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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Developing feasible person-centred care alternatives to emergency department responses for adults with epilepsy: a discrete choice analysis mixed-methods study

Background

Calls have been made for paramedics to have some form of care pathway that they could use to safely divert adults with epilepsy away from emergency departments and instigate ambulatory care improvements. Different configurations are possible. To know which to prioritise for implementation/evaluation, there is a need to determine which are acceptable to service users and likely National Health Service-feasible.

Objective(s)

(1) Identify configurations being considered, (2) understand service users' views of them and current provision, (3) identify what sort of care service users want and (4) determine which configuration(s) is considered to achieve optimal balance in meeting users' preference and being National Health Service-feasible.

Design

Service providers were surveyed to address objective 1. Interviews with service users addressed objective 2. Objective 3 was addressed by completing discrete choice experiments. These determined users' care preferences for different seizure scenarios. Objective 4 was addressed by completing 'knowledge exchange' workshops. At these, stakeholders considered the findings on users' stated preferences and judged different pathway configurations against Michie's 'acceptability, practicability, effectiveness, affordability, side-effects and equity' feasibility criteria.

Setting

This project took place in England. The survey recruited representatives from neurology and neuroscience centres and from urgent and emergency care providers. For the interviews, recruitment occurred via third-sector support groups. Recruitment for discrete choice experiments occurred via the North West Ambulance Service NHS Trust and public advert. Workshop participants were recruited from neurology and neuroscience centres, urgent and emergency care providers, support groups and commissioning networks.

Participants

Seventy-two services completed the survey. Interviews were conducted with 25 adults with epilepsy (and 5 relatives) who had emergency service contact in the prior 12 months. Discrete choice experiments were completed by 427 adults with epilepsy (and 167 relatives) who had ambulance service contact in the prior 12 months. Workshops were completed with 27 stakeholders.

Results

The survey identified a range of pathway configurations. They differed in where they would take the patient and their potential to instigate ambulatory care improvements. Users had been rarely consulted in designing them. The discrete choice experiments found that users want a configuration of care markedly different to that offered. Across the seizure scenarios, users wanted their paramedic to have access to their medical records; for an epilepsy specialist (e.g. an epilepsy nurse, neurologist) to be available to advise; for their general practitioner to receive a report; for the incident to generate an appointment with an epilepsy specialist; for the care episode to last < 6 hours; and there was a pattern of preference to avoid conveyance to emergency departments and stay where they were. Stakeholders judged this configuration to be National Health Service-feasible within 5-10 years, with some elements being immediately deployable.

Limitations

The discrete choice experiment sample was broadly representative, but those reporting recent contact with an epilepsy specialist were over-represented.

Conclusions

Users state they want a configuration of care that is markedly different to current provision. The configuration they prefer was, with support and investment, judged to likely be National Health Service-feasible. The preferred configuration should now be developed and evaluated to determine its actual deliverability and efficacy.

Study registration

The study is registered as researchregistry4723.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/05/62) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 24. See the NIHR Funding and Awards website for further award information.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

'I just need to know what they are and if you can help me': Medicalization and the search for legitimacy in people diagnosed with non-epileptic attack disorder

This paper focuses on the struggles for legitimacy expressed by people with non-epileptic attack disorder (NEAD), one of the most common manifestations of functional neurological disorder presenting to emergency and secondary care services. Nonepileptic attacks are episodes of altered experience, awareness, and reduced self-control that superficially resemble epileptic seizures or other paroxysmal disorders but are not associated with physiological abnormalities sufficient to explain the semiological features. "Organic" or medicalized explanations are frequently sought by patients as the only legitimate explanation for symptoms, and consequently, a diagnosis of NEAD is often contested. Drawing on narrative interviews with patients from a small exploratory study and using a sociological perspective, we propose that a psychological account of NEAD does not provide a sufficiently legitimate path into a socially sanctioned sick role. This is a reflection of the dominance of biomedicine and the associated processes of medicalization. These processes are, we argue, the sole route to achieving legitimacy. The stress-based or psychologically oriented explanations offered to patients in contemporary medical models of the etiology of NEAD engender an uncertain identity and social position and fail to provide many patients with an account of the nature or origin of their symptoms that they find satisfactory or convincing. These struggles for legitimacy (shared by others with functional or somatoform conditions) are sharpened by key features of the contemporary healthcare landscape, such as the increasing framing of health through a lens of 'responsibilization'.

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

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

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.

Persistent somatic symptom related stigmatisation by healthcare professionals: A systematic review of questionnaire measurement instruments

OBJECTIVE

Patients with persistent somatic symptoms (PSS) experience stigmatising attitudes and behaviours by healthcare professionals. While previous research has focussed on individual manifestations of PSS related stigma, less is known about sound ways to measure stigmatisation by healthcare professionals towards patients with PSS. This review aims to assess the quality of questionnaire measurement instruments and make recommendations about their use.

METHODS

A systematic review using six databases (PubMed, Embase, CINAHL, PsycINFO, Open Grey and EThOS). The search strategy combined three search strings related to healthcare professionals, PSS and stigma. Additional publications were identified by searching bibliographies. Three authors independently extracted the data. Data analysis and synthesis followed COSMIN methodology for reviews of outcome measurement instruments.

RESULTS

We identified 90 publications that met the inclusion criteria using 62 questionnaire measurement instruments. Stereotypes were explored in 92% of instruments, prejudices in 52% of instruments, and discrimination in 19% of instruments. The development process of the instruments was not rated higher than doubtful. Construct validity, structural validity, internal consistency and reliability were the most commonly investigated measurement properties. Evidence around content validity was inconsistent or indeterminate.

CONCLUSION

No instrument provided acceptable evidence on all measurement properties. Many instruments were developed for use within a single publication, with little evidence of their development or establishment of content validity. This is problematic because stigma instruments should reflect the challenges that healthcare professionals face when working with patients with PSS. They should also reflect the experiences that patients with PSS have widely reported during clinical encounters.

Factors associated with illness representations in adults with epileptic and functional seizures: A systematic review

Illness representations refer to a person's beliefs about their health condition and are thought to influence clinical outcomes. By understanding factors related to illness representations, potentially modifiable targets for psychological intervention can be identified. The aim of this systematic review was to synthesise the literature on factors associated with illness representations in people with epilepsy and functional seizures. Three electronic databases (Psychinfo, EMBASE, and Proquest (Theses and dissertations)) were searched for studies that reported on associations between Illness Perception Questionnaire scores (or variations thereof) and biopsychosocial factors in people with epilepsy or people with functional seizures. Seventeen studies met inclusion criteria and were assessed with a bespoke quality appraisal tool. Overall, there was moderately strong evidence for an association between more threatening illness representations and poorer clinical outcomes relating to seizure characteristics, distress, coping, and quality of life; the evidence for these relationships was stronger for people with epilepsy than functional seizures. There was no clear difference between the illness representations of the two groups. The results of this review highlight the clinical importance of illness representations in people with seizure disorders, as well as opportunities for further research.

Psycho-socio-clinical profiles and quality of life in seizure disorders: A cross-sectional registry study

OBJECTIVE

This prospective study aimed at comparing quality of life (QoL) and psycho-socio-clinical profiles between patients with epilepsy, psychogenic nonepileptic seizures (PNES), and syncope. We also intended to identify predictors of QoL in these three seizure disorders.

METHODS

A total of 245 inpatients (epilepsy n = 182, PNES n = 50, syncope n = 13) from a tertiary epilepsy clinic were included. Information on QoL as well as on psychological, sociodemographic, and clinical profiles was retrieved using questionnaires and medical records. Group comparisons on QoL and psycho-socio-clinical profiles were performed via analyses of variance, chi-square tests, and related post hoc tests. Predictors of QoL in epilepsy and PNES were determined using general linear modeling, which was not possible for syncope due to a small sample size.

RESULTS

Patients with epilepsy, PNES, and syncope reported levels of QoL impairment that did not differ significantly between groups (p = 0.266). However, there were significant group differences regarding sex distribution (p < 0.001), seizure disorder duration (p = 0.004), seizure frequency (p = 0.019), current treatment with antiseizure medications (ASM) (p < 0.001), number of current ASM (p < 0.001), and adverse ASM events (p = 0.019). More depressive symptoms (p = 0.001), more adverse ASM events (p = 0.036), and unemployment (p = 0.046) (in this order) independently predicted a diminished QoL in epilepsy. For PNES, more depressive symptoms were the only independent predictor of lower QoL (p = 0.029).

CONCLUSIONS

Patients with epilepsy, PNES, and syncope experience similarly diminished QoL and show a general psycho-socio-clinical burden with a specific pattern for each seizure disorder diagnosis. Although clinical aspects play an undisputed role for QoL in epilepsy, the psychosocial aspects and consequences are equally, or for PNES probably even more, meaningful. A comprehensive approach to research and treatment of seizure disorders seems mandatory to increase QoL for these patients. More research on QoL in syncope is needed.

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.

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.

Illness and Treatment Perceptions of Patients with Epilepsy Attending Treatment at a Tertiary Hospital in Addis Ababa - A Qualitative Exploration

Background

Epilepsy can be a large economic burden in countries where appropriate treatment is not taken due to religious and psychosocial beliefs. The objective of this study was to explore the perceptions and experiences of patients with epilepsy attending their treatment at Tikur Anbessa Specialized Hospital about their illness and treatment.

Methods

A qualitative exploratory design with an in-depth interview was followed. Fourteen purposively selected patients were used until saturation of key emerging themes was achieved.

Results

The finding showed that study participants expressed perceptions towards their illness including about its cause, timeline, severity and psychosocial consequences which at times may be considered different from the biomedical version. They also expressed concerns about their treatment, reported about social and psychological issues and in certain cases dissatisfaction with their healthcare providers. Such issues may have led to delays in treatment-seeking and non-adherence to recommended treatment regimens and as well use of traditional medicine and spiritual healing. On the other hand, reasons that were reported to positively influence their treatment experiences include necessity perceptions about their medications, family support and use of spiritual healing alongside their biomedical treatment.

Conclusion

The healthcare provision should improve to cater to these groups of patients including instituting chronic care management and appropriate health education provision.

'It's both challenging and probably the most rewarding work' - A qualitative study of psychological therapy provider's experiences of working with people with dissociative seizures

Limited research exists exploring the experiences of psychological therapy providers (PTPs) working with people with dissociative seizures (DS). PTPs play a key role in the treatment of DS, yet sit at the end of a long, often ineffective process of diagnosis and waiting before treatment can commence. This qualitative study was undertaken involving 12 PTPs from specialist DS services throughout England and Scotland. Semi-structured interviews were carried out, using thematic analysis to evaluate the data. Four key themes were identified, "neurological to psychological", "putting the person with DS at the center", "treatment process", and "issues and impact of therapy with patients with DS". The findings showed that an unclear and uncomprehended diagnosis, together with waiting times had a detrimental impact on patients at the starting point of therapy. People with DS were perceived as a heterogeneous group whose treatment needed to be individualized, using the PTPs' full 'toolkit' of modalities and techniques, with a focus on improving quality of life, rather than reducing seizures. The study highlighted the complexity for PTPs of working with major but also accumulated minor traumas, compounded by the impact of DS on both PTPs and treatment. The desire of PTPs to be totally patient-focused meant that individualized treatment was considered essential and meant that participants were doubtful about the possibility of compiling an effective manual for the psychological treatment for DS.

Patients' Explanatory Models about drug-resistant epilepsy in Argentina. A thematic analysis

OBJECTIVE

The aim of this study is to explore explanatory models (EM) about epilepsy in patients with drug-resistant epilepsy (DRE) in Buenos Aires, Argentina.

DESIGN

A qualitative approach gathered data through semi-structured interviews, oriented to gain an in-depth and contextual understanding of EM about epilepsy of patients with DRE. Data collection and analysis were followed by an inductive and interpretive approach informed by the principles of thematic analysis.

RESULTS

75 patients from two public hospitals participated. Emerging codes were grouped into three categories: Biomedical EM, Psychosocial EM, and Traditional EM. Also, factors that trigger or increase the frequency of seizures were reported.

CONCLUSIONS

Patients' EM regarding epilepsy are complex, as biological, psychological, and supernatural aspects intertwine. EM represent a method of understanding the way people explain, recognize, and act in relation to a medical condition. Since patients' beliefs regarding their illness are related to mental disorders, and quality of life, EM could shed light on the real impact of illness in the life of people, and, in turn, guide those intervention strategies to the patients' subjectivity, in order to improve the treatment compliance, reduce distress, and improve health-related quality of life, among other aspects.

Myths and truths about pediatric psychogenic nonepileptic seizures

Psychogenic nonepileptic seizures (PNES) is a neuropsychiatric condition that causes a transient alteration of consciousness and loss of self-control. PNES, which occur in vulnerable individuals who often have experienced trauma and are precipitated by overwhelming circumstances, are a body's expression of a distressed mind, a cry for help. PNES are misunderstood, mistreated, under-recognized, and underdiagnosed. The mindbody dichotomy, an artificial divide between physical and mental health and brain disorders into neurology and psychiatry, contributes to undue delays in the diagnosis and treatment of PNES. One of the major barriers in the effective diagnosis and treatment of PNES is the dissonance caused by different illness perceptions between patients and providers. While patients are bewildered by their experiences of disabling attacks beyond their control or comprehension, providers consider PNES trivial because they are not epileptic seizures and are caused by psychological stress. The belief that patients with PNES are feigning or controlling their symptoms leads to negative attitudes of healthcare providers, which in turn lead to a failure to provide the support and respect that patients with PNES so desperately need and deserve. A biopsychosocial perspective and better understanding of the neurobiology of PNES may help bridge this great divide between brain and behavior and improve our interaction with patients, thereby improving prognosis. Knowledge of dysregulated stress hormones, autonomic nervous system dysfunction, and altered brain connectivity in PNES will better prepare providers to communicate with patients how intangible emotional stressors could cause tangible involuntary movements and altered awareness.

Relationships among illness representations and depressive symptom severity in predominantly African-American and Caribbean-American people with epilepsy

Objective: Depression is the most common psychiatric comorbidity among people with epilepsy (PWE) and tends to be more prevalent among people of color (POC) and those with intractable seizures. However, the extent to which illness-related perceptions are associated with depressive symptom severity among POC with intractable seizures is unclear. Method: This cross-sectional study examined relationships among illness representations and self-rated depressive symptoms in 55 PWE (M Age = 41; 61.8% female) with intractable seizures (M seizures per month = 2) who identified as Black/African-American (52.7%), Black/Caribbean-American (27.3%), and/or Hispanic/Latino (21.8%). Epilepsy-related illness perceptions were assessed with the Illness Perception Questionnaire-Revised and depression was measured via the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E). Results: Nearly half of the sample (41.8%) scored above the NDDI-E depression cut-off. PWE endorsing more severe depressive symptoms indicated that their epilepsy had more negative consequences, was hard to comprehend, was insufficiently controlled by treatment, and had a negative emotional impact (p's ≤ 0.02). Controlling for sex, these four illness representations accounted for 48% of the variance in depression severity. Interestingly, participants with probable major depressive episodes were more likely to endorse several psychological causes of seizures compared to non-depressed PWE. Conclusions: Worse depression symptom severity was associated with negative illness perceptions and a tendency to attribute one's epilepsy to psychological causes. Future research is needed to understand how the relationship between negative illness perceptions and depression symptoms unfold over time and whether interventions aimed at modifying illness representations reduce psychological distress in diverse PWE.

Using Patient-Centered Clinical Neuroscience to Deliver the Diagnosis of Functional Neurological Disorder (FND): Results from an Innovative Educational Workshop

OBJECTIVES

Psychiatry training is lacking examples of neuroscience education that translates neuroscience literature into accessible clinically oriented concepts. The authors created a teaching activity using patient-centered neuroscience education that focused on delivering the diagnosis of functional neurological disorder (FND). This study aimed to (i) develop a workshop modeling a clinician-patient interaction, (ii) provide a modern neuroscience perspective of FND, and (iii) evaluate the change in clinicians' perceptions of FND.

METHODS

A total of six workshops (each 1 h long and consisting of a video, PowerPoint slides, and pre and post questionnaires) were conducted. Paired t tests were used to measure the change.

RESULTS

Forty-seven clinicians participated. After completing the workshop, nearly all endorsed that functional symptoms are "real" (95%) and that treatment is helpful (100%). Participants also reported a greater comfort level with discussing FND diagnosis (46% vs 85%, p < 0.001), an overall increase in understanding the disorder (33% vs 82%, p < 0.001), assessing need for tests (33% vs 66%, p < 0.001), understanding treatment options (26% vs 89%, p < 0.001), and recognition that treatment can help control these symptoms (81% vs 100%, p < 0.01). In addition, learners were more likely to report that patients with FND are truthful (75% vs 95%, p < 0.001) and less likely to be manipulative (48% vs 80%, p < 0.001).

CONCLUSIONS

A brief, educational intervention using neuroscience-based content was found to significantly improve clinicians' perception and confidence when delivering the diagnosis of FND.

Adults' experiences of living with pulmonary hypertension: a thematic synthesis of qualitative studies

OBJECTIVES

Pulmonary hypertension is a life-shortening disease that has a considerable impact on quality of life. Improving our understanding of how individuals are affected and cope with the disease will help to improve services and outcomes. This review synthesises the published qualitative research that has listened to adults discuss their experiences of living with the disease.

DESIGN

A comprehensive systematic search of four databases was conducted in May 2020: Web of Science, PubMed, PsycINFO and Cochrane Library. Suitable studies were evaluated using the Critical Appraisal Skills programme. Findings from the studies were extracted and subjected to a thematic synthesis.

RESULTS

Nineteen articles were identified reflecting the experiences of over 1900 individuals impacted by pulmonary hypertension from Europe, North and South America and Asia. Ten studies did not report participant's WHO functional class of pulmonary hypertension, which resulted in comparing experiences between different severity difficult. All studies met the majority of the quality assessment items. Six descriptive themes emerged discussing participant's experiences of diagnosis, treatment, prognosis, healthcare professionals, impact and coping with pulmonary hypertension. Four higher order analytical themes were developed from the descriptive themes, reflecting: (i) uncertainties and anxiety that participants encountered related to pulmonary hypertension; (ii) lack of recognition of the impact of the condition; (iii) frustration at the paucity of awareness of pulmonary hypertension in society and healthcare settings and (iv) participant's accounts of transitioning through different stages of living with the disease.

CONCLUSIONS

These findings form the first synthesis of experiences of life in individuals impacted by pulmonary hypertension and illustrate the multifaceted impact of the condition. The voices of numerous groups are missing from the literature highlighting the need for additional research. The results have implications for clinical practice emphasising the role of educational and psychological therapies to support those with the disease.

Stigma and functional neurological disorder: a research agenda targeting the clinical encounter

Stigma against patients with functional neurological disorder (FND) presents obstacles to diagnosis, treatment, and research. The lack of biomarkers and the potential for symptoms to be misunderstood, invalidated, or dismissed can leave patients, families, and healthcare professionals at a loss. Stigma exacerbates suffering and unmet needs of patients and families, and can result in poor clinical management and prolonged, repetitive use of healthcare resources. Our current understanding of stigma in FND comes from surveys documenting frustration experienced by providers and distressing healthcare interactions experienced by patients. However, little is known about the origins of FND stigma, its prevalence across different healthcare contexts, its impact on patient health outcomes, and optimal methods for reduction. In this paper, we set forth a research agenda directed at better understanding the prevalence and context of stigma, clarifying its impact on patients and providers, and promoting best practices for stigma reduction.

Stigma in psychogenic nonepileptic seizures

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Report on a psychoeducational intervention for psychogenic non-epileptic seizures in Argentina

PURPOSE

To examine the effects of a three-session psychoeducational intervention on patients diagnosed with psychogenic non-epileptic seizures (PNES) in an Argentinian public hospital. It was hypothesized that patients would experience improvements in their understanding of PNES, illness perception and affective scores, but might not necessarily experience a significant change in post-traumatic and dissociative symptoms and in seizure frequency.

METHODS

This study included 12 patients (10 women, 2 men) who were invited to participate in a psychoeducational group after receiving a V-EEG confirmed diagnosis of PNES. The group consisted of 3 sessions lasting 2 h each. Pre and post measures included Psychoeducational Intervention Questionnaire, State-Trait Anxiety Inventory, Beck Depression Inventory-II, Brief Illness Perception Questionnaire, Posttraumatic Stress Disorder Diagnostic Scale 5, Dissociative Experiences Scale (DES-M).

RESULTS

This psychoeducational intervention produced results that were similar to interventions reported in US and European studies with regard to changes on psychological measures. Moreover, many patients also reported (on the final day of the intervention) a decrease in seizure frequency. All patients reported that participating in the intervention was a positive experience. Also, all but one patient referred that the participation in the group would have a positive impact on their quality of life.

CONCLUSIONS

Psychoeducational interventions appear to have had positive results in Argentinian patients with PNES. This is initial step in the design of empirically based psychoeducational/supportive initiatives for patients in South America.

Enquête sur le niveau de connaissances et sur les perceptions des crises non épileptiques psychogènes des psychiatres exerçant en France

L’objectif de cette étude est de déterminer le niveau de connaissances générales et des perceptions sur les crises non épileptiques psychogènes (CNEP) des psychiatres et internes de psychiatrie exerçant en France. L’objectif secondaire est d’étudier la relation entre les connaissances et les perceptions des CNEP et le fait d’avoir bénéficié d’une formation ou d’avoir une expérience de suivi de patients présentant des CNEP. Dans cette enquête, les psychiatres ont été invités par courriel, à répondre à un questionnaire mis en ligne sur internet. Le questionnaire portait sur les connaissances générales des CNEP, puis les perceptions des CNEP étaient recueillies avec le Brief Illness Perception Questionnaire (Brief-IPQ). L’enquête a permis de recueillir les réponses de 1242 participants, et 963 réponses étaient exploitables. L’étude indique que trois quarts des psychiatres exerçant en France (75 %) n’ont jamais bénéficié de formation sur les CNEP, et 42 % des psychiatres n’ont jamais suivi de patients souffrant de CNEP. Les résultats révèlent que d’une manière générale les psychiatres considèrent les CNEP comme une maladie chronique, avec un retentissement important sur la qualité de vie. Ils admettent une compréhension limitée de cette pathologie même s’ils ont conscience de l’importance des traumatismes psychiques dans la survenue des CNEP. La terminologie et la classification de ces troubles sont peu connues des psychiatres et les liens avec la personnalité histrionique sont massivement surévalués. Le fait d’avoir bénéficié d’une formation sur les CNEP permet une nette amélioration du niveau de connaissances et une adaptation des perceptions. Les CNEP restent assez méconnues par les psychiatres français et certaines de leurs perceptions sont particulièrement erronées. Une formation spécifique semble indispensable pour une meilleure compréhension des CNEP.

First do no harm: Preventing harm and optimizing care in psychogenic nonepileptic seizures

Psychogenic nonepileptic seizures (PNES) are challenging clinical occurrences consisting of any combination of altered movement, sensation, or awareness that resemble epileptic seizures (ES) but do not coincide with electrographic ictal discharges and are presumed to be neuropsychiatric-neurobehavioral in origin. Securing the PNES diagnosis is a crucial first step and is best confirmed by recording events on video-electroencephalogram (v-EEG) and finding an absence of ictal EEG changes and the presence of normal awake EEG rhythms before, during, and after the event. However, obstacles to timely diagnosis and referral to psychiatric treatment frequently occur, placing these patients at risk for harm from unnecessary medications and procedure as well as placing high burden on medical systems. Although providers across all disciplines share the responsibility by maintaining high suspicion of PNES in relevant clinical settings and engaging swiftly and empathically in securing and sharing the diagnosis with patients and families, psychiatric and neurologic providers are uniquely positioned to help lead patients towards safe and effective long-term care through a cohesive approach that is rooted in therapeutic alliance, interdisciplinary collaboration, and realistic treatment goals.

Developing patient-centred, feasible alternative care for adult emergency department users with epilepsy: protocol for the mixed-methods observational 'Collaborate' project

INTRODUCTION

Emergency department (ED) visits for epilepsy are common, costly, often clinically unnecessary and typically lead to little benefit for epilepsy management. An 'Alternative Care Pathway' (ACP) for epilepsy, which diverts people with epilepsy (PWE) away from ED when '999' is called and leads to care elsewhere, might generate savings and facilitate improved ambulatory care. It is unknown though what features it should incorporate to make it acceptable to persons from this particularly vulnerable target population. It also needs to be National Health Service (NHS) feasible. This project seeks to identify the optimal ACP configuration.

METHODS AND ANALYSIS

Mixed-methods project comprising three-linked stages. In Stage 1, NHS bodies will be surveyed on ACPs they are considering and semi-structured interviews with PWE and their carers will explore attributes of care important to them and their concerns and expectations regarding ACPs. In Stage 2, Discrete Choice Experiments (DCE) will be completed with PWE and carers to identify the relative importance placed on different care attributes under common seizure scenarios and the trade-offs people are willing to make. The uptake of different ACP configurations will be estimated. In Stage 3, two Knowledge Exchange workshops using a nominal group technique will be run. NHS managers, health professionals, commissioners and patient and carer representatives will discuss DCE results and form a consensus on which ACP configuration best meets users' needs and is NHS feasible.

ETHICS AND DISSEMINATION

Ethical approval: NRES Committee (19/WM/0012) and King's College London ethics Committee (LRS-18/19-10353). Primary output will be identification of optimal ACP configuration which should be prioritised for implementation and evaluation. A pro-active dissemination strategy will make those considering developing or supporting an epilepsy ACP aware of the project and opportunities to take part in it. It will also ensure they are informed of its findings.

PROJECT REGISTRATION NUMBER

Researchregistry4723.

Management of uncertainty in the diagnosis communication of psychogenic nonepileptic seizures in a South African context

The process of communicating a diagnosis of psychogenic nonepileptic seizures (PNES) is an integral part of the treatment process. Many international studies have therefore focused on the PNES diagnosis communication process, but to date, none with a specific focus on the South African context. This current study considered the factors that influence the patient's experience of uncertainty and the strategies employed to manage that uncertainty within the provider-patient communication. This was considered from the healthcare provider's point of view, within the specific context of diagnosis communication. We conducted 13 semi-structured interviews with providers, eliciting their perceptions related to the communication of a PNES diagnosis to patients. Data were analyzed using thematic analysis, and themes were grouped according to the main tenets of the interpersonal health communication theory of uncertainty management, which included, the experience, appraisal, and management of uncertainty. The results revealed medical, personal, and social forms of uncertainty. The social sources of uncertainty, which include challenges related to the South African healthcare system, cultural, and language variability within the South African context, as well as possible stigmatization, seemed to have the biggest influence not only on the other areas of uncertainty, but was also indicated as a barrier to effective uncertainty management by providers. Providers in this study identified the importance of building the provider-patient relationship and ensuring patient understanding, as the main strategies used to reduce uncertainty. There was some evidence to suggest varied emotional appraisals of uncertainty by patients, but because of the subjective nature of this information, further research would be needed to confirm these findings. These findings suggest that as providers, one cannot apply a one-size-fits-all approach when aiding in uncertainty management. Furthermore, it is pertinent to remain cognizant of the social realities of the South African context and its impact on the patient's uncertainty experience. More research is needed to understand patients' perceptions of uncertainty management within the context of PNES diagnosis communication, and how they align with the perceptions of the providers provided here.

Neurologists' experiences of participating in the CODES study-A multicentre randomised controlled trial comparing cognitive behavioural therapy vs standardised medical care for dissociative seizures

PURPOSE

We investigated neurologists' experience of participating in the large CODES trial involving around 900 adults with dissociative seizures which subsequently evaluated the effectiveness of tailored cognitive behavioural therapy (CBT) plus standardised medical care versus standardised medical care alone in 368 patients with dissociative seizures.

METHOD

We asked all neurologists referring patients with dissociative seizures to the CODES study to complete a 43-item online survey. This examined neurologists' (i) demographics, (ii) knowledge of dissociative seizures before and after their involvement in the CODES trial, (iii) clinical practice before, during and since their involvement, and (iv) their experience of the CODES trial.

RESULTS

Forty-three (51%) neurologists completed the questionnaire. Only about half of neurologists could make referrals to psychological intervention specific for dissociative seizures before and after the trial. One-third of doctors reported having changed their referral practice following their involvement. The majority (>69%) agreed that patient satisfaction with different aspects of the trial was very high, and 83.7% thought that it was easy to recruit patients for the study. Over 90% agreed they would like the treatment pathway to continue. Respondents found different elements of the trial useful, in particular, the patient factsheet booklet (98%), diagnosis communication advice (93%) and the CBT package (93%).

CONCLUSIONS

Neurologists participating in CODES generally found it easy to recruit patients and perceived patient satisfaction as very high. However, 46.5% of neurologists could not offer psychotherapy once the trial had finished, suggesting that problems with lack of access to psychological treatment for dissociative seizures persist.

Suicidal Ideation and Traumatic Exposure Should Not Be Neglected in Epileptic Patients: A Multidimensional Comparison of the Psychiatric Profile of Patients Suffering From Epilepsy and Patients Suffering From Psychogenic Nonepileptic Seizures

Introduction: Patients with psychogenic nonepileptic seizures (PNESs) have often been exposed to traumatic events, which is a risk factor for suicidal behavior. This would suggest that the severity of suicidal ideation is greater in PNES than in patients suffering only from epileptic seizures (ESs). However, these psychiatric symptoms may be underestimated in the ES population. The specific features or similarities between the psychiatric clinical profiles of these two groups should be elaborated to improve therapeutic management. Our study is the first to compare suicidal ideation, suicide risk, posttraumatic stress disorder (PTSD), and depression disorder simultaneously in both groups, in a tertiary care epilepsy center. Material and methods: We prospectively enrolled patients hospitalized for video-electroencephalography (EEG) monitoring to assess repeated seizures before an ES or a PNES diagnosis was made. During the psychiatric consultation that accompanied the video EEG, we rated the severity of suicidal ideation and depressive symptoms, suicidal risk, traumatic exposure history, and PTSD symptoms. Results: Eighteen subjects were enrolled and diagnosed with PNES, and 42, with ES. The PNES group reported more exposures to traumatic events and more intense PTSD symptoms (median: 17 vs. 27; p = 0.001). The severity of suicidal ideation did not differ significantly between the two groups. Conclusion: It is the severity of PTSD symptoms in PNES patients that differentiates them from ES patients, although exposure to traumatic events is also frequent in ES patients. We demonstrated that suicidal ideation and suicide risk are equally high in the ES and PNES groups. Therefore, both groups require extreme vigilance in terms of suicidal risk.

Dissociative (non-epileptic) seizures: tackling common challenges after the diagnosis

Dissociative (non-epileptic) seizures are one of the three major causes of transient loss of consciousness. As such, their treatment cannot be left to superspecialised experts. In this article I draw on personal experience to suggest ways to tackle some challenges that commonly arise after diagnosing dissociative seizures, focusing on three issues: “I want to know what is wrong with me,” “I hear what you are saying but it doesn’t apply to me” and “What if I have a seizure?” The suggestions detail both actions and words that may help at a crucial point in the patient’s journey. If handled well, the process can leave the patient better equipped to understand their seizures and to engage in further treatment; if handled badly, patients may be left more traumatised, angry and with additional disability.

Functional seizures: An evaluation of the attitudes of general practitioners local to a tertiary neuroscience service in London

OBJECTIVE

Functional seizures are a common functional neurologic disorder. Given their chronic nature, and the biopsychosocial factors involved in their etiology, general practitioners (GPs) play a crucial role in the care of these patients. However, little is known about the attitudes of GPs toward, and knowledge of, functional seizures.

METHODS

The Atkinson Morley Regional Neuroscience Centre in London provides a comprehensive service to patients with functional seizures. As part of a service evaluation we conducted an online survey among local GPs over a 1-month period assessing their attitudes toward, and knowledge of, functional seizures.

RESULTS

One hundred twenty of 974 surveyed GPs replied to the survey (12.3%). Approximately 75% of GPs readily use the term "pseudoseizures," and over 50% were not sure or did not think that functional seizures were involuntary. Nearly 30% believed, or were unsure as to whether, functional seizures occur only when patients are stressed. Despite approximately 50% of GPs expressing interest in getting involved in the management of these patients, a similar proportion do not feel confident in dealing with queries from patients with functional seizures. Although most GPs felt that neurology and psychiatry should be the primary caregivers in the diagnosis and management, respectively, of functional seizures, 50% were also of the opinion that neurology should be involved in the management of these patients.

SIGNIFICANCE

This survey highlights the attitudes of, and descriptive terms used by, GPs toward patients with functional seizures. Our findings suggest a need for better and clearer provision of information to GPs about this condition.

Hiding in Plain Sight: Functional Neurological Disorders in the News

OBJECTIVE

Functional movement and seizure disorders are still widely misunderstood and receive little public and academic attention. This is in stark contrast to their high prevalence and levels of associated disability. In an exploratory observational study, the authors examined whether the relative lack of media coverage of functional neurological disorders is in part due to misidentification in "human interest" news stories.

METHODS

Thirteen recent news stories from high-impact English-language media outlets that portrayed patients with complex symptoms either attributed to other diagnoses or presented as medical mysteries were identified using online keyword searches. All selected news stories contained video or still images displaying relevant symptoms. Cases were categorized into movement disorders or seizure disorders and were then independently assessed by 10 respective expert raters. For each category, one story of a patient whose symptoms were due to a well-recognized neurological disease was also included. Both the diagnostic category and the respective confidence level were reported by each rater for each case. The interrater agreement was calculated for each group of disorders.

RESULTS

The raters confirmed almost unanimously that all presented news stories except the negative control cases portrayed misidentified functional movement or seizure disorders. The interrater agreement and average diagnostic confidence were high.

CONCLUSIONS

Functional neurological disorders are often wrongly considered a rare medical curiosity of the past. However, these findings suggest that, while they are largely absent from public discourse, they often appear in the news incognito, hiding in plain sight.

Paediatricians' attitudes to and management of functional seizures in children

OBJECTIVE

To explore paediatricians' attitudes to and treatment practice for children with functional seizures (FS).

METHODS

In a nationwide survey, all 64 Danish neuro-paediatricians and social paediatricians were invited to complete a structured questionnaire encompassing FS-related issues that included beliefs and attitudes about aetiology and diagnostic assessment, current strategies for management, experienced need for clinical guidelines and better treatment options.

RESULTS

A total of 61 paediatricians (95%) participated in the study. Nearly half (46%) had seen more than 30 children with FS during their career. Most (65%) believed in a primarily psychogenic aetiology. More than half (57%) stated that they could make the diagnosis by solely observing a seizure, and 18% indicated the children faked their symptoms. The paediatricians' responses to these issues did not significantly vary according to their level of clinical experience. Furthermore, the majority (78%) expressed a need for clinical guidelines, and only 13% rated existing treatment options as sufficient. Collaborative care between different specialties or management in a child and adolescent mental health services (CAMHS) setting was seen as the best model for treatment. However, only 23% reported often referring these children to CAMHS after making the diagnosis.

CONCLUSION

The findings suggest that introduction of clinical guidelines in this area is highly needed. Such guidelines could promote more formal training of paediatricians in understanding and assessing FS and increased collaboration between paediatrics and CAMHS regarding care for children with this challenging and potentially costly and disabling disorder.

First-aid management of tonic-clonic seizures among healthcare personnel: A survey by the Apulian section of the Italian League Against Epilepsy

INTRODUCTION

To evaluate the knowledge of healthcare workers about first-aid measures to be performed during and after a tonic-clonic seizure.

METHODS

One hundred and fifty-four healthcare workers (86 physicians) working at 8 tertiary hospitals in the Apulia region, Italy, responded to a questionnaire comprising of 28 questions based on available Italian and international recommendations about what to do during a tonic-clonic seizure.

RESULTS

One hundred and fifty-four healthcare workers completed and returned surveys with a response rate of 96.25%. There were 55 nurses (35.7%), 86 physicians (55.8%), and 13 healthcare workers with different roles (Electroencephalograph technicians, psychologists, social workers). Among physicians, there were 7 cardiologists, 3 surgeons, 12 infectious-disease specialists, 11 internal medicine specialists, 2 psychiatrists, 2 gynecologists, 27 specialists working in the emergency department, and 22 physicians with different specializations. Nearly 90% of the respondents identified head protection as important first aid, while 100% responded to not keep the legs elevated. To avoid tongue bite, both physicians and other healthcare workers would put something in the mouth (54.0%), like a Guedel cannula (71.0%) fingers (29.5%). Grabbing arms and legs, trying to stop the seizure, would be potentially performed by 11.6% of our sample. Physicians would administer a benzodiazepine during the seizure (65.7%) and during the postictal phase (29.2%), even if the patient is known to have epilepsy (23.7%), and in this case, 11.3% of respondents would administer the usual antiepileptic medications. More than half of respondents would call the emergency telephone number, because of necessary hospitalization in case of tonic-clonic seizure, even if it is experienced by a patient known to have epilepsy.

CONCLUSION

Our survey suggests the need for epilepsy educational programs on first-aid management of seizures among healthcare workers.

Illness representations of systemic lupus erythematosus and systemic sclerosis: a comparison of patients, their rheumatologists and their general practitioners

Objective

Discrepancies in illness representations between patients and physicians result in treatment difficulties, decreased well-being of patients and misunderstandings and disrupted communication. Hence, the objective of this study was to compare illness perceptions of individual patients with systemic lupus erythematosus (SLE) and systemic sclerosis (SSc), their rheumatologists and their general practitioners (GPs) and explore potential differences.

Methods

This study has a cross-sectional design. Patients with SLE and SSc, who were followed at the rheumatology department of the University Hospitals Leuven (Belgium), completed the revised Illness Perception Questionnaire which measures patients’ perceptions of their condition and captures nine dimensions. Physicians completed the Revised Illness Perception Questionnaire for Healthcare Professionals which consists of seven dimensions and measures perceptions of the healthcare professional regarding the disease of their patients. Intraclass correlation was performed to examine relationships between pairs of respondents; Cohen’s d was used for estimating the magnitude of the difference.

Results

Questionnaires were sent to 284 patients of whom 241 (113 SSc and 128 SLE patients) were included. Five rheumatologists and 160 GPs participated. For both diseases, positive correlations were found for ‘consequences’, ‘illness coherence’ and ‘emotional representations’ among patients, rheumatologists and GPs. GPs scored higher on the ‘consequences’ of these diseases for the patient (d=0.71 for SLE; d=0.80 for SSc). Differences between rheumatologists and GPs were small for SSc and moderate to large for ‘consequences’ (d=0.56) and ‘timeline acute/chronic’ (d=0.95) in SLE with higher scores for GPs.

Conclusions

For both diseases and among the three groups, significant correlations are detected for the dimensions ‘consequences’, ‘illness coherence’ and ‘emotional representations’. Differences between rheumatologists and GPs were mainly detected in the case of SLE patients. This can have implications for the collaboration between these two groups of physicians in daily clinical practice.

Clinical trial registration

NCT02655640; Pre-results.

Deconstructing stigma in psychogenic nonepileptic seizures: An exploratory study

Psychogenic nonepileptic seizures (PNES) are classified as a mental disorder, the manifestations of which superficially resemble epileptic seizures. There is a notable lack of in-depth qualitative or quantitative studies investigating the stigma attached to PNES. The current study is an exploratory analysis into the nature of perceived stigma in those with PNES when compared with individuals with epilepsy. Individuals with epilepsy (n=78) and PNES (n=47) were recruited from a United Kingdom hospital or membership-led organizations for individuals living with seizures. Participants were asked to complete a series of questionnaires investigating health-related quality-of-life components (NEWQOL-6D), anxiety (GAD-7), depression (NDDI-E), seizure frequency and severity (LSSS-3), and illness perception (B-IPQ). Perceived stigma was measured using one question taken from the NEWQOL-6D. Individuals with PNES reported a greater level of perceived stigma than those with epilepsy (p=0.04). Our results indicate that the risk of experiencing perceived stigma in PNES was 42% higher than the risk in epilepsy. In epilepsy, but not PNES, perceived stigma was significantly associated with seizure frequency, anxiety, depression, and many of the sequelae of the condition. In both conditions, self-control was associated with stigma (rho≥0.34, p≤0.01). This study was exploratory, and so definitive conclusions cannot be made; however, our findings suggest that the majority (87.2%) of individuals with PNES reported experiencing some degree of perceived stigma, the risk of which is greater than that in epilepsy. Further research is needed into the prevalence, nature, and consequences of stigma in PNES.

Factors affecting quality of life in Hungarian adults with epilepsy: A comparison of four psychiatric instruments

PURPOSE

We investigated the impact of 19 factors on life quality in Hungarian patients with epilepsy. Wellbeing was evaluated by several inventories to investigate the impact of factors in more detail.

METHODS

A cross-sectional study was performed in 170 patients. Wellbeing was evaluated with the WHO-5 Well-being Index (WHOQOL-5), Diener Satisfaction with Life Scale (SwLS), and the Quality of Life in Epilepsy-31 Questionnaire (Qolie-31). We investigated their association with demographic characteristics, general health status, epilepsy, and its treatment. The impact of these factors on illness perception (Illness Perception Questionnaire, IPQ) was also studied.

RESULTS

The four measures correlated highly significantly. In addition, the predictive power of factors was comparable with the four inventories as evaluated by Multiple Regression. Factors explained 52%, 41%, 63% and 46% in the variance of WHOQOL-5, SwLS, Qolie-31, and IPQ scores, respectively. However, associations with particular factors were instrument-specific. The WHOQOL-5 was associated with factors indicative of general health. SwLS scores were associated with health-related and several demographic factors. Neither showed associations with epilepsy-related factors. All four categories of factors were associated with Qolie-31 and IPQ scores. Factors had an additive impact on IPQ, but not on Qolie-31.

SIGNIFICANCE

Our findings reveal interactions between the method of life quality assessment and the factors that are identified as influencing life quality. This appears to be the first study that analyses the factors that influence illness perception in epilepsy patients, and suggests that the IPQ may become a valuable tool in epilepsy research.

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

PURPOSE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Disentangling Stigma from Functional Neurological Disorders: Conference Report and Roadmap for the Future

A multidisciplinary expert review of key issues and future directions from the conference “Controversial labels and clinical uncertainties: psychogenic disorders, conversion disorder, and functional symptoms.”

On October 9 and 10, 2015, a conference entitled “Controversial labels and clinical uncertainties: psychogenic disorders, conversion disorder, and functional symptoms” was held at the Center for Ethics, Emory University, Atlanta, GA, USA. This conference brought together a select group of 30 distinguished thought leaders and practitioners, including ethicists, researchers, clinicians, humanities scholars, and advocates to discuss the unique challenges and controversies related to the diagnosis, treatment, and stigma for patients with what is currently recognized as functional (“psychogenic”) neurological disorders. Our group of experts explored the conflicts and ethical tensions within health care that must be addressed in order to advance care for these disorders. What follows is a reflection on the conversations between conference attendees outlining key challenges and value conflicts in the diagnosis and treatment of patients with functional disorders. With this report, we aim to provide a roadmap for reducing stigma and improving care for functional neurological disorders (FND). A path forward would involve (1) setting a multifactorial research agenda that equally prioritized access to effective psychotherapy as well as identification of novel biomarkers; (2) empowering patients with FND to be heard and to drive changes in care; and (3) reducing isolation for clinicians by providing formal training and setting up multidisciplinary care teams and support networks.

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

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

Diagnosis by Documentary: Professional Responsibilities in Informal Encounters

Most work addressing clinical workers' professional responsibilities concerns the norms of conduct within established professional-patient relationships, but such responsibilities may extend beyond the clinical context. We explore health workers' professional responsibilities in such "informal" encounters through the example of a doctor witnessing the misdiagnosis and mistreatment of a serious long-term condition in a television documentary, arguing that neither internalist approaches to professional responsibility (such as virtue ethics or care ethics) nor externalist ones (such as the "social contract" model) provide sufficiently clear guidance in such situations. We propose that a mix of both approaches, emphasizing the noncomplacency and practical wisdom of virtue ethics, but grounding the normative authority of virtue in an external source, is able to engage with the health worker's responsibilities in such situations to the individual, the health care system, and the population at large.