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Is there such thing as idiopathic NEAD?

Is there such thing as idiopathic NEAD?

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Is there such thing as idiopathic NEAD?

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  1. 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

  2. Aims • Background and rationale • Methods • Results • Discussion points • Conclusions • Clinical Implications • Questions

  3. 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)

  4. 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

  5. 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

  6. 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?

  7. 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

  8. 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

  9. 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

  10. 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

  11. Results: Demographics T = Trauma NT = No-trauma

  12. 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

  13. 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

  14. 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

  15. 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

  16. 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

  17. 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

  18. 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

  19. 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

  20. 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

  21. 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

  22. 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

  23. Clinical Implications • Utility of self-report measures • Possible limitations of self-report measures (disclosure?) • Utility of individual psychological formulation T = Trauma NT = No-trauma

  24. Questions? T = Trauma NT = No-trauma

  25. References (1) Bodde, N. M., Brooks, J. L., Baker, G. A., Boon, P. A., Hendriksen, J. G., Mulder, O. G., et al. (2009). Psychogenic non-epileptic seizures--definition, etiology, treatment and prognostic issues: a critical review. Seizure, 18(8), 543-553. Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative research in psychology, 3(2), 77-101. Briere, J. (1995). Trauma symptom inventory. Odessa, FL: Psychological Assessment Resources. Brown, R. J. (2004). Psychological mechanisms of medically unexplained symptoms: an integrative conceptual model. Psychological Bulletin, 130(5), 793-812. Coolican, H. (2009). Research Methods and Statistics in Psychology (5th ed.). London: Hodder Education.

  26. References (2) Fiszman, A., Alves-Leon, S. V., Nunes, R. G., D'Andrea, I., & Figueira, I. (2004). Traumatic events and posttraumatic stress disorder in patients with psychogenic nonepileptic seizures: a critical review. Epilepsy Behav, 5(6), 818-825. Howlett, S., Grunewald, R. A., Khan, A., & Reuber, M. (2007). Engagement in psychological treatment for functional neurological symptoms - Barriers and solutions. Psychotherapy, 44(3), 354-360. Kubany, E. S. (1995). The Traumatic Life Events Questionnaire (TLEQ): A brief measure of prior trauma exposure. Unpublished scale. Available from the author. Lesser, R. P. (1996). Psychogenic seizures. Neurology, 46(6), 1499-1507. Marchetti, R. L., Kurcgant, D., Neto, J. G., von Bismark, M. A., Marchetti, L. B., & Fiore, L. A. (2008). Psychiatric diagnoses of patients with psychogenic non-epileptic seizures. Seizure, 17(3), 247-253.

  27. References (3) Millon, T., & Davis, R. (1996). The Millon Clinical Multiaxial Inventory-Ill. Major Psychological Assessment Instruments, 108. Moore, P. M., & Baker, G. A. (1997). Non-epileptic attack disorder: a psychological perspective. Seizure, 6(6), 429-434. Reuber, M. (2008). Psychogenic nonepileptic seizures: answers and questions. Epilepsy & Behaviour, 12(4), 622-635. Reuber, M., Howlett, S., Khan, A., & Grunewald, R. A. (2007). Non-epileptic seizures and other functional neurological symptoms: Predisposing, precipitating, and perpetuating factors. Psychosomatics: Journal of Consultation Liaison Psychiatry, 48(3), 230-238. Stokes, T., Shaw, E. J., Juarez-Garcia, A., Camosso-Stefinovic, J., & Baker, R. (2004). Clinical Guidelines and Evidence Review for the Epilepsies: diagnosis and management in adults and children in primary and secondary care. London: Royal College of General Practitioners.