Emotional dysregulation, alexithymia, and attachment in psychogenic nonepileptic seizures

A comparison of patients with epileptic seizures (ES) versus those with psychogenic non-epileptic seizures (PNES) on measures of alexithymia, mood, and anxiety

OBJECTIVE

To compare persons with epilepsy (PWE) to those with psychogenic non-epileptic seizures (PNES) on measures of depression, anxiety, and alexithymia subscales (i.e., difficulty identifying emotions, difficulty describing emotions, and external-oriented thinking).

MATERIAL AND METHODS

In this retrospective study, 235 epilepsy patients and 90 patients with PNES were evaluated between 2012 and 2020 at the Northeast Regional Epilepsy Group. These patients had completed the Toronto Alexithymia Scale (TAS-20), The Center for Epidemiologic Studies - Depression Scale (CES-D) and The State-Trait Anxiety Inventory (STAI). Background information was collected regarding work/student/disability status at the time of the evaluation history of psychiatric diagnosis; psychological trauma; and involvement in psychotherapy either at the time of the evaluation or prior.

RESULTS

Significant differences between PWEs and those with PNES were found not only in historical data (e.g., Psychiatric History, History of Trauma, and History of Therapy) (p < .001) but also on measures of Depression (p = .002) and Anxiety (p < .001). ANOVA analysis also revealed significant differences in the distribution of the TAS-Total score, TAS-Describing emotions, and TAS-Identifying emotions. Using logistic regression (stepwise model) the optimal set of predictors for a differential diagnosis of epilepsy and PNES was combination of TAS-Identifying emotions score, history of psychological trauma, and history of therapy. The accuracy of the prediction was determined to be 80.2 %.

CONCLUSIONS

Although higher alexithymia rates are present in PNES and PWEs, clinicians may find a combination of TAS-Identifying Emotion score, history of trauma, and history of psychotherapy useful in supporting a differential diagnosis. Also, a subgroup may exist among those with PNES with high levels of alexithymia, depression, and anxiety that may require a different treatment approach focused on addressing difficulties in identifying and describing their emotions and their other symptomatology.

Maladaptive personality traits in patients with epilepsy and psychogenic non-epileptic seizures

OBJECTIVE

We aimed to evaluate the sociodemographic, clinical, and psychological characteristics associated with psychogenic non-epileptic seizures (PNES) in patients with epilepsy, with particular emphasis on the personality profile assessed from a dimensional perspective.

METHODS

The cohort study included 77 consecutive inpatients with active epilepsy aged 36-55 years; 52 (67.5%) were female. The presence of PNES was confirmed by video-EEG monitoring. All patients underwent the Mini-International Neuropsychiatric Interview to diagnose psychiatric disorders. All participants completed the Neurological Disorders Depression Inventory in Epilepsy, the Epilepsy Anxiety Survey Instrument - brief version, and the Personality Inventory for DSM-5 and ICD-11 Brief Form Plus Modified. Chi-square and Fisher's exact tests were used to compare categorical variables, and the Brunner-Munzel test was used for quantitative variables.

RESULTS

Twenty-four patients (31.2%) had both epilepsy and PNES. There were no significant differences in social, demographic or clinical characteristics, psychiatric diagnoses or depression severity. Compared to patients with epilepsy alone, patients with epilepsy and PNES had higher anxiety scores and more pronounced maladaptive personality traits such as disinhibition and psychoticism.

SIGNIFICANCE

The main novelty of our study is that using the recently proposed dimensional approach to personality disorders and an appropriate instrument we assessed all personality domains listed in two of the most widely used classifications of mental disorders (DSM-5 and ICD-11) in PWE with and without PNES. To our knowledge, this is the first study to demonstrate the association of the maladaptive traits of psychoticism and disinhibition with the development of PNES in PWE.

Emotional Dysregulation and Temperament-Character Traits in Adolescents With Functional Neurological Symptom Disorder (Conversion Disorder)

ABSTRACT

The purpose of this study was to evaluate emotion dysregulation and temperament-character traits in adolescents with functional neurological symptom disorder (FNSD). Forty adolescents with FNSD and 40 healthy adolescents were evaluated by a semiconstructed diagnosis interview, Temperament and Character Inventory (TCI), Difficulties in Emotion Regulation Scale (DERS), Regulation of Emotions Questionnaire (REQ), and Children's Somatization Inventory-24 (CSI-24). The external and internal dysfunctional emotion regulation scores of REQ, all subscales of DERS, except the awareness subscale, and CSI-24 scores were significantly higher in FNSD patients compared with healthy controls. There were significant differences between the groups in terms of harm avoidance and reward dependence subscale scores of TCI. Multiple logistic regression analysis showed that the external dysfunctional emotion regulation strategy, somatization, and reward dependence are significant predictors of FNSD. Our results provide evidence that adolescents with FNSD experience emotional dysregulation and that the differential value of some temperament-character traits in the diagnosis of FNSD.

Expressive suppression moderates the relationship between PTSD from COVID-19 and somatization and validation of the Arabic version of Patient Health Questionnaire-15 (PHQ-15)

BACKGROUND

Lebanese adults have been crippled for years by several crises, including the lately COVID-19 pandemic. These massive civilian traumas have increased the risk of post-traumatic stress disorder (PTSD) in this population. Extensive literature pointed to the association between PTSD and somatization; however, the nature of this relationship remains unknown. We sought to contribute further to work in this area by testing the moderating role of emotion regulation in the relationship between COVID-19- related PTSD and somatization. As a secondary objective, we aimed to examine the psychometric properties of an Arabic translation of the somatization measure Patient Health Questionnaire-15 (PHQ-15) in terms of factorial validity and internal consistency before its use in the present study.

METHODS

This cross-sectional study was conducted between September and October 2021. A total of 403 Lebanese adults residing in Lebanon were recruited. Eligible participants received an online link to the survey. The Patient Health Questionnaire-15 was used to assess somatization, PTSD Checklist-Civilian Version for PTSD and Emotion Regulation Questionnaire for emotion regulation.

RESULTS

The results of the exploratory factor analysis (EFA) revealed a three-factor solution explaining 48.79% of the common variance. Confirmatory Factor Analysis results of the three-factor model obtained in the EFA indicated a good fit with a significant CFI of 0.98, TLI 0.98 and a GFI of .97, a RMSEA of .04 [90% CI .01, .06]. Higher PTSD symptoms were associated with somatization. In addition, we found that one specific ER component, i.e. expressive suppression, significantly moderated the relationship between PTSD from the COVID pandemic and somatization. In particular, the interaction PTSD from the COVID-19 pandemic by expressive suppression was significantly associated with somatization; at low, medium and high levels of expressive suppression, higher PTSD from the COVID-19 pandemic was significantly associated with higher somatization scores. As for our secondary objective, findings revealed that the Arabic version of the PHQ-15 exhibited good psychometric properties. In particular, the scale yielded a three-factor structure, and good internal consistency (Cronbach's alpha = 0.87).

CONCLUSION

The moderating role of expressive suppression on the link between PTSD and somatization presents a novel finding in the field of trauma. Additionally, making a psychometrically sound Arabic version of the PHQ-15 available is a valuable addition to the literature.

Personality traits related to cognitive functioning in patients with functional neurological disorder

Cognitive symptoms are prevalent in patients with functional neurological disorder (FND). Several studies have suggested that personality traits such as neuroticism may play a pivotal role in the development of FND. FND has also been associated with alexithymia: patients with FND report difficulties in identifying, analyzing, and verbalizing emotions. Whether or not alexithymia and other personality traits are associated with cognitive symptomatology in patients with FND is unknown. In the current study, we explored whether the Big Five personality model factors (neuroticism, extraversion, openness, agreeableness, and conscientiousness) and alexithymia were associated with cognitive functioning in FND. Twenty-three patients with FND were assessed using a neuropsychological assessment and questionnaire assessment to explore personality traits (Neuroticism-Extraversion-Openness Five-Factor Inventory) and alexithymia (Bermond-Vorst Alexithymia Questionnaire). The results indicated that high conscientiousness was associated with lower planning scores (ρ = -0.52, p = .012) and high scores on alexithymia were associated with lower scores on verbal memory scores (ρ = -0.46, p = .032) and lower sustained attention scores (ρ = -0.45, p = .046). The results did not remain significant after controlling for multiple testing. The preliminary results of our study suggest that personality and cognitive symptomatology in patients with FND are topics that should be further explored in future studies, as cognitive symptomology can affect treatment results.

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.

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.

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.

Dissociation and its biological and clinical associations in functional neurological disorder: systematic review and meta-analysis

BACKGROUND

Studies have reported elevated rates of dissociative symptoms and comorbid dissociative disorders in functional neurological disorder (FND); however, a comprehensive review is lacking.

AIMS

To systematically review the severity of dissociative symptoms and prevalence of comorbid dissociative disorders in FND and summarise their biological and clinical associations.

METHOD

We searched Embase, PsycInfo and MEDLINE up to June 2021, combining terms for FND and dissociation. Studies were eligible if reporting dissociative symptom scores or rates of comorbid dissociative disorder in FND samples. Risk of bias was appraised using modified Newcastle-Ottawa criteria. The findings were synthesised qualitatively and dissociative symptom scores were included in a meta-analysis (PROSPERO CRD42020173263).

RESULTS

Seventy-five studies were eligible (FND n = 3940; control n = 3073), most commonly prospective case-control studies (k = 54). Dissociative disorders were frequently comorbid in FND. Psychoform dissociation was elevated in FND compared with healthy (g = 0.90, 95% CI 0.66-1.14, I² = 70%) and neurological controls (g = 0.56, 95% CI 0.19-0.92, I² = 67%). Greater psychoform dissociation was observed in FND samples with seizure symptoms versus healthy controls (g = 0.94, 95% CI 0.65-1.22, I² = 42%) and FND samples with motor symptoms (g = 0.40, 95% CI -0.18 to 1.00, I² = 54%). Somatoform dissociation was elevated in FND versus healthy controls (g = 1.80, 95% CI 1.25-2.34, I² = 75%). Dissociation in FND was associated with more severe functional symptoms, worse quality of life and brain alterations.

CONCLUSIONS

Our findings highlight the potential clinical utility of assessing patients with FND for dissociative symptomatology. However, fewer studies investigated FND samples with motor symptoms and heterogeneity between studies and risk of bias were high. Rigorous investigation of the prevalence, features and mechanistic relevance of dissociation in FND is needed.

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.

A new science of emotion: implications for functional neurological disorder

Functional neurological disorder reflects impairments in brain networks leading to distressing motor, sensory and/or cognitive symptoms that demonstrate positive clinical signs on examination incongruent with other conditions. A central issue in historical and contemporary formulations of functional neurological disorder has been the mechanistic and aetiological role of emotions. However, the debate has mostly omitted fundamental questions about the nature of emotions in the first place. In this perspective article, we first outline a set of relevant working principles of the brain (e.g. allostasis, predictive processing, interoception and affect), followed by a focused review of the theory of constructed emotion to introduce a new understanding of what emotions are. Building on this theoretical framework, we formulate how altered emotion category construction can be an integral component of the pathophysiology of functional neurological disorder and related functional somatic symptoms. In doing so, we address several themes for the functional neurological disorder field including: (i) how energy regulation and the process of emotion category construction relate to symptom generation, including revisiting alexithymia, 'panic attack without panic', dissociation, insecure attachment and the influential role of life experiences; (ii) re-interpret select neurobiological research findings in functional neurological disorder cohorts through the lens of the theory of constructed emotion to illustrate its potential mechanistic relevance; and (iii) discuss therapeutic implications. While we continue to support that functional neurological disorder is mechanistically and aetiologically heterogenous, consideration of how the theory of constructed emotion relates to the generation and maintenance of functional neurological and functional somatic symptoms offers an integrated viewpoint that cuts across neurology, psychiatry, psychology and cognitive-affective neuroscience.

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.

A review of the treatment of functional neurological disorder with intensive short-term dynamic psychotherapy

The purpose of this article was to raise awareness of an under-recognized but well-supported treatment for Functional Neurological Disorders (FND) termed Intensive Short-term Dynamic Psychotherapy (ISTDP). There has been significant interest in the role of psychological mechanisms in FND onset and maintenance with specific evidence for maladaptive emotional processing. We outline how this supports the theoretical basis for ISTDP as an option in FND treatment and undertake a literature review of the current evidence base. We describe the application of ISTDP to FND illustrated through direct therapy transcripts. We conclude with reflections on the strengths and limitations of ISTDP as well as recommendations regarding future research.

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.

Shame in patients with psychogenic nonepileptic seizure: A narrative review

Psychogenic Nonepileptic Seizures (PNES) have been linked to dysregulated emotions and arousal. However, the question which emotions may be most relevant has received much less attention. In this multidisciplinary narrative review, we argue that the self-conscious emotion of shame is likely to be of particular importance for PNES. We summarize current concepts of the development of shame processing and its relationship with other emotional states. We demonstrate the potential of acute shame to cause a sudden disruption of normal cognitive function and trigger powerful behavioral, cognitive, physiological and secondary emotional responses which closely resemble key components of PNES. These responses may lead to the development of shame avoidance strategies which can become disabling in themselves. We discuss how excessive shame proneness and shame dysregulation are linked to several psychopathologies often associated with PNES (including depression and PTSD) and how they may predispose to, precipitate and perpetuate PNES disorders, not least by interacting with stigma. We consider current knowledge of the neurobiological underpinnings of shame and PNES. We explore how shame could be the link between PNES and a heterogeneous range of possible etiological factors, and how it may link historical aversive experiences with individual PNES events occurring much later and without apparent external trigger. We argue that, in view of the potential direct links between shame and PNES, the well-documented associations of shame with common comorbidities of this seizure disorder and the well-characterized relationship between chronic shame and stigma, there is a compelling case to pay greater attention to shame in relation to PNES. Its role in the treatment of patients with PNES is discussed in a separate, linked review incorporating case vignettes to highlight the complex interactions of different but interlinked shame-related issues in individual patients.

Evidence-Based Practice for the Clinical Assessment of Psychogenic Nonepileptic Seizures: A Report From the American Neuropsychiatric Association Committee on Research

The American Neuropsychiatric Association's Committee on Research assigned the task of defining the most helpful clinical factors and tests in establishing the diagnosis of psychogenic nonepileptic seizures (PNES) during a neuropsychiatric assessment. A systematic review of the literature was conducted using three search engines and specified search terms for PNES and the predetermined clinical factors and diagnostic tests, followed by a selection process with specific criteria. Data extraction results from selected articles are presented for clinical factors (semiology, psychiatric comorbidities, medical comorbidities, psychological traits) and diagnostic tests (EEG, psychometric and neuropsychological measures, prolactin level, clinical neuroimaging, autonomic testing). Semiology with video EEG (vEEG) remains the most valuable tool to determine the diagnosis of PNES. With the exception of semiology, very few studies revealed the predictive value of a clinical factor for PNES, and such findings were isolated and not replicated in most cases. Induction techniques, especially when coupled with vEEG, can lead to a captured event, which then confirms the diagnosis. In the absence of a captured event, postevent prolactin level and personality assessment can support the diagnosis but need to be carefully contextualized with other clinical factors. A comprehensive clinical assessment in patients with suspected PNES can identify several clinical factors and may include a number of tests that can support the diagnosis of PNES. This is especially relevant when the gold standard of a captured event with typical semiology on vEEG cannot be obtained.

Attachment styles, identification of feelings and psychiatric symptoms in functional neurological disorders

OBJECTIVE

The contribution of psychological and psychiatric symptoms in the development of Functional Neurological Disorders (FND) is unclear. We therefore aimed to investigate the role of different attachment styles (AS) and their relationship with psychiatric symptoms in FND patients as compared with both subjects with neurological disorders (ND) and healthy controls (HC); and the possible differences between patients with functional movement disorders (FMD) and with functional seizures.

METHODS

In this case-control study, forty-six patients with FND were compared to 34 with ND and 30 HC, by means of an extensive battery to investigate the presence of alexithymia, depression, anxiety, dissociation and to explore their AS using the Revised Experiences in Close Relationships instrument (ECR-R).

RESULTS

Patients with FND had higher depression and alexithymia as well as an avoidant pattern on the ECR-R than patients with ND. In the FND group, ECR-R avoidance was an independent predictor of psychiatric symptoms and, altogether, ECR-R avoidance, the somatic-affective component of depression and difficulty identifying feelings were independent predictors of FND. Gender, anxiety and difficulty identifying feelings predicted the presence of functional seizures.

CONCLUSION

The avoidant AS may be an important psychological factor influencing the presence of mood disorders and alexithymia. Their co-occurence might drive maladaptive responses underlying the presence of FND. Although we demonstrated a large overlap between FND phenotypes, patients with functional seizures might have higher alexithymia, which in turn could explain a defensive response less anchored to body reactions and physical symptoms.

What do we know about non-epileptic seizures in adults with intellectual disability: A narrative review

Psychogenic non-epileptic seizures (PNES) superficially resemble epileptic seizures, but are not associated with abnormal electrical activity in the brain. PNES are a heterogeneous entity and while there is increasing interest in the characterisation of PNES sub-groups, little is known about individuals with PNES who have an intellectual disability (ID). ID is a lifelong condition characterised by significant limitations in cognitive, social and practical skills. ID (commonly with comorbid epilepsy) has been identified as a risk factor for developing PNES. However, people with ID are often excluded from research in PNES. This has unfortunately resulted in a lack of evidence to help inform practice and policy for this population. This narrative review synthesises the currently available evidence in terms of the epidemiology, demographic and clinical profile of adults with PNES and ID. There is a particular focus on demographics, aetiological factors, PNES characteristics, diagnosis and treatment of the condition in this population. Throughout this article, we critique the existing evidence, discuss implications for clinical practice and highlight the need for further research and enquiry. What emerges from the evidence is that, even within the sub-group of those with ID, PNES are a heterogeneous condition. Individuals with ID and PNES are likely to present with diverse and complex needs requiring multidisciplinary care. This review is aimed at the broad range of healthcare professionals who may encounter this group. We hope that it will stimulate further discussion and research initiatives.

Theory of mind and its relationship with alexithymia and quality of life in patients with psychogenic nonepileptic seizures: Comparisons with generalised epilepsy and healthy controls

OBJECTIVE

Psychogenic nonepileptic seizures (PNES) are associated with high alexithymia, social cognition problems and low quality of life (QoL). Theory of Mind (ToM) has been studied in several conditions as a significant predictor of QoL. We aimed to assess the relationship between ToM abilities, alexithymia and subjective QoL in PNES patients and compare with generalised epilepsy (ES) patients and healthy controls.

METHOD

Patients with PNES (n = 28), ES (n = 28) and healthy volunteers (n = 28) were evaluated for alexithymia and quality of life (QoL) with Toronto Alexithymia Scale-20 (TAS-20) and Short Form-36 (SF-36). Reading the Mind in the Eyes test was used for assessment of affective ToM and Hinting Task and Strange Stories tests for cognitive ToM abilities.

RESULTS

Analyses revealed lower SF-36 scores and poorer ToM performance in the PNES group compared to healthy group and poorer cognitive ToM performance than ES group. Cognitive ToM performance was inversely correlated with TAS-20 "difficulty identifying feelings" subscale and "physical functioning" subscale of SF-36 in the PNES group.

CONCLUSION

These results are consistent with previous research on PNES and other somatoform disorders and suggest that PNES is associated with impaired ToM task performance. ToM task performance might be related to specific aspects of alexithymia and QoL.

Social aspects of life in patients with functional seizures: Closing the gap in the biopsychosocial formulation

The human, as a biological system, is an open system embedded within larger systems -including the family, culture, and socio-political environment. In this context, a patient with functional seizures (FS) is embedded in relationships, educational/professional institutions, culture, and society. Both connection to these broader systems and the quality of these connections, as well as the soundness of each system in and of itself, influence the health and well-being of patients in positive or negative ways. The social aspects of life are important determinants of health and quality of life across the lifespan. The current narrative review brings out several overarching themes in patients with FS. Sections on attachment, marriage, social networking, and stigma highlight the central roles of supportive and affirmative relationships across the lifespan. The section on education underscores the importance of keeping children and youth with FS connected within their school environments, as well as managing any barriers - learning difficulties, school response to FS events, stigma, etc.-that can diminish this connection. Finally, the sections on employment and driving highlight the value of being an active participant in one's society. In summary, FS impacts patients across most social aspects of life domains regardless of age - factors that are important when developing biopsychosocial formulations. This review concludes that the multidisciplinary management of FS requires careful assessment of social aspects of life in patients which can then be targeted for treatment, to improve their quality of life, facilitating recovery, and reducing the risk of relapse.

Increased Amygdala Activity Associated With Cognitive Reappraisal Strategy in Functional Neurologic Disorder

Cognitive reappraisal is an emotion regulation strategy to reduce the impact of affective stimuli. This regulation could be incomplete in patients with functional neurologic disorder (FND) resulting in an overflowing emotional stimulation perpetuating symptoms in FND patients. Here we employed functional MRI to study cognitive reappraisal in FND. A total of 24 FND patients and 24 healthy controls employed cognitive reappraisal while seeing emotional visual stimuli in the scanner. The Symptom Checklist-90-R (SCL-90-R) was used to evaluate concomitant psychopathologies of the patients. During cognitive reappraisal of negative IAPS images FND patients show an increased activation of the right amygdala compared to normal controls. We found no evidence of downregulation in the amygdala during reappraisal neither in the patients nor in the control group. The valence and arousal ratings of the IAPS images were similar across groups. However, a subgroup of patients showed a significant higher account of extreme low ratings for arousal for negative images. These low ratings correlated inversely with the item "anxiety" of the SCL-90-R. The increased activation of the amygdala during cognitive reappraisal suggests altered processing of emotional stimuli in this region in FND patients.

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.

Emotional Reactivity as a Vulnerability for Psychogenic Nonepileptic Seizures? Responses While Reliving Specific Emotions

OBJECTIVE

Dysfunction in emotional processes is a hypothesized contributor to functional neurological disorders (FNDs), yet few studies have evoked real-time emotion during multimethod assessment incorporating subjective, behavioral, and psychophysiological indicators. This approach may reveal clinical and neurobiological vulnerability to FND and clarify how dysfunctional emotional processes serve as perpetuating factors.

METHODS

Eleven participants with video-EEG-confirmed diagnoses of psychogenic nonepileptic seizures (PNES) were compared with 49 seizure-free trauma control subjects (TCs) with or without clinically elevated posttraumatic stress symptoms (25 clinically elevated [TC-clin], 24 not clinically elevated [TC-nonclin]). Participants recalled and described memories evoking anger, shame, happiness, and neutral feelings.

RESULTS

Even though PNES patients and TCs reported similar amounts of emotional experience, PNES patients reported more difficulty reliving emotions and were less likely to complete the relived shame task. During and after reliving happiness, PNES and TC-clin groups showed respiratory sinus arrhythmia (RSA) decreases, indicating parasympathetic withdrawal, whereas the TC-nonclin group showed RSA increases.

CONCLUSIONS

Findings from this pilot study are consistent with previous research and clinical observations that emotional engagement may be more effortful for PNES patients. Patterns of RSA change, which may also point to greater effortful engagement, were similar in PNES and TC-clin groups, suggesting that traumatic stress reactions may play a part. At the same time, experience of greater difficulty or avoidance may be even greater among PNES patients. Especially when regulatory resources are already limited, accumulated effort, coupled with self-threatening contexts such as shame, may be particularly problematic for those with PNES and perhaps other FNDs.

Psychological inflexibility and somatization in nonepileptic attack disorder

BACKGROUND

There is no clear understanding of what causes and maintains nonepileptic attack (NEA) disorder (NEAD), or which psychological therapies may be helpful. The relationships between variables of psychological inflexibility: experiential avoidance (EA), cognitive fusion (CF), mindfulness, and key outcome variables in NEAD: somatization, impact upon life, and NEA frequency were investigated.

METHOD

Two hundred eighty-five individuals with NEAD completed validated measures online. Linear regression was used to explore which variables predicted somatization and impact upon life. Ordinal regression was used to explore variables of interest in regard to NEA frequency.

RESULTS

Mindfulness, EA, CF, somatization, and impact upon life were all significantly correlated. Mindfulness uniquely predicted somatization when considered in a model with EA and CF. Higher levels of somatization increased the odds of experiencing more NEAs. Individuals who perceived NEAD as having a more significant impact upon their lives had more NEAs, more somatic complaints, and more EA.

CONCLUSIONS

Higher levels of CF and EA appear to be related to lower levels of mindfulness. Lower levels of mindfulness predicted greater levels of somatization, and somatization predicted NEA frequency. Interventions that tackle avoidance and increase mindfulness, such as, acceptance and commitment therapy, may be beneficial for individuals with NEAD. Future directions for research are suggested as the results indicate more research is needed.

Insecure and Unresolved/Disorganized Attachment in Patients With Psychogenic Nonepileptic Seizures

BACKGROUND

Psychogenic nonepileptic seizures (PNES) are still poorly understood and difficult to treat. Attachment theory could add new aspects to the understanding of the multifactorial genesis and maintenance of PNES and the therapeutic needs of this patient group.

OBJECTIVE

The aim of the present study is to systematically assess attachment in adult patients with PNES with a focus on the role of unresolved/disorganized attachment.

METHODS

A cross-sectional design was chosen to compare patients with confirmed PNES (n = 44) and healthy controls (n = 44) matched for gender, age, and education. Attachment was assessed using the Adult Attachment Projective Picture System. Psychometric questionnaires included the Childhood Trauma Questionnaire; Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) axis II disorders, Patient Questionnaire; the Somatoform Dissociation Questionnaire; and the Patient Health Questionnaire.

RESULTS

We found significantly less secure (P = 0.006) and more unresolved/disorganized (P = 0.041) attachment classifications in the PNES group. Among patients with PNES, 7% were classified secure and 43% were classified unresolved/disorganized. Patients with an unresolved attachment representation were significantly more likely to be screened positive for personality pathology in the Structured Clinical Interview for DSM-IV axis II disorders, Patient Questionnaire (P = 0.03) and to report more emotional abuse in the Childhood Trauma Questionnaire (P = 0.007) than patients with other attachment classifications.

CONCLUSIONS

Our findings suggest that unresolved/disorganized attachment might be the predominant attachment style in patients with PNES and might be associated with more severe personality pathology. This could be of therapeutic relevance. The present study is the first to assess adult attachment in patients with PNES using a semi-structured interview in comparison to matched healthy controls.

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.

The Importance of Considering Alexithymia during Initial Stages of Intimate Partner Violence Interventions to Design Adjuvant Treatments

Empirical evidence supports that individuals with alexithymia might be prone to certain types of violence, such as intimate partner violence against women (IPVAW). Moreover, considering that alexithymia is directly involved in behavior regulation, problems due to identifying and regulating emotional states might be postulated as responsible, at least in part, for the success of psychotherapeutic treatments designed for decreasing the future risk of reoffending. Therefore, we assessed whether alexithymia was a good predictor of the discontinuation of treatment (dropout) and the risk of recidivism during the initial stages of intervention in a sample of men convicted of IPVAW perpetration (n = 118), while controlling for potential confounding variables (i.e., socio-demographic characteristics, impulsivity, and drug misuse). Our data demonstrate that high alexithymic traits lead to dropout and a high risk of recidivism during the initial stages of treatment, remaining significant even after including potential confounding variables. Even though impulsivity and drug misuse increase the amount of explained variance, none of them moderates the association of alexithymia with dropout and/or reoffending. It should be noted that this study identified alexithymia as a direct modulator of violence due to its effects on discontinuing IPVAW treatment during initial stages. Therefore, as we gain knowledge analyzing the relationships between previously mentioned factors, it could be applied to develop valid screening methods along with strengthening current rehabilitation programs and designing adjuvant treatments to increase their effectiveness.

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.

Emotional and autonomic dysregulation in abstinent alcoholic men: An idiosyncratic profile?

Men who misuse alcohol tend to experience negative affect, which may entail difficulties in regulating emotions to cope effectively with stressful or anxiety-provoking situations, thus increasing the risk of alcohol relapse. This dysphoric state has been associated with alexithymia, which compromises an individual's abilities to acknowledge, recognize, and regulate emotional states. A physiological correlate of emotional regulation is autonomic flexibility, as shown by emotional dysregulation in men who misuse alcohol being correlated with reduced parasympathetic activation to control heart rate variability during stress and/or conflict situations. Hence, the main aim of this study was to investigate whether long-term abstinent alcoholic (LTAA) men exhibit higher levels of negative affect and sympathetic activation (cardiovascular and electrodermal) in response to acute standardized laboratory stress than non-alcoholic controls. In addition, we hypothesized that the higher the alexithymic traits, the greater would be the increase in negative affect and sympathetic activation in response to stress, especially in LTAAs. Our data demonstrated that LTAAs experienced slightly greater increases in anxiety, states of anger, and worsening of mood than controls. Moreover, they exhibited lower high-frequency heart rate variability, respiratory sinus arrhythmia values, shorter pre-ejection periods, and higher respiratory rates than controls. Finally, alexithymic traits imply greater worsening of mood and sympathetic predominance (shorter pre-ejection periods and smaller magnitude of response), with the associations being stronger in LTAAs. These findings indicate a different emotional and cardiovascular response to psychosocial stress in LTAA than non-alcoholic men. Improving our knowledge of the way this population reacts to stress may help identify risk factors for alcohol relapse.

Alexithymic traits are closely related to impulsivity and cognitive and empathic dysfunctions in intimate partner violence perpetrators: New targets for intervention

Clinical psychologists are interested in studying factors that interfere with the behavioral regulation of perpetrators of intimate partner violence against women (IPVAW), as well as the way these factors affect the risk of future recidivism after interventions that are designed for them are completed. Although several variables have been proposed as risk factors for IPVAW, the role of alexithymia and its relationships with other cognitive and empathic variables in IPVAW perpetrators has been neglected. Thus, the main aim of this study was to compare the alexithymic and cognitive and empathic traits in a carefully selected sample of IPVAW perpetrators (n = 47; mean age = 39) with a control group matched on sociodemographic characteristics (n = 41; mean age = 42). Moreover, we also aimed to study whether alexithymic traits are related to cognitive and empathic alterations in IPVAW perpetrators. Compared to controls, IPVAW perpetrators had higher alexithymic and self-reported impulsivity traits and worse attention and executive functioning (e.g., verbal fluency and cognitive flexibility) performance than controls. Moreover, they also presented greater personal distress, compared to controls. Notably, we observed that higher alexithymia was associated with high self-reported impulsivity, worse cognitive and empathic performance in both groups. Our study identifies different cognitive targets for specific neuropsychological rehabilitation interventions designed to prevent violence recidivism in the long term through their effects on emotional information processing and behavioral regulation.

Alexithymia is associated with neural reactivity to masked emotional faces in adolescents who self-harm

BACKGROUND

Non-suicidal self-injury (NSSI) is a major, trans-diagnostic mental health problem among adolescents. Alexithymia has been identified as a developmental risk factor for NSSI. Research on how alexithymia relates to the neurobiology of automatic emotion processing is only beginning to emerge. This study evaluates the relationship between alexithymic features and neural responses to automatic processing of emotional content in adolescents with NSSI.

METHODS

25 female adolescents (ages 13-21) with a history of repeated engagement in NSSI completed the Toronto Alexithymia Scale and the Difficulties with Emotion Regulation Scale and underwent functional magnetic resonance imaging (fMRI) during a task in which participants were exposed to masked emotions.

RESULTS

One facet of alexithymia, limited internal emotion awareness or externally-oriented thinking (EOT), was related to differential reactivity to masked emotional faces in clusters in the right supramarginal gyrus and right inferior frontal gyrus. Follow-up assessment of regional reactivity revealed that greater EOT is associated with lower activation to masked happy faces but higher activation to masked fearful faces. Other facets of alexithymia did not show relationships with reactivity to masked emotional faces.

LIMITATIONS

This is a cross-sectional and small sample that only includes females, which may attenuate generalizability of findings.

CONCLUSIONS

We report neural correlates of multiple facets of alexithymia in adolescents with NSSI. Among adolescents who self-harm, those with higher levels of EOT may be less alert to subtle positively-valenced emotion cues. For this subset of adolescents with NSSI, interventions designed to enhance mental representation of emotional responses and attention to positive emotions may be appropriate.

Fearful Attachment Linked to Childhood Abuse, Alexithymia, and Depression in Motor Functional Neurological Disorders

Insecure attachment is a predisposing risk factor for the development of functional neurological disorder (FND). There is limited research investigating connections between attachment styles, other predisposing vulnerabilities, and symptom severity in patients with motor FND. By using a within-group design with prospective data collection, the authors performed univariate tests followed by multivariate linear regressions to investigate neuropsychiatric factors associated with four attachment styles (secure, fearful, preoccupied, and dismissing) among 56 patients with motor FND (mean age=40.2 years [SD=13.0]; women, N=41; men, N=15). In univariate analyses, fearful attachment style was associated with self-reported adverse life event burden, alexithymia, dissociation, depression, anxiety, impaired stress coping skills, functional neurologic symptom severity, and marital status. In a multivariate stepwise linear regression analysis, childhood abuse, alexithymia, depression, and not being married independently predicted fearful attachment. In a post hoc analysis, childhood sexual and emotional abuse were each independently associated with fearful attachment tendencies. There were no independent predictors of secure, preoccupied, or dismissing attachment styles in this study population. Future studies with larger cohorts are needed to investigate nuanced relationships among predisposing vulnerabilities for the development of FND, as well as potential links between risk factors, functional neurologic symptom severity, and clinical outcomes.

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.

Secure Attachment and Depression Predict 6-Month Outcome in Motor Functional Neurological Disorders: A Prospective Pilot Study

BACKGROUND

The relationships between baseline neuropsychiatric factors and clinical outcome in patients with functional neurological disorder (FND)/conversion disorder remain poorly understood.

OBJECTIVE

This prospective, naturalistic pilot study investigated links between predisposing vulnerabilities (risk factors) and clinical outcome in patients with motor FND engaged in usual care within a subspecialty FND clinic.

METHODS

Thirty-four patients with motor FND were enrolled and completed baseline and 6-month follow-up psychometric questionnaires. Univariate screening tests followed by multivariate linear regression analyses were used to investigate neuropsychiatric predictors of 6-month clinical outcome in patients with motor FND.

RESULTS

In univariate analyses, baseline secure attachment traits and depression as measured by the Relationship Scales Questionnaire and Beck Depression Inventory-II positively correlated with improved Patient Health Questionnaire-15 scores. In a multivariate linear regression analysis adjusting for the interval time between baseline and follow-up data collection, baseline secure attachment and depression scores independently predicted improvements in Patient Health Questionnaire-15 scores. In additional analyses, patients with a diagnosis of psychogenic nonepileptic seizures compared to individuals with other motor FND subtypes showed a trend toward worse 6-month physical health outcomes as measured by the Short Form Health Survey-36.

CONCLUSION

Future large-scale, multi-site longitudinal studies are needed to comprehensively investigate neuropsychiatric predictors of clinical outcome in patients with motor FND, including functional weakness, functional movement disorders, and psychogenic nonepileptic seizures.

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.

A pilot randomised controlled trial of a home-based writing intervention for individuals with seizures

OBJECTIVE

We investigated the feasibility, acceptability and preliminary effectiveness of a writing intervention for individuals with epilepsy or psychogenic nonepileptic seizures.

METHODS

Individuals were randomised to write about potentially 'therapeutic' topics (n = 43) or about their daily events (n = 25). Participants were asked to write on four separate occasions for at least 20 min. Repeated-measures analysis of variance was used to investigate change in measures of health-related quality of life (NEWQoL-6D), depression (NDDI-E), anxiety (GAD-7) and illness perception (B-IPQ) from baseline to one and three-month follow-ups. Qualitative and quantitative data taken from a Writing Task Questionnaire was analysed between the two conditions.

RESULTS

Recruitment was acceptable with 52% of those randomised completing the full writing intervention. In both conditions, participants wrote for longer than 20 min suggesting those who completed the study engaged well with the procedure. Greater benefits were observed in the 'therapeutic' condition (p < 0.05), which was associated with an improvement in health-related quality of life at one-month follow-up (p = 0.02). No differences were found in the other measures.

CONCLUSIONS

A writing intervention is acceptable in this population. Self-reported benefits were modest, suggesting therapeutic writing may be more suitable as a supplement to other therapies rather than a stand-alone therapeutic intervention.

Resilience linked to personality dimensions, alexithymia and affective symptoms in motor functional neurological disorders

OBJECTIVE

Reduced resilience, a construct associated with maladaptive stress coping and a predisposing vulnerability for Functional Neurological Disorders (FND), has been under-studied compared to other neuropsychiatric factors in FND. This prospective case-control study investigated self-reported resilience in patients with FND compared to controls and examined relationships between resilience and affective symptoms, personality traits, alexithymia, health status and adverse life event burden.

METHODS

50 individuals with motor FND and 47 healthy controls participated. A univariate test followed by a logistic regression analysis investigated group-level differences in Connor-Davidson Resilience Scale (CD-RISC) scores. For within-group analyses performed separately in patients with FND and controls, univariate screening tests followed by multivariate linear regression analyses examined factors associated with self-reported resilience.

RESULTS

Adjusting for age, gender, education status, ethnicity and lifetime adverse event burden, patients with FND reported reduced resilience compared to controls. Within-group analyses in patients with FND showed that individual-differences in mental health, extraversion, conscientiousness, and openness positively correlated with CD-RISC scores; post-traumatic stress disorder symptom severity, depression, anxiety, alexithymia and neuroticism scores negatively correlated with CD-RISC scores. Extraversion independently predicted resilience scores in patients with FND. In control subjects, univariate associations were appreciated between CD-RISC scores and gender, personality traits, anxiety, alexithymia and physical health; conscientiousness independently predicted resilience in controls.

CONCLUSION

Patients with FND reported reduced resilience, and CD-RISC scores covaried with other important predisposing vulnerabilities for the development of FND. Future research should investigate if the CD-RISC is predictive of clinical outcomes in patients with FND.

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.

The Inpatient Assessment and Management of Motor Functional Neurological Disorders: An Interdisciplinary Perspective

BACKGROUND

Motor functional neurologic disorders (FND)-previously termed "hysteria" and later "conversion disorder"-are exceedingly common and frequently encountered in the acute hospital setting. Despite their high prevalence, patients with motor FND can be challenging to diagnose accurately and manage effectively. To date, there is limited guidance on the inpatient approach to the neuropsychiatric evaluation of patients with functional (psychogenic) neurologic symptoms.

OBJECTIVE

The authors outline an inpatient multidisciplinary approach, involving neurology, psychiatry, and physical therapy, for the assessment and acute inpatient management of motor FND.

METHODS

A vignette of a patient with motor FND is presented followed by a discussion of general assessment principles. Thereafter, a detailed description of the neurologic and psychiatric assessments is outlined. Delivery of a "rule-in" diagnosis is emphasized and specific guidance for what can be accomplished postdiagnosis in the hospital is suggested.

DISCUSSION

We encourage an interdisciplinary approach beginning at the early stages of the diagnostic assessment once an individual is suspected of having motor FND.

CONCLUSIONS

Practical suggestions for the inpatient assessment of motor FND are presented. It is also important to individualize the diagnostic assessment. Future research should be conducted to test best practices for motor FND management in the acute inpatient hospital setting.

Emotion regulation strategies in trauma-related disorders: pathways linking neurobiology and clinical manifestations

Emotion regulation impairments with traumatic origins have mainly been studied from posttraumatic stress disorder (PTSD) models by studying cases of adult onset and single-incident trauma exposure. The effects of adverse traumatic experiences, however, go beyond the PTSD. Different authors have proposed that PTSD, borderline personality, dissociative, conversive and somatoform disorders constitute a full spectrum of trauma-related conditions. Therefore, a comprehensive review of the neurobiological findings covering this posttraumatic spectrum is needed in order to develop an all-encompassing model for trauma-related disorders with emotion regulation at its center. The present review has sought to link neurobiology findings concerning cortico-limbic function to the field of emotion regulation. In so doing, trauma-related disorders have been placed in a continuum between under- and over-regulation of affect strategies. Under-regulation of affect was predominant in borderline personality disorder, PTSD with re-experiencing symptoms and positive psychoform and somatoform dissociative symptoms. Over-regulation of affect was more prevalent in somatoform disorders and pathologies characterized by negative psychoform and somatoform symptoms. Throughout this continuum, different combinations between under- and over-regulation of affect strategies were also found.