Assessment of patients with psychogenic non-epileptic seizures
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《神经病学神经外科学杂志》
Correspondence to:
L H Goldstein
Department of Psychology, PO77, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK; l.goldstein@iop.kcl.ac.uk
Psychogenic non-epileptic seizures pose a management problem
Keywords: psychogenic non-epileptic seizures; epilepsy; personality disorder
Psychogenic non-epileptic seizures (PNES), while superficially resembling epileptic seizures, are not accompanied by the abnormal electrical discharges associated with epilepsy and cannot be explained by other medical conditions. Instead they are psychologically determined and, as patients with PNES may be misdiagnosed as having epilepsy, this disorder poses a considerable management problem. The development of a better understanding of the psychiatric characteristics of PNES patients and other risk factors associated with having PNES may not only assist, along with medical investigations, in the correct diagnosis of patients’ attacks, but may also inform effective treatment.
Though personality disorder has been diagnosed in very variable proportions of PNES patients, and research in this area is complicated by the use of different psychiatric classification systems and measures, the most common diagnoses associated with PNES have been borderline, histrionic, avoidant, and antisocial personality disorder.1 Given that not all PNES patients satisfy formal diagnostic criteria for personality disorder, a different approach to understanding personality pathology is adopted in the paper by Reuber et al in this issue,2 who used the dimensional assessment of personality pathology–basic questionnaire (DAPP-BQ) to identify personality profiles in PNES patients. While indicating that PNES patients as a group have greater pathology of personality than people with epilepsy or healthy controls, Reuber et al also found that the PNES patients’ scores on the DAPP-BQ did not form a single profile of personality traits. Instead they identified two large and one much smaller clusters of patients accounting for 84 of their sample of 85 PNES patients. The DAPP-BQ scores of the two larger clusters resembled the characteristics of borderline personality disorder and compulsive personality disorder, respectively. The third cluster of PNES patients had traits resembling the characteristics associated with avoidant personality; this cluster contained only four individuals.
While a diagnosis of personality disorder per se has been considered a poor prognostic factor in people with PNES,1 Reuber et al’s approach to personality measurement in individuals with PNES offers the opportunity of moving away from the requirement to make a formal diagnosis of personality disorder before considering personality as one of the factors predictive of outcome. Reuber et al report, on the basis of their retrospective data, that those PNES patients with personality traits resembling borderline personality disorder had worse outcome on follow up in terms of seizure freedom than did the cluster with traits resembling compulsive personality disorder, despite the fact that more of the former than of the latter group had
REFERENCES
Bowman ES. Psychopathology and outcome in pseudoseizures. In: Ettinger AB, Kanner AM, eds. Psychiatric issues in epilepsy. A practical guide to diagnosis and treatment. Philadelphia: Lippincott Williams and Wilkins, 2001:355–77.
Reuber M, Pukrop R, Bauer J, et al. Multidimensional assessment of personality in patients with psychogenic non-epileptic seizures. J Neurol Neurosurg Psychiatry 2004;75:743–8.
Linehan M. Cognitive-behavioural treatment of borderline personality disorder. New York: Guilford, 1993.
Davidson KM, Tyrer P. Cognitive therapy for antisocial and borderline personality disorders: single case study series. Br J Clin Psychol 1996;35:413–29.
Chalder T. Non-epileptic attacks; a cognitive behavioural approach in a single case with a four year follow-up. Clin Psychol Psychotherapy 1996;3:291–7.(L H Goldstein)
L H Goldstein
Department of Psychology, PO77, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK; l.goldstein@iop.kcl.ac.uk
Psychogenic non-epileptic seizures pose a management problem
Keywords: psychogenic non-epileptic seizures; epilepsy; personality disorder
Psychogenic non-epileptic seizures (PNES), while superficially resembling epileptic seizures, are not accompanied by the abnormal electrical discharges associated with epilepsy and cannot be explained by other medical conditions. Instead they are psychologically determined and, as patients with PNES may be misdiagnosed as having epilepsy, this disorder poses a considerable management problem. The development of a better understanding of the psychiatric characteristics of PNES patients and other risk factors associated with having PNES may not only assist, along with medical investigations, in the correct diagnosis of patients’ attacks, but may also inform effective treatment.
Though personality disorder has been diagnosed in very variable proportions of PNES patients, and research in this area is complicated by the use of different psychiatric classification systems and measures, the most common diagnoses associated with PNES have been borderline, histrionic, avoidant, and antisocial personality disorder.1 Given that not all PNES patients satisfy formal diagnostic criteria for personality disorder, a different approach to understanding personality pathology is adopted in the paper by Reuber et al in this issue,2 who used the dimensional assessment of personality pathology–basic questionnaire (DAPP-BQ) to identify personality profiles in PNES patients. While indicating that PNES patients as a group have greater pathology of personality than people with epilepsy or healthy controls, Reuber et al also found that the PNES patients’ scores on the DAPP-BQ did not form a single profile of personality traits. Instead they identified two large and one much smaller clusters of patients accounting for 84 of their sample of 85 PNES patients. The DAPP-BQ scores of the two larger clusters resembled the characteristics of borderline personality disorder and compulsive personality disorder, respectively. The third cluster of PNES patients had traits resembling the characteristics associated with avoidant personality; this cluster contained only four individuals.
While a diagnosis of personality disorder per se has been considered a poor prognostic factor in people with PNES,1 Reuber et al’s approach to personality measurement in individuals with PNES offers the opportunity of moving away from the requirement to make a formal diagnosis of personality disorder before considering personality as one of the factors predictive of outcome. Reuber et al report, on the basis of their retrospective data, that those PNES patients with personality traits resembling borderline personality disorder had worse outcome on follow up in terms of seizure freedom than did the cluster with traits resembling compulsive personality disorder, despite the fact that more of the former than of the latter group had
REFERENCES
Bowman ES. Psychopathology and outcome in pseudoseizures. In: Ettinger AB, Kanner AM, eds. Psychiatric issues in epilepsy. A practical guide to diagnosis and treatment. Philadelphia: Lippincott Williams and Wilkins, 2001:355–77.
Reuber M, Pukrop R, Bauer J, et al. Multidimensional assessment of personality in patients with psychogenic non-epileptic seizures. J Neurol Neurosurg Psychiatry 2004;75:743–8.
Linehan M. Cognitive-behavioural treatment of borderline personality disorder. New York: Guilford, 1993.
Davidson KM, Tyrer P. Cognitive therapy for antisocial and borderline personality disorders: single case study series. Br J Clin Psychol 1996;35:413–29.
Chalder T. Non-epileptic attacks; a cognitive behavioural approach in a single case with a four year follow-up. Clin Psychol Psychotherapy 1996;3:291–7.(L H Goldstein)