Is there such thing as idiopathic NEAD? “Nothing bad’sever 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? • Absence of trauma/psychological comorbidity? • Non-expression? • Methodological factors, e.g. Underreporting in interviews (Fiszman, et al., 2004) • 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 • Experienced sudden and unexpected death of a close friend/loved one • Loved one survived life-threatening accident/assault/illness • Had a life-threatening illness • Been robbed/present during robbery involving a weapon • Hit/beaten up and badly hurt by a stranger • Seen a stranger attack/beat up someone, leading to serious injury/death • Threats to kill/seriously harm you T = Trauma NT = No-trauma
Traumatic Life Events Questionnaire (TLEQ)Kubany et. al (1995) • Physical abuse whilst growing up • Witness to domestic violence whilst growing up • Subject to domestic violence • Sexual abuse from an adult when under 13 • Sexual abuse from a peer when under 13 • Sexual abuse when aged 13-18 • Sexual assault when 18+ • Other unwanted sexual attention • Victim of stalking • Miscarriage • Abortion • Any other events T = Trauma NT = No-trauma
Results: Demographics 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): • Depressive (p=0.006; ES=1.21) • Sadistic/Aggressive (p=0.003; ES=1.31) • Masochistic/Self-defeating (p=0.050; ES=0.99) • Clinical Syndromes (Axis I disorders): • Anxiety (p=0.006; ES=1.26) • PTSD (p=0.002; ES=1.43) NB however: levels of Disclosure and Debasement 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? • Truly idiopathic NEAD group? • Clinical questioning nor questionnaires sufficiently sensitive? • NT group misdiagnosed as NEAD? • T group over-exaggerating experiences as traumatic and over-exaggerating psychological comorbidity? • 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
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