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Alexithymia and emotion regulation among individuals with epilepsy and psychogenic non-epileptic seizures (PNES).


Psychogenic non--epileptic seizure (PNES) is an observable abrupt paroxysmal change in behavior or consciousness that resembles an epileptic seizure. Yet it is not accompanied by electrophysiological changes that accompany an epileptic seizures (ES) or clinical evidence for epilepsy. PNES seizures have no somatic base of occurrence while positive evidence or a strong suspicion for psychological factors like trauma, depression, abuse, and bereavement may have lead to seizures (Bodde et al., 2009). PNES is psychologically manifested in terms of situational and gradual onset, precipitated by stimuli, motor activity, limb movements, pelvic movement, tongue bite, ictal atonia, cry and vocalization (Baslet, 2011). Patients, history includes age of manifestation, changes aggravating by anti epileptic drugs, seizures in presence of doctors with multiple unexplained symptoms and history of psychiatric treatment. No single agreed upon cause of PNES has been identified. So, an attempt has been made to classify PNES on the basis of eight underlying etiologies which are acute stresses, anxiety /panic/physical symptoms, depressed/ dissatisfaction, poor interpersonal skills and affect regulation, disturbed family system, psychosis, post-traumatic stress disorders (PTSD)/ dissociation, reinforced behavior pattern & somatization / somatoform / conversion (Gates, 2000; Bowman & Markand, 1996; La Farance & Devinsky, 2002; Reuber & House, 2002; & Barry & Sanborn, 2001; Rusch, Morris, Allen, & Lathrop, 2001). PNES, therefore, may be characterized as an unstable and inflexible cognitive-affective system.

There is no reliable information on the incidence and prevalence of PNES. However, data gathered from epilepsy centres provide an estimate of the proportion of PNES among patients admitted to hospital for diagnosis of PNES. The incidence of PNES has been reported as 1.4 per 100,000 or 3 per 100,000 per year (Sazaflarski, Ficker, Cahill, & Privitera, 2000). Approximately 25-30% of the patients referred to epilepsy centres for refractory epilepsy have been found actually patient of PNES (Abubakar, Kablinger & Caldito, 2003). Reports also indicate 24% patient of epilepsy admitted to highly specialised psychiatry and 14% of the patients admitted to specialised hospital were actually patient of PNES (Betts & Boden, 1992).

The core most obvious difference between epilepsy and PNES is that--in epilepsy--cause of seizure is abnormal discharge in the brain (La France & Barry, 2005) but in PNES--the cause is emotional trouble or turmoil condition due to various psychological and social causes, which is predisposed in form of somatic symptoms like clenching of teeth, tongue bite, tonic-clonic movement, jerky movement, incontinences and various other symptoms likeness with epilepsy (Brown, Syed, Benbadis, LaFrance, & Reuber, 2011). Though, few studies have identified some neuro-physiological reason also.

Problem faced with PNES is that they have inability in identification and expression of inner psychic distress leading to its expression in form of physical complaints. Alexithymia is one such often reported complaint seen in patients with PNES (Richard, Julia, Anna, Antonia, Gus, Steven, Christine, & Reuber, 2013). Further, emotion regulation is an identified mechanism underlying various forms of psychopathology (Uliaszek, Prensky, & Baslet, 2012). PNES patients also exhibit problem in emotion regulation (Baslet, 2011). Emotion regulation is ability to control one's behavior when experiencing intense emotion, rather than ability to directly control one's emotion themselves (Gratz & Tull, 2010). Moreover, PNES have been linked to a dysfunction in the processing of psychological or social distress (La France & Barry, 2005). Therefore, it is unlikely that PNES will be associated with one single pattern of emotion processing and regulation. Thus, we can conclude that PNES are poorly understood and difficult to treat suggesting the problems with recognizing, and regulating emotional states will contribute to the development and maintenance of PNES and very few studies had addressed this issue, so the present study is conducted to see that is there any difference between PNES and epileptic participants in emotion regulation and emotion identification? This study will helps us to establish and would provide support to argument that PNES has not any somatic base of occurrence instead psychological factors may have caused the seizure may gain support.

The main objective of the present study is to compare the level of alexithymia and emotion regulation among individual with epilepsy and psychogenic non-epileptic seizures and it was hypothesized that individuals with PNES would be more Alexithymic and would face more difficulty in emotional regulation as compared to individuals suffering from epilepsy.


Design: In the present study level of Alexithymia and DERS was assessed and compared between PNES and epileptic group. The design used for the present study is between group design.

Setting: The study was held at Neurology department of Sir Sunder Lal Hospital, Varanasi, Banaras Hindu University (BHU).

Study population: Participants aged between 18-30 years, registered in the department of Neurology, suffering from PNES or epilepsy was recruited for the purpose.

Sample: Both PNES and epileptic group in the age range of 18 to 30 years, who gave the assent, were recruited for the study. A written consent for the study was also taken from the attendant of the PNES and epileptic group participants. This study was conducted on a small sample 15 PNES and 15 epileptic participants to improve response rate, accuracy, and reliability of the responses. The forms were filled under the supervision of the researcher.

Inclusion criteria for PNES:

Neuro-imaging techniques were used, for differentiating between epileptic and non--epileptic patients. PNES participants were screened on the basis of Electroencephalography (EEG), Magnetic Resonance Imaging (MRI) and semiological history conducted by Neurologist.


Two questionnaires were used for the present study, Alexithymia and Difficulties in emotion regulation (DERS), English version. The alexithymia and DERS is a self-report questionnaire, five-point Likert scale, meant to study emotion recognition/identification and difficulty in emotion regulation respectively. Details of the questionnaire are below: Difficulties in Emotion Regulation Scale:(DERS) (Gratz & Roemer, 2004) is a 36-item Likert-type scale that measures clinically relevant emotion regulation. The DERS is separated into 6 subscales: Non-acceptance (non-acceptance of emotional responses); Goals (difficulties in engaging in goal-directed behavior); Impulse (impulse control difficulties); Awareness (lack of emotional awareness); Strategies (limited access to emotion regulation strategies); and Clarity (lack of emotional clarity. Reliability of the scale is 0.88.

Toronto Alexithymia Scale-20 (TAS-20):The TAS-20 (Bagby, Parker, & Taylor. 1994) is a 20-item self-report questionnaire designed to measure three different facets of the alexithymia construct: Difficulty Identifying Feelings, Difficulty Describing Feelings, and Externally Oriented Thinking. Participants were asked to indicate how much they agreed or disagreed with 20 statements on a five-point Likert scale where1 ("strongly disagree") to 5 ("strongly agree"). Reliability of the scale is 0.75.

Procedure: The participants were contacted individually in OPD of Sir Sunder Lal Hospital at department of Neurology. First of all, consent of the participants was taken. Thereafter, participants were told that they have to fill two questionnaires, which will help clinician to diagnose the problem so as to carry out the treatment procedure in a better way. After establishing rapport with the patient they were given the questionnaires. No time urgency was made but surety was there that participants should complete both the questionnaires in one sitting. Average 40 minute was taken by the patients to complete both questionnaires. After the completion of questionnaire their curiosity of the participants was attended, how it will help them was satisfied.


Present study was done to examine to find out that difference between PNES and epileptic participants on emotion regulation and emotion identification. Figure 1 shows the mean score of alexithymia among PNES and epileptic group. An independent sample t-test was conducted to compare alexithymia among PNES and epileptic participants. There was a significant difference in the scores of PNES participants (M= 64.13, SD= 7.95) and epileptic participants (M= 51.26, SD= 10.40); t (28) = 3.68, p< 0.01. Result reveal that level of alexithymia is high in PNES participants as compared to epileptic participants which shows that PNES participants feel difficulty in recognizing, perceiving and communicating their emotional problem which piles up in them and shows manifestation in the form of seizures.
Figure 1: Showing the mean score of alexithymia among PNES and
epileptic group.


PNES           64.13
Epilepsy       51.26

Note: Table made from bar graph.

Figure 2 shows the mean score of emotion regulation difficulty among PNES and epileptic group. An independent sample t-test was conducted to compare emotion regulation among PNES and epileptic participants. There was a significant difference in the scores of PNES participants (M= 119.46, SD= 22.46) and epileptic participants (M=74.06, SD= 10.06); t(28) = 6.98, p< 0.01 level. These result exhibits that PNES participants feels difficulty in regulating their emotion i.e. they are unable to suppress or reappraise their emotional difficulty which leads to seizures as compared to epileptic participants.
Figure 2: Showing the mean score of emotion regulation difficulty among
PNES and epileptic group.


PNES                119.46
Epilepsy             71.06

Note: Table made from bar graph.


The present study aimed to assess and compare difference between emotion regulation and emotion identification among PNES and epileptic participants. And the result revealed that due to weak cognitive-affective integrative system PNES participants had trouble in identifying and expressing their emotion as compared to epileptic participants. These results are consistent with the previous findings (Taylor, Bagby, & Parker, 1991). Also, this result gains support from the findings of Wrana, Bruder, Thomas, Lane, & Kohle, (2005) in which deficits in emotional awareness measured by rater-administered scales report more occurrence of unidentifying emotional problem in psychosomatic populations (PNES) compared to other psychiatric samples. Further, anxiety, affective, somatoform, personality and dissociative disorder are almost more or less common in PNES and epileptic participants (Bodde et al.2009). But this is not the case with Alexithymia in PNES and epileptic participants. Here, we got mixed finding, where PNES has not higher alexithymia than epileptic group Bewley, Murphy, Mallows, & Baker, (2005). Our result also reveal that PNES participants scored high on scale of DERS than epileptic participants which shows that PNES have more difficulty in emotion regulation than epileptic participants. Moreover, some studies Bewley, Murphy, Mallows, & Baker, 2005 have found that emotional problems lie at the core in PNES participants and have difficulty in specific aspects such as emotional recognition and regulation is strengthening our result. So, we see that individuals with PNES as compared to epilepsy have higher emotion dysregulation and alexithymia and inability to regulate their emotion due to weak cognitive-emotion integrative system. And makes individual vulnerable to which brings disruption in the integrated function of identity, memory, consciousness or perception of the environment (Alper, 1994).

From the present study we can conclude that participants of PNES have scored high on alexithymia which shows that they have more difficulty in recognition, identification and verbal expression of their emotion than epileptic participants. Similarly, PNES participants have scored high on DERS and have less emotion regulation ability as compared to epileptic participants. Mostly, PNES participants adopted undermodulation strategy to deal with stress sit


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Priyesh Kumar Singh (*), Tara Singh (**) and Vijay Nath Mishra (***)

(*) Research Scholar, (**) Professor, Department of Psychology, (***) Research Scholar, Institute of Medical Science, Banaras Hindu University, Varanasi, India

Received : October 15, 2017

Revised : December 30, 2017

Accepted : February 06, 2018
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Author:Singh, Priyesh Kumar; Singh, Tara; Mishra, Vijay Nath
Publication:Indian Journal of Community Psychology
Date:Mar 1, 2018
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