1. Is there such thing as idiopathic NEAD?
“Nothing bad’s ever happened to me”
Is there such thing as idiopathic NEAD?
Dr Jenny Taylor
Dr Sumeet Singhal
Dr Roshan das Nair
Dr Patrick Vesey

2. Aims Background and rationale Methods Results Discussion points
Conclusions
Clinical Implications
Questions

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 factors
Key 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 history
Invalidating?
Ineffective?

7. Methods: Participants
Patients diagnosed with PNES by neurologist
PNES-trauma (PNES-T): Those reporting trauma history/psychological comorbidity
N = 10
PNES-no-trauma (PNES-NT): Those not reporting the above
N = 9
T = Trauma NT = No-trauma

8. Methods: Measures & Analysis
Traumatic Life Events Questionnaire (TLEQ)
Trauma Symptom Inventory (TSI)
Millon Clinical Multiaxial Inventory III (MCMI-III)
Analysis
Mann-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 disaster
Motor vehicle accident
Other kind of accident
Lived/worked/military service in a war zone and exposed to warfare/combat
Experienced sudden and unexpected death of a close friend/loved one
Loved one survived life-threatening accident/assault/illness
Had a life-threatening illness
Been robbed/present during robbery involving a weapon
Hit/beaten up and badly hurt by a stranger
Seen a stranger attack/beat up someone, leading to serious injury/death
Threats to kill/seriously harm you
T = Trauma NT = No-trauma

10. Traumatic Life Events Questionnaire (TLEQ) Kubany et. al (1995)
Physical abuse whilst growing up
Witness to domestic violence whilst growing up
Subject to domestic violence
Sexual abuse from an adult when under 13
Sexual abuse from a peer when under 13
Sexual abuse when aged 13-18
Sexual assault when 18+
Other unwanted sexual attention
Victim of stalking
Miscarriage
Abortion
Any other events
T = Trauma NT = No-trauma

11. Results: Demographics
Group
P value
T (n=10)
NT (n=9)
Gender
2 M; 8 F (80% F)
3 M; 6 F (67% F)
.51
Age: Mean (SD)
40.7 (10.80)
33.67 (9.26)
.13
Time since onset, months: Mean (SD)
77.78 (73.55)
91.89 (65.64)
.34
Time since diagnosis, months: Mean (SD)
19.8 (10.83)
27.44 (22.33)
.72
Time to diagnosis from onset, months: Mean (SD)
56.67 (72.76)
= 4.7 years
62.56 (67.60)
= 5.2 years
.67
T = Trauma NT = No-trauma

12. Results: Traumatic Life Events Questionnaire
Between-group differences
Total 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 population
T 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 events
Childhood physical abuse & Miscarriage
T = Trauma NT = No-trauma

14. Results: Trauma Symptom Inventory
Between-group differences
Significantly 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 population
T group: Scored higher on all 11 subscales
NT group: Scored higher on only 3/11 subscales:
Sexual concerns, Dysfunctional sexual behaviour and Tension reduction behaviour
T = Trauma NT = No-trauma

16. Results: Millon Clinical Multiaxial Inventory–III
Between-group differences: Modifying Indices
Significantly 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 Scales
Significantly 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 Debasement
T = Trauma NT = No-trauma

18. Results: Millon Clinical Multiaxial Inventory–III
Comparison with general population
T group:
Modifying indices:
Higher Disclosure and Debasement; lower Desirability
Clinical/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 scales
Lower on Histrionic and Narcissistic
NT group:
Higher Debasement; similar Disclosure and Desirability
Higher on Somatoform, Thought Disorder and Major Depression
T = Trauma NT = No-trauma

19. Results: ROC curve analysis
Conducted for TLEQ to evaluate consistency of neurologist classification system with TLEQ
Based on analysis:
>4.5 life events  T group
<4.5 life events  NT group
16 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 results
T 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 group
T group reported more trauma and psychological pathology than the general population
NT group similar to general population
T = 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. Conclusions
Group differences remained following structured and more anonymous questioning
Supports ‘different’ groups, and NEAD causes being more heterogenous than previously suspected
However, if proven, the Disclosure differences could explain why groups appear different, but are not
Worthy of sufficiently powered formal study
T = Trauma NT = No-trauma

23. Clinical Implications
Utility of self-report measures
Possible limitations of self-report measures (disclosure?)
Utility of individual psychological formulation
T = Trauma NT = No-trauma

24. Questions?
T = 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.