Nothing Explains Everything

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Cora Gilbert
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1 Nothing Explains Everything

2 NES: Psychiatric Comorbidities Diagnosis LaFrance 2005 Lifetime Current MDD 80% 47% Any Affective d/o 98% 64% PTSD 58% 49% Any anxiety d/o except PTSD 51% 47% Any Somatoform d/o 98% 89% Conversion Sz 89% 78% Conversion NonSz 82% 4% Any Dissociative d/o 93% 91% Personality d/o 62% (Bowman, n=45)

3 PNES Psychological Factors Psychological Factors Number Percentage Anxiety, stress, breakdown 75 43% Physical abuse, assault 49 28% Significant bereavements 45 26% Relationship problems, family dysfunction 44 26% Depression 41 23% Disrupted childhood 28 16% Sexual abuse/rape 24 14% Pain, illness behavior 19 11% Suicide attempts 17 10% No psychological factors identified 8 5% LaFrance 2005 (Moore & Baker. Seizure. 1997;6;429 34)

4 Affective Disorders Idiopathic Depression Disorders are frequently co morbid with somatization. ¹ Commonalities with fronto temporal limbic network dysfunction and HPA axis abnormaities.² Depressive Disorders (DD) in PNES reported to be between 21 60%.³ Current DD in PNES not different from those of patients with refractory epilepsy.³ Depression and quality of life are directly proportional. 1. Rief et al. J Psychosom Res Voon V, Hallet M. "Psychogenic Movement Disorders" 2006,3. Fiszman et al. "Nonepileptic Seizures" LaFrance et al. Neurology

5 LaFrance, W. C. et al. Neurology 2009;73:

6 LaFrance, W. C. et al. Neurology 2009;73:

7 LaFrance, W. C. et al. Neurology 2009;73:

8 Trauma, Abuse and PTSD Seventeen studies met inclusion criteria for diagnosis of PNES. General trauma % (Trauma can be very idiosyncratic) Physical or sexual abuse 23 77% PNES pts higher rates of trauma, abuse and PTSD than controls Critique: 1. marker for family dysfunction, 2. some had co morbidity of epilepsy, 3. hospital population, 4. Gender issues, etc Fiszman et al. Epilepsy and Behavior

9 Child Trauma Questionnaire Results NES vs. EE NES ES p partial eta 2 n M SD n M SD Emotional Abuse Physical Abuse Sexual Abuse Emotional Neglect Physical Neglect Barry et al. for publication 9

10 Memory and Reliability

11 Dissociative Disorders¹ Dissociation is a defense mechanism where contents of the mind are banished from awareness. Traumatic memories are split from consciousness because they are inconsistent with the patient s selfconcept. Trauma is necessary but not sufficient to cause DD the family context is crucial. The devil one knows is often better than the devil one does not know predictability results in an external locus of control at the patients expense. Traumatic memories traumatic reenactments goal is to recover normal mental process and function. ¹from Gabbard GO. Psychodynamic Psychiatry in Clinical Practice 2005;

12 Conversion Theory Trauma and its lasting effect dissociated subcortical memories that are activated with resulting unexplained symptoms (Janet). Freud dissociation as a defense mechanism protecting against negative affect by converting it into somatic symptoms (primary gain) with resultant la belle indifference. In time, secondary gain may develop. Nature of the symptom may have a symbolic representation of the conflict, exp aphonia. Brown, R. Psychogenic Movement Disorders 2006, Janet P." The Major Symptoms of Hysteria" 1907, Breuer J, Freud S. Studies on Hysteria 1895

13 Dissociation Theory Hypnotic induction may discriminate between PNES and EE.¹ Dissociative Experience Scale scores for patients with PNES may be statistically no different than epilepsy controls.² Subsets of dissociation however may be discriminatory.² 1. Barry et al. Epilepsia Brown, R. Psychogenic Movement Disorders 2006

14 Validity of Conversion Theory La Belle indifference 6% 41%, clinical experience helpful if there but generally useless. Conflict resolution via symptoms two studies provide some support for this concept. Precipitated with stress not a discriminating factor Secondary gain not a discrimination factor either but more a product of learned illness behavior. Childhood abuse A review of 21 studies found that most demonstrate increased frequencies of sexual, physical and emotional abuse over controls. Perhaps the most important factor is that these studies reflect the presence of a pathological childhood environment. Brown, R. Psychogenic Movement Disorders 2006

15 Anxiety Disorders (not including PTSD) Frequency of Anxiety Disorders depends on whether it is classified as a co morbid component of the PNES or the PNES may be a component of an Anxiety or Panic Disorder.¹ Range: Kanner et al. N=45, 60% MDD, 7% dysthymia and 2% Panic and 9 GAD¹ ² Snyder et al. N=20, 45% MDD, 10% dysthymia and 70% PD and 20% Phobia¹ ³ Frequency > general population but may be = to controls.¹ 1. Fiszman et al, "Nonepileptic Seizures" 2010, 2.Kanner et al. Neurology 1999, 3. Snyder et al J Neuropsy Clin Neurosci

16 Personality Disorders Mostly : cluster B deficits in affect regulation, impulsivity and identity diffusion which include borderline, antisocial, histrionic and narcissistic personality disorders. Cluster C avoidant, dependant and obsessive Outcome varies with the presence or absence of a personality diagnosis. Those with mixed dx of MDD, Dissociative Disorders and/or personality disorder with high emotionality have a worse prognosis.¹ ² 1.Kanner et al Neurology 1999, 2. Reuber et al. J Neurol Neurosurg Psychiatry

17 PNES as a Cognitive Disorder: Alexithymia Alexithymia (pronounced l ks a mi /) from the Ancient Greek words and modified by an alpha privative literally "without words for emotions" is a term coined by psychotherapist Peter Sifneos in 1973 to describe a state of deficiency in understanding, processing, or describing emotions. Wikipedia

18 An Integrative Model Genetic Vulnerability Childhood Adversity (Loss, Abuse, Neglect) Adverse Life Events Maladaptive Attachment Depressive Anxiety Disorders PTSD Biobehavioral Risks for Chronic Disease obesity sedentary lifestyle smoking chronic stress metabolic syndrome Chronic Medical Disorders diabetes heart disease Self Care of Chronic Medical Disorder collaboration w/md exercise diet medication adherence monitoring symptoms or signs of exacerbation quitting smoking Consequences of Chronic Illness symptom burden functional impairment quality of life biologic changes in the brain secondary to chronic illness biologic complications Adapted from Katon WJ. Biol Psychiatry. 2003;54:

19 Overview Stonnington C, Barry JJ, Fisher R. AJP 2006

20 Conclusion Most prevalent psychiatric disorders in people with PNES include PTSD, Somatoform including Conversion Disorders, and additionally Dissociative Disorders, Depressive Disorders, Anxiety Disorders and Personality Disorders especially of the clusters B and C. PNES pts also may have increased incidences of trauma especially of sexual and emotional abuse. What constitutes trauma depends on the individual. This results in a psychosocial milieu conducive to alexithymia and somatic expression of psychological disturbances and possibly the development of a longstanding personality dysfunction as well.

Developing a core battery of outcome measures

Developing a core battery of outcome measures Markus Reuber Professor of Clinical Neurology Academic Neurology Unit University of Sheffield Royal Hallamshire Hospital Sheffield, 19.06.15 M. Reuber / 1