Emotion regulation profiles in psychogenic non-epileptic seizures
Highlights
► This study examines those diagnosed with psychogenic non-epileptic seizures (PNES). ► Two clusters were found: above (1) and below (2) average emotionally dysregulated. ► Cluster 1 was associated with psychiatric symptomatology and low quality of life. ► Cluster 2 may be characterized by emotion avoidance. ► Results support differential psychiatric presentations of those with PNES.
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.
Section snippets
Data collection
A total of 70 adult patients were referred by local academic epilepsy centers with a diagnosis of PNES to the University of Illinois at Chicago (UIC) Non-Epileptic Seizures Intervention Clinic (NESIC) for a neuropsychiatric evaluation and treatment. The protocol was approved by the UIC Institutional Review Board. All 70 participating subjects provided written informed consent allowing the authors to include their clinical information obtained during their initial evaluation as part of this
Demographic data
The current sample consisted of 70 PNES patients. This included 55 females (78.6%) and 15 males (21.4%). This sample was 71.4% Caucasian (n = 50) with a mean age of 37.07 (SD = 14.92). The most common marital status was single (n = 36), followed by married or having a live-in partner (n = 24), divorced or separated (n = 9), and widowed (n = 1). The most common employment status was employed (n = 25), followed by disabled (n = 23), unemployed (n = 15), and student (n = 7). Concerning educational level, the
Discussion
A cluster analysis was completed to determine if patients fell into distinct categories based on emotion regulation patterns as assessed by the DERS. We found two distinct clusters demonstrating dramatically differing DERS scores. Cluster 1 showed elevated levels on the DERS, while Cluster 2 showed low levels on the DERS. The two clusters significantly differed on the DERS total score, as well as all six subscales. Not only did the clusters differ from one another, they also were significantly
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2021, Epilepsy and BehaviorCitation Excerpt :The high levels of anxiety in this cohort align well with similar work that describes anxiety as a feature of PNES [44]. However, treatment adherence may also be affected due to possible high levels of emotional dysregulation in PNES patients [22,44], as evidenced by the fact that patients with panic disorders sought treatment more often. The opposite appears to be true for patients suffering with social anxiety, who tend to avoid seeking treatment easily.