3 Psychogenic non-epileptic seizures Psychogenic non-epileptic seizures (PNES) resemble epileptic seizures, but no abnormal electrical changes in the brain (Bodde, et al., 2009)Incidence: 25-30% of those referred to epilepsy centres (Bodde, et al., 2009)Accepted to be psychological in nature (Lesser, 1996)Higher rates of psychological problems and trauma history (review: Reuber, 2008)
4 Always psychological causality? Maybe not...Absence of psychological comorbidity or trauma history in 3 – 32% of people with PNES (Moore & Baker, 1997; Reuber, et al., 2007; Marchetti, et al., 2008)None of these studies examined the presenting profiles of those without causal factors
5 Why not always causal factors? Absence of trauma/psychological comorbidity?Non-expression?Methodological factors, e.g. Underreporting in interviews (Fiszman, et al., 2004)Other, e.g. Personality factorsKey aim of the current study
6 Why is this important?Treatment of choice is psychological (National Collaborating Centre for Primary Care : Stokes, et al., 2004)Treatment assumes psychological problems/trauma historyInvalidating?Ineffective?
7 Methods: Participants Patients diagnosed with PNES by neurologistPNES-trauma (PNES-T): Those reporting trauma history/psychological comorbidityN = 10PNES-no-trauma (PNES-NT): Those not reporting the aboveN = 9T = Trauma NT = No-trauma
8 Methods: Measures & Analysis Traumatic Life Events Questionnaire (TLEQ)Trauma Symptom Inventory (TSI)Millon Clinical Multiaxial Inventory III (MCMI-III)AnalysisMann-Whitney U-Tests (between-group differences)Cohen’s d effect sizes (between-group effect sizes)ROC curve analysis (evaluation of classification system)Chi-squared test (gender comparison)T = Trauma NT = No-trauma
9 Traumatic Life Events Questionnaire (TLEQ) Kubany et. al (1995) Natural disasterMotor vehicle accidentOther kind of accidentLived/worked/military service in a war zone and exposed to warfare/combatExperienced sudden and unexpected death of a close friend/loved oneLoved one survived life-threatening accident/assault/illnessHad a life-threatening illnessBeen robbed/present during robbery involving a weaponHit/beaten up and badly hurt by a strangerSeen a stranger attack/beat up someone, leading to serious injury/deathThreats to kill/seriously harm youT = Trauma NT = No-trauma
10 Traumatic Life Events Questionnaire (TLEQ) Kubany et. al (1995) Physical abuse whilst growing upWitness to domestic violence whilst growing upSubject to domestic violenceSexual abuse from an adult when under 13Sexual abuse from a peer when under 13Sexual abuse when aged 13-18Sexual assault when 18+Other unwanted sexual attentionVictim of stalkingMiscarriageAbortionAny other eventsT = Trauma NT = No-trauma
11 Results: Demographics GroupP valueT (n=10)NT (n=9)Gender2 M; 8 F (80% F)3 M; 6 F (67% F).51Age: Mean (SD)40.7 (10.80)33.67 (9.26).13Time since onset, months: Mean (SD)77.78 (73.55)91.89 (65.64).34Time since diagnosis, months: Mean (SD)19.8 (10.83)27.44 (22.33).72Time to diagnosis from onset, months: Mean (SD)56.67 (72.76)= 4.7 years62.56 (67.60)= 5.2 years.67T = Trauma NT = No-trauma
12 Results: Traumatic Life Events Questionnaire Between-group differencesTotal number of events experienced:Median (IQR); T = 6.5 (3); NT = 2 (1)Significantly more events in T group (p=0.007; ES=1.00)Amount of distress for most distressing experience:Median (IQR); T = 4.5 (3); NT = 2 (2.5)Difference not statistically significant (p=0.210; ES=0.67)T = Trauma NT = No-trauma
13 Results: Traumatic Life Events Questionnaire Comparison with general populationT group: Higher rates of reporting in 14/23 life events:Childhood physical abuse, miscarriage, motor vehicle accidents, sudden death of a friend or loved one, assault, threat of harm, witness to family violence, intimate partner abuse, sexual abuse across the lifespan , sexual harassment, and stalking.NT group: Higher rates of reporting in only 2/23 life eventsChildhood physical abuse & MiscarriageT = Trauma NT = No-trauma
14 Results: Trauma Symptom Inventory Between-group differencesSignificantly higher levels in T group than NT group on the following scales:Anger/Irritability (p=0.008; ES=1.18)Intrusive experiences (p=0.004; ES=1.25)Defensive avoidance (p=0.001; ES=1.59)Sexual concerns (p=0.040; ES=0.86)Tension reduction behaviour (p=0.040; ES=0.86)T = Trauma NT = No-trauma
15 Results: Trauma Symptom Inventory Comparison with general populationT group: Scored higher on all 11 subscalesNT group: Scored higher on only 3/11 subscales:Sexual concerns, Dysfunctional sexual behaviour and Tension reduction behaviourT = Trauma NT = No-trauma
16 Results: Millon Clinical Multiaxial Inventory–III Between-group differences: Modifying IndicesSignificantly higher levels of Debasement (tendency to describe oneself in pathological terms) in the T group (p=0.050; ES=0.90)Significantly lower levels of Disclosure (tendency towards being defensive and secretive in their answering) in the NT group (p=0.014; ES=1.18)T = Trauma NT = No-trauma
17 Results: Millon Clinical Multiaxial Inventory–III Between-group differences: Clinical & Personality ScalesSignificantly higher scores in the T than the NT group on the following scales:Personality Patterns (Axis II disorders):Depressive (p=0.006; ES=1.21)Sadistic/Aggressive (p=0.003; ES=1.31)Masochistic/Self-defeating (p=0.050; ES=0.99)Clinical Syndromes (Axis I disorders):Anxiety (p=0.006; ES=1.26)PTSD (p=0.002; ES=1.43)NB however: levels of Disclosure and DebasementT = Trauma NT = No-trauma
18 Results: Millon Clinical Multiaxial Inventory–III Comparison with general populationT group:Modifying indices:Higher Disclosure and Debasement; lower DesirabilityClinical/Personality scales:Higher on 8/18 scales (Avoidant, Depressive, Dependent, Negativistic/ Passive-Aggressive, Masochistic/Self-Defeating, Anxiety, Dysthymia, PTSD); PLUS 3/3 Severe Personality Pathology, 3/3 Severe Clinical Syndrome scalesLower on Histrionic and NarcissisticNT group:Higher Debasement; similar Disclosure and DesirabilityHigher on Somatoform, Thought Disorder and Major DepressionT = Trauma NT = No-trauma
19 Results: ROC curve analysis Conducted for TLEQ to evaluate consistency of neurologist classification system with TLEQBased on analysis:>4.5 life events T group<4.5 life events NT group16 out of 19 participants (84.2%) were classified in the same way by both the neurologist and the questionnaire data T = Trauma NT = No-trauma
20 Summary of resultsT group reported twice as many traumatic life events as NT group and a trend to more distress (ns)T group reported greater Axis I and II pathology than NT groupT group reported more trauma and psychological pathology than the general populationNT group similar to general populationT = Trauma NT = No-trauma
21 Discussion: Why the differences? Truly idiopathic NEAD group?Clinical questioning nor questionnaires sufficiently sensitive?NT group misdiagnosed as NEAD?T group over-exaggerating experiences as traumatic and over-exaggerating psychological comorbidity?NT group under-reporting?T = Trauma NT = No-trauma
22 ConclusionsGroup differences remained following structured and more anonymous questioningSupports ‘different’ groups, and NEAD causes being more heterogenous than previously suspectedHowever, if proven, the Disclosure differences could explain why groups appear different, but are notWorthy of sufficiently powered formal studyT = Trauma NT = No-trauma
23 Clinical Implications Utility of self-report measuresPossible limitations of self-report measures (disclosure?)Utility of individual psychological formulationT = Trauma NT = No-trauma
25 References (1)Bodde, N. M., Brooks, J. L., Baker, G. A., Boon, P. A., Hendriksen, J. G., Mulder, O. G., et al. (2009). Psychogenic non-epileptic seizures--definition, etiology, treatment and prognostic issues: a critical review. Seizure, 18(8), Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative research in psychology, 3(2), Briere, J. (1995). Trauma symptom inventory. Odessa, FL: Psychological Assessment Resources. Brown, R. J. (2004). Psychological mechanisms of medically unexplained symptoms: an integrative conceptual model. Psychological Bulletin, 130(5), Coolican, H. (2009). Research Methods and Statistics in Psychology (5th ed.). London: Hodder Education.
26 References (2)Fiszman, A., Alves-Leon, S. V., Nunes, R. G., D'Andrea, I., & Figueira, I. (2004). Traumatic events and posttraumatic stress disorder in patients with psychogenic nonepileptic seizures: a critical review. Epilepsy Behav, 5(6), Howlett, S., Grunewald, R. A., Khan, A., & Reuber, M. (2007). Engagement in psychological treatment for functional neurological symptoms - Barriers and solutions. Psychotherapy, 44(3), Kubany, E. S. (1995). The Traumatic Life Events Questionnaire (TLEQ): A brief measure of prior trauma exposure. Unpublished scale. Available from the author. Lesser, R. P. (1996). Psychogenic seizures. Neurology, 46(6), Marchetti, R. L., Kurcgant, D., Neto, J. G., von Bismark, M. A., Marchetti, L. B., & Fiore, L. A. (2008). Psychiatric diagnoses of patients with psychogenic non-epileptic seizures. Seizure, 17(3),
27 References (3)Millon, T., & Davis, R. (1996). The Millon Clinical Multiaxial Inventory-Ill. Major Psychological Assessment Instruments, 108. Moore, P. M., & Baker, G. A. (1997). Non-epileptic attack disorder: a psychological perspective. Seizure, 6(6), Reuber, M. (2008). Psychogenic nonepileptic seizures: answers and questions. Epilepsy & Behaviour, 12(4), Reuber, M., Howlett, S., Khan, A., & Grunewald, R. A. (2007). Non-epileptic seizures and other functional neurological symptoms: Predisposing, precipitating, and perpetuating factors. Psychosomatics: Journal of Consultation Liaison Psychiatry, 48(3), Stokes, T., Shaw, E. J., Juarez-Garcia, A., Camosso-Stefinovic, J., & Baker, R. (2004). Clinical Guidelines and Evidence Review for the Epilepsies: diagnosis and management in adults and children in primary and secondary care. London: Royal College of General Practitioners.