Autonomic nervous system functioning associated with psychogenic nonepileptic seizures: Analysis of heart rate variability.

OBJECTIVE: Psychogenic nonepileptic seizures (PNESs) resemble epileptic seizures but originate from psychogenic rather than organic causes. Patients with PNESs are often unable or unwilling to reflect on underlying emotions. To gain more insight into the internal states of patients during PNES episodes, this study explored the time course of heart rate variability (HRV) measures, which provide information about autonomic nervous system functioning and arousal. METHODS: Heart rate variability measures were extracted from double-lead electrocardiography data collected during 1-7days of video-electroencephalography monitoring of 20 patients with PNESs, in whom a total number of 118 PNESs was recorded. Heart rate (HR) and HRV measures in time and frequency domains (standard deviation of average beat-to-beat intervals (SDANN), root mean square of successive differences (RMSSD), high-frequency (HF) power, low-frequency (LF) power, and very low-frequency (VLF) power) were averaged over consecutive five-minute intervals. Additionally, quantitative analyses of Poincaré plot parameters (SD1, SD2, and SD1/SD2 ratio) were performed. RESULTS: In the five-minute interval before PNES, HR significantly (p<0.05) increased (d=2.5), whereas SDANN (d=-0.03) and VLF power (d=-0.05) significantly decreased. During PNES, significant increases in HF power (d=0.0006), SD1 (d=0.031), and SD2 (d=0.016) were observed. In the five-minute interval immediately following PNES, SDANN (d=0.046) and VLF power (d=0.073) significantly increased, and HR (d=-5.1) and SD1/SD2 ratio (d=-0.14) decreased, compared to the interval preceding PNES. CONCLUSION: The results suggest that PNES episodes are preceded by increased sympathetic functioning, which is followed by an increase in parasympathetic functioning during and after PNES. Future research needs to identify the exact nature of the increased arousal that precedes PNES.

Neurophysiological correlates of dissociative symptoms.

OBJECTIVE: Dissociation is a mental process with psychological and somatoform manifestations, which is closely related to hypnotic suggestibility and essentially shows the ability to obtain distance from reality. An increased tendency to dissociate is a frequently reported characteristic of patients with functional neurological symptoms and syndromes (FNSS), which account for a substantial part of all neurological admissions. This review aims to investigate what heart rate variability (HRV), EEG and neuroimaging data (MRI) reveal about the nature of dissociation and related conditions. METHODS: Studies reporting HRV, EEG and neuroimaging data related to hypnosis, dissociation and FNSS were identified by searching the electronic databases Pubmed and ScienceDirect. RESULTS: The majority of the identified studies concerned the physiological characteristics of hypnosis; relatively few investigations on dissociation related FNSS were identified. General findings were increased parasympathetic functioning during hypnosis (as measured by HRV), and lower HRV in patients with FNSS. The large variety of EEG and functional MRI investigations with diverse results challenges definite conclusions, but evidence suggests that subcortical as well as (pre)frontal regions serve emotion regulation in dissociative conditions. Functional connectivity analyses suggest the presence of altered brain networks in patients with FNSS, in which limbic areas have an increased influence on motor preparatory regions. CONCLUSIONS: HRV, EEG and (functional) MRI are sensitive methods to detect physiological changes related to dissociation and dissociative disorders such as FNSS, and can possibly provide more information about their aetiology. The use of such measures could eventually provide biomarkers for earlier identification of patients at risk and appropriate treatment of dissociative conditions.

Towards collaborative care for severe and enduring Anorexia Nervosa - a mixed-method approach.

BACKGROUND: Severe and Enduring Eating Disorders (SEED), in particular SEED-Anorexia Nervosa (SE-AN), may represent the most difficult disorder to treat in psychiatry. Furthermore, the lack of empirical research in this patient group, and, consequently the lack of guidelines, call for an urgent increase in research and discussion within this field. Meanwhile experts concur that effective care should be structured in a collaborative manner. OBJECTIVE: To identify the challenges in providing care to patients with SE-AN in the Dutch healthcare context, and propose a collaborative care treatment model to address these issues. METHODS: A pragmatic mixed-method approach was used, structured as follows: (1) Identifying perceived barriers and treatment needs from the viewpoint of both patients and eating disorder healthcare professionals through an evaluation questionnaire; (2) Investigating current treatment practices for SEED/SE-AN via benchmarking; (3) Gaining insight into the optimal structure and content of care by interviewing network partners and experts-by-experience. Based on these findings, and drawing from literature on severe and enduring disorders, a treatment model for SE-AN was proposed and implemented. RESULTS: The key challenges identified included a lack of knowledge about eating disorders among network partners, treatment ambivalence among patients and poor collaboration between professionals. The proposed model enhances self-management and collaborative relationships with healthcare providers, offers user-friendly and practical guidance, and aims at stabilization, reducing relapses, deterioration, and readmissions, thereby being cost-effective. Importantly, the model operates across levels of care (primary, secondary, tertiary). CONCLUSION: This study, describing a collaborative care program for SE-AN, developed and implemented in a highly specialized treatment center for eating disorders, sets the stage for further explanatory/efficacy research to build on the findings in this study, with the following aims: addressing the critical gap in care for SEED/SE-AN, improving better healthcare organization, reducing relapse rates, and lowering costs for this often overlooked patient group.

Severe and Enduring Eating Disorders (SEED), and particularly Severe and Enduring Anorexia Nervosa (SE-AN), present significant challenges in psychiatric treatment. This study aimed to understand the obstacles in caring for patients with SEED/SE-AN in the Dutch healthcare system and proposed a collaborative care model to address the issues. Through surveys, interviews, and benchmarking, key challenges were identified, including limited knowledge about eating disorders, patient ambivalence, and poor professional collaboration. The collaborative care model for SE-AN that was proposed in this study emphasizes structured care coordination, education for network partners, and support for eating disorder professionals, combining clinical management and psychotherapy. The study aims to bridge the gap in care for SE-AN and improve healthcare organization for this overlooked patient group.

Is a dissonance-based group intervention targeting thin-ideal internalization a successful potential add-on for specialized eating disorder care? A randomized feasibility and acceptability pilot study.

BACKGROUND: Dissonance-based eating disorder programs have successfully targeted body dissatisfaction by challenging the thin beauty ideal in the preventive context and in groups of patients with a subthreshold and full threshold DSM-5 eating disorder. As there is a need for interventions specifically targeting thin-ideal internalization in (highly) specialized treatment centres, the present study adapted Stice's et al.'s Body Project for its use as an add-on treatment for severe eating disorders with the aims to identify whether it was feasible and acceptable in this treatment context, to determine any necessary modifications with regard to the treatment and study procedures, and to test preliminary effectiveness. METHODS: The study was a randomized controlled pilot/feasibility trial. Thirty patients started in the Body Project group and 25 in the Psycho-education group. Measurements took place pre- and post-intervention, and at three and six months follow-up. Patients and staff evaluated treatment and study procedures, and patients completed questionnaires on thin-ideal internalization, body dissatisfaction, self-objectification, negative affect and eating disorder pathology. RESULTS: The Body Project group and Psycho-education group both proved highly feasible and acceptable, as well as preliminarily effective, based on quantitative scores and qualitative feedback. Preliminary analyses showed that treatment effects did not differ between treatment groups. As both groups were an add-on to standard treatment, treatment effects cannot be disentangled from effects resulting from standard treatment. Qualitative feedback for the Body Project group included several recommendations for future implementation: increasing the number of treatment sessions, creating homogeneous therapy groups, and optimizing timing of the treatment. CONCLUSIONS: Future research should examine further modifications to the Body Project group for severe eating disorders, as well as for whom, and when in the course of treatment the intervention is most effective. The present study also showed the benefits of implementing a structured Psycho-education group. We tested the feasibility and acceptability of a group intervention targeting the thin beauty ideal (Body Project group) in patients with severe eating disorders and compared this intervention to a group intervention focusing on psycho-education about eating disorders (Psycho-education group). Both interventions were added to standard treatment. We adapted the protocol for patients with severe eating disorders. Both the Body Project group and the Psycho-education group were evaluated by patients as well as staff as highly feasible and acceptable, and effects were positive. Treatment effects did not differ between treatment groups. As both treatments were an add-on to standard treatment, treatment effects cannot be disentangled from effects resulting from standard treatment. The study suggested further modifications to the Body Project group. Future research should examine these modifications as well as for whom, and when in the course of treatment the intervention is most effective. The present study also showed the benefits of implementing a structured Psycho-education group.

Functional connectivity of dissociation in patients with psychogenic non-epileptic seizures.

INTRODUCTION: Psychogenic non-epileptic seizures (PNES) resemble epileptic seizures, but lack epileptiform brain activity. Instead, the cause is assumed to be psychogenic. An abnormal coping strategy may be exhibited by PNES patients, as indicated by their increased tendency to dissociate. Investigation of resting-state networks may reveal altered routes of information and emotion processing in PNES patients. The authors therefore investigated whether PNES patients differ from healthy controls in their resting-state functional connectivity characteristics and whether these connections are associated with the tendency to dissociate. METHODS: 11 PNES patients without psychiatric comorbidity and 12 healthy controls underwent task-related paradigms (picture-encoding and Stroop paradigms) and resting-state functional MRI (rsfMRI). Global cognitive performance was tested using the Raven's Matrices test and participants completed questionnaires for evaluating dissociation. Functional connectivity analysis on rsfMRI was based on seed regions extracted from task-related fMRI activation maps. RESULTS: The patients displayed a significantly lower cognitive performance and significantly higher dissociation scores. No significant differences were found between the picture-encoding and Stroop colour-naming activation maps between controls and patients with PNES. However, functional connectivity maps from the rsfMRI were statistically different. For PNES patients, stronger connectivity values between areas involved in emotion (insula), executive control (inferior frontal gyrus and parietal cortex) and movement (precentral sulcus) were observed, which were significantly associated with dissociation scores. CONCLUSION: The abnormal, strong functional connectivity in PNES patients provides a neurophysiological correlate for the underlying psychoform and somatoform dissociation mechanism where emotion can influence executive control, resulting in altered motor function (eg, seizure-like episodes).

MMPI-II personality profiles of patients with psychogenic nonepileptic seizures.

This comparative study explored whether psychogenic nonepileptic seizures (PNES) are a unique disorder with distinctive personality characteristics or (seen from the personality profile) PNES are allied with the domain of a general functional somatic symptom and syndrome (FSSS). We compared the Minnesota Multiphasic Personality Inventory 2 (MMPI-2) results for 41 patients with newly diagnosed PNES and 43 patients with newly diagnosed insomnia. There were no statistically significant quantitative scoring differences on the main clinical scales, indicating that there is no substantial difference in "personality makeup" between the two groups with a FSSS. Additional subscale analysis indicated that patients with PNES reported significantly more somatic complaints (Hysteria 4) and bizarre sensory experiences (Schizophrenia 6). Further profile analysis revealed that the personality pattern of patients with PNES was characterized by a strong tendency toward "conversion V, a lack of control pattern and less excessive worries" as compared with patients with insomnia. Patients with PNES are characterized by a stronger tendency toward somatization and externalization, which has treatment implications.

COVID-19, anorexia nervosa and obese patients with an eating disorder - some considerations for practitioners and researchers.

Since COVID-19 is a global health emergency, there is an urgent need to share experiences on decision-making with regard to safety recommendations and for hypotheses that can inform a more focused prevention and treatment. Moreover, combining research into eating disorders and obesity with research into COVID-19 may provide a unique opportunity to shed light on the susceptibility to COVID-19.

Psychogenic nonepileptic seizures in adults with epilepsy and intellectual disability: A neglected area.

PURPOSE: To describe the main characteristics of psychogenic nonepileptic seizures (PNES) in adults with epilepsy and intellectual disability (ID), and to analyse the differences regarding psychosocial functioning, epilepsy severity and ID between patients with PNES and a control group without PNES. METHODS: Medical records of adults with ID and epilepsy living at an epilepsy care facility (N = 240) were screened for PNES and evaluated by a neurologist. A control group consisting of patients with epilepsy and ID, without PNES, was matched according to age, sex and level of ID. Characteristics of PNES and epilepsy were provided by the subject's nursing staff or retrieved from patient charts, psychosocial data were collected by standardised questionnaires and level of ID was individually assessed using psychometric instruments. RESULTS: The point prevalence of PNES was 7.1%. The patients with PNES (n = 15) were most often female and had a mild or moderate level of ID. Compared to controls, they showed more depressive symptoms, experienced more negative life events and had more often an ID discrepancy (ID profile with one domain particularly more impaired than another). Stress-related triggers were recognised in a large majority by the nursing staff. CONCLUSION: PNES appears to be a relatively rare diagnostic entity among inpatients with both epilepsy and ID. However, the complexity of diagnosing PNES in this population, and the similarities in stress-related triggers for PNES in patients with and without ID, suggest that PNES may be underdiagnosed in the ID population. Diagnostic challenges of PNES and, as subcategory, reinforced behavioural patterns are discussed.

Factors involved in the long-term prognosis of psychogenic nonepileptic seizures.

INTRODUCTION: Information on the long-term effects of psychogenic nonepileptic seizures (PNES) is limited. We therefore reassessed 22 patients 4-6 years after the initial diagnosis of PNES in a tertiary referral epilepsy center. The diagnosis was confirmed using clinical description and additional electroencephalogram investigations in 1998, 1999, and 2000. Patients with epilepsy and PNES as comorbid symptoms were not included. Reassessments were aimed at seizure reduction and possible psychogenic factors. METHODS: Three psychological tests were used at baseline at the time of diagnosis and repeated at end point. These three tests assessed different "levels" of psychological function [i.e., complaints (The Symptoms Check List Revised), coping strategy (The Dissociation Questionnaire), and personality factors/psychopathology Nederlandse Verkorte MMPI]. RESULTS: Twenty-two patients were included. Seizure frequency showed statistically significant reduction. At the time of diagnosis, none of the patients was seizure-free or had only yearly seizures, whereas at end point, 7 of 22 patients were completely in remission and 3 patients had only occasional seizures. The number of patients with daily seizures dropped from nine to two. It has not been fully clarified which factors caused this improvement, but the common denominators are that a definitive expert diagnosis in a tertiary center was made and all possible efforts were made to inform the patient in a respectful manner about the diagnosis. In addition to seizure reduction, there was improvement on different levels of psychological function, showing reduction in psychological distress, reduction in dissociative features such as amnesia, increase in self-control, reduction in feelings of dissatisfaction and passive avoidant behavior, and a more active attitude towards social contact. CONCLUSION: In the long term, the patients with PNES who were included in our study have more self-control and approach social contact with a more self-confident attitude. This does not necessary reflect a causal relationship with the observed seizure reduction. Nonetheless, it is noteworthy that, post aut propter, the eradication of a symptom (i.e., seizures) with social consequences is followed by or is associated with a more confident social attitude. This opens possibilities for treatment strategies.

Resting-state networks and dissociation in psychogenic non-epileptic seizures.

OBJECTIVE: Psychogenic non-epileptic seizures (PNES) are epilepsy-like episodes which have an emotional rather than organic origin. Although PNES have often been related to the process of dissociation, the psychopathology is still poorly understood. To elucidate underlying mechanisms, the current study applied independent component analysis (ICA) on resting-state fMRI to investigate alterations within four relevant networks, associated with executive, fronto-parietal, sensorimotor, and default mode activation, and within a visual network to examine specificity of between-group differences. METHODS: Twenty-one patients with PNES without psychiatric or neurologic comorbidities and twenty-seven healthy controls underwent resting-state functional MR imaging at 3.0T (Philips Achieva). Additional neuropsychological testing included Raven's Matrices test and dissociation questionnaires. ICA with dual regression was used to identify resting-state networks in all participants, and spatial maps of the networks of interest were compared between patients and healthy controls. RESULTS: Patients displayed higher dissociation scores, lower cognitive performance and increased contribution of the orbitofrontal, insular and subcallosal cortex in the fronto-parietal network; the cingulate and insular cortex in the executive control network; the cingulate gyrus, superior parietal lobe, pre- and postcentral gyri and supplemental motor cortex in the sensorimotor network; and the precuneus and (para-) cingulate gyri in the default-mode network. The connectivity strengths within these regions of interest significantly correlated with dissociation scores. No between-group differences were found within the visual network, which was examined to determine specificity of between-group differences. CONCLUSIONS: PNES patients displayed abnormalities in several resting-state networks that provide neuronal correlates for an underlying dissociation mechanism.

Nondrug treatments for psychogenic nonepileptic seizures: what's the evidence?

OBJECTIVE: The purpose of this Cochrane Review was to establish the evidence base for treatment of psychogenic nonepileptic seizures. METHODS: Six hundred eight references were identified using a search strategy designed with the support of the Cochrane Review Epilepsy Group library. The search employed Medline and PsychInfo, and included hand searches of relevant journals (Seizure, Epilepsia, Epilepsy &Behavior, Epilepsy Research). RESULTS: Three studies were found that met the inclusion criteria; two used hypnosis and one used paradoxical therapy. None included detailed reports of improved seizure frequency or quality of life, although reduction in seizure frequency was mentioned. All three studies concluded that the intervention used was beneficial in the treatment of psychogenic nonepileptic seizures. CONCLUSIONS: The limited number of studies and poor methodology preclude these results from being generalizable. There is a need for well-designed clinical trials to identify the most suitable treatments for this population.