The experience of adjusting to a diagnosis of non-epileptic attack disorder (NEAD) and the subsequent process of psychological therapy

Stigma in functional neurological disorder (FND) - A systematic review

OBJECTIVE

The purpose of this systematic review was to evaluate stigma and Functional Neurological Disorder (FND) regarding: 1) prevalence and associated factors, 2) the nature and context of stigma in FND, and 3) stigma-reduction interventions.

METHODS

We searched four relevant databases from inception to December 2023, using search terms relevant to FND and stigma themes. We employed the method of synthesis by "aggregation and configuration" to synthesise and analyse the data into emergent themes.

RESULTS

We found 127 studies, spanning 148 countries, involving 18,886 participants. Of these, 4889 were patients, 13,123 were healthcare professionals, and 526 were caregivers. Quantitatively, stigma has been mainly studied in patients with functional seizures, and was higher than patients with epilepsy in three studies. Stigma experienced by patients is associated with poorer quality of life and caregiver burden. We found 10 themes and 29 subthemes revealing stigma as a systemic process, with intrapersonal, interpersonal and structural aspects. Few studies examined the perspective of caregivers, the public or online community. We identified six anti-stigma interventions.

CONCLUSION

Stigma in FND is a layered process, and affects patient quality of life and provision of care. Stigma needs to be addressed from the top structures, at governmental level, so that appropriate care pathways can be created, giving patients with FND parity of esteem with other medical conditions.

"This is real", "this is hard" and "I'm not making it up": Experience of diagnosis and living with non-epileptic attack disorder

PURPOSE

To use a qualitative research approach to explore adults' experience of living with non-epileptic attack disorder.

OBJECTIVE

The objective was to explore the experience of adults (18 years+) with a confirmed diagnosis of non-epileptic attack disorder (NEAD) across the trajectory of the disorder. The topics investigated included the onset of symptoms, the experience of non-epileptic attacks, the diagnostic process and living with NEAD.

METHOD

Twelve people diagnosed with NEAD who attended a tertiary hospital neurology department took part in semi-structured interviews. The data generated were analysed using reflexive thematic analysis.

RESULTS

Eleven women and one man with median age of 25 years took part. Three themes were developed: mind-body (dis)connect, a stigmatised diagnosis and a role for containment. Adults spoke about their experience of nonepileptic attacks, the diagnostic and management process and the impact of both nonepileptic attacks and the NEAD diagnosis on their lives.

CONCLUSIONS

Adults' experience's within the healthcare system across the trajectory of NEAD influenced their own understanding and trust in their NEAD experience, how they shared this with others in their social and work lives and how they managed their NEAD symptoms on a daily basis. The research suggests the need for a consistent, timely implementation of a rule-in diagnostic approach and multi-disciplinary management of NEAD. It is recommended that lessons be taken from theoretical models including the common-sense model and a modified version of the reattribution model to support the de-stigmatisation of this diagnosis to inform psychoeducation and professionally facilitated peer-support groups.

Illness representations of people with later-onset functional seizures

PURPOSE

Although functional seizures can start at any age, little is known about the individuals for whom onset occurs after the age of 40. It has been proposed that health-related traumatic events are more relevant causal factors for people with 'later-onset functional seizures' than for those whose functional seizures begin earlier in life, however, the illness representations of people with later-onset functional seizures have not yet been investigated. This study aimed to understand the experiences and illness representations of people with later-onset functional seizures.

METHODS

This was a mixed-methods study. People with later-onset functional seizures were recruited via a neurologist's caseload and online membership-led organisations. Semi-structured interview transcripts were analysed using Template Analysis according to the Common-Sense Model (CSM). Self-report measures of demographic and clinical details were collected to characterise the sample and verify themes.

RESULTS

Eight people with later-onset functional seizures participated in the study. Illness representations relating to all domains of the CSM as well as an additional theme of 'Triggers' were identified. Functional seizures were characterised as a mysterious brain disorder analogous to a computer malfunction and involving involuntary movements associated with alterations in consciousness. Perceptions of duration were indefinite, and triggers were unknown or at the extremes of autonomic arousal. Half of the sample identified health-related events/trauma as causal. Opinions were divided on 'cumulative life stress' as a causal factor. Most perceived themselves to have limited or no control but having 'control' over seizures was conceptualised as different to reducing their likelihood, frequency, or impact. Later-onset functional seizures were viewed as being more detrimental for caring and financial responsibilities but to have advantages for acceptance.

CONCLUSIONS

This is the first study to assess the illness representations of people with later-onset functional seizures. Many themes were similar to those identified in samples including people with earlier-onset functional seizures. Health-related trauma or events were the most strongly endorsed perceived causal factor, but with the exception of 'consequences', all representations were characterised by uncertainty. Clinicians should hold in mind the interaction between life stage and the consequences of later-onset functional seizures.

Functional neurological disorder: A qualitative study exploring individuals' experiences of psychological services

OBJECTIVES

Individuals with a diagnosis of FND report experiencing stigma in medical settings, however, there is a paucity of research exploring their experiences in psychological services. The aim of this research was to explore experiences of accessing UK psychological services, from the perspective of those with FND.

METHODS

This study utilised a qualitative approach with data collected from semi-structured interviews (n = 15) and analysed using reflexive thematic analysis.

RESULTS

One superordinate theme, 'the stigmatised self within the therapeutic relationship', and five interrelated subthemes were identified: 'internalised stigma and self-doubt', 'selective disclosure to professionals', 'perceptions of psychological explanations', 'having to educate the professionals' and 'attunement and trust within the therapeutic relationship'. Positive therapeutic relationships were perceived to mitigate the impact of these perceived barriers. The conceptualisation of FND and the perception of how this was responded to by services and professionals was a central tenet throughout the related themes.

CONCLUSIONS

Intra-personal, interpersonal and organisational stigma impact access and engagement to psychological treatment. The findings of this study highlight the need for increased training provision for practitioners with a focus on actively challenging FND stigma within services at both an individual and systemic level.

A meta-ethnographic synthesis of the experiences of stigma amongst people with functional neurological disorder

PURPOSE

Functional neurological disorder (FND) causes many neurological symptoms and significant disability. It is often misunderstood by medical professionals and the public meaning stigma is regularly reported. The aim of this review was to synthesise the qualitative findings in the literature to develop a more in-depth understanding of how people with FND experience stigma to inform future interventions.

METHOD

This review used a meta-ethnography approach. Five databases were searched (PsycINFO, Web of Science, CINAHL, MEDLINE, and EMBASE) in February 2021 and updated in July 2022 for qualitative papers in FND. Included papers were critically assessed using the critical appraisal skills programme (CASP) checklist. Data were analysed and synthesised utilising meta-ethnography.

RESULTS AND CONCLUSION

Sixteen papers were included in the final synthesis. Four major themes emerged: stigmatized by delegitimization; stigmatized by social exclusion and rejection; coping with stigma; and stigma and identity. The results identified negative, stigmatizing attitudes towards people experiencing FND symptoms in a variety of contexts including healthcare and other social institutions. The effects of stigma led to further exclusion for participants and appeared to trigger coping styles that led to additional difficulty. Stigma is a key part of the illness experience of FND and needs to be addressed.

Does explaining psychogenic nonepileptic seizures using either a biomedical or biopsychosocial framework affect young people's illness representations? An experimental vignette study

Lay representations of psychogenic nonepileptic seizures (PNES) are important both for understanding public stigma and anticipating patient responses to PNES diagnosis. The current study presents the first evidence of the general public's representations of PNES and the malleability of these understandings to different ways of explaining PNES. An online experimental study exposed participants (n = 193, aged 18-25 years) to a vignette describing a case of PNES in biomedical terms, PNES in biopsychosocial terms, or epilepsy. Subsequent questionnaires assessed participants' illness representations, causal attributions, and stigmatising attitudes regarding the case about which they read. Results suggest that compared with biomedical framings, biopsychosocial explanations increased perceptions of PNES as threatening. While epilepsy was attributed to significantly more biological and less social causes than either of the PNES vignettes, causal attributions did not differ between biomedically- vs. biopsychosocially-framed PNES. Neither were there any differences between the three conditions in stigmatising attitudes towards people who experience seizures. These findings are useful for clinicians delivering a PNES diagnosis and patients disclosing a PNES diagnosis, in helping anticipate responses to these communications. Further research is required to confirm the clinical and societal significance of the study's first insights into the dynamics of lay responses to PNES.

Cultural issues: Perspectives and experiences of patients with dissociative seizures in Argentina

PURPOSE

To explore patients' subjective experience when receiving a diagnosis of Dissociative Seizures (DS) in Buenos Aires, Argentina, and their explanatory models about DS.

METHOD

A qualitative approach using semi-structured interviews was used to gain an in-depth and contextual understanding of the perspectives of 19 patients with DS. Data collection and analysis were followed by an inductive and interpretive approach informed by the principles of thematic analysis.

RESULTS

Four main themes emerged: 1) Reactions to the Diagnosis; 2) Ways of Naming the Disease; 3) Own Explanatory Models; 4) External Explanatory Models.

CONCLUSIONS

This information might help achieve an adequate knowledge of the local characteristics of patients with DS. Most patients could not express any emotions or considerations about being diagnosed with DS, and they related their seizures to a personal or social-emotional conflict and environmental stress; however, family members related patients' seizures to a biological cause. It is important to analyze cultural differences in patients with DS in order to develop appropriate interventions for this specific population.

The clinical management of functional neurological disorder: A scoping review of the literature

OBJECTIVE

To date, there have been no reviews bringing together evidence on the clinical management of functional neurological disorder (FND) and patients', caregivers', and healthcare workers' experiences. This review provides an overview of the literature focused on the clinical management of FND.

METHODS

Four databases were searched, and a consultation exercise was conducted to retrieve relevant records dated from September 2010 to September 2020. Articles documenting diagnostic methods, treatments or interventions, or the experiences and perspectives of patients and healthcare workers in the clinical management of FND were included.

RESULTS

In total, 2756 records were retrieved, with 162 included in this review. The diagnostic methods reported predominantly included positive clinical signs, v-EEG and EEG. Psychological treatments and medication were the most reported treatments. Mixed findings of the effectiveness of CBT were found. Haloperidol, physiotherapy and scripted diagnosis were found to be effective in reducing FND symptoms. Several facilitators and barriers for patients accessing treatment for FND were reported.

CONCLUSION

The literature describing the clinical management for FND has increased considerably in recent times. A wide variety of diagnostic tools and treatments and interventions were found, with more focus being placed on tests that confirm a diagnosis than 'rule-out' tests. The main treatment type found in this review was medication. This review revealed that there is a lack of high-quality evidence and reflects the need for official clinical guidelines for FND, providing healthcare workers and patients the support needed to navigate the process to diagnose and manage FND.

Consequences of a Diagnostic Label: A Systematic Scoping Review and Thematic Framework

Objectives: To develop a thematic framework for the range of consequences arising from a diagnostic label from an individual, family/caregiver, healthcare professional, and community perspective.

Design: Systematic scoping review of qualitative studies.

Search Strategy: We searched PubMed, Embase, PsycINFO, Cochrane, and CINAHL for primary studies and syntheses of primary studies that explore the consequences of labelling non-cancer diagnoses. Reference lists of included studies were screened, and forward citation searches undertaken.

Study Selection: We included peer reviewed publications describing the perceived consequences for individuals labelled with a non-cancer diagnostic label from four perspectives: that of the individual, their family/caregiver, healthcare professional and/or community members. We excluded studies using hypothetical scenarios.

Data Extraction and Synthesis: Data extraction used a three-staged process: one third was used to develop a preliminary framework, the next third for framework validation, and the final third coded if thematic saturation was not achieved. Author themes and supporting quotes were extracted, and analysed from the perspective of individual, family/caregiver, healthcare professional, or community member.

Results: After deduplication, searches identified 7,379 unique articles. Following screening, 146 articles, consisting of 128 primary studies and 18 reviews, were included. The developed framework consisted of five overarching themes relevant to the four perspectives: psychosocial impact (e.g., positive/negative psychological impact, social- and self-identity, stigma), support (e.g., increased, decreased, relationship changes, professional interactions), future planning (e.g., action and uncertainty), behaviour (e.g., beneficial or detrimental modifications), and treatment expectations (e.g., positive/negative experiences). Perspectives of individuals were most frequently reported.

Conclusions: This review developed and validated a framework of five domains of consequences following diagnostic labelling. Further research is required to test the external validity and acceptability of the framework for individuals and their family/caregiver, healthcare professionals, and community.

What is it like to live with a functional movement disorder? An interpretative phenomenological analysis of illness experiences from symptom onset to post-diagnosis

OBJECTIVES

With few empirically supported treatments, functional movement disorders (FMD) can be challenging to manage. To enable service providers to better support people with FMD, this study sought to understand the lived experience of FMD: to gain insight into how individuals make sense of their experience from symptom onset through medical evaluation and diagnosis to post-diagnostic adaptation.

DESIGN

An interpretative phenomenological analysis (IPA) of patient accounts of living with FMD.

METHODS

Eight participants were recruited from a UK teaching hospital adult neurology service: seven females, varying in age (20s-70s), FMD symptom type (tremor, dystonia, and tics), and time to diagnosis (10 - 192 months). Semi-structured interviews facilitated participant accounts of key events. Interviews lasted 75-125 minutes and were transcribed verbatim.

RESULTS

Three super-ordinate themes were apparent. The first covered the experiences of onset ('Something is wrong with me'), including loss of control - with the affected body part often described as a separate entity - threats to identity and disturbance in relationships. 'At last! What now?' outlined the bittersweet experience of diagnosis and of treatments. Third, 'Living my life with it' incorporated ongoing experiences of coping with symptoms. While some continued to struggle with the emotional impact of symptoms, others developed a compassionate relationship with their self and maintained satisfying activities.

CONCLUSIONS

FMD has a significant impact on patients' relationships with themselves and others, which in turn affects well-being. These findings suggest some nuanced additions to interventions (diagnosis, psychotherapy, physiotherapy, public education.).

Stigma in psychogenic nonepileptic seizures

OBJECTIVE

There is scarce literature on stigma in families living with psychogenic nonepileptic seizures (PNES). Using a cohort of patients with epileptic seizures (ES) and their caregivers as controls, we aimed to quantify the level of patient and caregiver stigma in PNES and identify associations of patient and caregiver characteristics with it.

METHODS

Patients with PNES and ES and their caregivers completed surveys about demographic, clinical, and psychosocial characteristics. Multivariate regression analysis was used to identify correlates of patient and caregiver stigma.

RESULTS

Forty-three patients with PNES and 165 patients with ES were recruited. Compared with patients with ES, patients with PNES had shorter disease duration, higher seizure frequency, normal diagnostic data, poorer psychosocial health, and fewer antiseizure medications (ASMs). A total of 76.5% of patients with PNES and 59.5% of patients with ES felt stigmatized. Patient stigma level was higher in patients with PNES compared with those with ES, and it was negatively associated with patient quality of life (QOL). Additionally, 28 caregivers of patients with PNES and 99 caregivers of patients with ES were recruited. There were no significant demographic, caregiving, or psychosocial differences between the two caregiver cohorts. Seventy-two percent of caregivers of patients with PNES and 47% of caregivers of patients with ES felt stigmatized. Caregiver stigma level was also higher in caregivers of patients with PNES compared with caregivers of patients with ES, and it was negatively associated with patient QOL and positively associated with patient and caregiver anxiety.

CONCLUSION

Compared with those with ES, patients and caregivers living with PNES experience stigma more frequently and to a higher extent. Patient QOL emerges as a consistent correlate of that stigma.

La experiencia de pacientes con crisis no epilépticas psicógenas: marcos interpretativos y de acción

Resumen La perspectiva del paciente se presenta como algo importante a tener en cuenta para la comprensión del padecimiento y para lograr un tratamiento efectivo. El objetivo de la presente investigación es indagar las trayectorias terapéuticas y las experiencias durante el recorrido terapéutico de pacientes con Crisis No Epilépticas Psicógenas (CNEP) pertenecientes a un Hospital General de la Ciudad Autónoma de Buenos Aires. Se realizaron entrevistas semiestructuradas a diez pacientes diagnosticados con CNEP. Para el análisis de los datos se utilizó una metodología cualitativa basada en los principios del análisis temático. Se ha identificado una categoría central: Itinerarios terapéuticos dentro del sistema etnomédico y tres subcategorías: (1) Diagnósticos Recibidos; (2) Recursos del sistema etnomédico y (3) Evaluaciones de los recursos utilizados. La dificultad de arribar a un diagnóstico y un tratamiento que permitiera mejorar las CNEP, así como el uso de distintas medicinas, fue destacada por la totalidad de los pacientes.

Experiences and Illness Perceptions of Patients with Functional Symptoms Admitted to Hyperacute Stroke Wards: A Mixed-Method Study

INTRODUCTION

A proportion of patients admitted to acute-stroke settings have not had a stroke, but have conditions mimicking a stroke. Approximately 25% of suspected stroke cases are "stroke mimics" and 2% are patients with functional symptoms - "functional stroke mimics". This study aimed to explore experiences and illness perceptions of patients with functional symptoms admitted to hyperacute stroke wards.

METHODS

This study used mixed methods. Patients with functional stroke symptoms participated in semistructured qualitative interviews immediately after admission to one of two acute-stroke units in London and again 2 months after hospital discharge. Qualitative data were assessed using thematic analysis. The Brief Illness Perception Questionnaire (Brief-IPQ) measured illness perceptions at admission and at 2-month follow-up.

RESULTS

A total of 36 participants completed baseline interviews and 25 completed follow-up. Six themes emerged: physical symptom experience, emotional and coping responses, symptom causes, hospital experiences, views on the future, and uncertainty after hospital discharge. Mean Brief-IPQ score at admission was 49.3 (SD: 9.9), indicating a moderate-high level of perceived illness threat. Participants presented with a range of functional symptoms. At baseline, participants were highly concerned about their symptoms, but this had decreased at 2-month follow-up. Two months later, many were confused as to the cause of their admission.

CONCLUSION

This is the first study to examine functional stroke patients' experiences of acute-stroke admission. At admission, patients expressed confusion regarding their diagnosis, experienced high levels of emotional distress, and were concerned they were perceived as time wasting by stroke clinicians. While most participants experienced symptom recovery, there was a significant subgroup for whom symptoms persisted or worsened. A lack of care guidelines on the management of functional stroke patients may perpetuate functional symptoms.

Written Accounts of Living With Epilepsy or Psychogenic Nonepileptic Seizures: A Thematic Comparison

This study examines the subjective experience of living with epilepsy or psychogenic nonepileptic seizures (PNES) by thematically comparing individuals' written accounts of their condition. Five key differences emerged. Theme 1: "Seizure onset" revealed differences in how individuals think about and ruminate over the possible causes of their condition. Theme 2: "Emotive tone" demonstrated that writings of those with epilepsy reflected stable emotions (no intense emotional reactions), whereas those of writers with PNES reflected anxiety and low mood. Theme 3: "Seizure symptoms" showed differences in the conceptualization of seizures. Theme 4: "Treatment" explored differences in the diagnostic journey and experiences of health care professionals. Theme 5: "Daily life" revealed that those with epilepsy perceived sequelae and seizures as something that must be fought, whereas those with PNES tended to describe their seizures as a place they enter and something that has destroyed their lives. The findings have implications for treatment and management.

Health related quality of life of people with non-epileptic seizures: The role of socio-demographic characteristics and stigma

PURPOSE

People with non-epileptic seizures (NES) consistently report poorer Health-Related Quality of Life (HRQoL) than people with epilepsy. Yet, unlike in epilepsy, knowledge of how social factors influence the HRQoL of adults with NES is limited. To add to the evidence base, this study explores the relationship between HRQoL and perceived stigma among adults with NES, and the role of socio-demographic characteristics.

METHODS

Data was gathered from a survey of 115 people living with the condition, recruited from online support groups. Participants provided socio-demographic and health-related data and completed a series of questions investigating their HRQoL (QOLIE-31) and stigma perceptions (10-item Epilepsy Stigma Scale).

RESULTS

Participants were found to experience high levels of perceived stigma (median 5.2, mean 4.9). A significant and moderate inverse correlation was observed between HRQoL and stigma (r_s - 0.474, p = < 0.001); suggesting higher perceptions of stigma contribute to poorer HRQoL among adults with NES. Stigma perceptions were found to be most strongly associated with the seizure worry (r_s = - 0.479), emotional wellbeing (r_s = - 0.421), and social functioning (r_s = 0.407) HRQoL domains. Participants who reported being in employment or education were found to have significantly better HRQoL than those who were not (p = < 0.001).

CONCLUSION

More (qualitative and quantitative) research is justified to understand how - and why - those with the condition experience stigmatisation, and the factors that impede and help facilitate the participation of people with NES in education and employment.

" Blaming, shaming, humiliation": Stigmatising medical interactions among people with non-epileptic seizures

Background: People with non-epileptic seizures (NES) describe challenging relationships with health professionals, and explain negative interactions as common and expected. Despite these difficulties, little is known about how people with NES experience difficult healthcare encounters. Methods: Using a thematic discourse analysis approach, we analysed the free-text survey responses of 135 people with NES and asked: what kind of challenges do people living with this condition encounter when interacting with health professionals, and how do they experience the consequences of difficult interactions? We explore their experiences by interpreting the latent meaning of participants' texts from a social-constructionist perspective on health and illness. Results: The overarching narrative depicts a fundamental breakdown in patient-provider relationships. According to our data, the negative experiences of study participants emerge from more than practitioners' lack of awareness of NES and access to information about the condition - to the extent that it is available. In examining the challenges people with NES encounter when interacting with health professionals, their main experiences centre on blame and humiliation. When exploring their experiences, theories of stigma serve as a useful theoretical framework. Conclusions: Normative judgements arising from psychogenic understandings of NES are stigmatising and restrict professional displays of respectful (patient-centred) care. Those with the condition depict being negatively stereotyped, illegitimated and held morally culpable by health professionals. Perceived to lack medical, moral and credible status, participants describe practitioners who treat them with disrespect, and some recount conduct that defies all ethical and professional obligations and standards. These encounters can have wide-ranging adverse consequences for patients: emotionally, physically, and for their future healthcare. The quality of healthcare interactions for people with NES requires urgent improvements. In addition to increased awareness of the condition, practitioners need to be conscious of making and acting on adverse moral appraisals when interacting with this patient group.

" Blaming, shaming, humiliation": Stigmatising medical interactions among people with non-epileptic seizures

Background: People with non-epileptic seizures (NES) describe challenging relationships with health professionals, and explain negative interactions as common and expected. Despite these difficulties, little is known about how people with NES experience difficult healthcare encounters. Methods: Using a thematic discourse analysis approach, we analysed the free-text survey responses of 135 people with NES and asked: what kind of challenges do people living with this condition encounter when interacting with health professionals, and how do they experience the consequences of difficult interactions? We explore their experiences by interpreting the latent meaning of participants' texts from a social-constructionist perspective on health and illness. Results: The overarching narrative depicts a fundamental breakdown in patient-provider relationships. According to our data, the negative experiences of study participants emerge from more than practitioners' lack of awareness of NES and access to information about the condition - to the extent that it is available. In examining the challenges people with NES encounter when interacting with health professionals, their main experiences centre on blame and humiliation. When exploring their experiences, theories of stigma serve as a useful theoretical framework. Conclusions: Normative judgements arising from psychogenic understandings of NES are stigmatising and restrict professional displays of respectful (patient-centred) care. Those with the condition depict being negatively stereotyped, illegitimated and held morally culpable by health professionals. Perceived to lack medical, moral and credible status, participants describe practitioners who treat them with disrespect, and some recount conduct that defies all ethical and professional obligations and standards. These encounters can have wide-ranging adverse consequences for patients: emotionally, physically, and for their future healthcare. The quality of healthcare interactions for people with NES requires urgent improvements. In addition to increased awareness of the condition, practitioners need to be conscious of making and acting on adverse moral appraisals when interacting with this patient group.

What patients think about psychogenic nonepileptic seizures in Buenos Aires, Argentina: A qualitative approach

PURPOSE

To analyse the methods of reasoning with regard to patients' experiences of living with psychogenic nonepileptic seizures (PNES) in Buenos Aires, Argentina.

METHOD

A qualitative approach using semi-structured interviews was used to gain an in-depth and contextual understanding of the perspectives of five patients with PNES. Data collection and analysis were followed by an inductive and interpretive approach informed by the principles of thematic analysis.

RESULTS

Explanatory models and prototypes were identified from the patients' narratives. Four patients related their suffering regarding psychosocial causes -family conflicts, sexual harassment, and life changes, among others-. Hereditary and organic hypotheses appeared to be unspecific. Folk explanations were common to all participants (magic, witchcraft, energetic causes). Four patients used the term epilepsy as an illness prototype, focusing on seizures and the use of antiepileptic drugs. Three of them also compared their illness to other people's "attacks" (heart attacks, panic attacks, nervous breakdown). Only one of them referred to someone who was suspected of having epilepsy.

CONCLUSION

Patients' psychosocial explanatory models are different from the results of previous studies because these studies indicate that most patients support somatic explanations. Patients also use folk explanations related to traditional medicine, which highlights the interpersonal aspects of the disease. Doctor-patient communication is essential for a correct understanding of PNES, resulting in better outcomes. It could also help to reduce the cultural distance between professionals and patients, leading to narrowing inequalities present in multicultural healthcare services.

Written accounts of living with psychogenic nonepileptic seizures: A thematic analysis

PURPOSE

Qualitative studies examining lived experiences of psychogenic nonepileptic seizures (PNES) have predominantly relied on datasets collected using clinical or research interviews. This study pursued a different approach by investigating individuals' written accounts of their condition.

METHODS

Participants (n=19) were recruited from membership-led organisations for individuals living with seizures and from a United Kingdom hospital. Participants were instructed to produce four pieces of writing: 1) about their thoughts and feelings about their condition; 2) a letter to their condition; 3) a letter to their younger self; and 4) about a personal value. All writings were analysed using thematic analysis.

RESULTS

Six main-themes emerged from the data. Theme 1: 'living with PNES' demonstrated that all participants presented the condition as having a debilitating effect. Theme 2: 'Emotions' revealed that individuals were struggling with anxiety, low mood and self-worth. Theme 3: 'Seizure symptoms' showed variability was a prominent feature in the description of ictal events. Theme 4: 'Treatment and outcomes' demonstrated that individual's perception of diagnosis and therapy differed greatly. Theme 5: 'Causation and development' revealed that the majority of participants spontaneously reported experiencing a traumatic event in the past. Theme 6: 'Lack of understanding' by themselves, the public and healthcare professionals appeared to pose considerable challenges to participants.

CONCLUSIONS

Qualitative research has an important role to play for improving our understanding of PNES. The findings contribute to the literature by highlighting the nature of stigma that people with PNES experience, and also their proneness to demonstrate problems with self-worth.

Predictors of health-related quality of life in patients with epilepsy and psychogenic nonepileptic seizures

Epilepsy and psychogenic nonepileptic seizures (PNES) are associated with reduced health-related quality of life (HRQoL). The present study investigated the profile, relationship, and predictive power of illness perceptions, psychological distress (depression and anxiety), seizure activity, and demographic factors on HRQoL in these patient groups. Patients with epilepsy (n=62) and PNES (n=45) were recruited from a United Kingdom hospital and from membership-led organizations for individuals living with seizures. Patients completed a series of self-report questionnaires assessing: anxiety (GAD-7), depression (NDDI-E), illness perceptions (B-IPQ), HRQoL (NEWQOL-6D), and seizure frequency and severity (LSSS-3). Correlational and hierarchical multiple regression analyses were conducted. Patients with epilepsy reported higher HRQoL and scored lower on measures of depression and anxiety. Patients with PNES perceived their condition as more threatening overall. In both conditions, HRQoL was negatively correlated with more severe illness perceptions and psychological distress. In epilepsy and PNES, psychological distress (epilepsy: 27%; PNES: 24.8%) and illness perceptions (epilepsy: 23.1%; PNES: 23.3%) accounted for the largest amount of variance in HRQoL. Clinical factors were found not to be significant predictors, while demographic factors predicted HRQoL in epilepsy (12.6%), but not in PNES. Our findings support the notion that psychological factors are a stronger predictor of HRQoL in epilepsy and PNES than condition-related and demographic variables. Prior research suggests that anxiety and depression are key predictors of HRQoL; this study demonstrates that the relationship between illness perceptions and HRQoL is similarly close. These findings highlight the importance of addressing patients' beliefs about their condition.

Emotion and dissociative seizures: A phenomenological analysis of patients' perspectives

Quantitative research has indicated that patients with dissociative seizures (DS) show altered responses to emotional stimuli, in addition to considerable emotional distress and dysregulation. The present study sought to further explore emotional processes in this population, to extend previous findings, and to provide a phenomenological insight into patients' perspectives on these issues. Semistructured interviews were carried out with 15 patients with DS, and the principles of interpretative phenomenological analysis (IPA) were adopted in data analysis. Key themes elicited included: i) general emotional functioning; ii) adverse (stressful/traumatic) life experiences; iii) the role of emotions in DS; iv) relating to others; and v) resilience, protective factors, and coping mechanisms. The clinical and theoretical implications of the findings are discussed.