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“Nothing bad’s ever happened to me”
Dr Jenny Taylor
Dr Sumeet Singhal
Dr Roshan das Nair
Dr Patrick Vesey
Aims
 Background and rationale
 Methods
 Results
 Discussion points
 Conclusions
 Clinical Implications
 Questions
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)
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
Why not always causal factors?
1. Absence of trauma/psychological comorbidity?
2. Non-expression?
a)
Methodological factors, e.g. Underreporting in interviews
(Fiszman, et al., 2004)
b)
Other, e.g. Personality factors
Key aim of the current study
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?
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
Methods: Measures & Analysis
Measures
 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
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
5. Experienced sudden and unexpected death of a close friend/loved one
6. Loved one survived life-threatening accident/assault/illness
7. Had a life-threatening illness
8. Been robbed/present during robbery involving a weapon
9. Hit/beaten up and badly hurt by a stranger
10. Seen a stranger attack/beat up someone, leading to serious injury/death
11. Threats to kill/seriously harm you
1.
2.
3.
4.
T = Trauma
NT = No-trauma
Traumatic Life Events Questionnaire (TLEQ)
Kubany et. al (1995)
12. Physical abuse whilst growing up
13. Witness to domestic violence whilst growing up
14. Subject to domestic violence
15. Sexual abuse from an adult when under 13
16. Sexual abuse from a peer when under 13
17. Sexual abuse when aged 13-18
18. Sexual assault when 18+
19. Other unwanted sexual attention
20. Victim of stalking
21. Miscarriage
22. Abortion
23. Any other events
T = Trauma
NT = No-trauma
Results: Demographics
Group
T (n=10)
Gender
NT (n=9)
P value
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)
Time since diagnosis,
months: Mean (SD)
Time to diagnosis from
onset, months: Mean (SD)
77.78 (73.55)
91.89 (65.64)
.34
19.8 (10.83)
27.44 (22.33)
.72
56.67 (72.76)
= 4.7 years
62.56 (67.60)
= 5.2 years
.67
T = Trauma
NT = No-trauma
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
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
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
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
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
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):
NB however:
 Depressive (p=0.006; ES=1.21)
levels of
 Sadistic/Aggressive (p=0.003; ES=1.31)
Disclosure and
 Masochistic/Self-defeating (p=0.050; ES=0.99)
Debasement
 Clinical Syndromes (Axis I disorders):
 Anxiety (p=0.006; ES=1.26)
 PTSD (p=0.002; ES=1.43)
T = Trauma
NT = No-trauma
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:
 Modifying indices:
Higher Debasement; similar Disclosure and Desirability
 Clinical/Personality scales:
Higher on Somatoform, Thought Disorder and Major Depression
T = Trauma
NT = No-trauma
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
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
Discussion: Why the differences?
1. Truly idiopathic NEAD group?
2. Clinical questioning nor questionnaires sufficiently
sensitive?
3. NT group misdiagnosed as NEAD?
4. T group over-exaggerating experiences as traumatic and
over-exaggerating psychological comorbidity?
5. NT group under-reporting?
T = Trauma
NT = No-trauma
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
Clinical Implications
 Utility of self-report measures
 Possible limitations of self-report measures (disclosure?)
 Utility of individual psychological formulation
T = Trauma
NT = No-trauma
Questions?
T = Trauma
NT = No-trauma
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), 543-553.
Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology.
Qualitative research in psychology, 3(2), 77-101.
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),
793-812.
Coolican, H. (2009). Research Methods and Statistics in Psychology (5th ed.).
London: Hodder Education.
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),
818-825.
Howlett, S., Grunewald, R. A., Khan, A., & Reuber, M. (2007). Engagement in
psychological treatment for functional neurological symptoms - Barriers
and solutions. Psychotherapy, 44(3), 354-360.
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), 1499-1507.
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), 247-253.
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), 429-434.
Reuber, M. (2008). Psychogenic nonepileptic seizures: answers and questions.
Epilepsy & Behaviour, 12(4), 622-635.
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), 230-238.
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.