets up a sensitivity to falls in the future
2.A random attack of dissociation while standing or walking, or one triggered by slightly faint feelings leads to a second fall, this time a functional ‘drop attack’ – this leads to even more of a fright or a shock
3.The person’s body and nervous system is now ‘primed’ in neuroscience terms, to have falls with no trigger. Every subsequent fall they have tends to reinforce the ‘habit’ that their nervous system has got in to, typically with no trigger. As with all functional symptoms and disorders, drop attacks are genuine and are not caused by the person deliberately falling.
4.The person with drop attacks develops, naturally, a fear of further falls which in itself appears to make falls generally more likely. Its not that the person is frightened about falling all the time, but worrying about falls and the consequences of falls seems to make drop attacks more likely to happen, at least in some people.
5.Some people with drop attacks say that they have days when they feel a fall is more likely to happen, they just don’t know when. Having the fall is horrible but afterwards they feel that they are much less likely to have another one that day or that week.
What is the treatment
Understanding the diagnosis
As with all functional symptoms and disorders, understanding the nature of the diagnosis is an important first step. Its bad enough having functional drop attacks without also being worried that you might have epilepsy or a heart condition. Worrying about those things as well is likely to make functional drop attacks worse.
Understanding that drop attacks are a very typical clinical problem which an experienced doctor can immediately recognise, and that actually very little else in medicine looks or sounds anything like them can be a good start.
Try to recognise warning symptoms
Most people with drop attacks have no warning symptoms, or if they did then that was only in the first few attacks. Occasionally patients can learn to recognise warning symptoms, either of dissociation or symptoms that suggest the body is going in to ‘red alert’ like palpitations or going hot. If you do get some warning symptoms, even if they only last for a few seconds then this is something that you may be able to lengthen using distraction techniques. This is the same kind of treatment advice given for patients with dissociative (non-epileptic) attacks,
Are there certain situations when drop attacks happen?
A minority of patients report only having drop attacks when outside the house, in the same way that people with panic attacks tend to have attacks only when away from the security of their home.
If you don’t have any warning symptoms
As with dissociative attacks, sometimes although the patient doesn't experience any warning symptoms, those around them like friends and family do sometimes notice some changes just before. These include 'going quiet' or looking 'spaced out', with a 'glazed' expression or as if they are 'not there'. If your friends and family can spot these kinds of dissociative symptoms, ask them to tell you as it may help you recognise the feeling of dissociation that you are looking for.
It sounds a bit weird but in some cases it seems that when people dissociate, they also dissociate from the feeling of being spaced out when it happens! So they do need a bit of help learning to recognise that feeling
When none of the above apply
In the majority of patients with drop attacks, there are no warning symptoms, they can't be found even when looking hard for them by anyone, the attacks happen anywhere including at home and so it feels as if there is no 'way in' to treatment. This is often the case even when the patient fully accepts and understands the diagnosis. Treatment approaches worth considering include
Some of the medications described on the treatment - medication page may be worth trying. These include medicines like Amitryptiline and Clomipramine. These are sometimes used to treat another kind of falls called Cataplexy and there are anecdotal reports of success
If your drop attacks have come to dominate your life you may be locked in a vicious circle whereby the constant worry of when the next attack will be and what injury you will have next are actually making the problem worse and keeping it going. Talking openly about this with a doctor or psychologist can sometimes be helpful. A psychologist might use a similar approach to that used for panic attacks, although the disorders are different. This may involve doing things such as gradually experimenting with going out on your own or learning how to avoid acute feelings of embarrassment and accept help if you do fall in a public place going over your fears about serious injury and looking at whether these are realistic
Even after trying these things some people with drop attacks still have the problem. It could be that there are things about drop attacks that we don't understand yet. Or it could be that in some people it becomes such an ingrained 'habit' that it's just too difficult to change it.
In this situation you need the understanding of family, friends and health professionals to live with the problem as best as possible. Talk over how you would like people to behave if you have an attack. Many people can manage to work and have a social life despite frequent drop attacks.
What about Driving?
In the UK there is no specific guidance about drop attacks. This is something to discuss with your doctor.