Maladaptive emotional regulation in patients diagnosed with psychogenic non-epileptic seizures (PNES) compared with healthy volunteers

How does cognitive behavior therapy for dissociative seizures work? A mediation analysis of the CODES trial

BACKGROUND

We compared dissociative seizure specific cognitive behavior therapy (DS-CBT) plus standardized medical care (SMC) to SMC alone in a randomized controlled trial. DS-CBT resulted in better outcomes on several secondary trial outcome measures at the 12-month follow-up point. The purpose of this paper is to evaluate putative treatment mechanisms.

METHODS

We carried out a secondary mediation analysis of the CODES trial. 368 participants were recruited from the National Health Service in secondary / tertiary care in England, Scotland, and Wales. Sixteen mediation hypotheses corresponding to combinations of important trial outcomes and putative mediators were assessed. Twelve-month trial outcomes considered were final-month seizure frequency, Work and Social Adjustment Scale (WSAS), and the SF-12v2, a quality-of-life measure providing physical (PCS) and mental component summary (MCS) scores. Mediators chosen for analysis at six months (broadly corresponding to completion of DS-CBT) included: (a) beliefs about emotions, (b) a measure of avoidance behavior, (c) anxiety and (d) depression.

RESULTS

All putative mediator variables except beliefs about emotions were found to be improved by DS-CBT. We found evidence for DS-CBT effect mediation for the outcome variables dissociative seizures (DS), WSAS and SF-12v2 MCS scores by improvements in target variables avoidance behavior, anxiety, and depression. The only variable to mediate the DS-CBT effect on the SF-12v2 PCS score was avoidance behavior.

CONCLUSIONS

Our findings largely confirmed the logic model underlying the development of CBT for patients with DS. Interventions could be additionally developed to specifically address beliefs about emotions to assess whether it improves outcomes.

BOLD signal variability as potential new biomarker of functional neurological disorders

BACKGROUND

Functional neurological disorder (FND) is a common neuropsychiatric condition with established diagnostic criteria and effective treatments but for which the underlying neuropathophysiological mechanisms remain incompletely understood. Recent neuroimaging studies have revealed FND as a multi-network brain disorder, unveiling alterations across limbic, self-agency, attentional/salience, and sensorimotor networks. However, the relationship between identified brain alterations and disease progression or improvement is less explored.

METHODS

This study included resting-state functional magnetic resonance imaging (fMRI) data from 79 patients with FND and 74 age and sex-matched healthy controls (HC). First, voxel-wise BOLD signal variability was computed for each participant and the group-wise difference was calculated. Second, we investigated the potential of BOLD signal variability to serve as a prognostic biomarker for clinical outcome in 47 patients who attended a follow-up measurement after eight months.

RESULTS

The results demonstrated higher BOLD signal variability in key networks, including the somatomotor, salience, limbic, and dorsal attention networks, in patients compared to controls. Longitudinal analysis revealed an increase in BOLD signal variability in the supplementary motor area (SMA) in FND patients who had an improved clinical outcome, suggesting SMA variability as a potential state biomarker. Additionally, higher BOLD signal variability in the left insula at baseline predicted a worse clinical outcome.

CONCLUSION

This study contributes to the understanding of FND pathophysiology, emphasizing the dynamic nature of neural activity and highlighting the potential of BOLD signal variability as a valuable research tool. The insula and SMA emerge as promising regions for further investigation as prognostic and state markers.

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

ABSTRACT

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

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.

Case report on psychogenic nonepileptic seizures: A series of unfortunate events

Psychogenic nonepileptic seizures, also called Functional Seizures, are a highly disabling form of Functional Neurological Disorder. The diagnosis of PNES could be missed in clinical scenarios where patients exhibit concurrent musculoskeletal/neurological findings. Characterization of convulsions and judicious use of diagnostics are equally valuable in establishing the diagnosis.

Neuropsychological performance and effort in patients diagnosed with psychogenic nonepileptic seizures - Descriptive study of a Czech sample

PURPOSE

The aim of the study was to examine the neuropsychological performance and effort in patients with a confirmed PNES diagnosis. The second aim of the study was to investigate the relationship between validity indicators from the cognitive battery with validity and clinical scales from a personality scale.

METHOD

Patients with PNES (N = 250; F:M 186:64; mean age 38.32 (13.23)) were assessed utilizing the RBANS (Czech Research version) to evaluate cognitive performance and to obtain the Effort Index. The MMPI-2 was used to evaluate personality and psychopathology.

RESULTS

Global cognitive performance was 0.92 SD below average (according to the Gaussian distribution) in patients with PNES. The lowest scores in the sample were in the Attention domain (-1.7SD). Insufficient effort was detected in 10% of patients. Education correlated negatively with the Effort index (rs = -0.25, p = 0.01). A mild significant correlation in Scale 7 (rs = 0.21, p = 0.01) and Scale 8 (rs = 0.24, p = 0.01), and a significant correlation between Effort Index and Back F Scale (rs = 0.23, p = 0.01) were noted.

CONCLUSIONS

Assessment of cognitive performance and effort is an essential part of the comprehensive evaluation of patients with PNES during their hospitalization at Epilepsy centers. Many aspects of the neuropsychological assessment can offer useful indications for reaching a differential diagnosis, including clinical history, behavioral observations, cognitive and symptom validity testing, and structured psychological inventories.

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.

Are Functional (Psychogenic Nonepileptic) Seizures the Sole Expression of Psychological Processes?

Functional [psychogenic nonepileptic/dissociative] seizures (FND-seiz) and related functional neurological disorder subtypes were of immense interest to early founders of modern-day neurology and psychiatry. Unfortunately, the divide that occurred between the both specialties throughout the mid-twentieth century placed FND-seiz at the borderland between the two disciplines. In the process, a false Cartesian dualism emerged that labeled psychiatric conditions as impairments of the mind and neurological conditions as disturbances in structural neuroanatomy. Excitingly, modern-day neuropsychiatric perspectives now consider neurologic and psychiatric conditions as disorders of both brain and mind. In this article, we aim to integrate neurologic and psychiatric perspectives in the conceptual framing of FND-seiz. In doing so, we explore emerging relationships between symptoms, neuropsychological constructs, brain networks, and neuroendocrine/autonomic biomarkers of disease. Evidence suggests that the neuropsychological constructs of emotion processing, attention, interoception, and self-agency are important in the pathophysiology of FND-seiz. Furthermore, FND-seiz is a multi-network brain disorder, with evidence supporting roles for disturbances within and across the salience, limbic, attentional, multimodal integration, and sensorimotor networks. Risk factors, including the magnitude of previously experienced adverse life events, relate to individual differences in network architecture and neuroendocrine profiles. The time has come to use an integrated neuropsychiatric approach that embraces the closely intertwined relationship between physical health and mental health to conceptualize FND-seiz and related functional neurological disorder subtypes.