NothingExplainsEverything
LaFrance 2005
NES: Psychiatric Comorbidities
(Bowman, 1996. n=45)
Diagnosis Lifetime CurrentMDD 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%
LaFrance 2005
PNES Psychological FactorsPsychological Factors Number PercentageAnxiety, 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%
(Moore & Baker. Seizure. 1997;6;42934)
Affective Disorders• Idiopathic Depression Disorders are frequently co
morbid with somatization. ¹– Commonalities with frontotemporallimbic network
dysfunction and HPA axis abnormaities.²• Depressive Disorders (DD) in PNES reported to be
between 2160%.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 20102. Voon V, Hallet M. "Psychogenic
Movement Disorders" 2006,3.Fiszman et al. "Nonepileptic
Seizures" 2010 4. LaFrance et al.Neurology 2010 4
LaFrance, W. C. et al. Neurology 2009;73:366371
LaFrance, W. C. et al. Neurology 2009;73:366371
LaFrance, W. C. et al. Neurology 2009;73:366371
Trauma, Abuse and PTSDSeventeen studies met inclusion criteria for
diagnosis of PNES.General trauma –44100% (Trauma can be veryidiosyncratic)Physical or sexual abuse –2377%PNES pts –higher rates of trauma, abuse andPTSD than controls
Critique: 1. marker for family dysfunction, 2.some had comorbidity of epilepsy, 3. hospitalpopulation, 4. Gender issues, etc
8
Fiszman et al. Epilepsy and Behavior2004
NES ES p partial eta2
n M SD n M SD
Emotional Abuse 58 12.54 6.17 40 10.48 5.52 0.09 .029
Physical Abuse 60 9.52 5.68 40 8.17 4.68 0.21 .016
Sexual Abuse 55 10.44 7.53 40 7.68 5.79 0.06 .039
Emotional Neglect 59 11.51 6.10 39 11.55 5.56 0.98 .000
Physical Neglect 62 7.84 3.54 41 8.17 4.24 0.67 .002
9
Child Trauma QuestionnaireResults NES vs. EE
Barry et al. for publication
Memory and Reliability
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 devilone does not know” predictability results in anexternal locus of control at the patients expense.
• Traumatic memories traumatic reenactments goal is to recover normal mental process andfunction.¹from Gabbard GO. Psychodynamic Psychiatry in Clinical Practice 2005;283312.
Conversion Theory• Trauma and its lasting effect dissociated subcortical
memories that are activated with resultingunexplained symptoms (Janet).
• Freud –dissociation as a defense mechanismprotecting against negative affect by converting it intosomatic symptoms (primary gain) with resultant “labelle indifference”. In time, secondary gain maydevelop.– Nature of the symptom may have a symbolic
representation of the conflict, exp aphonia.
Brown, R. Psychogenic MovementDisorders 2006, Janet P." The MajorSymptoms of Hysteria" 1907, BreuerJ, Freud S. Studies on Hysteria 1895
Dissociation Theory• Hypnotic induction may discriminate between
PNES and EE.¹• Dissociative Experience Scale scores for
patients with PNES may be statistically nodifferent than epilepsy controls.²
• Subsets of dissociation however may bediscriminatory.²
1. Barry et al. Epilepsia 20002.Brown, R. “Psychogenic Movement
Disorders” 2006
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 andemotional abuse over controls. Perhaps the most importantfactor is that these studies reflect the presence of a“pathological childhood environment.”
Brown, R. Psychogenic MovementDisorders 2006
Anxiety Disorders (not includingPTSD)• Frequency of Anxiety Disorders depends on whether
it is classified as a comorbid component of thePNES or the PNES may be a component of anAnxiety 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
15
1. Fiszman et al, "NonepilepticSeizures" 2010, 2.Kanner et al.
Neurology 1999, 3. Snyder et al JNeuropsy Clin Neurosci 1994
Personality Disorders• Mostly :
– cluster B –deficits in affect regulation, impulsivityand identity diffusion which include borderline,antisocial, histrionic and narcissistic personalitydisorders.
– 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
16
1.Kanner et al Neurology 1999, 2.Reuber et al. J Neurol Neurosurg
Psychiatry 2004
Wikipedia
PNES as a Cognitive Disorder:Alexithymia
• Alexithymia (pronounced l ks a mi /)from the Ancient Greek words andmodified by an alphaprivative— literally "withoutwords for emotions"— is a term coined bypsychotherapist Peter Sifneos in 1973 todescribe a state of deficiency in understanding,processing, or describing emotions.
An Integrative Model
Adapted from Katon WJ. Biol Psychiatry. 2003;54:216226.
Genetic VulnerabilityChildhood Adversity(Loss, Abuse, Neglect)Adverse Life Events
MaladaptiveAttachment
DepressiveAnxiety
DisordersPTSD
Biobehavioral Risksfor Chronic Disease
obesitysedentary lifestylesmokingchronic stress–metabolic
syndrome
ChronicMedical
Disordersdiabetesheart disease
SelfCare ofChronic Medical Disorder
collaboration w/MDexercisedietmedication adherencemonitoring symptoms or signs
of exacerbationquitting smoking
Consequences ofChronic Illness
symptom burdenfunctional impairmentquality of lifebiologic changes in the brain
secondary to chronic illnessbiologic complications
Stonnington C, Barry JJ, Fisher R.AJP 2006
Overview
Conclusion• Most prevalent psychiatric disorders in people with PNES
include –PTSD, Somatoform including ConversionDisorders, and additionally Dissociative Disorders,Depressive Disorders, Anxiety Disorders and PersonalityDisorders especially of the clusters B and C.
• PNES pts also may have increased incidences of traumaespecially 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 psychologicaldisturbances and possibly the development of alongstanding personality dysfunction as well.
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