Different dissociation and alexithymia domains specifically relate to patients with psychogenic non-epileptic seizures (PNES) and with PNES and comorbid epilepsy (PNES+EP)

Andrea Poli,Ciro Conversano,Mario Miccoli,Giancarlo Muscas,Angelo Giovanni Icro Maremmani,Angelo Gemignani,Andrea Pozza

doi:10.1016/j.jadr.2021.100296

Abstract

• We investigated dissociation and alexithymia in psychogenic non-epileptic seizures (PNES). • We compared four samples: patients with PNES, PNES with epilepsy (EP), EP and healthy controls. • Dissociative experiences Scale-II (DES-II) and Toronto alexithymia Scale-20 (TAS-20) totals did not predict TAS-20 and DES-II totals, respectively. • In PNES sample, depersonalization/derealization (Dep/Der) was fully mediated by difficulty identifying feelings (DIF) and absorption (Abs) in predicting difficulty describing feelings (DDF). • In PNES with EP sample, DEP/DER was partially mediated by ABS in predicting DDF. Several studies previously examined the role of dissociation and alexithymia in patients with psychogenic non-epileptic seizures (PNES). However, their relationship remains unclear. We administered questionnaires for dissociation (DES-II), alexithymia (TAS-20), anxiety and depression to 57 subjects: 14 patients with PNES, 13 patients with comorbid PNES and epilepsy (PNES+EP), 14 patients with EP and 16 healthy controls. For between-group comparisons we applied Chi-square test, ANOVA and Kruskal-Wallis. The Spearman correlations, hierarchical regression analyses and path models, goodness-of-fit indices and maximum-likelihood estimates of model parameters were obtained through SPSS 27 and AMOS 27. Hierarchical regression analyses showed that nor DES-II neither TAS-20 total scores were able to predict TAS-20 and DES-II total scores, respectively, possibly due to subscale score pooling. Following modification indexes of AMOS 27, in PNES sample, we found that only Depersonalization/Derealization (Dep/Der) was fully mediated by Difficulty Identifying Feelings (DIF) and Absorption (Abs) in predicting Difficulty Describing Feelings (DDF), and a partial effect of DIF and Dep/Der implement DDF, while both DIF and DDF implement Abs. In PNES+EP group, Dep/Der was able to predict DDF, with a partial mediation of Abs that predicted Externally Oriented Thinking, while DDF was able to promote Abs, and DIF effect on Abs was fully mediated by Amnesia (Amn). Our study is cross-sectional, participants were self-selected and the data were derived from self-report measures. Conclusions: In PNES, Dep/Der and DIF may play a prominent role, while in PNES+EP, Dep/Der, Abs, DIF and Amn may be involved. Clinical implications are discussed.

Highlights

Psychogenic non-epileptic seizures (PNES) are paroxysmal time limited alterations in autonomic, sensory, motor, emotional and cogni tive domains, similar to epileptic seizures (EP) but, unlike them, psy chogenic non-epileptic seizures (PNES) are not associated with ictal epileptiform activity and are thought to have psychological underpinnings (Asadi-Pooya, 2020; Devinsky et al., 2011; LaFrance et al, 2013; Popkirov et al, 2017)
Difficulty Describing Feelings (DDF) and Abs subscales were found to show a strong positive correlation, suggesting that higher scores on difficulty describing feelings are associated with a higher tendency to absorption symptoms. These results suggest a relationship between dissociation and alexithymia scores in both PNES and PNES and epilepsy (PNES+EP) groups
Between groups comparisons demonstrate that only PNES patients show higher levels of dissociation, in particular Abs and Dep/Der, even if the latter is not significant at the level of between groups comparisons

Summary

Introduction

Psychogenic non-epileptic seizures (PNES) are paroxysmal time limited alterations in autonomic, sensory, motor, emotional and cogni tive domains, similar to epileptic seizures (EP) but, unlike them, PNES are not associated with ictal epileptiform activity and are thought to have psychological underpinnings (Asadi-Pooya, 2020; Devinsky et al., 2011; LaFrance et al, 2013; Popkirov et al, 2017). There is still growing evidence that experiencing overwhelming emotions, especially of trau matic nature, quenches central nervous system key hub regions with a prominent role in integrating sensorimotor output, regulating arousal levels and translating experience in words (Clancy et al, 2017), and it has been shown that patients with PNES, especially those with active PTSD and childhood trauma, have lower clarity of their emotions and lower ability to adjust to emotional states than healthy individuals (Rosales et al, 2020). Previous studies reported no overall differences in alexithymia scores between PNES and epileptic patients (Myers et al, 2013b), while Urbanek et al (2014) reported that, in PNES patients, levels of alexithymia were positively associated with self-reported seizure severity. Several studies previously examined the role of dissociation and alexithymia in patients with psy chogenic non-epileptic seizures (PNES).

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