Differences in illness perceptions between patients with non-epileptic seizures and functional limb weakness

Illness perception in functional neurological disorder: low illness coherence and personal control

Introduction

Illness perception refers to patients' subjective representations and appraisals of somatic and mental symptoms. These are relevant for self-management and outcome. In clinical practice, patients with functional neurological disorder (FND) often encounter a fragmented biomedical attitude, which leaves them without clear concepts. In this context, illness perception is relevant.

Methods

Illness perception was assessed in FND patients and compared with samples of psychosomatic patients (PSM) as well as poststroke patients (STR). The three samples (FND, n=87; PSM, n=97 and STR, n=92) were almost all in inpatient treatment or rehabilitation. Illness perception was assessed with the revised German version of the Illness Perception Questionnaire (IPQ-R). For assessments of correlations, depressive symptoms were tested with the Patient Health Questionnaire-9, dissociative and functional neurological symptoms by the German adaption of the Dissociative Experiences Scale and biopsychosocial complexity by the INTERMED Self-Assessment questionnaire.

Results

Apart from the chronicity subscale, all dimensions of the IPQ-R differed between groups. FND patients perceived lower illness coherence and personal control than both other groups and attributed their illness more to chance than to behavioural risk factors. PSM patients had the strongest emotional representations. There were only few correlations with dissociative scores and biopsychosocial complexity.

Conclusion

Illness perception is an important issue in patients with FND with particular emphasis on low illness coherence and personal control. Missing associations with biopsychosocial complexity suggest that subjective illness perception is an important complementary but separate issue, which likely influences therapeutic alliance and self-management in FND. Future studies should assess its influences on outcome.

Trial registration number

DRKS00024685; German Clinical Trials Register; www.drks.de.

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.

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.

A Review and Expert Opinion on the Neuropsychiatric Assessment of Motor Functional Neurological Disorders

Functional neurological (conversion) disorder (FND) is a prevalent and disabling condition at the intersection of neurology and psychiatry. Advances have been made in elucidating an emerging pathophysiology for motor FND, as well as in identifying evidenced-based physiotherapy and psychotherapy treatments. Despite these gains, important elements of the initial neuropsychiatric assessment of functional movement disorders (FND-movt) and functional limb weakness/paresis (FND-par) have yet to be established. This is an important gap from both diagnostic and treatment planning perspectives. In this article, the authors performed a narrative review to characterize clinically relevant variables across FND-movt and FND-par cohorts, including time course and symptom evolution, precipitating factors, medical and family histories, psychiatric comorbidities, psychosocial factors, physical examination signs, and adjunctive diagnostic tests. Thereafter, the authors propose a preliminary set of clinical content that should be assessed during early-phase patient encounters, in addition to identifying physical signs informing diagnosis and potential use of adjunctive tests for challenging cases. Although clinical history should not be used to make a FND diagnosis, characteristics such as acute onset, precipitating events (e.g., injury and surgery), and a waxing and waning course (including spontaneous remissions) are commonly reported. Active psychiatric symptoms (e.g., depression and anxiety) and ongoing psychosocial stressors also warrant evaluation. Positive physical examination signs (e.g., Hoover's sign and tremor entrainment) are key findings, as one of the DSM-5 diagnostic criteria. The neuropsychiatric assessment proposed emphasizes diagnosing FND by using "rule-in" physical signs while also considering psychiatric and psychosocial factors to aid in the development of a patient-centered treatment plan.

'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.

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.

Assessment of Potential Risk Factors for the Development of Persistent Postural-Perceptual Dizziness: A Case-Control Pilot Study

Objectives: (1) To assess whether neuroticism, state anxiety, and body vigilance are higher in patients with persistent postural-perceptual dizziness (PPPD) compared to a recovered vestibular patient group and a non-dizzy patient group; (2) To gather pilot data on illness perceptions of patients with PPPD. Materials and Methods: 15 cases with PPPD and two control groups: (1) recovered vestibular patients (n = 12) and (2) non-dizzy patients (no previous vestibular insult, n = 12). Main outcome measures: Scores from the Big Five Inventory (BFI) of personality traits, Generalized Anxiety Disorder - 7 (GAD-7) scale, Body Vigilance Scale (BVS), Dizziness Handicap Inventory (DHI), modified Vertigo Symptom Scale (VSS) and Brief Illness Perception Questionnaire (BIPQ). Results: Compared to non-dizzy patients, PPPD cases had higher neuroticism (p = 0.02), higher introversion (p = 0.008), lower conscientiousness (p = 0.03) and higher anxiety (p = 0.02). There were no differences between PPPD cases and recovered vestibular patients in BFI and GAD-7. PPPD cases had higher body vigilance to dizziness than both control groups and their illness perceptions indicated higher levels of threat than recovered vestibular patients. Conclusion: PPPD patients showed statistically significant differences to non-dizzy patients, but not recovered vestibular controls in areas such as neuroticism and anxiety. Body vigilance was increased in PPPD patients when compared with both recovered vestibular and non-dizzy patient groups. PPPD patients also exhibited elements of negative illness perception suggesting that this may be the key element driving the development of PPPD. Large scale studies focusing on this area in the early stages following vestibular insult are needed.

Clinical differences between patients with psychogenic nonepileptic seizures and functional motor disorder

OBJECTIVES

Why a patient might present with psychogenic nonepileptic seizures (PNES) as opposed to another functional neurological symptom is unknown. A recent review suggested that patients with PNES and functional motor disorders (FMD) differ on demographic and clinical factors of potential aetiological and mechanistic significance, arguing they might represent different disorders, though direct comparisons are limited. We sought to determine whether these factors differed in patients presenting with FMD and PNES at our clinic, as well as whether preceding medical complaints would differ between the two, particularly those affecting the limbs or head.

METHODS

A retrospective chart review of all presentations with FMD or PNES patients to a functional neurology clinic, collecting demographic and clinical data, including medical and surgical history.

RESULTS

Fifty-six patients with FMD and 52 with PNES were included. Significantly more patients with FMD had functional somatic syndromes (46% vs 27%, p = 0.036) and preceding medical events that affected their limbs than patients with PNES (34% vs 14%, p = 0.013); significantly more patients with PNES had dissociative symptoms (31% vs 4%, p < 0.001) and lifetime suicidal ideation (56% vs 32%, p = 0.013).

SIGNIFICANCE

These results highlight the substantial comorbidities affecting FMD and PNES, but find clinical differences between the two groups that may be of aetiological or mechanistic significance.

Towards an Outpatient Model of Care for Motor Functional Neurological Disorders: A Neuropsychiatric Perspective

Functional neurological disorder (FND), a condition at the intersection of neurology and psychiatry, is a common and disabling outpatient referral to neurology and neuropsychiatry clinics. In this perspective article, we focus on the motor spectrum of FND (mFND), including individuals with functional movement disorders (FND-movt), functional limb weakness/paresis (FND-par) and functional [psychogenic non-epileptic/dissociative] seizures (FND-seiz). Over the past several decades, there have been dedicated efforts within the neurologic and psychiatric communities to create "rule-in" diagnostic criteria, as well as thoughtful approaches to the clinical interview, delivery of the diagnosis and the development of a patient-centered treatment plan. These advances allow the promotion of good clinical practices in the outpatient assessment and management of mFND. Informed by the literature and our prior clinical experiences, we provide suggestions on how to evaluate individuals with suspected functional motor symptoms - including conducting sensitive psychiatric and psychosocial screenings. Additional sections discuss common "rule-in" neurological examination and semiologic signs of motor FND, as well as approaches to deliver the diagnosis and formulate a treatment plan based on individual patient needs. To aid the development of shared (partially overlapping) expertise that catalyzes an interdisciplinary approach to mFND, the use of physiotherapy for therapeutic motor retraining and cognitive behavioral therapy to examine relationships between symptoms, thoughts, behaviors and emotions are also discussed. Additional clinical research is needed to further refine and operationalize the assessment and management of mFND, across clinics, healthcare settings and countries.

Experiences and Illness Perceptions of Patients with Functional Symptoms Admitted to Hyperacute Stroke Wards: A Mixed-Method Study

INTRODUCTION

A proportion of patients admitted to acute-stroke settings have not had a stroke, but have conditions mimicking a stroke. Approximately 25% of suspected stroke cases are "stroke mimics" and 2% are patients with functional symptoms - "functional stroke mimics". This study aimed to explore experiences and illness perceptions of patients with functional symptoms admitted to hyperacute stroke wards.

METHODS

This study used mixed methods. Patients with functional stroke symptoms participated in semistructured qualitative interviews immediately after admission to one of two acute-stroke units in London and again 2 months after hospital discharge. Qualitative data were assessed using thematic analysis. The Brief Illness Perception Questionnaire (Brief-IPQ) measured illness perceptions at admission and at 2-month follow-up.

RESULTS

A total of 36 participants completed baseline interviews and 25 completed follow-up. Six themes emerged: physical symptom experience, emotional and coping responses, symptom causes, hospital experiences, views on the future, and uncertainty after hospital discharge. Mean Brief-IPQ score at admission was 49.3 (SD: 9.9), indicating a moderate-high level of perceived illness threat. Participants presented with a range of functional symptoms. At baseline, participants were highly concerned about their symptoms, but this had decreased at 2-month follow-up. Two months later, many were confused as to the cause of their admission.

CONCLUSION

This is the first study to examine functional stroke patients' experiences of acute-stroke admission. At admission, patients expressed confusion regarding their diagnosis, experienced high levels of emotional distress, and were concerned they were perceived as time wasting by stroke clinicians. While most participants experienced symptom recovery, there was a significant subgroup for whom symptoms persisted or worsened. A lack of care guidelines on the management of functional stroke patients may perpetuate functional symptoms.

The prognosis of functional limb weakness: a 14-year case-control study

Reliable data on the prognosis of functional motor disorder are scarce, as existing studies of the prognosis of functional motor disorder are nearly all retrospective, small and uncontrolled. In this study we used a prospectively recruited, controlled cohort design to assess misdiagnosis, mortality and symptomatic and health outcome in patients with functional limb weakness compared to neurological disease and healthy control subjects. We also carried out an exploratory analysis for baseline factors predicting outcome. One hundred and seven patients with functional limb weakness, 46 neurological and 38 healthy control subjects from our previously studied prospective cohort were traced for follow-up after an average of 14 years. Misdiagnosis was determined in a consensus meeting using information from records, patients and their GPs. Numbers and causes of death were collected via death certificates. Outcome of limb weakness, physical and psychiatric symptoms, disability/quality of life and illness perception were recorded with self-rated questionnaires. Outcome measures were compared within and between groups. Seventy-six patients (71%) with functional limb weakness, 31 (67%) neurological and 23 (61%) healthy controls were included in follow-up. Misdiagnosis was found in one patient in the functional limb weakness group (1%) and in one neurological control (2%). Eleven patients with functional limb weakness, eight neurological control subjects and one healthy control subject had died. Weakness had completely remitted in 20% of patients in the functional limb weakness group and in 18% of the neurological controls (P = 0.785) and improved in a larger proportion of functional limb weakness patients (P = 0.011). Outcomes were comparable between patient groups, and worse than the healthy control group. No baseline factors were independent predictors of outcome, although somatization disorder, general health, pain and total symptoms at baseline were univariably correlated to outcome. This study is the largest and longest follow-up study of functional limb weakness. Misdiagnosis in functional limb weakness is rare after long-term follow-up. The disorder is associated with a higher mortality rate than expected, and symptoms are persistent and disabling. It appears difficult to predict outcome based on common baseline variables. These data should help inform clinicians to provide a more realistic outlook of the outcome and emphasize the importance of active and targeted therapy.

Using Acceptance and Commitment Therapy to Improve Outcomes in Functional Movement Disorders: A Case Study

Although there are many theories of functional movement disorders (FMD), the causes and prognosis remain unclear, and there are no treatments with high-quality empirical support. Acceptance and commitment therapy (ACT) is an acceptance-based behavior therapy which, via altering a process called psychological flexibility, aims to support behaviors that are consistent with a person’s overarching values—even in difficult, uncertain, or immutable contexts. It may, therefore, have pragmatic benefits in the context of FMD. We outline the theoretical basis for ACT and detail a case study of a brief (six session) intervention for increasing personally meaningful activity with FMD. The participant was in her early 20s and had been diagnosed with functional propriospinal myoclonus. ACT techniques including relational framing, defusion, and mindfulness exercises were used to increase psychological flexibility, with the goal of enabling effective functioning within the difficult context created by FMD. Following treatment, the participant showed a reliable change/clinical recovery in psychological flexibility (Acceptance and Action Questionnaire II [AAQ-II]), FMD symptom interference (Work and Social Adjustment Scale [WSAS]; primary outcome), and mood (Clinical Outcomes in Routine Evaluation 10-item scale [CORE-10]; secondary outcome). This case study demonstrates an approach that focuses first on improving functioning with FMD, as opposed to eliminating or controlling symptoms.

Are psychogenic non-epileptic seizures just another symptom of conversion disorder?

BACKGROUND

Psychogenic non-epileptic seizures (PNES) are classified with other functional neurological symptoms as 'Conversion Disorder', but there are reasons to wonder whether this symptomatology constitutes a distinct entity.

METHODS

We reviewed the literature comparing PNES with other functional neurological symptoms.

RESULTS

We find eight studies that directly examined this question. Though all but one found significant differences-notably in presenting age, trauma history, and dissociation-they were divided on whether these differences represented an important distinction.

CONCLUSION

We argue that the aetiological and mechanistic distinctions they support, particularly when bolstered by additional data, give reason to sustain a separation between these conditions.

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.

Preliminary Predictors of Initial Attendance, Symptom Burden, and Motor Subtype in a US Functional Neurological Disorders Clinic Population

BACKGROUND AND OBJECTIVE

Although many patients present with functional neurological symptoms (FNS), few US clinics offer specialized FNS care, and data on clinic attendees remain limited. We determined predictors of initial attendance, symptom burden, and FNS subtype in the first patients referred to our Functional Neurological Disorders Clinic for suspected FNS.

METHODS

We reviewed the charts of 62 consecutive patients (46 women, 16 men). Regression analyses investigated predictors of keeping the first scheduled clinic appointment. For the 49 patients who did keep that appointment, regression analyses examined neuropsychiatric factors associated with symptom burden and motor FNS subtypes.

RESULTS

The odds of not keeping the first appointment were 10.4 times greater for patients referred from the emergency department than from other sources. The patients who kept their appointment reported a symptom burden that was significantly associated with a past FNS-related emergency department visit and a diagnosis of another medically unexplained somatic syndrome. The number of FNS findings on neurological examination also correlated with a history of an FNS-related emergency department visit. Patients with psychogenic non-epileptic seizures reported cognitive complaints and prior psychiatric hospitalizations significantly more often than did patients with other FNS. One fourth of all patients had two or more motor FNS.

CONCLUSIONS

In our FNS cohort, patients were less likely to keep an initial clinic appointment if they were referred from the emergency department than from other sources. Patients with psychogenic non-epileptic seizures were more likely to report cognitive symptoms and past psychiatric hospitalizations than patients with other FNS.

Do patients want choice? An observational study of neurology consultations

OBJECTIVES

To determine how often patients are given choice in neurology outpatient consultations and whether choice is associated with greater patient satisfaction.

METHODS

Prospective study in outpatient clinics in two United Kingdom centres. Interactions between 14 neurologists and 223 patients were studied. Participating doctors and patients completed post-appointment questionnaires asking whether choice had been offered/perceived. Patients completed the Medical Interview Satisfaction Scale 21 (MISS-21).

RESULTS

Choice was reported after most encounters (patients 71.8%, neurologists 67.9%). Patients and Neurologists failed to agree about whether choice was offered after 32% of consultations. Choice was not associated with increased patient satisfaction. In fact, satisfaction was greater when no choice had been offered (p=0.05). Satisfaction scores were also greater when doctors were more certain about the diagnosis and when symptoms were considered explained by a medical condition (p≤0.001).

CONCLUSIONS

Choice featured in the majority of clinical interactions but clinicians and patients often disagreed whether this was the case. Choice was not associated with greater patient satisfaction.

PRACTICE IMPLICATIONS

Clinicians need to be very explicit if they want patients to know that they are being given choices. Choice is not necessarily valued by patients in all clinical interactions.

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

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

Psychologic theories in functional neurologic disorders

In this chapter we review key psychologic theories that have been mooted as possible explanations for the etiology of functional neurologic symptoms, conversion disorder, and hysteria. We cover Freudian psychoanalysis and later object relations and attachment theories, social theories, illness behavior, classic and operant conditioning, social learning theory, self-regulation theory, cognitive-behavioral theories, and mindfulness. Dissociation and modern cognitive neuroscience theories are covered in other chapters in this series and, although of central importance, are omitted from this chapter. Our aim is an overview with the emphasis on breadth of coverage rather than depth.