Shiri Ben-Naim’s research while affiliated with Hebrew University of Jerusalem and other places

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Publications (9)


A Novel Integrative Psychotherapy for Psychogenic Nonepileptic Seizures Based on the Biopsychosocial Model: A Retrospective Pilot Outcome Study
  • Article

February 2020

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139 Reads

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11 Citations

Psychosomatics

Shiri Ben-Naim

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Objective Psychogenic non-epileptic seizures (PNES) represent one of the most sizable treatment challenges in neuropsychiatry. Although the underlying mechanism far from being understood, several interventions have been suggested. However, patients with comorbid psychiatric diagnoses and epilepsy are excluded from most intervention studies. Methods We present a within-group post vs pre-treatment study representing the retrospective clinical results of 22 patients with PNES diagnosed in the Epilepsy Center and treated in our neuropsychiatry clinic utilizing an integrative rehabilitative psychotherapy. Therapy included presenting the diagnosis, psychoeducation, seizure reduction behavioral techniques and coping with past and present stressors. Insomuch as integrative biopsychosocial psychotherapy is based on an individualized treatment protocol for each patient, treatment was individualized and case specific. Results By the end of treatment, 36% of patients had become seizure free, a further 54% achieved a major seizure reduction (reduction of more than 70%). 72% kept at least 70% seizure reduction at follow up. General assessment of functioning (GAF) scores improved from a mean of 43.09 to a mean of 72.81 at the end of treatment and 69.72 at follow up. Additionally, we present three case descriptions that emphasize the individualized nature of psychotherapeutic decisions. Conclusions Our results support the feasibility and effectiveness of biopsychosocial based integrative psychotherapy for PNES and set principles for future treatment and prospective clinical trials in the field of individualized psychotherapy.



FIG. 1. Electrophysiological division of STN by HMM algorithm. (A-C) Electrophysiological division of an example trajectory. (A) NRMS and (B) NPSD (percentage of total power, filtered with Gaussian window for presentation purposes) were fed to HMM algorithm, which classified recording sites to the six possible categories seen in (D). Y-axis in (A) and (B) marks the distance of the microelectrode from the predefined target (mm). HMM results for current trajectory are presented in the color bar at (B) right, color legend presented at (C) right. A black arrow points at the ventromedial theta-alpha oscillations. (C) HMM results for the example trajectory presented in (A) and (B) are shown on an STN functional atlas. Note the overlap between VMOR electrophysiological region and the STN limbic anatomical region. (D) A schematic description of STN division by HMM. The STN electrophysiological areas are DLOR, VMNR, and VMOR. Transition probabilities between the different areas were analyzed for the data set of 933 trajectories, and are demonstrated by arrow width. The full transition matrix, including probability to stay in the same region, is presented in Supporting Information Table S1. In this analysis, only one continuous VMOR section was allowed within a trajectory. Note that the probability of leaving the STN from a VMOR is higher than the probability of moving from a VMOR to a VMNR. [Color figure can be viewed at wileyonlinelibrary.com]
FIG. 2. VMOR prevalence. Average NPSD of the full data set (A), and after HMM division to trajectories with (B) and without (C) VMOR. Y-axis represents normalized position within the STN. 0 marks the STN anterior-dorsal-lateral border, and 1 marks the STN posterior-ventral-medial border. X-axis represents frequency. [Color figure can be viewed at wileyonlinelibrary.com]
FIG. 3. Electrophysiology and topography of VMOR. (A) Average NPSD of the DLOR, VMNR, and VMOR. (B) Theta-alpha peak frequency and (C) theta-alpha power in DLOR, VMNR, and VMOR. The central line indicates the median and the bottom and top edges of the box indicate the 25th and 75th percentiles, respectively. The whiskers extend to the most extreme data points not considered outliers (distance from box edge of over 1.5*interquartile range). (D) VMOR probability as a function of normalized position within the STN. 0 marks the STN anterior-dorsallateral border, and 1 marks the STN posterior-ventral-medial border. (E) VMOR length distribution. Marked with a dashed line is the average VMOR length. (F) VMOR laterality, expressed as percentage of patients with left, right, or bilateral VMOR, detected in one or more trajectories. Only patients with bilateral recording (n = 250) were included in this analysis. (G) Theta-alpha peak frequency and (H) theta-alpha power in left and right VMOR. Box plots in (G,H) follow the same conventions as in (B,C). [Color figure can be viewed at wileyonlinelibrary.com]
FIG. 4. Localization of theta-alpha activity in the DISTAL functional atlas of the STN. (A,B) 3D representation of the STN DISTAL atlas in MNI space with localized electrodes. (A) Posterior-medial view. (B) Anterior-lateral view. Left side: left STN (n = 76 electrodes); right side: right STN (n = 75 electrodes). (C) Posterior-medial view with average trajectories; X-axis: lateral-medial plane, Y-axis: AC-PC plane, Z axis: dorsal-ventral plane. Marked with black circles is the average position of lead DBS contacts. The average location of the most dorsal contact is dorsal to the STN and is not seen in the figure. (D) Sagittal slices of the STN with interpolated theta-alpha activity (7-10 Hz), averaged over 0.44 mm along the medial-lateral plane; X-axis: AC-PC plane, Y-axis: dorsalventral plane. Slice center along the medial-lateral plane is stated in the title. STN anatomical border is presented as a gray shade. Functional anatomical border of the limbic STN is marked in orange. Black arrows point to the location of ventral theta-alpha activity. Inset: coronal view of the STN with the slice center along the medial-lateral plane marked by a red line. X-axis: mediallateral plane, Y-axis: dorsal-ventral plane. Left column: left STN; right column: right STN. AC-PC, anterior commissure-posterior commissure. [Color figure can be viewed at wileyonlinelibrary.com]
Theta‐alpha Oscillations Characterize Emotional Subregion in the Human Ventral Subthalamic Nucleus
  • Article
  • Full-text available

November 2019

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326 Reads

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44 Citations

Movement Disorders

Background: Therapeutic outcomes of STN-DBS for movement and psychiatric disorders depend on electrode location within the STN. Electrophysiological and functional mapping of the STN has progressed considerably in the past years, identifying beta-band oscillatory activity in the dorsal STN as a motor biomarker. It also has been suggested that STN theta-alpha oscillations, involved in impulse control and action inhibition, have a ventral source. However, STN local field potential mapping of motor, associative, and limbic areas is often limited by poor spatial resolution. Objectives: Providing a high-resolution electrophysiological map of the motor, associative and limbic anatomical sub-areas of the subthalamic nucleus. Methods: We have analyzed high-spatial-resolution STN microelectrode electrophysiology recordings of PD patients (n = 303) that underwent DBS surgery. The patients' STN intraoperative recordings of spiking activity (933 electrode trajectories) were combined with their imaging data (n = 83 patients, 151 trajectories). Results: We found a high theta-alpha (7-10 Hz) oscillatory area, located near the STN ventromedial border in 29% of the PD patients. Theta-alpha activity in this area has higher power and lower central frequency in comparison to theta-alpha activity in more dorsal subthalamic areas. When projected on the DISTAL functional atlas, the theta-alpha oscillatory area overlaps with the STN limbic subarea. Conclusions: We suggest that theta-alpha oscillations can serve as an electrophysiological marker for the ventral subthalamic nucleus limbic subarea. Therefore, theta-alpha oscillations can guide optimal electrode placement in neuropsychiatric STN-DBS procedures and provide a reliable biomarker input for future closed-loop DBS device. © 2019 International Parkinson and Movement Disorder Society.

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Memory and motor control in patients with psychogenic nonepileptic seizures ☆

August 2019

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74 Reads

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13 Citations

Epilepsy & Behavior

Psychogenic nonepileptic seizures (PNES) are of the most elusive phenomena in epileptology. Patients with PNES present episodes resembling epileptic seizures in their semiology yet lacking the underlying epileptic brain activity. These episodes are assumed to be related to psychological distress from past trauma, yet the underlying mechanism of this manifestation is still unknown. Using resting-state functional magnetic resonance imaging (fMRI), we investigated functional connectivity changes within and between large-scale brain networks in 9 patients with PNES, compared with a group of 13 age-and gender-matched healthy controls. Functional magnetic resonance imaging analyses identified functional connectivity disturbances between the medial temporal lobe (MTL) and the sensorimotor cortex and between the MTL and ventral attention networks in patients with PNES. Within network connectivity reduction was found within the visual network. Our findings suggest that PNES relate to changes in connectivity in between areas that are involved in memory processing and motor activity and attention control. These results may shed new light on the way by which traumatic memories may relate to PNES.


Direct and indirect effect of ADHD on marital satisfaction through parental stress and parental self-efficacy (beta scores).
Means, Standard Deviations, and F Scores for ANOVAs Between Parents to Children With and Without ADHD.
Pearson Colorations Among Variables.
Hierarchical Regression Analysis for Predicting Marital Satisfaction.
Parental Stress and Parental Self-Efficacy as Mediators of the Association Between Children’s ADHD and Marital Satisfaction

March 2019

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230 Reads

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47 Citations

Parents of children with ADHD often experience low marital satisfaction, since the child’s increased susceptibility to maladjustment can affect family dynamics as a whole. Objectives: To explore this association by examining parental stress and parental self-efficacy as two possible mediators. Method: Totally, 182 Israeli parents of children in the first to ninth grades (63 parents of children with ADHD and 119 without) completed parental self-efficacy, marital satisfaction, and parental stress questionnaires. Results: As expected, parents of children with ADHD reported higher parental stress, and lower self-efficacy and marital satisfaction than non-ADHD parents. The association between ADHD parents and marital satisfaction was fully explained by parental stress and self-efficacy, suggesting that personal characteristics and situation appraisal are tapped when facing strain and hardship. Conclusion: These findings provide a window of hope for an otherwise deterministic view of the ADHD-marital dissolution relationship and propose individual and familial interventions that may minimize these damaging effects.


One year double blind study of high vs low frequency subcallosal cingulate stimulation for depression

October 2017

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101 Reads

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59 Citations

Journal of Psychiatric Research

Subcallosal Brodmann's Area 25 (Cg25) Deep Brain Stimulation (DBS) is a new promising therapy for treatment resistant major depressive disorder (TR-MDD). While different DBS stimulating parameters may have an impact on the efficacy and safety of the therapy, there is no data to support a protocol for optimal stimulation parameters for depression. Here we present a prospective multi-center double-blind randomized crossed-over 13-month study that evaluated the effects of High (130 Hz) vs Low (20 Hz) frequency Cg25 stimulation for nine patients with TR-MDD. Four out of nine patients achieved response criteria (≥40% reduction of symptom score) compared to mean baseline values at the end of the study. The mean percent change of MADRS score showed a similar improvement in the high and low frequency stimulation groups after 6 months of stimulation (-15.4 ± 21.1 and -14.7 ± 21.1 respectively). The mean effect at the end of the second period (6 months after cross-over) was higher than the first period (first 6 months of stimulation) in all patients (-23.4 ± 19.9 (n = 6 periods) and -13.0 ± 22 (n = 9 periods) respectively). At the end of the second period, the mean percent change of the MADRS scores improved more in the high than low frequency groups (-31.3 ± 19.3 (n = 4 patients) and -7.7 ± 10.9 (n = 2 patients) respectively). Given the small numbers, detailed statistical analysis is challenging. Nonetheless the results of this study suggest that long term high frequency stimulation might confer the best results. Larger scale, randomized double blind trials are needed in order to evaluate the most effective stimulation parameters.


Sampling and flow chart of participants through the experiment
Interaction effect on intimacy score as a function of group (ADHD or comparison) and gender. * p < .05; ** p < .01
Indirect effect of spouses’ ADHD on marital satisfaction through intimacy (beta scores)
Life With a Partner with ADHD: The Moderating Role of Intimacy

May 2017

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1,721 Reads

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35 Citations

Adult attention deficit and hyperactivity disorder (ADHD) manifests itself through a variety of symptoms, some of which affect not only occupational and recreational activities but also intimate relationships. Previous findings have focused on the effects of adult ADHD on intimacy and relationships from the ADHD diagnosed person’s point of view. However, spouses of people with ADHD are a neglected population with regard to the effects that ADHD has on their romantic relationships. Our aim was to assess the effects of being married to a spouse with ADHD on marital relationships, and the moderating role of intimacy. We compared healthy spouses of people with ADHD to healthy spouses of healthy adults (M = 38.23, SD = 4.78) in their degree of self-reported intimacy and marital satisfaction. Our findings indicate that spouses of individuals with ADHD report significantly lower intimacy and lower marital satisfaction compared to spouses of individuals without ADHD. Moreover, our findings indicate that spousal reports about their degree of intimacy mediate the relationships between their spouses’ ADHD and their marital satisfaction. Results are discussed in relation to the broad implications that adult ADHD has for romantic intimacy. Our research addresses healthy partners married to a spouse with ADHD, suggesting that living with a partner with ADHD behaviors is challenging. ADHD symptoms negatively affect various qualities in the person experiencing them, but of equal importance is the damage occurring to his or her spouse. Implications for future research and recommendations for clinical work are suggested.


Figure 1. direct and indirect effects of ld on aSE through Soc, agency and paths (beta scores). note. aSE = academic Self-Efficacy; ld = learning disabilities; and Soc = Sense of coherence. *p < 0.05; **p < 0.01.
Table 2 . Means, standard deviations and F scores for anoVas between male and female students.
Table 3 . pearson correlations among variables.
indirect and direct Effects of ld on aSE.
Academic self-efficacy, sense of coherence, hope and tiredness among college students with learning disabilities

January 2017

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4,762 Reads

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76 Citations

Some resilient students with LD succeed ‘against the odds’ and reach college. The goals of the study are to explore their resources and barriers during their studies. The relationships between academic self-efficacy (ASE) and personal resources (sense of coherence (SOC) and hope) among college students with learning disabilities (LD) will be examined. The sample consisted of 438 college students divided into two subgroups: 149 students with LD and 289 Non-LD students. Results indicated that college students with LD reported lower levels of ASE, as well as lower levels of hope subscales and SOC. Persistent challenges of early learning distress experienced by those students during school periods continue to be prevalent during their college years. The ASE was predicted by the personal resources, and the risk factor (tiredness lost its significance). The importance of personal resources (SOC and hope subscales) was further emphasised by the mediation model (PROCESS). They mediated the relationships between LD and ASE. These outcomes call for empowering interventional programmes in order to promote hopeful thinking and personal coherence.


Hope as a Mediator of Loneliness and Academic Self-efficacy Among Students With and Without Learning Disabilities during the Transition to College

May 2016

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434 Reads

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79 Citations

Learning Disabilities Research and Practice

The transition to college often occasions excitement as well as elevated stress for students. The latter may be especially the case for those with learning disabilities (LD), who can encounter problems both socially and academically. This study follows students both with and without LD during the first month of college to explore the relationships between LD status and two outcomes: loneliness/social distress and academic self-efficacy. In particular, we hypothesized that hope and optimism would mediate the relationship between LD status and these outcomes. The sample consisted of 344 first-year undergraduates at the beginning of the academic year (Time-1) and a month later (Time-2). Results showed that LD status predicted Time-2 levels of academic self-efficacy and loneliness only indirectly, demonstrating that relationships between LD and loneliness as well as between LD and academic self-efficacy are mediated by hope.

Citations (9)


... Clinical trials and case studies are required to validate patient-specific models. Integrative psychotherapy models for psychogenic nonepileptic seizures have demonstrated promising outcomes in terms of seizure frequency reduction and improved patient functioning [216]. Patient-derived xenograft models have been used in clinical trials to evaluate the efficacy of anticancer drugs, providing a strong foundation for personalized cancer treatment [216]. ...

Reference:

From Serendipity to Precision: Integrating AI, Multi-Omics, and Human-Specific Models for Personalized Neuropsychiatric Care
A Novel Integrative Psychotherapy for Psychogenic Nonepileptic Seizures Based on the Biopsychosocial Model: A Retrospective Pilot Outcome Study
  • Citing Article
  • February 2020

Psychosomatics

... For example, the Demand Control Model theory explains that burnout can occur when there is an imbalance between the demands faced and the control that individuals have. College students who feel less control over their academic assignments or feel burdened by unrealistic expectations are more susceptible to burnout, regardless of their personality type (Ben-Naim et al., 2019). ...

Academic self-efficacy, sense of coherence, hope and tiredness among college students with learning disabilities
  • Citing Chapter
  • December 2019

... , as well as in network connectivity 46 , electrophysiology47 , and the effects of DBS 48 . Recent efforts in STN electrophysiology mapping using microelectrode recordings introduce a novel approach to de ning STN subregions, complementing anatomical divisions and demonstrating signi cant clinical relevance20,22,[49][50][51] . ...

Theta‐alpha Oscillations Characterize Emotional Subregion in the Human Ventral Subthalamic Nucleus

Movement Disorders

... The findings from functional imaging studies were more consistent. Several resting-state fMRI studies using traditional stationary analysis methods (Amiri et al., 2021, Szaflarski et al., 2018, Allendorfer et al., 2019, Dienstag et al., 2019, van der Kruijs et al, 2012, van der Kruijs et al., 2014, Ding et al., 2013, Ding et al.,2014, Li et al., 2015a for example describe what could be called emotional hyperconnectivity, i.e., an increased functional connectivity between structures involved in emotion processing/regulation that often extended to structures controlling nonemotional aspects as well. If emotional hyperconnectivity represents indeed an expression of the disturbances underlying DS, one would expect it to reflect the paroxysmal nature of DS, i.e., to vary in its expression over time. ...

Memory and motor control in patients with psychogenic nonepileptic seizures ☆
  • Citing Article
  • August 2019

Epilepsy & Behavior

... These findings suggest other potential moderators of stress that may have been particularly experienced by parents in the high and low L-PSE groups. For example, other studies have found that the more significant the child's need, the higher a parent's level of stress (e.g., Ben-Naim et al., 2019;Essler et al., 2021;MacInnes, 2009); this relationship may certainly have been exacerbated during school closures when parents took on the additional role of educator and full-time caregiver. ...

Parental Stress and Parental Self-Efficacy as Mediators of the Association Between Children’s ADHD and Marital Satisfaction

... Regarding the "factors affecting trial success", perhaps the major obstacle to trial success is the adequate recruitment of participants, for which several factors contribute: stringent eligibility criteria exclude many patients (Eitan et al., 2018); the invasive nature of the procedure deters potential participants due to concerns about associated risks; the availability of alternative therapies such as vagal nerve stimulation, ketamine infusions, and transcranial magnetic stimulation reduces willingness to try experimental procedures; low professional referrals from psychiatrists critical of surgical interventions for depression limit patient access (Filkowski et al., 2016); and geographical and logistical barriers such as travel difficulties and costs impede participation. Suppose we successfully address all preceding challenges and achieve sufficient patient recruitment; another issue emerges: patient withdrawal or fatality during the research. ...

One year double blind study of high vs low frequency subcallosal cingulate stimulation for depression
  • Citing Article
  • October 2017

Journal of Psychiatric Research

... This may be especially true for ADHD adults who have been found to show increased sensitivity to messages that include criticism (Beaton et al., 2020). In qualitative interviews by Björk and colleagues (2020), ADHD adults expressed feelings of hurt because of (perceived) unavailable support, which in turn, leads to lowered relationship satisfaction, higher rates of isolation, and depression (Ben-Naim et al., 2017;Lebowitz, 2016). Although previous research has not distinguished between the three ADHD symptoms as predictors of hurt feelings in conversation, due to their influence of cognitive processing, ED, hyperactivity, and inattentiveness may be associated with hurt feelings from support to varying degrees. ...

Life With a Partner with ADHD: The Moderating Role of Intimacy

... The relevance of non-cognitive factors is particularly evident in students with learning disabilities, who often face heightened emotional, motivational, and cognitive challenges (Ghisi et al. 2016;Hitches, Woodcock, and Ehrich 2023). This underscores the importance of targeted interventions and support services aimed at fostering the inclusion of students with SLD, promoting positive attitudes towards university (Ben-Naim et al. 2017), and raising awareness of these issues among faculty and administrative staff (Björnsdóttir 2017;Moriña 2017). ...

Academic self-efficacy, sense of coherence, hope and tiredness among college students with learning disabilities

... With the duration of online formal learning getting longer, the effect of loneliness on online learning burnout was not strengthened. These results align with Feldman et al. [24] and Hendryadi et al. [33], who found a stable effect over time on student loneliness, the level of burnout is consistent across time. This may be due to the measurement of online learning duration. ...

Hope as a Mediator of Loneliness and Academic Self-efficacy Among Students With and Without Learning Disabilities during the Transition to College
  • Citing Article
  • May 2016

Learning Disabilities Research and Practice