Emotion regulation profiles in psychogenic non-epileptic seizures

[Functional neurological disorders: A clinical anthology]

Functional neurological disorders have a broad phenotypic spectrum and include different clinical syndromes, which are sometimes associated to each other or appear consecutively over the course of the disease. This clinical anthology provides details on the specific and sensitive positive signs that are to be sought in the context of a suspected functional neurological disorder. Beside these positive elements leading to the diagnosis of functional neurological disorder, we should keep in mind the possibility of an associated organic disorder as the combination of both organic and functional disorders is a relatively frequent situation in clinical practice. Here we describe the clinical characteristics of different functional neurological syndromes: motor deficits, abnormal hyperkinetic and hypokinetic movements, voice or speech disorders, sensory disorders, and functional dissociative seizures. The clinical examination and the identification of positive signs play a critical role in the diagnosis of functional neurological disorder. Knowledge of the specific signs associated with each phenotype render possible to make an early diagnosis. For that matter, it contributes to the improvement of patient care management. It allows to a better engagement in an appropriate care pathway, which influence their prognosis. Highlighting and discussing positive signs with patients can also be an interesting step in the process of explaining the disease and its management.

Socioemotional self- and co-regulation in functional seizures: comparing high and low posttraumatic stress

Functional seizures (FS) are seizure-like symptoms without electroencephalogram (EEG)-based epileptic activity. Those with FS often show emotion-related dysfunction and disrupted interpersonal relationships, in which posttraumatic stress disorder symptoms (PTS) may play a role. We sought to better understand trauma comorbidities and socioemotional processes in FS, including affectionate touch, a form of social connection linked to emotion regulation and awareness. We administered questionnaires online to a community sample of 89 trauma-exposed FS participants (FS diagnoses were self-reported), 51 with and 38 without clinical-level PTS (FS-PTShi, FS-PTSlo) and 216 seizure-free matched trauma-exposed controls (TCs), 91 with and 125 without clinical-level PTS (TC-PTShi, TC-PTSlo) per the Posttraumatic Stress Disorder Symptom Checklist (PCL). As hypothesized, both FS-PTShi and FS-PTSlo reported more emotional avoidance (Brief Experiential Avoidance Questionnaire), more emotion regulation difficulties (Difficulties in Emotion Regulation Scale), and more perceived stress (Perceived Stress Scale) than PTS-matched counterparts. FS-PTShi also reported less reappraisal (Emotion Regulation Questionnaire), more loneliness (UCLA Loneliness Scale), and less frequent affectionate touch (Physical Affection Scale) during waking and surrounding sleep than TC-PTShi, whereas FS-PTSlo and TC-PTSlo did not differ. Neither FS group differed from PTS-matched controls in emotion suppression (Emotion Regulation Questionnaire) or comfort with social touch (Social Touch Questionnaire). Among FS, FS-PTShi reported more difficulties than FS-PTSlo on nearly all measures (non-significant trend for social support). Findings underscore potential synergistic effects of FS and PTS clinical symptoms in shaping experiences of one's emotions and social world, suggesting fostering meaningful connections with others, including via affectionate touch, is an important treatment target.

Effect of alexithymia and difficulty of emotion regulation, neuroticism, low extraversion, and suicidality on quality of life in epilepsy

OBJECTIVE

The objective of this study was to investigate alexithymia, emotion dysregulation, suicidality, and personality traits in people with epilepsy (PWE) and to evaluate their effects on quality of life.

MATERIALS AND METHODS

Forty-six consecutive PWE and forty healthy control subjects (HC) were recruited for the study. Both PWE and HC were interviewed and completed the following questionnaires: Toronto Alexithymia Scale-20(TAS-20), Difficulties in Emotion Regulation Scale (DERS), Eysenck Personality Questionnaire, Suicidal Ideation Scale, Beck Depression Inventory-II, Beck Anxiety Inventory, and Quality Of Life In Epilepsy-31.

RESULTS

TAS-20 and difficulty identifying feelings which was the subgroup of TAS-20, scores of total and non-acceptance, goals, impulse, strategies, and clarity subgroups of DERS were statistically significantly higher in PWE (p = 0.01, 0.004, 0.01, 0.07, 0.009, 0.06, 0.01, respectively). Considering the personality characteristics, neuroticism was more common in PWE, while extraversion was less common. Suicidal ideation and anxiety scores were higher in PWE than HC (p = 0.02, p = 0.003). Anxiety, suicidal ideation, neuroticism, alexithymia and emotion dysregulation had a negative relationship on quality of life. (r = -0.54, p < 0.001; r = -0.54, p < 0.001; r = -0.62, p < 0.001; r = -0.32, p = 0.02; r = -0.52, p < 0.001).

CONCLUSION

Difficulty identifying feelings, dysregulation of emotions especially nonacceptance, goals, impulse, strategies, and clarity are common in PWE. Anxiety, suicidal ideation, neuroticism, alexithymia, and emotion dysregulation had a negative impact on quality of life. Each of these are important for psychosocial wellbeing of our patients and must be questioned considering their effects on quality of life.

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.

Heterogeneity of patients with functional/dissociative seizures: Three multidimensional profiles

OBJECTIVE

Current concepts highlight the neurological and psychological heterogeneity of functional/dissociative seizures (FDS). However, it remains uncertain whether it is possible to distinguish between a limited number of subtypes of FDS disorders. We aimed to identify profiles of distinct FDS subtypes by cluster analysis of a multidimensional dataset without any a priori hypothesis.

METHODS

We conducted an exploratory, prospective multicenter study of 169 patients with FDS. We collected biographical, trauma (childhood and adulthood traumatic experiences), semiological (seizure characteristics), and psychopathological data (psychiatric comorbidities, dissociation, and alexithymia) through psychiatric interviews and standardized scales. Clusters were identified by the Partitioning Around Medoids method. The similarity of patients was computed using Gower distance. The clusters were compared using analysis of variance, chi-squared, or Fisher exact tests.

RESULTS

Three patient clusters were identified in this exploratory, hypothesis-generating study and named on the basis of their most prominent characteristics: A "No/Single Trauma" group (31.4%), with more male patients, intellectual disabilities, and nonhyperkinetic seizures, and a low level of psychopathology; A "Cumulative Lifetime Traumas" group (42.6%), with clear female predominance, hyperkinetic seizures, relatively common comorbid epilepsy, and a high level of psychopathology; and A "Childhood Traumas" group (26%), commonly with comorbid epilepsy, history of childhood sexual abuse (75%), and posttraumatic stress disorder, but also with a high level of anxiety and dissociation.

SIGNIFICANCE

Although our cluster analysis was undertaken without any a priori hypothesis, the nature of the trauma history emerged as the most important differentiator between three common FDS disorder subtypes. This subdifferentiation of FDS disorders may facilitate the development of more specific therapeutic programs for each patient profile.

Functional (psychogenic non-epileptic/dissociative) seizures: why and how?

Functional seizures (FS) known also as psychogenic non-epileptic seizures or dissociative seizures, present with ictal semiological manifestations, along with various comorbid neurological and psychological disorders. Terminology inconsistencies and discrepancies in nomenclatures of FS may reflect limitations in understanding the neuropsychiatric intricacies of this disorder. Psychological and neurobiological processes of FS are incompletely understood. Nevertheless, important advances have been made on underlying neuropsychopathophysiological mechanisms of FS. These advances provide valuable information about the underlying mechanisms of mind-body interactions. From this perspective, this narrative review summarises recent studies about aetiopathogenesis of FS at two levels: possible risk factors (why) and different aetiopathogenic models of FS (how). We divided possible risk factors for FS into three categories, namely neurobiological, psychological and cognitive risk factors. We also presented different models of FS based on psychological and neuroanatomical understanding, multilevel models and integrative understanding of FS. This work should help professionals to better understand current views on the multifactorial mechanisms involved in the development of FS. Shedding light on the different FS profiles in terms of aetiopathogenesis will help guide how best to direct therapy, based on these different underlying mechanisms.

Are Functional (Psychogenic Nonepileptic) Seizures the Sole Expression of Psychological Processes?

Functional [psychogenic nonepileptic/dissociative] seizures (FND-seiz) and related functional neurological disorder subtypes were of immense interest to early founders of modern-day neurology and psychiatry. Unfortunately, the divide that occurred between the both specialties throughout the mid-twentieth century placed FND-seiz at the borderland between the two disciplines. In the process, a false Cartesian dualism emerged that labeled psychiatric conditions as impairments of the mind and neurological conditions as disturbances in structural neuroanatomy. Excitingly, modern-day neuropsychiatric perspectives now consider neurologic and psychiatric conditions as disorders of both brain and mind. In this article, we aim to integrate neurologic and psychiatric perspectives in the conceptual framing of FND-seiz. In doing so, we explore emerging relationships between symptoms, neuropsychological constructs, brain networks, and neuroendocrine/autonomic biomarkers of disease. Evidence suggests that the neuropsychological constructs of emotion processing, attention, interoception, and self-agency are important in the pathophysiology of FND-seiz. Furthermore, FND-seiz is a multi-network brain disorder, with evidence supporting roles for disturbances within and across the salience, limbic, attentional, multimodal integration, and sensorimotor networks. Risk factors, including the magnitude of previously experienced adverse life events, relate to individual differences in network architecture and neuroendocrine profiles. The time has come to use an integrated neuropsychiatric approach that embraces the closely intertwined relationship between physical health and mental health to conceptualize FND-seiz and related functional neurological disorder subtypes.

A South African review of routinely-collected health data of psychogenic nonepileptic seizure patients referred to psychiatrists in Johannesburg

Patients with psychogenic nonepileptic seizures (PNES) are often referred to psychiatrists for treatment of functional neurological symptom disorder (FNSD). However, not all patients with FNSD have an identified psychiatric comorbidity [1]. The aim of this observational study was to characterize the clinical and psychiatric features of patients with PNES from Johannesburg, South Africa, where a high frequency of PNES has been reported [2], and compare these findings to other reports. We hypothesized that patient outcomes regarding treatment adherence and episode frequency would improve when treated within a closed multidisciplinary team. The data included a retrospective record review of patients diagnosed with PNES from an epilepsy monitoring unit and referred for psychiatric assessment and treatment between November 2013 and July 2017. Fifty-nine cases met the criteria for the study. There were 7 male and 52 female participants, aged between 14 and 72 years (M = 33.76, SD = 13.88). The most frequently reported comorbid symptoms were anxiety (90%); dissociative symptoms (51%); headaches (76%) and gastrointestinal symptoms (36%). Important patient characteristics included past substance abuse (76%); impaired attachment (86%); past trauma (69%) and sexual trauma (29%). Generalized anxiety disorder (76%), major depressive disorder (64%) and PTSD (22%) were the most prevalent psychiatric diagnoses. After receiving psychiatric treatment, 47% of patients experienced a decrease in the frequency of episodes, while 86% became aware of the precipitants of their episodes. Psychiatric data can valuably inform current theories of PNES management. This study contributes to the understanding of comorbid, aetiological, and prognostic factors that are crucial to refining coherent models that will guide practice.

Sleep Disturbances in Patients with Nonepileptic Seizures

OBJECTIVE

Up to 20% of patients treated for epileptic seizures experience psychogenic nonepileptic paroxysms (PNES). These patients present a significant burden for the health care systems because of poor treatment outcomes. The presented review aims to summarize the current state of knowledge on sleep disturbances in patients with nonepileptic seizures.

METHODS

Articles were acquired via PubMed and Web of Science, and papers between January 1990 and March 2020 were extracted. Inclusion criteria were (1) published in a peer-reviewed journal: (2) studies in humans only; or (3) reviews on a related topic; (4) English language. The exclusion criteria were: (1) abstracts from conferences; (2) commentaries; (3) subjects younger than 18 years. From primary assessment, 122 articles were extracted; after obtaining full texts and secondary articles from reference lists, 45 papers were used in this review.

RESULTS

Limited data are available regarding sleep disorders in PNES patients, over the last 30 years only nine original research papers addressed sleep problems in patients with PNES with only six studies assessing objectively measured changes in sleep. Current literature supports the subjective perception of the sleep disturbances with mixed results in objective pathophysiological findings. Conflicting results regarding the REM phase can be found, and studies reported both shortening and prolonging of the REM phase with methodological limitations. Poor sleep quality and shortened duration have been consistently described in most of the studies.

CONCLUSION

Further research on a broader spectrum of patients with PNES is needed, primarily focusing on objective neurophysiological findings. Quality of life in patients suffering from PNES can be increased by good sleep habits and treatment of comorbid sleep disorders.

Correlates of health-related quality of life in youth with psychogenic non-epileptic seizures

BACKGROUND

Few studies have examined factors associated with health-related quality of life (HRQoL) in youth with psychogenic non-epileptic seizures (PNES). In adults, internalizing symptoms such as depression have been shown to be more closely associated with HRQoL than seizure frequency, however, this has not been studied in samples of youth. Investigations into these areas are needed in order to enhance our understanding of the impact of this condition on children and adolescents and inform future clinical intervention.

METHODS

The current study includes 37 youth and one of their parents who attended a clinic visit for treatment of PNES. Children and parents completed measures of psychological functioning, and medical data were extracted from patient charts.

RESULTS

Parent-reported anxiety (B=-0.45, p = 0.05) and depression (B=-0.60, p = 0.01) were related to parent-report of HRQoL; self-report of depression was related to self-reported HRQoL (B=-0.90, p < 0.001). Seizure frequency, somatic complaints, and social problems were not related to HRQoL in this sample.

CONCLUSIONS

Internalizing symptoms, not seizure frequency, are associated with poorer overall functioning in youth with PNES. Interventions focused on improving anxiety and depression in addition to seizure cessation may contribute to improved HRQoL in youth with PNES more so than those focused on seizure cessation alone.

The experience of trial participation, treatment approaches and perceptions of change among participants with dissociative seizures within the CODES randomized controlled trial: A qualitative study

BACKGROUND

Nested within a large, multicenter randomized controlled trial (RCT) for people with dissociative seizures (DS), the study used purposive sampling to explore participants' experience of participating in an RCT, their experience of DS-specific cognitive behavioral therapy (CBT) and another component of the RCT, Standardized Medical Care (SMC) and their perceptions of and reflections on seizure management and change.

METHODS

A qualitative study using semistructured interviews was conducted with 30 participants in an RCT (the COgnitive behavioral therapy vs standardized medical care for adults with Dissociative non-Epileptic Seizures (CODES) Trial) investigating the effectiveness of two treatments for DS. Key themes and subthemes were identified using thematic framework analysis (TFA).

RESULTS

Analysis yielded three overarching themes: taking part in a treatment trial - "the only thing out there", the experience of treatment techniques that were perceived to help with seizure management, and reflections on an "unpredictable recovery".

CONCLUSIONS

People with DS are amenable to participating in a psychotherapy RCT and described a largely positive experience. They also described the applicability of aspects of DS-specific CBT and SMC in the management of their DS, received within the confines of the CODES trial. Factors that appeared to account for the variability in response to treatment delivery included individual preferences for the nature of sessions, the nature of therapeutic relationships, readiness to discuss trauma, other aspects of emotional avoidance, and whether therapy provided something new.

The experiences of therapists providing cognitive behavioral therapy (CBT) for dissociative seizures in the CODES randomized controlled trial: A qualitative study

OBJECTIVES

Little is known about the experiences of therapists delivering psychotherapy for patients with dissociative seizures (DS), a complex disorder associated with a range of comorbid psychosocial and mental health difficulties. This study set out to explore therapists' experiences of delivering DS-specific, manualized cognitive behavioral therapy (CBT) to adults with DS within the context of a randomized control trial.

METHODS

Interviews were conducted with 12 therapists involved in the COgnitive behavioral therapy vs standardized medical care for adults with Dissociative non-Epileptic Seizures (CODES) trial and were analyzed using thematic framework analysis (TFA).

RESULTS

Six main themes emerged, namely 1) aspects of the intervention that were favored, while others were not always considered applicable; 2) multiple and complex difficulties faced by patients; 3) working effectively within the protocol; 4) limitations of the protocol; 5) significance of formulation; and 6) quality of standardized medical care (SMC) and difficulties of diagnosis delivery. These addressed valued aspects of the intervention, complexities of the patient group, and experiences working within a structured treatment protocol. Family involvement and psychoeducation were highlighted as important components; the applicability of graded exposure techniques, however, was restricted by patients' apparent emotional avoidance. The structure provided by the treatment protocol was valued, but flexibility was important to individualize treatment in complex cases. A comprehensive formulation was fundamental to this. The initial diagnostic explanation provided by neurologists and psychiatrists was generally considered beneficial, with patients often perceived to enter therapy with a better understanding of their condition.

CONCLUSIONS

This study demonstrated that the DS-specific CBT intervention met with general approval from therapists who also highlighted some practical challenges. Because of the nature of the condition, the need for experience of working with complex patients should be considered when applying the intervention to individual cases. Setting the CBT intervention in the context of a structured care pathway involving neurology and psychiatry may facilitate the therapeutic process.

A Comprehensive Machine-Learning-Based Software Pipeline to Classify EEG Signals: A Case Study on PNES vs. Control Subjects

The diagnosis of psychogenic nonepileptic seizures (PNES) by means of electroencephalography (EEG) is not a trivial task during clinical practice for neurologists. No clear PNES electrophysiological biomarker has yet been found, and the only tool available for diagnosis is video EEG monitoring with recording of a typical episode and clinical history of the subject. In this paper, a data-driven machine learning (ML) pipeline for classifying EEG segments (i.e., epochs) of PNES and healthy controls (CNT) is introduced. This software pipeline consists of a semiautomatic signal processing technique and a supervised ML classifier to aid clinical discriminative diagnosis of PNES by means of an EEG time series. In our ML pipeline, statistical features like the mean, standard deviation, kurtosis, and skewness are extracted in a power spectral density (PSD) map split up in five conventional EEG rhythms (delta, theta, alpha, beta, and the whole band, i.e., 1-32 Hz). Then, the feature vector is fed into three different supervised ML algorithms, namely, the support vector machine (SVM), linear discriminant analysis (LDA), and Bayesian network (BN), to perform EEG segment classification tasks for CNT vs. PNES. The performance of the pipeline algorithm was evaluated on a dataset of 20 EEG signals (10 PNES and 10 CNT) that was recorded in eyes-closed resting condition at the Regional Epilepsy Centre, Great Metropolitan Hospital of Reggio Calabria, University of Catanzaro, Italy. The experimental results showed that PNES vs. CNT discrimination tasks performed via the ML algorithm and validated with random split (RS) achieved an average accuracy of 0.97 ± 0.013 (RS-SVM), 0.99 ± 0.02 (RS-LDA), and 0.82 ± 0.109 (RS-BN). Meanwhile, with leave-one-out (LOO) validation, an average accuracy of 0.98 ± 0.0233 (LOO-SVM), 0.98 ± 0.124 (LOO-LDA), and 0.81 ± 0.109 (LOO-BN) was achieved. Our findings showed that BN was outperformed by SVM and LDA. The promising results of the proposed software pipeline suggest that it may be a valuable tool to support existing clinical diagnosis.

Mindfulness-based therapy for psychogenic nonepileptic seizures

BACKGROUND

Mindfulness-based therapies (MBTs) are effective in many neuropsychiatric disorders, and represent a potential therapeutic strategy for psychogenic nonepileptic seizures (PNES).

OBJECTIVE

The objective of this study was to investigate the clinical effect of a manualized 12-session MBT for PNES in an uncontrolled trial. We hypothesized reductions in PNES frequency, intensity, and duration, and improvements in quality of life and psychiatric symptom severity at treatment completion.

METHODS

Between August 2014 and February 2018, 49 patients with documented PNES (with video electroencephalography [EEG]) were recruited at Brigham and Women's Hospital to participate in the MBT for PNES treatment study. Baseline demographic and clinical information and self-rating scales were obtained during the diagnostic evaluation (T0). Baseline PNES frequency, intensity, and duration were collected at the first follow-up postdiagnosis (T1). Frequency was obtained at each subsequent MBT session and analyzed over time with median regression analysis. Outcomes for other measures were collected at the last MBT session (T3), and compared to baseline measures using linear mixed models.

RESULTS

Twenty-six patients completed the 12-session MBT program and were included in the analysis. Median PNES frequency decreased by 0.12 events/week on average with each successive MBT session (p = 0.002). At session 12, 70% of participants endorsed a reduction in PNES frequency of at least 50%. Freedom from PNES was reported by 50% of participants by treatment conclusion. Seventy percent reported a 50% reduction in frequency from baseline and 50% reported remission at session 12. By treatment end, PNES intensity decreased (p = 0.012) and quality of life improved (p = 0.002). Event duration and psychiatric symptom severity were lower after treatment, but reductions were not statistically significant.

CONCLUSIONS

Completion of a manualized 12-session MBT for PNES provides improvement in PNES frequency, intensity, and quality of life. The high dropout rate is consistent with adherence studies in PNES. Possible reasons for dropout are discussed. Randomized controlled trials and longer-term outcomes are needed to demonstrate the efficacy of MBT in PNES.

Cognitive-emotion processing in psychogenic nonepileptic seizures

BACKGROUND

Previous literature suggests that cognitive-emotion processing contributes to the pathogenesis of psychogenic nonepileptic seizures (PNES). Characterization of alterations in cognitive-emotion processing in PNES could inform treatment.

METHODS

In this descriptive, cross-sectional study, 143 patients with video electroencephalogram (EEG) confirmed PNES were prospectively recruited. Patients completed self-report questionnaires on emotion perception (Trait Meta-Mood Scale (TMMS) attention and clarity subscales) and coping style (Affective Styles Questionnaire [ASQ] concealing, adjusting, and tolerating subscales) at the time of their initial evaluation for PNES. Demographic, clinical data and measures of psychopathology severity were also obtained. The TMMS and ASQ subscale scores were compared to available normative data and between PNES subgroups (based on presence of trauma-related factors). Correlation coefficients were obtained to evaluate associations between subscale scores and measures of psychopathology.

RESULTS

Mean scores on both TMMS subscales (attention 47.0 [SD 7.4] and clarity 37.5 [SD 8.0]) and the ASQ adjusting subscale (22.2 [SD 6.3]) were significantly lower than available normative data (p < .001). Among patients with PNES, those with a history of childhood abuse or active posttraumatic stress disorder (PTSD) were found to have significantly lower scores on emotion clarity, adjustment, and tolerance subscales than those without such histories (p < .05). Degree of clarity of emotions correlated negatively with severity of depression, anxiety, stress, and illness perception (p ≤ .001). Adjustment to and tolerance of emotional states correlated negatively with severity of depression and stress (p < .01).

CONCLUSIONS

Patients with PNES, especially those with active PTSD and childhood trauma, have lower clarity of their emotions and lower ability to adjust to emotional states than healthy individuals. These cognitive-emotion processing deficits are more pronounced in patients with more severe depression and reported stress. This study characterizes alterations in cognitive-emotion processing in PNES that are well-suited therapeutic targets and can therefore inform treatment interventions.

Emotion regulation in patients with somatic symptom and related disorders: A systematic review

Background

Somatic symptoms and related disorders (SSD) are prevalent phenomena in the health-care system. Disturbances in emotion regulation (ER) are commonly observed in patients suffering from SSD.

Objectives

This review aimed to examine ER processes that characterize SSD by a systematic analysis of the available empirical studies.

Data sources

PsycINFO and PubMed databases for the articles published between January 1985 and June 2018.

Search terms

“emotion/al regulation” or “affect regulation” and various forms of SSD.

Study eligibility criteria

Empirical studies that a) assigned adolescent or adult patients suffering from SSD based on a clinical diagnosis, and b) examined the relationship between ER and SSD, were included.

Study synthesis methods

A tabular summary of the articles was generated according to study characteristics, study quality, variables, and findings. The findings were organized based on ER variables used in the articles and diagnoses of SSD, which were then re-organized under the main constituents of ER (attention, body, and knowledge).

Results

The findings of the 64 articles largely supported the association between SSD and disturbances in ER, which are usually shared by different diagnoses of SSD. The results indicate that patients show a reduced engagement with cognitive content of emotions. On the other hand, bodily constituents of ER seem to depict an over-reactive pattern. Similarly, the patients tend to encounter difficulties in flexibly disengaging their (spontaneous) attention from emotional material.

Limitations

There is a scarcity of longitudinal designs, randomized controlled trials, experiments, and diary studies suited to investigate the short- and long-term causal relationship between ER and SSD. Symptoms of SSD and measures to assess emotion regulation are heterogeneous.

Conclusions and implications

Assessment of ER processes is potentially useful to understand SSD and for treatment planning. Furthermore, a concurrent investigation of the dynamic interaction of the ER modalities promises insights for better understanding of the role of ER in development, course, and maintenance of SSD.

Avoidance in nonepileptic attack disorder: A systematic review and meta-analyses

BACKGROUND

Avoidance is the active process of trying to escape from or not experience situations, places, thoughts, or feelings. This can be done through behavioral or cognitive strategies, or more broadly, a combination of both, utilized in an attempt to disengage from private experiences referred to as experiential avoidance (EA). Avoidance is considered important in the development and maintenance of nonepileptic attack disorder (NEAD). This review aimed to understand avoidance in NEAD and evaluate its role as a contributory factor.

METHODS

Fourteen articles were identified by searching Cumulative Index to Nursing and Allied Health (CINAHL), MEDLINE Complete, PsycINFO, and EMBASE and were combined in a narrative synthesis. Six of these articles were included in a meta-analysis comparing levels of EA for individuals with NEAD and healthy controls (HC), and four were included in a meta-analysis comparing EA in NEAD to epilepsy comparisons (EC).

CONCLUSIONS

Experiential avoidance appears to be a strategy that is used by a high proportion of the population with NEAD. The group with NEAD utilized significantly more avoidance compared with both the HC and EC. However, further research is needed to understand the extent and types of avoidance that are relevant.

Exploring psychiatrists' perspectives of working with patients with dissociative seizures in the UK healthcare system as part of the CODES trial: a qualitative study

OBJECTIVE

There is currently limited research exploring healthcare professionals' (HCPs) experiences of working with patients with dissociative seizures (DS). Existing studies do not focus on the role of psychiatrists in treating this complex condition. The objective of this study was to gain an understanding of UK-based psychiatrists' experiences of the DS patient group. Against the backdrop of a UK-wide randomised controlled trial (RCT), the focus was broadened to encompass issues arising in everyday practice with the DS patient group.

DESIGN, PARTICIPANTS AND METHODS

A qualitative study using semistructured interviews was undertaken with 10 psychiatrists currently working with DS patients within the context of a large RCT investigating treatments for DS. Thematic analysis was used to identify key themes and subthemes.

SETTING

The psychiatrists were working in Liaison or Neuropsychiatry services in England.

RESULTS

The key themes identified were other HCPs' attitudes to DS and the challenges of the DS patient group. There is a clear knowledge gap regarding DS for many HCPs and other clinical services can be reluctant to take referrals for this patient group. Important challenges posed by this patient group included avoidance (of difficult emotions and help), alexithymia and interpersonal difficulties. Difficulties with alexithymia meant DS patients could struggle to identify triggers for their seizures and to express their emotions. Interpersonal difficulties raised included difficulties in attachment with both HCPs and family members.

CONCLUSIONS

A knowledge gap for HCPs regarding DS has been identified and needs to be addressed to improve patient care. Given the complexity of the patient group and that clinicians from multiple disciplines will come into contact with DS patients, it is essential for any educational strategy to be implemented across the whole range of specialties, and to account for those already in practice as well as future trainees.

TRIAL REGISTRATION NUMBER

ISRCTN05681227; NCT02325544; Pre-results.

Emotion dysregulation in patients with psychogenic nonepileptic seizures: A systematic review based on the extended process model

Psychogenic nonepileptic seizures (PNES) are characterized by paroxysmal alterations in motor and sensory functions resembling epileptic seizures, but are not caused by epileptiform activity. In recent years, there has been increasing scientific interest in emotion dysregulation in patients with PNES (pwPNES), but the literature has not yet been interpreted within a broader model of emotion dysregulation. The aim of this review was therefore to synthesize the existing literature on emotion dysregulation in pwPNES within the extended process model (EPM) of emotion regulation.

METHODS

PubMed and Web of Science were searched for studies relevant to emotion dysregulation as defined by the EPM. These studies were subjected to a bespoke quality appraisal tool. Studies of acceptable quality were categorized to the different stages of the EPM and critically appraised.

RESULTS

Studies of emotion regulation in pwPNES were generally of low quality - a finding largely driven by small sample sizes. However, there was evidence of emotion dysregulation characterized by deficits in the identification of patients' own emotional states, as well as the selection and implementation of maladaptive regulatory strategies, and altered exteroceptive emotional processing. However, heterogeneity in findings suggests that emotion dysregulation is likely linked to other psychological factors and not common to all pwPNES.

SIGNIFICANCE

This review suggests that while pwPNES are likely to experience emotion dysregulation as defined by the EPM, there is variability in the distribution of regulatory deficits in this patient population, and a person-centered approach should be taken when working with these patients. There is a need for more high quality and better-powered studies in this area.

Individual differences in corticolimbic structural profiles linked to insecure attachment and coping styles in motor functional neurological disorders

BACKGROUND

Insecure attachment and maladaptive coping are important predisposing vulnerabilities for Functional Neurological Disorders (FND)/Conversion Disorder, yet no prior structural neuroimaging studies have investigated biomarkers associated with these risk factors in FND populations. This magnetic resonance imaging study examined cortical thickness and subcortical volumes associated with self-reported attachment and coping styles in patients with FND. We hypothesized that insecure attachment and maladaptive coping would relate to limbic-paralimbic structural alterations.

METHODS

FreeSurfer cortical thickness and subcortical volumetric analyses were performed in 26 patients with motor FND (21 women; 5 men) and 27 healthy controls (22 women; 5 men). For between-group comparisons, patients with FND were stratified by Relationship Scales Questionnaire, Ways of Coping Scale-Revised, and Connor-Davidson Resilience Scale scores. Within-group analyses were also performed in patients with FND. All analyses were performed in the complete cohort and separately in women only to evaluate for gender-specific effects. Cortical thickness analyses were whole-brain corrected at the cluster-wise level; subcortical analyses were Bonferroni corrected.

RESULTS

In women with FND, dismissing attachment correlated with reduced left parahippocampal cortical thickness. Confrontive coping was associated with reduced right hippocampal volume, while accepting responsibility positively correlated with right precentral gyrus cortical thickness. These findings held adjusting for anti-depressant use. All FND-related findings were within the normal range when compared to healthy women.

CONCLUSION

These observations connect individual-differences in limbic-paralimbic and premotor structures to attachment and coping styles in FND. The relationship between parahippocampal thickness and dismissing attachment may indicate aberrant social-emotional and contextual appraisal in women with FND.

Integrating neurobiology of emotion regulation and trauma therapy: reflections on EMDR therapy

Emotion dysregulation is a frequent feature in trauma-related disorders. Different kinds of emotion dysregulation seem to be linked to particular psychiatric conditions, and there is growing evidence of the association between neurobiological correlates and those dysregulation patterns. Nevertheless, many of the recent findings from the field of the neurobiology have not been translated into clinical practice and are insufficiently contemplated in trauma-oriented therapies. The aim of this article is to review recent developments in the field of emotion regulation connecting these issue with the practical implementation of psychotherapeutic procedures. The evaluation of emotion dysregulation patterns can guide decision making during the therapy independently to the approach, but there are some findings that can be especially useful for some concrete modalities of therapy. In this article we will focus our discussion on how emotion dysregulation may influence eye movement desensitization and reprocessing (EMDR) treatment in trauma-related disorders. EMDR is a well-defined and protocol-based intervention, with a strong empirical support for post-traumatic stress disorder (PTSD). We describe how different patterns of emotion dysregulation may influence EMDR treatment and procedures, and also how the application of EMDR beyond non-dissociative PTSD should take into account the predominant emotion-regulation strategies in specific posttraumatic disorders.

Implicit attentional bias for facial emotion in dissociative seizures: Additional evidence

This study sought to extend knowledge about the previously reported preconscious attentional bias (AB) for facial emotion in patients with dissociative seizures (DS) by exploring whether the finding could be replicated, while controlling for concurrent anxiety, depression, and potentially relevant cognitive impairments. Patients diagnosed with DS (n=38) were compared with healthy controls (n=43) on a pictorial emotional Stroop test, in which backwardly masked emotional faces (angry, happy, neutral) were processed implicitly. The group with DS displayed a significantly greater AB to facial emotion relative to controls; however, the bias was not specific to negative or positive emotions. The group effect could not be explained by performance on standardized cognitive tests or self-reported depression/anxiety. The study provides additional evidence of a disproportionate and automatic allocation of attention to facial affect in patients with DS, including both positive and negative facial expressions. Such a tendency could act as a predisposing factor for developing DS initially, or may contribute to triggering individuals' seizures on an ongoing basis. Psychological interventions such as Cognitive Behavioral Therapy (CBT) or AB modification might be suitable approaches to target this bias in clinical practice.

Altered responsiveness in psychogenic nonepileptic seizures and its implication to underlying psychopathology

PURPOSE

Altered responsiveness during psychogenic nonepileptic seizures (PNES) is a distinct semiological feature that may signal a psychological vulnerability. We hypothesized that altered responsiveness is related to difficulties with emotion tolerance, experiential avoidance, difficulty coping, dissociation and trauma and prior experiences of loss of awareness.

METHODS

71 patients with video-EEG confirmed PNES were divided into two groups based on their responsiveness at the time of the captured event during long-term monitoring. Demographic information, clinical history and self-rated questionnaires highlighting psychopathology were compared between the groups.

RESULTS

47 patients (66%) had altered responsiveness during their captured event. Married or partnered subjects were more represented in the altered responsiveness group. Experiential avoidance, as measured by the Acceptance and Action Questionnaire-II, and affect intolerance, as measured by the Affective Style Questionnaire, were significantly higher in the altered responsiveness group. The Connor Davidson Resilience Scale was significantly higher among intact responsiveness subjects. Subjects with altered responsiveness were more likely to have a family history of seizures, comorbid headaches, and loss of consciousness (LOC) during traumatic brain injury. There were no differences in measures of dissociation, somatization, mood or anxiety, or presence of psychiatric comorbidities, including PTSD or history of trauma.

CONCLUSION

Altered responsiveness during PNES is a marker of lower emotional resilience or ability to tolerate emotions among patients with PNES. Emotion management may be an important therapeutic target for these patients. Prior experiences with LOC also contribute to the presence of altered responsiveness. Trauma and dissociation did not differentiate responsiveness during PNES.

Evaluation of a pilot innovative cognitive-behavioral therapy-based psychoeducation group treatment for functional non-epileptic attacks

A high proportion of patients presenting at epilepsy clinics experience functional non-epileptic attacks (FNEA), and while psychological treatment is generally thought to be the required intervention, evidence regarding psychological treatment of FNEA is limited. A small number of psychoeducation treatments have been evaluated, with promising results. As part of routine care within a neuropsychiatry service, a 3-session cognitive-behavior therapy- (CBT-) informed psychoeducation group was developed. Patients with comorbid epilepsy were included. The group's effectiveness was evaluated in terms of attack frequency, mood, illness perception, dissociative experiences, and patient feedback. Pre- and post-treatment data were obtained for 19 patients. The proportion of patients experiencing attacks significantly decreased, with almost 40% of treatment completers reporting being attack-free at the end of treatment. Significant improvements were also found on level of psychological distress, illness beliefs, and understanding of the condition. No significant changes in mood or general functioning were observed. High satisfaction was reported by almost all patients. Treatment outcome was not significantly affected by the level of dissociative experiences. The results suggest that CBT-based psychoeducation group treatment can be a beneficial part of treatment for those with FNEA, even for those experiencing high levels of dissociation. Further controlled studies with larger sample sizes are required.

Insights into Chronic Functional Movement Disorders: The Value of Qualitative Psychiatric Interviews

BACKGROUND

Patients with functional movement disorders (FMDs) are commonly seen by neurologists and psychosomatic medicine psychiatrists. Research literature provides scant information about the subjective experiences of individuals with this often chronic problem.

OBJECTIVE

To enhance our understanding of psychologic aspects of FMDs by conducting qualitative interviews of research subjects.

METHODS

In total, 36 patients with FMDs were recruited from the Human Motor Control clinic at the National Institutes of Health. Each subject participated in a qualitative psychiatric interview and a structured diagnostic psychiatric interview.

RESULTS

Of our 36 subjects, 28 had current or lifetime psychiatric disorders in addition to conversion disorder and 22 had current disorders. Qualitative interviews provided rich information on patients' understanding of their illnesses and impaired cognitive processing of emotions.

CONCLUSION

Our study supports the addition of open-ended qualitative interviews to delineate emotional dynamics and conceptual frameworks among such patients. Exploratory interviews generate enhanced understanding of such complex patients, above and beyond that gained by assessing DSM diagnostic comorbidities.

Clinical Approaches to Psychogenic Nonepileptic Seizures

Psychogenic nonepileptic seizures (PNES) are a subtype of conversion disorder (also called functional neurological symptom disorder in DSM-5). Patients with PNES are high utilizers of health care and can have disability levels similar to those of patients with epilepsy. PNES is a common, complex neuropsychiatric somatoform disorder at the interface of neurology and psychiatry disciplines and is largely overlooked and avoided by mental health providers. Despite advances in establishing accurate diagnosis and evidence-based treatments, recent knowledge about PNES has not been well translated into clinical practice. Long diagnostic delays have been associated with poor prognosis. Recent advances in possible neurophysiological biomarkers include functional MRI studies that show abnormalities in emotional, cognitive, executive, and sensorimotor neurocircuits. Although the gold standard for diagnosis is video electroencephalograph, this test is underused by psychiatrists. The International League Against Epilepsy proposed a staged approach to PNES diagnosis using history, semiologic features, and EEG. Thorough psychiatric assessment can identify relevant biopsychosocial and predisposing, precipitating, and perpetuating factors, as well as assess the comorbid psychiatric disorders, which can inform a treatment plan. Clear and thoughtful delivery of diagnosis is the first step in treatment. Regular follow-up with the patient's neurologist, in addition to treatment by mental health professionals familiar with somatic symptom disorders, is recommended. Psychotherapy is the mainstay of treatment, and randomized clinical trials using cognitive-behavioral therapies reveal significant reduction in seizures and other psychiatric symptoms. After centuries, mental health providers now have access to the tools to diagnose and effectively treat PNES and other conversion disorders.

Coping Profiles Differentiate Psychological Adjustment in Chinese Women Newly Diagnosed With Breast Cancer

Objective. The study aimed to explore latent profiles of coping in Chinese women newly diagnosed with breast cancer and examine the differences of psychological distress, demographic, and medical characteristics across profiles. Methods. Latent profile analysis was used to identify 3 classes of copers based on data from 618 Chinese women newly diagnosed with breast cancer who completed questionnaires assessing their coping strategies and psychological distress. Results. “Adaptive coper,” reporting most use of adaptive cognitive coping strategies, behaviors of acceptance and shifting attention, and least use of maladaptive cognitive coping strategies, had the best psychological adjustment. “Negative coper,” characterized by most use of maladaptive cognitive coping strategies, least use of adaptive cognitive coping strategies except “putting in perspective,” and median levels of medical coping behaviors, had the worst psychological adjustment. “Inconsistent coper,” with great use of all cognitive coping strategies, and most behaviors of fighting against the disease, and fewest behaviors of attention shift, had relatively high levels of psychological distress. Younger age, less education, shorter time since diagnosis, widowed, living in rural areas, and undergoing chemotherapy are possible markers for patients with less adaptive coping patterns. Conclusions. Interventions should be developed according to the different coping profiles of patients, and the key group to target is “negative copers,” who may benefit from cognitive behavioral approaches that combine emotion, cognition and behavior, which could help them more effectively appraise and cope with stressful events.

Psychological and psychiatric aspects of psychogenic non-epileptic seizures (PNES): A systematic review

Psychogenic non-epileptic seizures (PNES) are common in neurological settings and often associated with considerable distress and disability. The psychological mechanisms underlying PNES are poorly understood and there is a lack of well-established, evidence-based treatments. This paper advances our understanding of PNES by providing a comprehensive systematic review of the evidence pertaining to the main theoretical models of this phenomenon. Methodological quality appraisal and effect size calculation were conducted on one hundred forty empirical studies on the following aspects of PNES: life adversity, dissociation, anxiety, suggestibility, attentional dysfunction, family/relationship problems, insecure attachment, defence mechanisms, somatization/conversion, coping, emotion regulation, alexithymia, emotional processing, symptom modelling, learning and expectancy. Although most of the studies were only of low to moderate quality, some findings are sufficiently consistent to warrant tentative conclusions: (i) physical symptom reporting is elevated in patients with PNES; (ii) trait dissociation and exposure to traumatic events are common but not inevitable correlates of PNES; (iii) there is a mismatch between subjective reports of anxiety and physical arousal during PNES; and (iv) inconsistent findings in this area are likely to be attributable to the heterogeneity of patients with PNES. Empirical, theoretical and clinical implications are discussed.

Nonepileptic seizures - subjective phenomena

Psychogenic nonepileptic seizures (PNES) superficially resemble epileptic seizures or syncope and most patients with PNES are initially misdiagnosed as having one of the latter two types of transient loss of consciousness. However, evidence suggests that the subjective seizure experience of PNES and its main differential diagnoses are as different as the causes of these three disorders. In spite of this, and regardless of the fact that PNES are considered a mental disorder in the current nosologies, research has only given limited attention to the subjective symptomatology of PNES. Instead, most phenomenologic research has focused on the visible manifestations of PNES and on physiologic parameters, neglecting patients' symptoms and experiences. This chapter gives an overview of qualitative and quantitative studies providing insights into subjective symptoms associated with PNES, drawing on a wide range of methodologies (questionnaires, self-reports, physiologic measures, linguistic analyses, and neuropsychologic experiments). After discussing the scope and limitations of these approaches in the context of this dissociative phenomenon, we discuss ictal, peri-ictal and interictal symptoms described by patients with PNES. We particularly focus on impairment of consciousness. PNES emerges as a clinically heterogeneous condition. We conclude with a discussion of the clinical significance of particular subjective symptoms for the engagement of patients in treatment, the formulation of treatment, and prognosis.

Theory of mind abilities in patients with psychogenic nonepileptic seizures

BACKGROUND

Psychogenic nonepileptic seizures (PNES) have been frequently linked to deficits in affect regulation and altered processing of emotionally salient information. However, less is known about how patients suffering from PNES actually process and interpret affective social stimuli. Thus, the present study aimed to investigate basal facial affect recognition as well as mind-reading skills in a sample of patients with PNES and matched control subjects.

METHODS

Patients with PNES (N=15) and healthy controls (N=15) completed self-report questionnaires that measured alexithymia and perceived stress vulnerability. Affect perception was tested using a series of computerized movies of models whose facial expressions slowly change from neutral to full-blown emotions (anger, fear, sadness, happiness, disgust, and surprise), allowing for a fine-grained assessment of facial emotion recognition impairments. Further, all participants were presented with the Movie for the Assessment of Social Cognition, a well-validated video-based test for the evaluation of subtle mind-reading deficits.

RESULTS

Data analyses revealed increased alexithymic traits and, impaired mentalizing skills in individuals with PNES, while basal facial expression recognition was not compromised.

DISCUSSION

The present findings are the first to demonstrate that patients with PNES exhibit several deficits in reasoning about their own and other people's mental states. Patients with PNES may benefit from psychotherapeutic interventions that focus on disturbed affect regulation and aim to enhance emotional awareness.

People with psychogenic non-epileptic seizures: A South African perspective

BACKGROUND

Psychogenic non-epileptic seizures (PNES) is a disabling disorder which has a negative effect on the quality of life of individuals with PNES. A clear understanding of the disorder is necessary, however, to date, research about PNES in South Africa is limited.

OBJECTIVES

The aims of this study were to explore the demographic variables of individuals with PNES in South Africa, to review the available body of research on PNES, and to compare it with our results.

METHOD

Twenty-two people with PNES, with confirmed video EEG, were recruited by means of convenience sampling from two hospitals. Descriptive statistics were used to describe the demographic variables of the participants.

RESULTS

Internationally comparable results revealed misdiagnoses and low treatment delivery amongst a primarily female population.

CONCLUSION

This study provided greater insight into individuals with PNES in South Africa, highlighting the need for more information, support, effective treatment and accurate diagnosis of PNES.

New insights into psychogenic nonepileptic seizures 2011-2014

PURPOSE

There has been a rapid increase in the rate of publications about psychogenic nonepileptic seizures (PNES). This review summarises insights from the 50 most important original articles about PNES published since 2011 and describes the advances made in the understanding of PNES over the last 3 years.

METHOD

We carried out a systematic literature search of all English language publications about PNES published between October 2011 and October 2014 on Scopus, Ovid Medline and Web of Knowledge, and inspected all abstracts. Having excluded all review articles, case reports, conference abstracts, articles exploring PNES in children, and articles not actually focussing on PNES, we considered 150 papers for inclusion in this review. We assessed the quality of the identified studies and used expert judgement to identify the 50 most important publications from the review period and composed a narrative review based on these original papers.

RESULTS

Almost one half of the studies initially identified only provided Class 4 evidence. Recent work has provided more support for a biopsychosocial account of PNES. It has illustrated the heterogeneity of PNES, identifying varying and distinct psychological profiles of individuals with this disorder. These findings suggest that intervention needs to be flexible or adaptive if it is appropriately to target the different mechanisms which may give rise to PNES. Several educational and psychotherapeutic interventions for PNES have been described, but sufficiently powered randomised controlled trials are yet to be undertaken. Recent research using social, economic and quality of life indicators has provided further evidence of the societal and individual burden of PNES.

CONCLUSION

The research into PNES published over the last 3 years has deepened our understanding of the condition as a biopsychosocial disorder which is neither a "physical" nor a "psychological" condition. A number of small studies have demonstrated the potential of educational and psychotherapeutic treatments, but rigorous and sufficiently large trials still need to be conducted to determine the effectiveness of these interventions.

Quality of life in psychogenic nonepileptic seizures and epilepsy: the role of somatization and alexithymia

It is clear that many individuals with psychogenic nonepileptic seizures (PNESs) often present with poorer quality of life compared with those with epileptic seizures (ESs). However, the mechanisms linking seizure diagnosis to quality-of-life outcomes are much less clear. Alexithymia and somatization are emotional markers of psychological functioning that may explain these differences in quality of life. In the current study, patients from an epilepsy monitoring unit with vEEG-confirmed diagnosis of PNESs or ESs were compared on measures of alexithymia, somatization, quality of life, and a variety of demographic and medical variables. Two models using alexithymia and somatization individually as mediators of the relations between diagnosis and quality of life were tested. Results indicated that patients with PNESs had significantly poorer quality of life compared with those with ESs. Alexithymia was associated with poor quality of life in both groups but did not differentiate between diagnostic groups. Further, alexithymia did not mediate the relationship between diagnosis and quality of life. Somatization was associated with poor quality of life, and patients with PNESs reported greater somatization compared with patients with ESs. Somatization also significantly mediated the relationship between diagnosis and quality of life. In conclusion, somatization may be one mechanism affecting poor quality of life among patients with PNESs compared with ESs and should be a target of comprehensive treatments for PNESs. Alexithymia proved to be an important factor impacting quality of life in both groups and should also be targeted in treatment for patients with PNESs and patients with ESs.

Treatment of psychogenic nonepileptic seizures: updated review and findings from a mindfulness-based intervention case series

Psychogenic nonepileptic seizures (PNES) were first described in the medical literature in the 19th century, as seizure-like attacks not related to an identified central nervous system lesion, and are currently classified as a conversion disorder, according to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5). While a universally accepted and unifying etiological model does not yet exist, several risk factors have been identified. Management of PNES should be based on interdisciplinary collaboration, targeting modifiable risk factors. The first treatment phase in PNES is patient engagement, which is challenging given the demonstrated low rates of treatment retention. Acute interventions constitute the next phase in treatment, and most research studies focus on short-term evidence-based interventions. Randomized controlled pilot trials support cognitive-behavioral therapy. Other psychotherapeutic and psychopharmacological interventions have been less well-studied using controlled and uncontrolled trials. Within the discussion of acute interventions, we present a preliminary evaluation for feasibility of a mindfulness-based psychotherapy protocol in a very small sample of PNES patients. We demonstrated in 6 subjects that this intervention is feasible in real-life clinical scenarios and warrants further investigation in larger scale studies. The final treatment phase is long-term follow-up. Long-term outcome studies in PNES show that a significant proportion of patients remains symptomatic and experiences continued impairments in quality of life and functionality. We believe that PNES should be understood as a disease that requires different types of intervention during the various phases of treatment.

Cognitive impairment and evaluation in psychogenic nonepileptic seizures: an integrated cognitive-emotional approach

Neuropsychological studies comparing patients with psychogenic nonepileptic seizures (PNES) to those with epilepsy have been largely equivocal. The variability in the neuropsychological literature highlights the heterogeneity of the PNES population across a number of psychiatric and neurologic factors. Phenotypic presentations in PNES arise from complex interactions between vulnerable cognitive and emotional systems. We propose that variability in neuropsychological findings in PNES emerge in the context of diverse psychiatric, neurologic, and clinical factors. Traditional assessments that fail to integrate cognitive and emotional/behavioral profiles sufficiently would fall short in characterizing the complexity of brain-behavior relationships in this population. To advance the neuropsychology of PNES, we propose a systematic approach to measure a number of factors that influence cognitive impairment in this population. We begin by reviewing the current neuropsychological literature in PNES and discussing a number of factors that influence cognitive deficits. We then present a comprehensive neuropsychological battery designed to capture elements (cognitive dysfunction, psychopathology, emotion processing deficits) underlying the proposed vulnerable cognitive-emotional system in PNES. It is our hope that the proposed battery will facilitate the aggregation of data across neuropsychological investigations, to allow more advanced statistical analyses, and ultimately enhance our understanding of PNES and the development of effective management and treatment options.

Multimodular psychotherapy intervention for nonepileptic attack disorder: an individualized pragmatic approach

Nonepileptic attack disorder (NEAD) is a highly distressing and costly condition commonly seen in specialist epilepsy clinics. Consistently effective treatments for NEAD remain elusive, and findings from research indicate that there is no one form of psychological therapy that will be effective in such a heterogeneous group of patients. In this paper, we propose a multimodular approach to psychological therapy in NEAD, which allows the clinician to tailor an individualized management program for the patient appropriate to his/her needs.

Altered Functional Connectivity Patterns of the Insular Subregions in Psychogenic Nonepileptic Seizures

Neuroimaging studies have demonstrated that psychogenic nonepileptic seizures (PNES) are characterized by unstable cognitive-emotional and motor system, which is engaged in hyperactivity of limbic regions and sensorimotor area. The insula, which is a part of the limbic system, includes various subregions with some distinct connectivity patterns separately. However, whether these insular subregions show different connectivity patterns respectively in PNES remains largely unknown. We aimed to investigate the functional connectivity (FC) of insular subregions in PNES and extend the understanding of the complex pathophysiological mechanisms of this disease. A resting-state FC based on the insular subregions were conducted in 18 patients and 20 healthy controls. We examined the differences in FC values between PNES patients and controls using two sample t test. Our results showed patients had significantly stronger FC between insular subregions and sensorimotor network, lingual gyrus, superior parietal gyrus and putamen, which suggested a hyperlink pattern of insular subregions involved in abnormal emotion regulation, cognitive processes and motor function in PNES. Pearson correlation analysis between the mean FC values within abnormal regions and the frequency of PNES further indicated PNES exhibited abnormal functional organization whose stressful emotion of patients have great direct influence on their motor functions. The differentially impaired functional connectivity patterns of insular subregions might provide new insights into the complex neurological mechanism of PNES.

Regulation of emotions in psychogenic nonepileptic seizures

BACKGROUND

Despite the long history of psychogenic nonepileptic seizures (PNES), relatively little is known about the mechanisms that cause and maintain this condition. Emerging research evidence suggests that patients with PNES might have difficulties in regulating their emotions. However, much remains to be learned about the nature of these difficulties and the emotional responses of individuals with PNES. This study aimed to gain a detailed understanding of emotion regulation processes in patients with PNES by examining differences between patients with PNES and a healthy control group with regard to intensity of emotional reactions, understanding of one's emotional experience, beliefs about emotions, and managing emotions by controlling emotional expression.

METHOD

A cross-sectional design was used to compare the group with PNES (n=56) and the healthy control group (n=88) on a range of self-report measures.

RESULTS

Participants with a diagnosis of PNES reported significantly poorer understanding of their emotions, more negative beliefs about emotions, and a greater tendency to control emotional expression compared to the control group. While intensity of emotions did not discriminate between the groups, poor understanding and negative beliefs about emotions were found to be significant predictors of PNES, even after controlling for age, education level, and emotional distress. Furthermore, the presence of some emotion regulation difficulties was associated with self-reported seizure severity.

CONCLUSIONS

The results of this study are largely consistent with previous literature and provide evidence for difficulties in emotion regulation in patients with PNES. However, this research goes further in bringing together different aspects of emotion regulation, including beliefs about emotions, which have not been examined before. As far as it is known, this is the first study to suggest that levels of alexithymia in a population with PNES are positively associated with self-reported seizure severity. The findings suggest a need for tailored psychological therapies addressing specific emotion regulation difficulties in individuals with PNES.

Abnormal functional connectivity density in psychogenic non-epileptic seizures

PURPOSE

Psychogenic non-epileptic seizures (PNES) are paroxysmal behaviors that resemble epileptic seizures but lack abnormal electrical activity. Some neuroimaging studies have reported that PNES exhibits aberrant functional connectivity in specific brain networks. Thus, advanced neuroimaging technologies may aid clinical diagnosis and treatment of PNES.

METHODS

We investigated changes in brain functional connectivity in 18 patients with PNES and 20 healthy controls. Functional connectivity density mapping (FCDM), a voxelwise data-driven technique, was employed to compute local and global FCD maps. Then, short-range and long-range FCD values were calculated and group analyses performed between patents with PNES and healthy controls. A correlation analysis with clinical variables was also performed.

RESULTS

We found that patients with PNES showed abnormal FCD regions mainly in the frontal cortex, sensorimotor cortex, cingulate gyrus, insula and occipital cortex. Seed-voxel correlation analyses also showed disrupted functional connectivity between these regions. In addition, the occipital cortex FCD correlated with duration of disease.

CONCLUSION

The present results support the hypothesis that patients with PNES are associated with altered attention, sensorimotor and emotion systems. Furthermore, correlations between altered regions in the occipital cortex and duration of disease may reflect an adaptation in these patients for long-term hypervigilance and increased response to external stimuli. This study adds new knowledge to our understanding of the pathophysiological mechanisms underlying PNES.

Emotional dysregulation, alexithymia, and attachment in psychogenic nonepileptic seizures

OBJECTIVES

Psychogenic nonepileptic seizures (PNESs) are poorly understood and difficult to treat. Research and theory suggest that problems with recognizing, acknowledging, and regulating emotional states (i.e., emotional dysregulation) may contribute to the development and maintenance of PNESs. However, there is a lack of well-controlled studies using dedicated measures of emotional regulation with patients with PNESs. The current study sought to address this gap.

METHODS

Forty-three patients with PNESs and 24 with epilepsy completed a postal survey comprising measures of emotional dysregulation (Difficulties in Emotion Regulation Scale), alexithymia (Toronto Alexithymia Scale), attachment (Relationship Scales Questionnaire), and psychopathology (Generalized Anxiety Disorder-7; Patient Health Questionnaire-9; Somatoform Dissociation Questionnaire-20). Cluster analysis was used to identify possible subgroups of patients with PNESs characterized by distinct patterns of emotional dysregulation.

RESULTS

Two clusters of patients with PNESs were identified. The first (n=11) was characterized by higher levels of psychopathology, somatization, alexithymia, and difficulties with most aspects of emotional regulation (including identifying, accepting, and describing feelings, accessing adaptive regulatory strategies, performing goal-directed behaviors, and controlling feelings and actions) compared with the group with epilepsy. The second (n=32) was characterized by relatively high somatization and depression scores but comparatively normal levels of alexithymia and emotional regulation.

CONCLUSIONS

The findings suggest that patients with PNESs can be divided into at least two meaningful subgroups characterized by distinct psychological profiles, only one of which is characterized by significant problems with emotional dysregulation. Further research is needed to determine whether the relatively normal emotional dysregulation and high somatization scores of some patients with PNESs are due to emotional avoidance or more basic problems with perceptual and behavioral control.