Alterations of consciousness in psychogenic nonepileptic seizures: Emotion, emotion regulation and dissociation

School of Social and Behavioral Sciences, Arizona State University, Glendale, AZ, USA. Electronic address: .
Epilepsy & Behavior (Impact Factor: 2.26). 11/2013; 30. DOI: 10.1016/j.yebeh.2013.09.035
Source: PubMed


Impairment of consciousness and reduced self-control are key features of most psychogenic nonepileptic seizures (PNESs), although, compared with patients with epilepsy, those with PNESs demonstrate greater conscious awareness during their seizures. The neurobiological underpinnings of PNESs and of alterations of awareness associated with PNESs remain relatively unknown. We suggest that an understanding of conscious experiences and discrepancies between subjective impairment of consciousness and the lack of objectifiable neurobiological changes in PNESs may benefit from an examination of emotion processing, including understanding sensory, situational, and emotional triggers of PNESs; emotional and physiological changes during the attacks; and styles of emotional reactivity and regulatory capacity. We also suggest that in addition to the typical comparisons between patients with PNESs and those with epilepsy, studies of PNESs would benefit from the inclusion of comparison groups such as those with PTSD, dissociation, and other forms of psychopathology where dissociative and emotion regulatory mechanisms have been explored more fully. We conclude that current evidence and theory suggest that impairment of consciousness in PNESs is only "dissociative" in one subgroup of these seizures, when consciousness is suppressed as a collateral effect of the excessive inhibition of emotion processing. We propose that PNES behaviors and experiences of reduced control or awareness may also represent direct behavioral manifestation of overwhelming emotions, or that minor emotional fluctuations or relatively neutral stimuli may trigger PNESs through conditioning or other preconscious processes. Future studies exploring the neurobiological mechanisms underpinning PNESs are likely to be more fruitful if researchers bear in mind that it is unlikely that all PNESs result from the same processes in the brain. This article is part of a Special Issue entitled Epilepsy and Consciousness.

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Available from: Markus Reuber, Jun 19, 2014
    • "Clearly, qualitative techniques have much to offer in enhancing our understanding of the experiences of individuals with DS and may also serve to generate hypotheses for further quantitative testing. Historically and contemporarily, abnormal emotional processes have been posited to play a crucial role in triggering or underlying DS27282930. Recent experimental research has yielded findings supportive of the hypothesis that patients with DS exhibit altered emotional func- tioning31323334, including differences in attentional, behavioral, and subjective responses to affective stimuli. "
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    ABSTRACT: Quantitative research has indicated that patients with dissociative seizures (DS) show altered responses to emotional stimuli, in addition to considerable emotional distress and dysregulation. The present study sought to further explore emotional processes in this population, to extend previous findings and provide a phenomenological insight into patients' perspectives on these issues. Semi-structured interviews were carried out with 15 patients with DS and the principles of interpretative phenomenological analysis (IPA) were adopted in data analysis. Key themes elicited included: i) general emotional functioning; ii) adverse (stressful/traumatic) life experiences; iii) the role of emotions in DS; (iv) relating to others; and v) resilience, protective factors and coping mechanisms. The clinical and theoretical implications of the findings are discussed.
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    • "Higher alexithymia and emotion dysregulation rates have been related to lower somatization and depression rates (Brown et al., 2013) pointing at the role of alexithymia and emotional impoverishment as protective mechanisms. In summary, psychoform dissociative, conversive and somatoform patients do not show a unitary emotion regulation pattern (Felmingham et al., 2008;Oathes and Ray, 2008;Kozlowska et al., 2011;Barnow et al., 2012;Fisher, 2014;Roberts and Reuber, 2014;Del Río-Casanova et al., 2016). This discrepancy of data can be due to the complexity of the different dissociative responses, but it can also originate in the possibility of both regulatory strategies (over-and under-regulation of affect) being present with sometimes rapid cycling between them. "
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    ABSTRACT: Emotion regulation impairments with traumatic origins have mainly been studied from posttraumatic stress disorder (PTSD) models by studying cases of adult onset and single-incident trauma exposure. The effects of adverse traumatic experiences, however, go beyond the PTSD. Different authors have proposed that PTSD, borderline personality, dissociative, conversive and somatoform disorders constitute a full spectrum of trauma-related conditions. Therefore, a comprehensive review of the neurobiological findings covering this posttraumatic spectrum is needed in order to develop an all-encompassing model for trauma-related disorders with emotion regulation at its center. The present review has sought to link neurobiology findings concerning cortico-limbic function to the field of emotion regulation. In so doing, trauma-related disorders have been placed in a continuum between under- and over-regulation of affect strategies. Under-regulation of affect was predominant in borderline personality disorder, PTSD with re-experiencing symptoms and positive psychoform and somatoform dissociative symptoms. Over-regulation of affect was more prevalent in somatoform disorders and pathologies characterized by negative psychoform and somatoform symptoms. Throughout this continuum, different combinations between under- and over-regulation of affect strategies were also found.
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    • "Experiential avoidance is not merely the avoidance of certain situations but rather the avoidance of one's own thoughts, sensations, and emotions , particularly anxiety-provoking ones [14]. Such avoidance can be voluntary or involuntary, with the involuntary aspect arguably most likely to precipitate clinical syndromes such as PNESs [15]. Anxiety itself is a complex physiological and behavioral experience with both 'explicit' and 'implicit' cognitive components [16] [17]. "
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    ABSTRACT: This study examined implicit and explicit anxiety in individuals with epilepsy and psychogenic nonepileptic seizures (PNESs) and explored whether these constructs were related to experiential avoidance and seizure frequency. Based on recent psychological models of PNESs, it was hypothesized that nonepileptic seizures would be associated with implicit and explicit anxiety and experiential avoidance. Explicit anxiety was measured by the State-Trait Anxiety Inventory; implicit anxiety was measured by an Implicit Relational Assessment Procedure; and experiential avoidance was measured with the Multidimensional Experiential Avoidance Questionnaire. Although both groups with epilepsy and PNESs scored similarly on implicit measures of anxiety, significant implicit–explicit anxiety discrepancies were only identified in patients with PNESs (p < .001). In the group with PNESs (but not in the group with epilepsy), explicit anxiety correlated with experiential avoidance (r = .63, p < .01) and frequency of seizures (r = .67, p < .01); implicit anxiety correlated with frequency of seizures only (r = .56, p < .01). Our findings demonstrate the role of implicit anxiety in PNESs and provide additional support for the contribution of explicit anxiety and experiential avoidance to this disorder.
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