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Roberts NA, Reuber M. Alterations of consciousness in psychogenic nonepileptic seizures: emotion, emotion regulation and dissociation. Epilepsy Behav 2014; 30:43-9. [PMID: 24196398 DOI: 10.1016/j.yebeh.2013.09.035] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Accepted: 09/26/2013] [Indexed: 11/19/2022]
Abstract
Impairment of consciousness and reduced self-control are key features of most psychogenic nonepileptic seizures (PNESs), although, compared with patients with epilepsy, those with PNESs demonstrate greater conscious awareness during their seizures. The neurobiological underpinnings of PNESs and of alterations of awareness associated with PNESs remain relatively unknown. We suggest that an understanding of conscious experiences and discrepancies between subjective impairment of consciousness and the lack of objectifiable neurobiological changes in PNESs may benefit from an examination of emotion processing, including understanding sensory, situational, and emotional triggers of PNESs; emotional and physiological changes during the attacks; and styles of emotional reactivity and regulatory capacity. We also suggest that in addition to the typical comparisons between patients with PNESs and those with epilepsy, studies of PNESs would benefit from the inclusion of comparison groups such as those with PTSD, dissociation, and other forms of psychopathology where dissociative and emotion regulatory mechanisms have been explored more fully. We conclude that current evidence and theory suggest that impairment of consciousness in PNESs is only "dissociative" in one subgroup of these seizures, when consciousness is suppressed as a collateral effect of the excessive inhibition of emotion processing. We propose that PNES behaviors and experiences of reduced control or awareness may also represent direct behavioral manifestation of overwhelming emotions, or that minor emotional fluctuations or relatively neutral stimuli may trigger PNESs through conditioning or other preconscious processes. Future studies exploring the neurobiological mechanisms underpinning PNESs are likely to be more fruitful if researchers bear in mind that it is unlikely that all PNESs result from the same processes in the brain.
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Affiliation(s)
- Nicole A Roberts
- School of Social and Behavioral Sciences, Arizona State University, Glendale, AZ, USA.
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52
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Chen DK, Maheshwari A, Franks R, Trolley GC, Robinson JS, Hrachovy RA. Brief group psychoeducation for psychogenic nonepileptic seizures: a neurologist-initiated program in an epilepsy center. Epilepsia 2013; 55:156-66. [PMID: 24446955 DOI: 10.1111/epi.12481] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2013] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate therapeutic efficacy upon augmenting the initial communication to patients regarding the diagnosis of psychogenic nonepileptic seizures (PNES) with a novel, brief group psychoeducation administered by the same team that provided the video-electroencephalography (VEEG) confirmed diagnosis and within 4 weeks of the diagnosis. METHODS Prior to discharge from the epilepsy monitoring unit (EMU), a standardized communication strategy was utilized to explain the diagnosis of PNES to all patients prior to enrollment. Enrolled patients were then randomized to either participation in three successive and monthly group psychoeducational sessions (intervention group), or routine seizure clinic follow-up visits (control group). Both groups completed questionnaires at time of enrollment, and then at approximately 3 months (follow-up 1) and 6 months (follow-up 2) after discharge, assessing for: (1) primary outcomes that include a measure of psychosocial functioning, as well as interval difference in seizure frequency/intensity; and (2) secondary outcomes that include interval seizure-related emergency room visits or hospitalizations, development of new and medically unexplained symptoms, and results of an internal measure of knowledge and perception outcomes. RESULTS The majority (73%) of patients from the intervention group commenced on therapy sessions within 4 weeks after learning of the diagnosis. Although we did not observe significant group difference in seizure frequency/intensity, patients from the intervention group showed significant improvement on the Work and Social Adjustment Scale (WSAS) scores at both follow-up 1 (p = 0.013) and follow-up 2 (p = 0.038) after discharge from the EMU. In addition, we observed a trend toward lesser likelihood for seizure-related emergency room visits or hospitalizations for the intervention group (p = 0.184), as well as meaningful insights from an internal measure of intervention outcomes. SIGNIFICANCE These findings suggest that our cost/resource effective, brief group psychoeducational program, when administered early and by the same team who confirmed and communicated the diagnosis of PNES, may contribute to significant functional improvement among participating patients.
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Affiliation(s)
- David K Chen
- Peter Kellaway Section of Neurophysiology, Department of Neurology, Baylor College of Medicine, Houston, Texas, U.S.A.; Neurology Care Line, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, U.S.A
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53
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Douzenis A, Seretis D. Descriptive and predictive validity of somatic attributions in patients with somatoform disorders: a systematic review of quantitative research. J Psychosom Res 2013; 75:199-210. [PMID: 23972408 DOI: 10.1016/j.jpsychores.2013.05.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Revised: 05/07/2013] [Accepted: 05/12/2013] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Research on hypochondriasis and other somatoform disorders (SFD) has provided evidence that patients with SFD tend to attribute their symptoms to organic dysfunctions or disease. However, recent studies appear to discredit this. There is no systematic evidence on whether patients with SFD predominantly rely on somatic attributions, despite calls to include somatic attributions as a positive criterion of somatic symptom disorder (SSD) in the upcoming Diagnostic and Statistical Manual of Mental Disorders (DSM-5). METHODS This study is a systematic review of quantitative studies which assess the descriptive and predictive validity of somatic attribution in SFD. The literature search was restricted to studies with patients who met the DSM-IV criteria for SFD. RESULTS Somatic attribution style in SFD has acceptable descriptive but insufficient predictive validity. This confirms that the overlap between somatic and psychological attributions is often substantial. Attribution style can discriminate between SFD patients with and without comorbidity. CONCLUSION A somatic attribution style does not qualify as a positive criterion in SSD. However, there is an urgent need for further research on causal illness perceptions in the full spectrum of medically unexplained symptoms in order to confirm this result. Given its high prevalence, research on psychological attribution style is warranted. Re-attribution does not provide a framework sophisticated enough to address the needs of patients in primary care.
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Affiliation(s)
- Athanassios Douzenis
- Second Psychiatry Department, Athens University Medical School, Attikon General Hospital, 1 Rimini St., Athens, 12462, Greece.
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54
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Fritzsche K, Baumann K, Götz-Trabert K, Schulze-Bonhage A. Dissociative seizures: a challenge for neurologists and psychotherapists. DEUTSCHES ARZTEBLATT INTERNATIONAL 2013; 110:263-8. [PMID: 23667393 PMCID: PMC3647137 DOI: 10.3238/arztebl.2013.0263] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Accepted: 01/14/2013] [Indexed: 02/01/2023]
Abstract
BACKGROUND The prevalence of dissociative seizures is between 2 and 33 sufferers per 100,000 persons. 70% of sufferers are women. Dissociative seizures markedly impair quality of life. Their close superficial resemblance to epileptic seizures makes them hard to diagnose. METHODS Selective literature search in PubMed and PsycINFO. RESULTS Persons with dissociative seizures constitute a mixed group with a wide variety of predisposing, precipitating, and maintaining factors. Some 90% have comorbid psychiatric disorders such as depression, anxiety, somatoform disorders, personality disorders, or post-traumatic stress disorder. Video-EEG monitoring enables highly reliable diagnosis. Psychotherapy is considered the treatment of first choice; in prospective studies, it has been found to lower the frequency of dissociative seizures by at least 50%, or to eliminate them completely, in 50% to 80% of patients. An individually tailored combination of behavioral therapeutic, imagery-based, and psychodynamic approaches seems reasonable. For the treatment of psychiatric comorbidities, psychotherapy is indicated, in combination with psychoactive drugs if necessary. Before any treatment is provided, the diagnosis should be communicated to the patient in an appropriate way, ideally by both the neurologist and the psychotherapist, so that the patient can develop an alternative disease model. CONCLUSION When the diagnosis of dissociative seizures has been made, psychotherapy is indicated, possibly in combination with psychoactive medication, in the setting of long-term treatment provided in collaboration by the neurologist, psychiatrist, psychotherapist, and family physician. Further randomized trials are needed to determine which treatments are best for which subgroups of patients.
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Affiliation(s)
- Kurt Fritzsche
- Department of Psychosomatic Medicine, University Medical Center Freiburg, Germany.
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55
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LaFrance WC, Reuber M, Goldstein LH. Management of psychogenic nonepileptic seizures. Epilepsia 2013; 54 Suppl 1:53-67. [DOI: 10.1111/epi.12106] [Citation(s) in RCA: 193] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- W. Curt LaFrance
- Neuropsychiatry and Behavioral Neurology Division; Rhode Island Hospital; Brown University, Alpert Medical School; Providence; Rhode Island; U.S.A
| | - Markus Reuber
- Academic Neurology Unit; Royal Hallamshire Hospital; University of Sheffield; Sheffield; United Kingdom
| | - Laura H. Goldstein
- Department of Psychology; Institute of Psychiatry; King's College London; London; United Kingdom
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Abstract
The behavioural aspects of somatic symptom disorders have received minimal research attention to date. The first section of this paper identifies key theoretical perspectives relevant to behavioural responses to illness. Specifically, the sociological concept of illness behaviour is offered as a general framework in which to consider the range of psychosocial factors associated with responses to perceived illness. Further, the potential relevance of the construct of abnormal illness behaviour and the cognitive behavioural conceptualization of health anxiety is explored. The second part of the paper describes various approaches to the operationalization of illness behaviour, with particular emphasis on the Illness Behaviour Questionnaire, an instrument with a rich history of application. Additional insight is provided into two contemporary instruments which aim to measure overt behavioural aspects of illness more specifically. The third and final section of the paper makes recommendations for how future research may advance the understanding of state- versus trait-based characteristics of illness behaviour. Suggestions are made for how adaptive forms of behaviour (e.g. self-management, appropriate coping) may reduce the risk of developing a somatic symptom disorder or alternatively, minimizing the potentially negative psychosocial implications of such a presentation.
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Affiliation(s)
- Kirsty N Prior
- School of Medicine, Flinders University, Adelaide, South Australia, Australia
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57
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Aybek S, Hubschmid M, Mossinger C, Berney A, Vingerhoets F. Early intervention for conversion disorder: neurologists and psychiatrists working together. Acta Neuropsychiatr 2013; 25:52-6. [PMID: 26953074 DOI: 10.1111/j.1601-5215.2012.00668.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate the efficacy of an early multidisciplinary (neurology and psychiatry) intervention for conversion disorder (CD). METHODS Consecutive patients newly diagnosed with CD from 2005 to 2007 were compared to a control group of newly diagnosed CD patients receiving usual care. At 3 years, a questionnaire evaluated self-rated subjective outcome, symptom severity, SF-36 scores, employment status and medical care use. RESULTS Data from 12 cases (mean age 25.5 ± 8.2; 9 females) and 11 controls (mean age 34.7 ± 13.5; 10 females) showed that 83% of cases had a good subjective outcome (symptom improved or cured) when only 36% of controls had a good outcome (p < 0.05). Cases significantly improved their SF-36 scores on subscales involving physical complaints compared to controls. A minority (20%) of cases reduced or ceased professional activity when 70% of controls did (p < 0.001). Only 16% of cases sought further medical advice for the initial symptom when 73% of controls did. Both groups accepted psychiatric referrals (83% of cases and 73% of controls) and found it beneficial. CONCLUSIONS Early intervention involving both neurologists and psychiatrists is effective for CD in alleviating physical complaints, reducing sick leave and health care use.
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Affiliation(s)
- Selma Aybek
- 1 Neurology Service, Department of Clinical Neuroscience, CHUV, Lausanne, Switzerland
| | - Monica Hubschmid
- 2 Liaison Psychiatry Service, Department of Psychiatry, CHUV, Lausanne, Switzerland
| | - Corinna Mossinger
- 1 Neurology Service, Department of Clinical Neuroscience, CHUV, Lausanne, Switzerland
| | - Alexandre Berney
- 2 Liaison Psychiatry Service, Department of Psychiatry, CHUV, Lausanne, Switzerland
| | - François Vingerhoets
- 1 Neurology Service, Department of Clinical Neuroscience, CHUV, Lausanne, Switzerland
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58
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Whitehead K, Kandler R, Reuber M. Patients' and neurologists' perception of epilepsy and psychogenic nonepileptic seizures. Epilepsia 2013; 54:708-17. [DOI: 10.1111/epi.12087] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2012] [Indexed: 11/28/2022]
Affiliation(s)
| | - Rosalind Kandler
- Department of Clinical Neurophysiology; STH NHS Foundation Trust; Sheffield; United Kingdom
| | - Markus Reuber
- Academic Neurology Unit; University of Sheffield; Sheffield; United Kingdom
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59
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Testa SM, Krauss GL, Lesser RP, Brandt J. Stressful life event appraisal and coping in patients with psychogenic seizures and those with epilepsy. Seizure 2012; 21:282-7. [DOI: 10.1016/j.seizure.2012.02.002] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2011] [Revised: 02/09/2012] [Accepted: 02/11/2012] [Indexed: 10/28/2022] Open
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60
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Emotion in psychogenic nonepileptic seizures: responses to affective pictures. Epilepsy Behav 2012; 24:107-15. [PMID: 22520585 DOI: 10.1016/j.yebeh.2012.03.018] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2012] [Revised: 03/04/2012] [Accepted: 03/12/2012] [Indexed: 11/22/2022]
Abstract
We examined emotional responses to standard affective pictures in 18 psychogenic nonepileptic seizure (PNES) patients. Given reports of trauma and posttraumatic stress symptoms (PTS) in many PNES patients, comparison groups were seizure-free individuals high and low in PTS (PTS-high, PTS-low; n=18 per group). Patients with psychogenic nonepileptic seizures (1) reported more emotional intensity to neutral and pleasant pictures than PTS-low and more intensity to neutral pictures than PTS-high, and (2) showed less positive emotional behavior to pleasant pictures than PTS-high. Groups did not differ in pleasantness/unpleasantness ratings, negative emotional behavior, cardiac interbeat interval, or respiratory sinus arrhythmia (RSA) reactivity to the pictures. Patients with psychogenic nonepileptic seizures reported more general emotion regulation difficulties and showed lower baseline RSA than PTS-low but not PTS-high. In sum, intense emotional experience and diminished positive emotional behavior characterized PNES patients' emotional responses.
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61
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Illness perceptions of neurologists and psychiatrists in relation to epilepsy and nonepileptic attack disorder. Seizure 2012; 21:104-9. [DOI: 10.1016/j.seizure.2011.09.012] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2011] [Revised: 09/25/2011] [Accepted: 09/29/2011] [Indexed: 11/23/2022] Open
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62
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63
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Stone J, LaFrance WC, Brown R, Spiegel D, Levenson JL, Sharpe M. Conversion disorder: current problems and potential solutions for DSM-5. J Psychosom Res 2011; 71:369-76. [PMID: 22118377 DOI: 10.1016/j.jpsychores.2011.07.005] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2011] [Revised: 07/10/2011] [Accepted: 07/19/2011] [Indexed: 11/16/2022]
Abstract
Conversion disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) describes neurological symptoms, including weakness, numbness and events resembling epilepsy or syncope, which can be positively identified as not being due to recognised neurological disease. This review combines perspectives from psychiatry, psychology and neurology to identify and discuss key problems with the current diagnostic DSM-IV criteria for conversion disorder and to make the following proposals for DSM-5: (a) abandoning the label "conversion disorder" and replacing it with an alternative term that is both theoretically neutral and potentially more acceptable to patients and practitioners; (b) relegating the requirements for "association of psychological factors" and the "exclusion of feigning" to the accompanying text; (c) adding a criterion requiring clinical findings of internal inconsistency or incongruity with recognised neurological or medical disease and altering the current 'disease exclusion' criteria to one in which the symptom must not be 'better explained' by a disease if present, (d) adding a 'cognitive symptoms' subtype. We also discuss whether conversion symptoms are better classified with other somatic symptom disorders or with dissociative disorders and how we might address the potential heterogeneity of conversion symptoms in classification.
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Affiliation(s)
- Jon Stone
- Dept Clinical Neurosciences, University of Edinburgh, Western General Hospital, Crewe Rd, Edinburgh EH4 2XU, UK.
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64
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Strutt AM, Hill SW, Scott BM, Uber-Zak L, Fogel TG. Motivation, psychopathology, locus of control, and quality of life in women with epileptic and nonepileptic seizures. Epilepsy Behav 2011; 22:279-84. [PMID: 21788158 DOI: 10.1016/j.yebeh.2011.06.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2011] [Revised: 05/26/2011] [Accepted: 06/13/2011] [Indexed: 11/19/2022]
Abstract
To examine factors that may potentially aid in the differential diagnosis and subsequent tailoring of treatment for patients with epileptic (ES) and psychogenic nonepileptic (PNES) seizures, thirty female patients with PNES and 51 female patients with temporal lobe epilepsy were assessed in the areas of motivation, psychopathology, health-related locus of control (HRLOC), and health-related quality of life (HRQOL). The two groups demonstrated equivalent levels of motivation, clinically elevated yet comparable mood symptoms, and no general differences in HRLOC. Despite similar mood disturbances in both groups, the participants with PNES had a later age of seizure onset, exhibited greater personality disturbances, attributed more control over their condition to nonphysicians, and endorsed a greater negative impact of their seizures on physical and emotional aspects of HRQOL. Preliminary analyses suggest that chronic anxiety and overall HRQOL may be core discriminators between these seizure groups. Addressing such issues may prove useful in tailoring more specific treatments for these etiologically disparate conditions.
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Affiliation(s)
- Adriana M Strutt
- Department of Neurology, Baylor College of Medicine, Houston, TX, USA.
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65
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Reuber M, Jamnadas-Khoda J, Broadhurst M, Grunewald R, Howell S, Koepp M, Sisodiya S, Walker M. Psychogenic nonepileptic seizure manifestations reported by patients and witnesses. Epilepsia 2011; 52:2028-35. [DOI: 10.1111/j.1528-1167.2011.03162.x] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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66
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Worsley C, Whitehead K, Kandler R, Reuber M. Illness perceptions of health care workers in relation to epileptic and psychogenic nonepileptic seizures. Epilepsy Behav 2011; 20:668-73. [PMID: 21440511 DOI: 10.1016/j.yebeh.2011.01.029] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2011] [Revised: 01/28/2011] [Accepted: 01/28/2011] [Indexed: 10/18/2022]
Abstract
Illness perceptions of health care professionals are likely to affect patient care. This study describes the illness perceptions of two groups of health care staff toward epilepsy and psychogenic nonepileptic seizures (PNES). Sixty-one health care professionals (30 emergency care [EC] and 31 neuroscience ward [NW] staff) who regularly see patients with seizures completed the adapted Illness Perception Questionnaire-Revised (IPQ-R) and the Symptom Attribution Question for epilepsy and PNES. Respondents reported a poorer understanding of PNES than of epilepsy (P<0.001), thought epilepsy was a more chronic condition (P=0.001/P<0.001) and that patients with PNES had more "personal control" of their seizures (P=0.014/P<0.001). Staff from both departments identified psychological causes as most important for PNES (P<0.001). EC staff also attributed PNES to behavioral issues or alcohol. The Illness Perception Questionnaire-Revised and Symptom Attribution Question demonstrated important differences in attitudes of health care staff toward epilepsy and PNES. The findings illustrate why some patients with PNES have traumatic encounters with health care professionals.
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67
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Dickinson P, Looper KJ, Groleau D. Patients diagnosed with nonepileptic seizures: their perspectives and experiences. Epilepsy Behav 2011; 20:454-61. [PMID: 21316310 DOI: 10.1016/j.yebeh.2010.12.034] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2010] [Revised: 12/20/2010] [Accepted: 12/21/2010] [Indexed: 11/26/2022]
Abstract
The objective of this qualitative study was to examine how patients with nonepileptic seizures (NES) make sense of their illness experience in light of the many obstacles they may face when seeking treatment. We conducted semistructured interviews with five patients with NES to explore their illness perspectives and different modes of reasoning in regard to their illness and treatment experiences. The data were examined using thematic content analysis. The participants who implicitly incorporated epilepsy as an illness prototype demonstrated less effective treatment expectations and imposed greater life constraints on themselves than the participant who used anxiety attacks. The participants who defined an explanatory model with a psychosocial basis for illness onset were receptive and demanding of psychotherapeutic intervention. Emergent themes included accounts of adverse and positively perceived life events coinciding with illness onset, head injury, presence of caregivers during events, comorbid illness, and previously witnessing epilepsy in others.
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Affiliation(s)
- Philip Dickinson
- Department of Neurology and Neurosurgery, McGill University, Montreal, QC, Canada
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68
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Siket MS, Merchant RC. Psychogenic seizures: A review and description of pitfalls in their acute diagnosis and management in the emergency department. Emerg Med Clin North Am 2010; 29:73-81. [PMID: 21109104 DOI: 10.1016/j.emc.2010.08.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Patients with psychogenic (nonepileptic) seizures (PS) are frequently encountered by clinicians in the emergency medicine setting. Despite the tendency for these patients to seek frequent medical attention, the time between onset of symptoms and diagnosis is often more than 7 years. The cause of PS is multifactorial, but most patients are thought to have an underlying dissociative condition. The diagnostic evaluation in the emergency department is challenging and relies heavily on clinical suspicion, based on historical and physical features. Laboratory testing and therapeutic maneuvers are of limited utility; prolonged video electroencephalography is the diagnostic gold standard. Once the diagnosis has been secured, the mainstay of treatment involves addressing the underlying psychological distress.
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Affiliation(s)
- Matthew S Siket
- Department of Emergency Medicine, Rhode Island Hospital, Alpert Medical School of Brown University, 593 Eddy Street, Claverick Building, Providence, RI 02903, USA
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69
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Stone J, Warlow C, Sharpe M. The symptom of functional weakness: a controlled study of 107 patients. ACTA ACUST UNITED AC 2010; 133:1537-51. [PMID: 20395262 DOI: 10.1093/brain/awq068] [Citation(s) in RCA: 161] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Functional weakness describes weakness which is both internally inconsistent and incongruent with any recognizable neurological disease. It may be diagnosed as a manifestation of conversion disorder or dissociative motor disorder. Other names include psychogenic or 'non-organic' paralysis. We aimed to describe the incidence, demographic and clinical characteristics of cases with functional weakness of less than 2 years duration, and to compare these with controls with weakness attributable to neurological disease. Both cases and controls were recruited from consultant neurologists in South East Scotland. Participating patients underwent detailed assessments which included: physical examination, structured psychiatric interview (Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders), measures of symptoms, disability and distress [Short Form (36) Health Survey, Hospital and Anxiety Depression Scale], and assessment of their illness beliefs using an augmented version of the Illness Perception Questionnaire. In total, 107 cases (79% female, mean age 39 years, median duration of illness 9 months) were recruited. This number suggests a minimum annual incidence of 3.9/100 000. Forty-six controls (83% female, median age 39 years, duration 11 months) were also recruited. Compared to controls, cases had similar levels of disability but more physical symptoms, especially pain. They had a higher frequency of psychiatric disorders, especially current major depression (32 versus 7%, P < 0.0001), generalized anxiety disorder (21 versus 2%, P < 0.005), panic disorder (36 versus 13%, P < 0.001) and somatization disorder (27 versus 0%, P < 0001). There was no difference in median self-rated anxiety and depression scores. Paradoxically, they were less likely than controls to agree that stress was a possible cause of their illness (24 versus 56%, P < 0.001). Cases were twice as likely as controls to report that they were not working because of their symptoms (65 versus 33%, P < 0.0005). Functional weakness is a commonly encountered clinical problem. Patients with this symptom are as disabled as patients with weakness of similar duration due to neurological disease. There is a paradox between the frequency of depression and anxiety diagnoses and the patient's willingness to accept these as potentially relevant to their symptoms. We discuss the theoretical and practical implications of these findings for the concept of conversion disorder.
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Affiliation(s)
- Jon Stone
- Department Clinical Neurosciences, School of Molecular and Clinical Medicine, University of Edinburgh, Western General Hospital, Crewe Rd, Edinburgh EH4 2XU, UK.
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70
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Hall-Patch L, Brown R, House A, Howlett S, Kemp S, Lawton G, Mayor R, Smith P, Reuber M. Acceptability and effectiveness of a strategy for the communication of the diagnosis of psychogenic nonepileptic seizures. Epilepsia 2010; 51:70-8. [PMID: 19453708 DOI: 10.1111/j.1528-1167.2009.02099.x] [Citation(s) in RCA: 132] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Lindsey Hall-Patch
- Academic Unit of Psychiatry and Behavioural Sciences, University of Leeds, Leeds, United Kingdom
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71
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Karterud HN, Knizek BL, Nakken KO. Changing the diagnosis from epilepsy to PNES: patients' experiences and understanding of their new diagnosis. Seizure 2009; 19:40-6. [PMID: 19963406 DOI: 10.1016/j.seizure.2009.11.001] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2009] [Revised: 10/26/2009] [Accepted: 11/06/2009] [Indexed: 10/20/2022] Open
Abstract
OBJECTIVE To describe patients' experiences when diagnosed with psychogenic non-epileptic seizures (PNES). METHODS The study was based on in-depth interviews with ten patients, previously diagnosed with epilepsy and treated with antiepileptic drugs (AEDs) whose seizures were subsequently defined as PNES. The empirical material was analyzed by systematic text condensing strategies within the interpretative tradition. RESULTS Switch in diagnosis was demanding, both cognitively and emotionally. The patients had difficulty understanding the diagnosis. When the cause of the seizures was unclear, this resulted in feelings of hopelessness and helplessness, a need for re-evaluation of self-understanding, and increased levels of patient stress. The patients felt that with the change in diagnosis, responsibility was transferred from the health authorities to themselves. CONCLUSIONS The mode of communicating the PNES diagnosis may be decisive for the patients' treatment motivation and ability to cope with the disorder. In order to avoid the patients feeling that they have been abandoned with a difficult diagnosis, close cooperation between neurologists and psychiatrists is essential.
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Affiliation(s)
- Hilde Nordahl Karterud
- Department of Neurology, Education and Resource Center, Division of Neuroscience, Rikshospitalet University Hospital, Norway.
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72
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Lund C, Haraldsen I, Lossius MI, Bjørnaes H, Lossius R, Nakken KO. [Psychogenic non-epileptic seizures]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2009; 129:2348-51. [PMID: 19935934 DOI: 10.4045/tidsskr.09.0300] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Psychogenic non-epileptic seizure is the term used for epilepsy-like seizures assumed to have psychological causes. Many patients with such seizures are misdiagnosed with epilepsy, and are consequently treated with antiepileptic drugs for many years. Assessment of a thorough medical history and ictal EEG-recordings will lead to the right diagnosis in most cases. The article provides an overview of this condition, which often represents large diagnostic and therapeutic challenges and is the most frequent differential diagnosis in epilepsy. MATERIAL AND METHODS The article is based on literature identified through a non-systematic search in PubMed up to January 2009. RESULTS Much literature is available in the field. 10-20 % of those referred to epilepsy centers because of therapy-resistant epilepsy, have psychogenic non-epileptic seizures. 70-80 % of these patients are women. The attacks may resemble all types of epileptic seizures, from absence-like episodes to tonic-clonic-like seizures. INTERPRETATION Such seizures may have a wide spectre of causes, including chronic psychological conflicts and psychotraumas. Treatment should therefore be tailored to individuals.
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Affiliation(s)
- Caroline Lund
- Epilepsisenteret - SSE Nevrologisk avdeling, Oslo, Norway.
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LaFrance WC, Syc S. Depression and symptoms affect quality of life in psychogenic nonepileptic seizures. Neurology 2009; 73:366-71. [PMID: 19652140 PMCID: PMC2725930 DOI: 10.1212/wnl.0b013e3181b04c83] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND In patients with active epilepsy, adverse medication effects and severity of depression are correlated with health-related quality of life, but seizure frequency is not. We sought to examine if the same pattern exists in patients with psychogenic nonepileptic seizures (PNES). METHODS We administered seizure calendars, quality of life (QOL) scales, depression scales, and symptom checklists to 49 patients with video EEG-confirmed PNES. Data analysis consisted of performing Pearson correlation coefficients, scatter plots, and t tests. RESULTS Depression and symptom scores significantly increased as health-related QOL scores decreased (partial correlation coefficient r = -0.73 for both comparisons), whereas seizure count was nonsignificant (partial correlation coefficient r = -0.19). CONCLUSIONS As is seen in epilepsy, patients with psychogenic nonepileptic seizures demonstrate that higher depressive symptoms and somatic symptoms are independently related to worsening quality of life (QOL); however, seizure frequency is not. Seizure frequency is an important focus in patient care and treatment trials. The findings underscore the importance of, along with seizure counts, also examining QOL, depression, and somatic symptoms in patients with seizures.
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Affiliation(s)
- W Curt LaFrance
- Departments of Neurology and Psychiatry (W.C.L.), Rhode Island Hospital, Brown Medical School, Providence, RI, USA.
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75
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Ahern L, Stone J, Sharpe MC. Attitudes of Neuroscience Nurses Toward Patients With Conversion Symptoms. PSYCHOSOMATICS 2009; 50:336-9. [DOI: 10.1176/appi.psy.50.4.336] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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What is it like to receive a diagnosis of nonepileptic seizures? Epilepsy Behav 2009; 14:508-15. [PMID: 19162228 DOI: 10.1016/j.yebeh.2008.12.014] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2008] [Accepted: 12/24/2008] [Indexed: 11/23/2022]
Abstract
The aim of this qualitative study was to provide insight into the experience of receiving the diagnosis of nonepileptic seizures (NES) from the patient's perspective. Semistructured interviews were conducted with eight patients who had received the diagnosis of NES over the preceding 6 months. All participants were on a waiting list for psychological treatment. Verbatim records of the interviews were analyzed using interpretative phenomenological analysis (IPA). Six main themes emerged from the data ("the experience of living with nonepileptic seizures", "label and understanding", "being left in limbo land", "doubt and certainty", "feeling like a human being again", and "emotional impact of diagnosis"). An ability to integrate the diagnosis into a personal narrative was key to participants' acceptance of the diagnosis. The communication of the diagnosis left some participants feeling distressed. The results suggest that patients need more time and resources to understand the diagnosis and more support after they have received it.
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Reuber M. Psychogenic nonepileptic seizures: answers and questions. Epilepsy Behav 2008; 12:622-35. [PMID: 18164250 DOI: 10.1016/j.yebeh.2007.11.006] [Citation(s) in RCA: 164] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2007] [Accepted: 11/18/2007] [Indexed: 10/22/2022]
Abstract
Psychogenic nonepileptic seizures (PNES) superficially resemble epileptic seizures, but are not associated with ictal electrical discharges in the brain. PNES constitute one of the most important differential diagnoses of epilepsy. However, despite the fact they have been recognized as a distinctive clinical phenomenon for centuries and that access to video/EEG monitoring has allowed clinicians to make near-certain diagnoses for several decades, our understanding of the etiology, underlying mental processes, and, subsequently, subdifferentiation, nosology, and treatment remains seriously deficient. Emphasizing the clinical picture throughout, the first part of this article is intended to "look and look again" at what we know about the epidemiology, semiology, clinical context, treatment, and prognosis of PNES. The second part is dedicated to the questions that remain to be answered. It argues that the most important reason our understanding of PNES remains limited is the focus on the visible manifestations of PNES or the seizures themselves. In contrast, subjective seizure manifestations and the biographic or clinical context in which they occur have been relatively neglected.
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Affiliation(s)
- Markus Reuber
- Academic Neurology Unit, University of Sheffield/Royal Hallamshire Hospital, Glossop Road, Sheffield, South Yorkshire S10 2JF, UK.
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Stone J, Hewett R, Carson A, Warlow C, Sharpe M. The 'disappearance' of hysteria: historical mystery or illusion? J R Soc Med 2008; 101:12-8. [PMID: 18263908 PMCID: PMC2235919 DOI: 10.1258/jrsm.2007.070129] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Jon Stone
- Department of Clinical Neurosciences, University of Edinburgh, Western General Hospital, Crewe Rd, Edinburgh EH4 2XU, UK.
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79
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Lacey C, Cook M, Salzberg M. The neurologist, psychogenic nonepileptic seizures, and borderline personality disorder. Epilepsy Behav 2007; 11:492-8. [PMID: 18054130 DOI: 10.1016/j.yebeh.2007.09.010] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2007] [Revised: 09/06/2007] [Accepted: 09/07/2007] [Indexed: 01/08/2023]
Abstract
Patients with psychogenic nonepileptic seizures (PNES) are common in tertiary epilepsy centers, emergency departments, and neurological practices. Psychiatric discussion of patients with PNES has emphasized the role of trauma and dissociation. Personality disorder has been considered, but its extensive implications for neurological management have not been fully appreciated. We propose that the most difficult aspects of management stem not from the convulsive episodes, but from the personality disorder that frequently accompanies them. Although it is not the neurologist's role to treat personality disorder, the conduct of the physician-patient relationship can have potent consequences for good or ill on the outcome. We present a brief guide to current concepts of personality disorder; discuss the literature concerning its association with PNES, and offer practical guidelines for the conduct of the neurologist-patient relationship. This perspective offers resolutions to longstanding controversies, including how to communicate the diagnosis, discontinuing medication, and ongoing neurological contact.
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Affiliation(s)
- Cameron Lacey
- Centre for Clinical Neuroscience and Neurological Research, St. Vincent's Hospital Melbourne, Melbourne, Australia.
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Keeley RD, Davidson AJ, Crane LA, Matthews B, Pace W. An association between negatively biased response to neutral stimuli and antidepressant nonadherence. J Psychosom Res 2007; 62:535-44. [PMID: 17467408 DOI: 10.1016/j.jpsychores.2006.12.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2005] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Our primary objective was to test whether negatively biased response to neutral physical or visual stimuli was associated with antidepressant nonadherence. METHODS We surveyed 22 primary care adults receiving pharmacological treatment for depression. Somatoform complaints, in addition to interpretation of and response to neutral facial expressions (NFEs), were assessed with surveys. Seven response anchors to NFE were classified as "negative" or "neutral/positive." Antidepressant adherence was ascertained after 3 months by self-report and pharmacy refill records. RESULTS Elevated somatoform complaints were associated with early antidepressant discontinuation (P=.01). Exclusively negative emotional response to NFE, reported by 55% (12/22) of subjects, was associated with clinically significant missed antidepressant doses (R=-.69, P=.0004). Two multivariate models adjusted for depressive symptoms demonstrated that exclusively positive or neutral emotional response to NFE was associated with improved adherence relative to an exclusively negative response (beta=34.0, t=3.7, P=.002); the somatoform complaints subscale "health concerns" adversely influenced depressive symptom improvement (beta=-.3, t=-3.0, P=.008). CONCLUSION Negatively biased responses to neutral stimuli in the physical and visual axes were associated with early antidepressant discontinuation and missed doses, respectively. If substantiated, these initial findings might contribute to improved understanding and treatment of antidepressant nonadherence.
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Affiliation(s)
- Robert D Keeley
- The Colorado Research Network and Department of Family Medicine at University of Colorado-Denver Health Sciences Center, Aurora, CO 80045, USA.
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Abstract
In this series of case vignettes, the authors have emphasized that the diagnosis of functional symptoms should normally rest on the presence of positive evidence of the problem being functional rather than the absence of evidence of organic disease. In addition, practitioners should be prepared to make a functional diagnosis in a patient who also has evidence of disease. Misdiagnosis of functional symptoms occurs no more than for other neuro-logical and psychiatric disorders. The neurologist has an important role in being able to transmit the diagnosis in a way that will not offend the patient but will also facilitate recovery. The key elements of this explanation are making the patient feel believed and emphasizing potential reversibility. A multidisciplinary approach involving concurrent physical and psychological treatments is often recommended, although further study is required to determine the best approaches to explain and treat these conditions.
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Affiliation(s)
- Jon Stone
- School of Molecular and Clinical Medicine, University of Edinburgh, Western General Hospital, Crewe Road, Edinburgh EH4 2XU, Scotland.
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Kirmayer LJ, Looper KJ. Abnormal illness behaviour: physiological, psychological and social dimensions of coping with distress. Curr Opin Psychiatry 2006; 19:54-60. [PMID: 16612180 DOI: 10.1097/01.yco.0000194810.76096.f2] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Pilowsky introduced the term 'abnormal illness behaviour' to characterize syndromes of excessive or inadequate response to symptoms, including hypochondriasis, somatization, and denial of illness. This review summarizes recent work from sociology, health psychology and psychiatry that contributes to an understanding of the processes that may underlie abnormal illness behaviour. RECENT FINDINGS Disturbances in the regulation of physiological systems may account for many 'unexplained' symptoms and sickness behaviour. Increased attention to bodily sensations, sensitivity to pain and catastrophizing play important roles in illness behaviour in medical illness. Developmental adversities and parental modelling of illness behaviour in childhood may increase bodily preoccupation and health care utilization. Apparent cross-national differences in illness behaviour may reflect differences in health care systems, but cultural models of illness and social stigma remain important determinants of illness denial and avoidance of mental health services. SUMMARY Research into illness behaviour is relevant to efforts to rethink the psychiatric nosology of somatoform disorders. The discrete somatoform disorders might well be replaced by a dimensional framework that identifies specific pathological processes in cognition, perception and social behaviour that contribute to bodily distress, impaired coping, inappropriate use of health services, chronicity and disability.
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Affiliation(s)
- Laurence J Kirmayer
- Division of Social & Transcultural Psychiatry, McGill University, and Department of Psychiatry, Sir Mortimer B. Davis--Jewish General Hospital, Montreal, Quebec, Canada.
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