Narrative analysis of written accounts about living with epileptic or psychogenic nonepileptic seizures

Physiotherapy management of functional movement disorders: the patient perspective

PURPOSE

People with functional movement disorders (FMD) are commonly seen in neurology clinics. Despite a recent increase in research, no standardised treatment pathway across the UK exists. Currently only a few qualitative studies in FMD with a focus on psychological aspects and diagnosis have been published. This study aimed to understand people with FMD perceptions of their physiotherapy treatment.

METHOD

Qualitative web-based interviews were conducted with seven participants and an interpretive phenomenological approach was used to identify themes from the data.

RESULTS

Four themes were identified; 1) my brain, mind and body are all me, 2) physiotherapy; what helps and what doesn't, 3) what recovery is to me, and 4) barriers to treatment. Participants desired a combination of psychological and physical approaches, which were holistic, individualised, and delivered by experienced physiotherapists. Limited availability and funding of specialist treatments were barriers to recovery.

CONCLUSION

Holistic management combining psychological and physiological systems seems to be crucial for effective management of FMD. Large variations in physiotherapy treatment exist across the UK. It is hoped that increasing the understanding, amongst healthcare professionals will lead to the development of timely and appropriate pathways for patients that otherwise find themselves lost between medical specialities.IMPLICATIONS FOR REHABILITATIONPatients report more positive experiences when a combined and detailed psychological and physiological explanation to their symptoms is given.An individualised approach working with the patient on activities they find challenging is more preferable than group exercise or impairment based (e.g., strengthening/stretching) treatments.Having a physiotherapist who is experienced in treating functional movement disorders or prepared to learn and understand them helped with adherence to treatment.

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.

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.

The promises and pitfalls of seizure phenomenology

The typical adult patient presenting with a first seizure has a normal clinical examination, uninformative investigations, and often has no witness to their episode. The assessing clinician, therefore, has one primary source of information to guide their assessment; the patient's experience. However, seizure phenomenology - the subjective seizure experience - has received relatively less attention by researchers than objective semiology or investigations. This essay reviews the clinical importance of seizure phenomenology, and the challenges clinicians face in eliciting accurate and clinically relevant descriptions of ictal experience. I conclude by discussing tools that clinicians may use to support the clinical application of seizure phenomenology, and exploring the subjectivity of epilepsy more broadly.

The neurobiology of functional neurological disorders characterised by impaired awareness

We review the neurobiology of Functional Neurological Disorders (FND), i.e., neurological disorders not explained by currently identifiable histopathological processes, in order to focus on those characterised by impaired awareness (functionally impaired awareness disorders, FIAD), and especially, on the paradigmatic case of Resignation Syndrome (RS). We thus provide an improved more integrated theory of FIAD, able to guide both research priorities and the diagnostic formulation of FIAD. We systematically address the diverse spectrum of clinical presentations of FND with impaired awareness, and offer a new framework for understanding FIAD. We find that unraveling the historical development of neurobiological theory of FIAD is of paramount importance for its current understanding. Then, we integrate contemporary clinical material in order to contextualise the neurobiology of FIAD within social, cultural, and psychological perspectives. We thus review neuro-computational insights in FND in general, to arrive at a more coherent account of FIAD. FIAD may be based on maladaptive predictive coding, shaped by stress, attention, uncertainty, and, ultimately, neurally encoded beliefs and their updates. We also critically appraise arguments in support of and against such Bayesian models. Finally, we discuss implications of our theoretical account and provide pointers towards an improved clinical diagnostic formulation of FIAD. We suggest directions for future research towards a more unified theory on which future interventions and management strategies could be based, as effective treatments and clinical trial evidence remain limited.

Unmet needs of people with epilepsy: A qualitative study exploring their journey from presentation to long-term management across five European countries

Introduction

Epilepsy is a neurological disease that can negatively impact a person's physical, psychological, social, and emotional well-being. The aim of this study was to provide insights into the experiences of people with epilepsy on polytherapy (i.e., people on a combination of two or more anti-seizure medications [ASMs]), with an emphasis on their emotional journey.

Methods

Market research was conducted with 40 people with epilepsy from France, Germany, Italy, Spain, and the United Kingdom. Semi-structured interviews were analyzed using both a content and framework analysis approach. A content analysis of participants' expressed emotions was used to illustrate the changes of emotions experienced by people with epilepsy from presentation through to monitoring and follow-up stages.

Results

In each stage of the journey, themes and subthemes were identified under the overarching headings: Stage 1: Presentation - Life is turned upside down; Stage 2: Diagnosis - Period of learning; Stage 3: Treatment - Aspirations and experimentation; and Stage 4: Monitoring and follow-up - Feeling "out on a limb". The research identified key unmet needs and opportunities for people with epilepsy to improve their subjective experiences at different stages of their disease journey, namely: (1) establish and promote support networks from presentation through to monitoring and follow-up stages; (2) accelerate pathway to diagnosis; (3) provide opportunities to discuss the diagnosis with patients; (4) clarify treatment-change guidelines for patients; and (5) develop a shared treatment decision-making/empowerment tool.

Discussion

The research findings and recommendations have the potential to drive change at an individual level, as well as at a healthcare level.

Quality of Life in Psychogenic Nonepileptic Seizures: An Evolutionary Concept Analysis

Psychogenic nonepileptic seizures (PNES) pose a serious threat to quality of life (QOL) in patients who battle the disorder. As psychological treatment options have progressed, improvement in QOL has become a more common desired outcome. Despite its relevance in PNES research and treatment, QOL has not been defined in the PNES population. Rodgers' Evolutionary Method of concept analysis was used to analyze 47 articles and clarify the concept of QOL in PNES. QOL in PNES is subjective, multidimensional, associated with symptoms, and dynamic in nature. This conceptualization of QOL in PNES may be useful in future PNES research and treatment.

Catastrophising and repetitive negative thinking tendencies in patients with psychogenic non-epileptic seizures or epilepsy

PURPOSE

Previous research suggests that catastrophisation and perseverative, or repetitive negative thinking (RNT) could play an important role in the aetiology of Psychogenic Nonepileptic Seizures (PNES). This study was designed to explore whether these cognitive tendencies are more prevalent in patients with PNES than those with epilepsy and to examine the relationship between these cognitions, depression, anxiety, seizure frequency and diagnosis.

METHODS

26 patients with PNES (PWPNES) and 29 with epilepsy (PWE) self-reported RNT (Perseverative Thinking Questionnaire), catastrophisation tendencies (modified Safety Behaviors and Catastrophizing Scale), symptoms of anxiety (Generalised Anxiety Disorder Assessment 7) and depression (Primary Health Questionnaire 9) as well as seizure frequency.

RESULTS

RNT and catastrophic thinking were highly correlated with each other and more prevalent in PWPNES than PWE. Positive correlations were also found between all other self-report measures and seizure frequency. The PNES diagnosis predicted RNT (perseverative thinking) independently of catastrophic thinking, anxiety, depression and seizure frequency.

CONCLUSION

PWPNES exhibit greater negative perseverative and catastrophising cognitive tendencies than PWE. PNES as a diagnosis independently predicted RNT. Hence, RNT and catastrophisation should be considered as possible specific targets for psychological interventions in patients with PNES.

Perceptions in PNES: A Bidirectional Problem

Health Care Practitioners' Perceptions of Psychogenic Nonepileptic Seizures: A Systematic Review of Qualitative and Quantitative Studies Rawlings GH, Reuber M. Epilepsia. 2018;59(6):1109-1123. doi:10.1111/epi.14189. Epub 2018 May 11. A recent systematic synthesis of qualitative research demonstrated that patients with psychogenic nonepileptic seizures (PNES) often experience unsatisfactory encounters with health-care practitioners (HCPs). It is important to understand such interactions from the perspective of those responsible for delivering care. This systematic review aimed to examine the attitudes and perceptions of HCPs toward PNES. A systematic search of 3 databases (Web of Science, PubMed, and CINAHL) was conducted in November 2017. Studies from around the world published after 1997 using qualitative or quantitative methodologies were reviewed. An interpretative stance was taken to analyze the data utilizing a grounded theory approach. The quality of studies included was assessed using the Mixed Methods Appraisal Tool. Overall, 30 separate studies capturing the views of at least 3900 professionals were included. Five concepts emerged from the analysis: (1) HCPs' responses demonstrated uncertainty about many aspects of PNES, including diagnosis and treatment; (2) HCPs understood PNES in dualistic terms, perceiving the condition as largely associated with psychological factors; (3) patients with PNES were considered challenging and frustrating; (4) HCPs held mixed or contested views about who is responsible for treating patients with PNES; and (5) PNES was viewed as less severe or disabling than epilepsy and associated with a greater degree of volition. Although some HCPs have an excellent understanding of PNES, the views of many give rise to concern. The number of qualitative studies that directly ask HCPs about their perceptions of PNES is limited. Moreover, some professional groups (ie, mental health specialists) are underrepresented in current research. This study reveals a demand for additional training. However, effort is needed also to change the attitudes of some practitioners toward PNES.