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Dissociation in patients with dissociative seizures: relationships with trauma and seizure symptoms

Published online by Cambridge University Press:  09 January 2017

S. Pick ,
J. D. C. Mellers  and
L. H. Goldstein
S. Pick
Affiliation:
Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK Department of Psychological Sciences, University of London, Birkbeck College, London, UK
J. D. C. Mellers
Affiliation:
Neuropsychiatry Outpatients Department, Maudsley Hospital, South London and Maudsley NHS Foundation Trust, London, UK
L. H. Goldstein*
Affiliation:
Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
*
*Address for correspondence: L. H. Goldstein, Ph.D., Department of Psychology, PO77, Institute of Psychiatry, Psychology & Neuroscience, King's College London, De Crespigny Park, London SE5 8AF, UK. (Email: laura.goldstein@kcl.ac.uk)
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Abstract

Background

This study aimed to extend the current understanding of dissociative symptoms experienced by patients with dissociative (psychogenic, non-epileptic) seizures (DS), including psychological and somatoform types of symptomatology. An additional aim was to assess possible relationships between dissociation, traumatic experiences, post-traumatic symptoms and seizure manifestations in this group.

Method

A total of 40 patients with DS were compared with a healthy control group (n = 43), matched on relevant demographic characteristics. Participants completed several self-report questionnaires, including the Multiscale Dissociation Inventory (MDI), Somatoform Dissociation Questionnaire-20, Traumatic Experiences Checklist and the Post-Traumatic Diagnostic Scale. Measures of seizure symptoms and current emotional distress (Hospital Anxiety and Depression Scale) were also administered.

Results

The clinical group reported significantly more psychological and somatoform dissociative symptoms, trauma, perceived impact of trauma, and post-traumatic symptoms than controls. Some dissociative symptoms (i.e. MDI disengagement, MDI depersonalization, MDI derealization, MDI memory disturbance, and somatoform dissociation scores) were elevated even after controlling for emotional distress; MDI depersonalization scores correlated positively with trauma scores while seizure symptoms correlated with MDI depersonalization, derealization and identity dissociation scores. Exploratory analyses indicated that somatoform dissociation specifically mediated the relationship between reported sexual abuse and DS diagnosis, along with depressive symptoms.

Conclusions

A range of psychological and somatoform dissociative symptoms, traumatic experiences and post-traumatic symptoms are elevated in patients with DS relative to healthy controls, and seem related to seizure manifestations. Further studies are needed to explore peri-ictal dissociative experiences in more detail.

Keywords

Compartmentalizationdetachmentdissociationseizurestrauma

Information

Type
Original Articles
Information
Psychological Medicine , Volume 47 , Issue 7 , May 2017 , pp. 1215 - 1229
Copyright
Copyright © Cambridge University Press 2017 

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References

Alper, K, Devinsky, O, Perrine, K, Luciano, D, Vazquez, B, Pacia, S, Rhee, E (1997). Dissociation in epilepsy and conversion nonepileptic seizures. Epilepsia 38, 991–997.CrossRefGoogle ScholarPubMed
American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders, 4th edn (DSM-IV). American Psychiatric Association: Washington, DC.Google Scholar
American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th edn (DSM-5). American Psychiatric Association: Washington, DC.Google Scholar
Anderson, G, Yasenik, L, Ross, CA (1993). Dissociative experiences and disorders among women who identify themselves as sexual abuse survivors. Child Abuse and Neglect 17, 677–686.CrossRefGoogle ScholarPubMed
Avbersek, A, Sisodiya, S (2010). Does the primary literature provide support for clinical signs used to distinguish psychogenic nonepileptic seizures from epileptic seizures? Journal of Neurology, Neurosurgery and Psychiatry 81, 719–725.CrossRefGoogle ScholarPubMed
Baslet, G (2011). Psychogenic non-epileptic seizures: a model of their pathogenic mechanism. Seizure 20, 1–13.CrossRefGoogle Scholar
Bernstein, EM, Putnam, FW (1986). Development, reliability, and validity of a dissociation scale. Journal of Nervous and Mental Disease 174, 727–735.CrossRefGoogle ScholarPubMed
Bodde, NMG, van der Kruijs, SJM, Ijff, DM, Lazeron, RHC, Vonck, KEJ, Boon, PAJM, Aldenkamp, AP (2013). Subgroup classification in patients with psychogenic non-epileptic seizures. Epilepsy and Behavior 26, 279–289.CrossRefGoogle ScholarPubMed
Bowman, ES (2010). Posttraumatic stress disorder, abuse, and trauma: relationships to psychogenic nonepileptic seizures. In Gates and Rowan's Nonepileptic Seizures, 3rd edn (ed. Schachter, SC and LaFrance, WCJ), pp. 213–224. Cambridge University Press: Cambridge.Google Scholar
Brand, BL, Lanius, RA (2014). Chronic complex dissociative disorders and borderline personality disorders: disorders of emotion regulation? Borderline Personality Disorder and Emotion Dysregulation 1, 13.CrossRefGoogle Scholar
Brière, J (2002). Multiscale Dissociation Inventory: Professional Manual. Psychological Assessment Resources, Incorporated: Odessa, FL.Google Scholar
Brown, RJ (2002). Epilepsy, dissociation and nonepileptic seizures. In The Neuropsychiatry of Epilepsy (ed. Trimble, MR and Schmitz, B), pp. 189–209. Cambridge University Press: Cambridge.CrossRefGoogle Scholar
Brown, RJ, Bouska, JF, Frow, A, Kirkby, A, Baker, GA, Kemp, S, Burness, C, Reuber, M (2013). Emotional dysregulation, alexithymia, and attachment in psychogenic nonepileptic seizures. Epilepsy and Behavior 29, 178–183.CrossRefGoogle ScholarPubMed
Brown, RJ, Reuber, M (2016). Towards an integrative theory of psychogenic non-epileptic seizures (PNES). Clinical Psychology Review 47, 55–70.CrossRefGoogle ScholarPubMed
Brown, RJ, Schrag, A, Trimble, MR (2005). Dissociation, childhood interpersonal trauma, and family functioning in patients with somatization disorder. American Journal of Psychiatry 162, 899–905.CrossRefGoogle ScholarPubMed
Cardena, E (1994). The domain of dissociation. In Dissociation: Clinical and Theoretical Perspectives (ed. Lynn, SJ and Rhue, JW), pp. 15–31. Guilford Press: New York.Google Scholar
Chu, JA, Dill, DL (1990). Dissociative symptoms in relation to childhood physical and sexual abuse. American Journal of Psychiatry 147, 887–892.Google ScholarPubMed
Dalenberg, CJ, Brand, BL, Gleaves, DH, Dorahy, MJ, Loewenstein, RJ, Cardeña, E, Frewen, PA, Carlson, EB, Spiegel, D (2012). Evaluation of the evidence for the trauma and fantasy models of dissociation. Psychological Bulletin 138, 550–588.CrossRefGoogle ScholarPubMed
Diprose, W, Sundram, F, Menkes, DB (2016). Psychiatric comorbidity in psychogenic nonepileptic seizures compared with epilepsy. Epilepsy and Behavior 56, 123–130.CrossRefGoogle ScholarPubMed
Ejareh dar, M, Kanaan, RAA (2016). Uncovering the etiology of conversion disorder: insights from functional neuroimaging. Neuropsychiatric Disease and Treatment 12, 143–153.Google ScholarPubMed
Faul, F, Erdfelder, E, Buchner, A, Lang, A (2009). Statistical power analyses using G* Power 3.1: tests for correlation and regression analyses. Behavior Research Methods 41, 1149–1160.CrossRefGoogle ScholarPubMed
Faul, F, Erdfelder, E, Lang, A, Buchner, A (2007). G* power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behavior Research Methods 39, 175–191.CrossRefGoogle ScholarPubMed
Fiszman, A, Alves-Leon, SV, Nunes, RG, D'Andrea, I, Figueira, I (2004). Traumatic events and posttraumatic stress disorder in patients with psychogenic nonepileptic seizures: a critical review. Epilepsy and Behavior 5, 818–825.CrossRefGoogle ScholarPubMed
Foa, EB, Cashman, L, Jaycox, L, Perry, K (1997). The validation of a self-report measure of posttraumatic stress disorder: The posttraumatic diagnostic scale. Psychological Assessment 9, 445–451.CrossRefGoogle Scholar
Gershuny, BS, Thayer, JF (1999). Relations among psychological trauma, dissociative phenomena, and trauma-related distress: a review and integration. Clinical Psychology Review 19, 631–657.CrossRefGoogle ScholarPubMed
Goldstein, LH, Drew, C, Mellers, J, Mitchell-O'Malley, S, Oakley, DA (2000). Dissociation, hypnotizability, coping styles and health locus of control: characteristics of pseudoseizure patients. Seizure 9, 314–322.CrossRefGoogle ScholarPubMed
Goldstein, LH, Mellers, JD, Landau, S, Stone, J, Carson, A, Medford, N, Reuber, M, Richardson, M, McCrone, P, Murray, J, Chalder, T (2015). COgnitive behavioural therapy vs standardised medical care for adults with Dissociative non-Epileptic Seizures (CODES): a multicentre randomised controlled trial protocol. BMC Neurology 15, 98.CrossRefGoogle ScholarPubMed
Goldstein, LH, Mellers, JDC (2006). Ictal symptoms of anxiety, avoidance behaviour, and dissociation in patients with dissociative seizures. Journal of Neurology, Neurosurgery and Psychiatry 77, 616–621.CrossRefGoogle ScholarPubMed
Goodwin, JM, Sachs, RG (1996). Child abuse in the etiology of dissociative disorders. In Handbook of Dissociation: Theoretical, Empirical, and Clinical Perspectives (ed. Michelson, LK and Ray, WJ), pp. 91–105. Plenum Press: New York.CrossRefGoogle Scholar
Hayes, AF (2012). PROCESS: a versatile computational tool for observed variable mediation, moderation, and conditional process modeling (http://processmacro.org/index.html).Google Scholar
Hendrickson, R, Popescu, A, Dixit, R, Ghearing, G, Bagic, A (2014). Panic attack symptoms differentiate patients with epilepsy from those with psychogenic nonepileptic spells (PNES). Epilepsy and Behavior 37, 210–214.CrossRefGoogle ScholarPubMed
Hendrickson, R, Popescu, A, Ghearing, G, Bagic, A (2015). Thoughts, emotions, and dissociative features differentiate patients with epilepsy from patients with psychogenic nonepileptic spells (PNESs). Epilepsy and Behavior 51, 158–162.CrossRefGoogle ScholarPubMed
Hingray, C, Maillard, L, Hubsch, C, Vignal, J, Bourgognon, F, Laprevote, V, Lerond, J, Vespignani, H, Schwan, R (2011). Psychogenic nonepileptic seizures: characterization of two distinct patient profiles on the basis of trauma history. Epilepsy and Behavior 22, 532–536.CrossRefGoogle ScholarPubMed
Holmes, EA, Brown, RJ, Mansell, W, Fearon, R, Hunter, E, Frasquilho, F, Oakley, DA (2005). Are there two qualitatively distinct forms of dissociation? A review and some clinical implications. Clinical Psychology Review 25, 1–23.CrossRefGoogle ScholarPubMed
Hosmer, DW, Lemeshow, S (2000). Applied Logistic Regression, 2nd edn. Wiley Online Library: Hoboken, NJ.CrossRefGoogle Scholar
Kanner, AM (2010). Who should treat psychogenic nonepileptic seizures? In Gates and Rowan's Nonepileptic Seizures, 3rd edn (ed. Schachter, SC and LaFrance, WCJ), pp. 213–224. Cambridge University Press: Cambridge.Google Scholar
Kuyk, J, VanDyck, R, Spinhoven, P (1996). The case for a dissociative interpretation of pseudoepileptic seizures. Journal of Nervous and Mental Disease 184, 468–474.CrossRefGoogle ScholarPubMed
LaFrance, WC Jr., Reuber, M, Goldstein, LH (2013). Management of psychogenic non-epileptic seizures. Epilepsia 54 (Suppl. 1), 53–67.CrossRefGoogle Scholar
Lally, N, Spence, W, McCusker, C, Craig, J, Morrow, J (2010). Psychological processes and histories associated with nonepileptic versus epileptic seizure presentations. Epilepsy and Behavior 17, 360–365.CrossRefGoogle ScholarPubMed
Lanius, RA, Vermetten, E, Loewenstein, RJ, Brand, B, Schmahl, C, Bremner, JD, Spiegel, D (2010). Emotion modulation in PTSD: clinical and neurobiological evidence for a dissociative subtype. American Journal of Psychiatry 167, 640–647.CrossRefGoogle ScholarPubMed
Lawton, G, Baker, GA, Brown, RJ (2008). Comparison of two types of dissociation in epileptic and nonepileptic seizures. Epilepsy and Behavior 13, 333–336.CrossRefGoogle ScholarPubMed
Litwin, R, Cardeña, E (2001). Demographic and seizure variables, but not hypnotizability or dissociation, differentiated psychogenic from organic seizures. Journal of Trauma and Dissociation 1, 99–122.CrossRefGoogle Scholar
Martlew, J, Pulman, J, Marson, AG (2014). Psychological and behavioural treatments for adults with non-epileptic attack disorder. Cochrane Database of Systematic Reviews, issue 2, CD006370.CrossRefGoogle ScholarPubMed
Medford, N (2014). Dissociative symptoms and epilepsy. Epilepsy and Behavior 30, 10–13.CrossRefGoogle ScholarPubMed
Mykletun, A, Stordal, E, Dahl, AA (2001). Hospital Anxiety and Depression (HAD) Scale: factor structure, item analyses and internal consistency in a large population. British Journal of Psychiatry 179, 540–544.CrossRefGoogle ScholarPubMed
Nicholson, TR, Aybek, S, Craig, T, Harris, T, Wojcik, W, David, AS, Kanaan, RA (2016). Life events and escape in conversion disorder. Psychological Medicine 46, 2617–2626.CrossRefGoogle ScholarPubMed
Nicholson, TRJ, Kanaan, RAA (2009). Conversion disorder. Psychiatry 8, 164–169.CrossRefGoogle Scholar
Nijenhuis, ER (2001). Somatoform dissociation: major symptoms of dissociative disorders. Journal of Trauma and Dissociation 1, 7–32.CrossRefGoogle Scholar
Nijenhuis, ER, Spinhoven, P, Van Dyck, R, Van Der Hart, O, Vanderlinden, J (1996). The development and psychometric characteristics of the Somatoform Dissociation Questionnaire (SDQ-20). Journal of Nervous and Mental Disease 184, 688–694.CrossRefGoogle ScholarPubMed
Nijenhuis, ER, van der Hart, O, Vanderlinden, J (1999). The Traumatic Experiences Checklist (TEC). In Somatoform Dissociation: Phenomena, Measurement, and Theoretical Issues (ed. Nijenhuis, ER), pp. 223–229. Van Gorcum: Assen, the Netherlands.Google Scholar
Nijenhuis, ERS, Spinhoven, P, van Dyck, R, van der Hart, O, Vanderlinden, J (1997). The development of the Somatoform Dissociation Questionnaire (SDQ-5) as a screening instrument for dissociative disorders. Acta Psychiatrica Scandinavica 96, 311–318.CrossRefGoogle ScholarPubMed
O'Brien, FM, Fortune, GM, Dicker, P, O'Hanlon, E, Cassidy, E, Delanty, N, Garavan, H, Murphy, KC (2015). Psychiatric and neuropsychological profiles of people with psychogenic nonepileptic seizures. Epilepsy and Behavior 43, 39–45.CrossRefGoogle ScholarPubMed
Ozcetin, A, Belli, H, Ertem, U, Bahcebasi, T, Ataoglu, A, Canan, F (2009). Childhood trauma and dissociation in women with pseudoseizure-type conversion disorder. Nordic Journal of Psychiatry 63, 462–468.CrossRefGoogle ScholarPubMed
Peduzzi, P, Concato, J, Kemper, E, Holford, TR, Feinstein, AR (1996). A simulation study of the number of events per variable in logistic regression analysis. Journal of Clinical Epidemiology 49, 1373–1379.CrossRefGoogle ScholarPubMed
Prueter, C, Schultz-Venrath, U, Rimpau, W (2002). Dissociative and associated psychopathological symptoms in patients with epilepsy, pseudoseizures, and both seizure forms. Epilepsia 43, 188–192.CrossRefGoogle ScholarPubMed
Reuber, M, House, AO, Pukrop, R, Bauer, J, Elger, CE (2003). Somatization, dissociation and general psychopathology in patients with psychogenic non-epileptic seizures. Epilepsy Research 57, 159–167.CrossRefGoogle ScholarPubMed
Reuber, M, Howlett, S, Khan, A, Grunewald, RA (2007). Non-epileptic seizures and other functional neurological symptoms: predisposing, precipitating, and perpetuating factors. Psychosomatics 48, 230–238.CrossRefGoogle ScholarPubMed
Reuber, M, Jamnadas-Khoda, J, Broadhurst, M, Grunewald, R, Howell, S, Koepp, M, Sisodiya, S, Walker, M (2011). Psychogenic nonepileptic seizure manifestations reported by patients and witnesses. Epilepsia 52, 2028–2035.CrossRefGoogle ScholarPubMed
Roberts, NA, Reuber, M (2014). Alterations of consciousness in psychogenic nonepileptic seizures: emotion, emotion regulation and dissociation. Epilepsy and Behavior 30, 43–49.CrossRefGoogle ScholarPubMed
Roelofs, K, Keijsers, GPJ, Hoogduin, KAL, Näring, GWB, Moene, FC (2002). Childhood abuse in patients with conversion disorder. American Journal of Psychiatry 159, 1908–1913.CrossRefGoogle ScholarPubMed
Rosenberg, HJ, Rosenberg, SD, Williamson, PD, Wolford, GL (2000). A comparative study of trauma and posttraumatic stress disorder prevalence in epilepsy patients and psychogenic nonepileptic seizure patients. Epilepsia 41, 447–452.CrossRefGoogle ScholarPubMed
Salmon, P, Al-Marzooqi, SM, Baker, G, Reilly, J (2003). Childhood family dysfunction and associated abuse in patients with nonepileptic seizures: towards a causal model. Psychosomatic Medicine 65, 695–700.CrossRefGoogle ScholarPubMed
Sar, V, Akyuz, G, Kundakci, T, Kiziltan, E, Dogan, O (2004). Childhood trauma, dissociation, and psychiatric comorbidity in patients with conversion disorder. American Journal of Psychiatry 161, 2271–2276.CrossRefGoogle ScholarPubMed
Sharpe, D, Faye, C (2006). Non-epileptic seizures and child sexual abuse: a critical review of the literature. Clinical Psychology Review 26, 1020–1040.CrossRefGoogle ScholarPubMed
Sobel, ME (1982). Asymptotic confidence intervals for indirect effects in structural equation models. Sociological Methodology 13, 290–312.CrossRefGoogle Scholar
Stone, J, LaFrance, WC Jr., Brown, R, Spiegel, D, Levenson, JL, Sharpe, M (2011). Conversion disorder: current problems and potential solutions for DSM-5. Journal of Psychosomatic Research 71, 369–376.CrossRefGoogle ScholarPubMed
van der Kruijs, SJ, Bodde, NM, Vaessen, MJ, Lazeron, RH, Vonck, K, Boon, P, Hofman, PA, Backes, WH, Aldenkamp, AP, Jansen, JF (2012). Functional connectivity of dissociation in patients with psychogenic non-epileptic seizures. Journal of Neurology, Neurosurgery and Psychiatry 83, 239–247.CrossRefGoogle ScholarPubMed
van Dijke, A, van der Hart, O, Ford, JD, van Son, M, van der Heijden, P, Bühring, M (2010). Affect dysregulation and dissociation in borderline personality disorder and somatoform disorder: differentiating inhibitory and excitatory experiencing states. Journal of Trauma and Dissociation 11, 424–443.CrossRefGoogle ScholarPubMed
Waller, G, Hamilton, K, Elliott, P, Lewendon, J, Stopa, L, Waters, A, Kennedy, F, Lee, G, Pearson, D, Kennerley, H (2001). Somatoform dissociation, psychological dissociation, and specific forms of trauma. Journal of Trauma and Dissociation 1, 81–98.CrossRefGoogle Scholar
Wechsler, D (1999). Wechsler Abbreviated Scale of Intelligence (WASI). Pearson: Oxford.Google Scholar
World Health Organization (1992). The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. World Health Organization: Geneva, Switzerland.Google Scholar
Xue, Q, Wang, Z, Xiong, X, Tian, C, Wang, Y, Xu, P (2013). Altered brain connectivity in patients with psychogenic non-epileptic seizures: a scalp electroencephalography study. Journal of International Medical Research 41, 1682–1690.CrossRefGoogle ScholarPubMed
Yayla, S, Bakım, B, Tankaya, O, Ozer, OA, Karamustafalioglu, O, Ertekin, H, Tekin, A (2015). Psychiatric comorbidity in patients with conversion disorder and prevalence of dissociative symptoms. Journal of Trauma and Dissociation 16, 29–38.CrossRefGoogle ScholarPubMed
Zigmond, AS, Snaith, RP (1983). The Hospital Anxiety and Depression Scale. Acta Psychiatrica Scandinavica 67, 361–370.CrossRefGoogle ScholarPubMed
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