Emotion regulation profiles in psychogenic non-epileptic seizures

Abstract

Background

Psychogenic non-epileptic seizures (PNES) are frequently encountered in epilepsy referral centers, yet there is limited understanding of the emotion processing style in this psychiatrically heterogeneous population. Understanding profiles of emotion regulation in PNES will provide further evidence of the psychogenic nature of the disorder and will potentially inform psychotherapeutic interventions.

Methods

Fifty-five patients with PNES underwent a neuropsychiatric evaluation and completed self-report questionnaires that measured difficulties in emotion regulation, psychopathology severity and quality of life.

Results

Through the use of cluster analysis, two groups were identified; Cluster 1 represented a highly emotion dysregulated group while Cluster 2 represented a low emotion dysregulated group. Additional analyses revealed that each group significantly differed from normative data. Finally, Cluster 1 was significantly associated with several measures of psychiatric symptoms, higher rates of comorbid psychiatric diagnoses and impairment in quality of life.

Conclusions

These findings suggest that patients with PNES may be subject to high levels of emotion dysregulation, severe psychiatric symptomatology and impaired quality of life, or to low emotion dysregulation characterized by emotional unawareness or avoidance. These profiles clearly differ from normative data regarding emotion regulation and their identification may help tailor psychotherapeutic interventions.

Introduction

Psychogenic non-epileptic seizures (PNES) are seizure-like attacks not explained by epileptiform activity or other physiological paroxysms. They consist of sudden, involuntary changes in behavior, sensation, motor activity, cognitive processing or autonomic function. Diagnosis is confirmed via video-electroencephalography monitoring (v-EEG) in approximately a quarter of patients evaluated at epilepsy referral centers [1]. Etiologically, PNES have been linked to a dysfunction in the processing of psychological or social distress [2], [3].

Linking medically unexplained symptoms to psychosocial problems has been associated with a reduction in unnecessary pharmacological or surgical interventions in patients [4]. This finding suggests that awareness of one's psychological response to stress, as well as patterns of emotion regulation, is associated with positive outcomes. On the other hand, those with PNES constitute a heterogeneous population with varying degrees of psychiatric symptomology and somatic complaints [5], [6]; therefore, it is unlikely that PNES will be associated with one single pattern of emotion processing and regulation.

Limited data exist on how PNES subjects process emotional information. Baseline levels of autonomic hypervigilance and a positive attentional bias when processing social threat stimuli at a preconscious level have been documented in PNES subjects [7]. This finding may be indicative of increased emotional reactivity in those with PNES.

Identification and expression of an emotional experience constitute another stage in the processing of emotions. Alexithymia is defined as difficulty in verbal expressions of affect leading to an expression of inner psychic distress in the form of physical complaints and description of emotions as physiological reactions as opposed to feelings [8]. Alexithymia has been reported to be higher in subjects with PNES compared to healthy controls based on a self-report measure (the Toronto Alexithymia Scale-20 [9], [10]) [11]. Furthermore, deficits in emotional awareness, as measured by rater-administered scales, are more pronounced in psychosomatic populations compared to other psychiatric samples [12].

Emotion regulation is an identified mechanism underlying various forms of psychopathology [13], [14], [15], [16]. One model conceptualizes emotion regulation as the ability to control one's behaviors when experiencing intense emotions, rather than the ability to directly control one's emotions themselves [17]. Following this model, “effective” regulation entails responses to affective states that minimize subjective and psychological distress with continued ability to pursue short- and long-term goals that are important to the individual [14]. Based on these concepts, Gratz and Roemer [18] postulated that emotion regulation involves the (a) awareness and understanding of emotions, (b) acceptance of emotions, (c) ability to control impulsive behaviors and behave in accordance with desired goals when experiencing negative emotions, and (d) ability to use situation-appropriate emotion regulation strategies flexibly to modulate behavioral responses.

A description of emotion regulation patterns in PNES subjects will provide clinicians with an explanatory model linking emotion regulation dysfunction to PNES and may facilitate transition to a psychotherapeutic intervention. The aims of this study are to: (1) identify subgroups of PNES subjects based on their emotion regulation profile; (2) compare the emotion regulation profile of PNES subgroups to existing normative data; and (3) describe such PNES subgroups clinically based on psychopathology measures.