Seizure 44 (2017) 199–205

Contents lists available at ScienceDirect

Seizure
journal homepage: www.elsevier.com/locate/yseiz

Review

Understanding psychogenic nonepileptic seizures—Phenomenology,

semiology and the Integrative Cognitive Model$
Markus Reubera,b,* , Richard J. Browna,b
a
Academic Neurology Unit, University of Sheffield, Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2JF, United Kingdom
b
Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Manchester M13 9PL, United Kingdom

A R T I C L E I N F O A B S T R A C T

Article history:
Received 21 October 2016 Psychogenic Nonepileptic Seizures (PNES) are one of the commonest differential diagnoses of epilepsy.
Accepted 25 October 2016 This paper provides a narrative review of what has been learnt in the last 25 years regarding the visible
manifestations, physiological features, subjective experiences and interactional aspects of PNES. We then
Keywords: explore how current insights into PNES semiology and phenomenology map onto the Integrative
Aetiology Cognitive Model (ICM), a new account of these phenomena that unifies previous approaches within a
Cognition single explanatory framework. We discuss to what extent recent psychological and neurophysiological
Psychogenic nonepileptic seizures research is consistent with the ICM and indicate how the more detailed analysis of physiological data,
Electroencephalography
connectivity analyses of EEG and functional or structural MRI data may provide greater insights into the
Functional magnetic resonance imaging
biopsychosocial underpinnings of a disabling and under-researched disorder.
© 2016 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.

1. Introduction another disorder (e.g., Somatic Symptom, Dissociative, Panic, Post-

Traumatic Stress) or even be deliberately feigned (as in Factitious
Psychogenic nonepileptic seizures (PNES) are involuntary Disorder).
experiential and behavioural responses to internal or external Progress in our understanding of PNES has not been linear or
triggers that superficially resemble epileptic seizures (ES) but that continuous. A period in the late 19th and early 20th centuries,
are not associated with the abnormal electrical activity associated when the phenomenon was a key feature of “major hysteria” and
with the latter [1]. About one in five patients first presenting to a attracted a lot of attention, was followed by a long hiatus during
seizure clinic is diagnosed with PNES [2], which is one of the three which neurologists seemed to focus more on conditions they could
most common diagnoses in patients presenting with temporary attribute to demonstrable structural or physiological changes in
loss of consciousness [3]. About 75% of patients diagnosed with the nervous system. Over the same period, psychiatrists noted the
this condition are female, and PNES disorders most frequently start disappearance of hysteria from their practice [3]—and, with few
in late adolescence or early adulthood, although seizures may first exceptions, research on phenomena which would currently be
manifest in children as young as five and in older people [11,12]. called PNES stopped. This situation changed with the introduction
PNES are not a nosological entity in their own right. Rather, the of longer term ambulatory EEG and simultaneous video-EEG
diagnostic label “PNES” is applied in a range of clinical scenarios in recordings to routine clinical practice. From the 1970s, these
which seizures are thought to have “psychological” causes. Most, techniques allowed clinicians to categorise epileptic seizure
but not all presentations, fulfil the diagnostic criteria of Functional disorders much more accurately, and to improve their ability to
Neurological Symptom (Conversion) Disorder in DSM-5 (American identify patients who might benefit from epilepsy surgery. The
Psychiatric Association, 2013), although some may be a feature of availability of these investigations also meant that it was harder for
epileptologists to ignore the fact that a substantial group of their
patients had seizures that were evidently not caused by epileptic
$
One of the authors of this paper is a member of the current editorial team of activity.
Seizure. The supervision of the independent peer review process was undertaken This, and the realisation that seizure disorders in general were
and the decision about the publication of this manuscript were made by other better understood as more complex biopsychosocial phenomena
members of the editorial team.
* Corresponding author at: Academic Neurology Unit, University of Sheffield, rather than purely “neurological” or “psychiatric” problems, were
Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2JF, United Kingdom. key motivations for the foundation of the Journal Seizure 25 years
E-mail address: m.reuber@sheffield.ac.uk (M. Reuber).

http://dx.doi.org/10.1016/j.seizure.2016.10.029
1059-1311/© 2016 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.
200 M. Reuber, R.J. Brown / Seizure 44 (2017) 199–205

ago. As founding editor Tim Betts put it in his editorial heading up In most series, seizures with stiffening and tremor, or seizures with
the first issue: “this journal is not just about epilepsy, but is about atonia are less frequent [1].
seizures in general” [4]. Several more recent studies have suggested that visible (or
This paper marks the prominent role played by Seizure in the subjective) semiological elements are not combined randomly but
development of our thinking about PNES by exploring how our that there may be several distinct PNES types. The most advanced
understanding of the objective and subjective manifestations of study of (mainly visible) features of PNES focussed on 22 different
PNES has grown since the inaugural issue of the Journal. We begin observations and identified five different PNES types by hierarchi-
with a narrative review of studies on neurological comorbidity, cal cluster analysis [15]. This semiological typology has been
visible seizures manifestations, physiological changes and subjec- replicated in a very different (Indian) patient cohort [16]. Although
tive experiences associated with PNES, as well as how patients other authors have described somewhat different categories, they
with PNES talk about their seizures. We then explore how this also found that PNES could be subdivided into a moderate number
research fits with recent thinking about the psychological of discrete semiological groups [17].
mechanisms of PNES (the Integrative Cognitive Model; ICM) [5], While the “meaning” of these different PNES types was not
and consider how our understanding of PNES may deepen over the explored in the studies discussed above, other studies have
next quarter century. demonstrated links between semiological and other clinical
features. One showed that patients with a history of sexual abuse
2. Phenomenology and manifestations more often have convulsive PNES and a history of nocturnal spells,
ictal injuries and incontinence. Patients who had previously been
2.1. Neurological comorbidity sexually abused were also more likely to report flashbacks and
emotional triggers of their PNES or experience seizures prodromes
PNES have been found to be associated with a range of [18]. Another study showed that patients with convulsive PNES
neurological disorders, most importantly with epilepsy. All had poorer outcomes [19].
published case series of patients with PNES that did not exclude Although many authors have claimed that PNES tend to change
patients with a history of epilepsy demonstrate that the prevalence more over time than epileptic seizures [1], recent research has
of epilepsy is increased in patients with PNES. Having said that, the demonstrated that the semiology of PNES in individual patients is
most robust studies indicate that no more than 10% of adults with actually quite stereotyped, at least over the short term [17].
PNES have concurrent epilepsy [6]. In patients with comorbid Nevertheless, some change in PNES manifestations is often
epilepsy, PNES are almost invariably preceded by the manifesta- apparent, especially over the course of the first few events or
tion of epileptic seizures [7]. Although epidemiological data about over the longer term. While there is no published proof for the
other comorbid brain problems are less certain, patients with clinical observation that new seizure elements sometimes become
intellectual disabilities or head injuries may also be at increased part of the visible seizure manifestations when patients with PNES
risk of PNES [8]. However, no clear links between PNES and have been exposed to epileptic seizures (for instance on Epilepsy
particular types of structural or functional brain lesions have been Monitoring Units), there is some evidence for the idea that
found [9,10]. This suggests that a range of different brain problems symptom modelling may play a role: in one study, patients with
may predispose patients to developing PNES and/or that the link PNES were six times more likely to report having witnessed
between PNES and these problems is mediated by other someone in a seizure before experiencing their own first seizure
mechanisms, including iatrogenicity, exposure to seizure models than those with epilepsy (11 versus 66%) [20].
or traumatisation. Likewise, the fact that PNES sometimes stop Overall, evidence concerning visible seizure manifestations
after successful epilepsy surgery in patients with mixed seizure does not support older notions of PNES as activations of inherent,
disorders does not mean that PNES were directly linked to epileptic hard-wired behaviour patterns akin to freeze or startle responses
seizures or interictal epileptic activity [11]. [21]. Rather, the limited typology and the relatively stereotyped
but somewhat malleable nature of PNES across different cultures is
2.2. Visible ictal observations more consistent with the idea that these seizures have a
conditioned, reflex-like element that is embellished by learning
The first two decades after the introduction of seizure and experience.
observation with simultaneous video-EEG generated a number
of studies focusing on visible seizure manifestations [1]. The main 2.3. Physiological changes
focus in many cases was to generate lists of features with
differential diagnostic potential. Numerous such signs have been The first studies of Electrocardiographic (ECG) changes in PNES
described, with a systematic review indicating that the most were published around the launch of Seizure 25 years ago. It was
reliable indicators of PNES are long duration, occurrence from recognised that ictal sinus tachycardia was common, but more
apparent sleep with EEG-verified wakefulness, fluctuating course, gradual in onset, less marked and less persistent after PNES
asynchronous movements, pelvic thrusting, side-to-side head or cessation than in epileptic seizures [22,23]. Subsequent studies
body movement, closed eyes during the episode, ictal crying, have demonstrated that a rapid heart rate increase has a high
memory recall and absence of postictal confusion [12]. No positive predictive value for the identification of epileptic seizures
individual observation can provide a firm basis for a diagnosis [24,25].
of PNES in isolation and all of these “typical” features of PNES Although these observations demonstrated less marked acute
could, conceivably, be observed in epileptic seizures; nevertheless, physiological changes during PNES than epileptic seizures, several
these visible seizure manifestations allow experienced clinicians more recent studies have highlighted the fact that PNES are also
to differentiate between epileptic and nonepileptic seizures with a associated with autonomic arousal. One study showed a lower
high level of accuracy if they are able to examine patients during a parasympathetic tone and higher sympathetic tone during PNES
seizure or see a recording of a typical event [13,14]. than at rest, with HRV markers correctly categorising over three
The initial video-EEG studies also established that PNES may quarters of ECG segments from patients with PNES as capturing the
manifest in different ways. The most commonly observed ictal or interictal state [26]. A more recent study using a slightly
semiology involves excessive movement of limbs, trunk and head. different approach and different time windows demonstrated an
increase in heart rate variability (HRV) markers of sympathetic
 M. Reuber, R.J. Brown / Seizure 44 (2017) 199–205 201

tone just prior to a PNES but suggested that the seizures experiences in the 1980s and 1990s. Since then, several studies
themselves were associated with parasympathetic activation, have demonstrated that ictal impairment of consciousness is less
consistent with the idea that PNES may provide some relief from profound in PNES than in epileptic seizures. For instance, patients
heightened arousal or the stimuli giving rise to it [27]. with PNES were shown to have greater recall of aspects of an ictal
Despite the demonstrable differences in arousal between the examination than those who were tested after a complex partial
seizure and non-seizure states, a number of studies have indicated epileptic seizures [49]. An increased recall of ictal events under
that PNES themselves should be regarded as the “tip of the iceberg” hypnosis also proved to be a useful diagnostic indicator of PNES in
of a more persistent (interictal) state of hyperarousal. Evidence of one small study [50].
this has been provided by HRV studies as well as by a study It has become apparent that many patients with PNES
comparing cortisol day curves in patients with PNES and healthy experience panic symptoms (at least in some of their seizures)
controls [28–30]. In another study, the elevated resting cortisol and that it can be difficult to distinguish clearly between some
levels detected in patients with PNES were found to be positively PNES and panic attacks [39,40]. However, it appears that panic
correlated with increased threat vigilance [31]. symptoms may be experienced differently during PNES. Goldstein
Interictal physiological abnormalities have also been found in and Mellers, for example, found that patients with PNES reported
several small studies exploring brain networks using functional more somatic symptoms of anxiety during their attacks than
Magnetic Resonance Imaging (fMRI). One comparing patients with patients with epilepsy, although they did not seem to experience
PNES and healthy controls suggested that, in the patient group, subjectively higher levels of anxiety during their seizures. As PNES
there was stronger connectivity between areas involved in patients reported more agoraphobic-type avoidance behaviour
emotion processing (insula), executive control (inferior frontal than those with epilepsy, PNES were interpreted as a dissociative
gyrus and parietal cortex) and movement (precentral sulcus) response to anxious arousal, that is, “panic without panic” [41].
which was positively correlated with dissociation scores (r = 0.59) Other studies have also demonstrated that PNES are more likely to
[32]. In contrast, another study comparing MRI connectivity feel “physical” than “psychological” [42,43], and qualitative
density maps of patients with PNES and healthy controls found research has demonstrated that patients often find doctors’
patients with PNES to have reduced Functional Connectivity accounts of PNES as a response to stress or other psychosocial
Density values in frontal, sensorimotor and occipital cortices, triggers unconvincing, even though many (but by no means all)
cingulate gyrus and insula [33]. In a second study by the same report past or current stressful events [44,45].
group, resting state fMRI data were combined with Diffusion Nevertheless, one of the largest studies of subjective PNES
Tensor Imaging (DTI) tractography. In line with their previous experiences demonstrated that a simple score of >4/13 panic
findings, PNES patients showed reduced connectivity compared to symptoms predicted a diagnosis of PNES rather than epilepsy with
healthy controls, suggesting that PNES could be the result of poor a sensitivity of 83% and a specificity of 65% [46]. Another study
integration of emotion processing, executive control and motor achieved similar levels of differential diagnostic accuracy between
networks in the brain. This study also demonstrated a reduced epilepsy and PNES (77% of cases correctly classified) with a more
coupling strength of functional and structural connectivity in the detailed questionnaire focusing on a wider range of self-reportable
PNES population. The measure of coupling strength showed high symptoms associated with transient loss of consciousness,
sensitivity and specificity in the differentiation of individuals with although the questionnaire differentiated better between syncope
PNES from healthy controls [34]. and epilepsy (91%) and between syncope and PNES (94%). In that
Studies based on computer-aided scalp EEG analysis have study, patients’ relative endorsement of 74 possible TLOC-
provided further indication of reduced network connectivity in associated symptoms contributed to five separate experiential
patients with PNES. One small study using a graph theoretical factors focusing on the themes “feeling overpowered”, “sensory
approach and comparing patients with healthy controls described experience”, “amnesia”, “mind/body/world disconnection” and
a weakness in local connectivity and skewed balance between local “catastrophic experience”. The latter two (ictal dissociation- and
and global connectedness in EEG alpha band. These topological anxiety-linked) themes differentiated patients with PNES most
indices were positively correlated with PNES frequency [35]. clearly from the other two groups and are therefore likely to be
Another small study comparing PNES patients to healthy controls most characteristic of the PNES experience (typical questions: “In
identified decreased clustering coefficients in the gamma band, a my attacks I see things which are not really there”; “During my
measure thought to be associated with reduced efficiency of attacks I am frightened I am going to die”) [47]. Another study
information transfer. This finding could reflect reduced prefrontal focusing on the relationship between different types of symptoms
connectivity and result in impairment of executive control [36]. in the PNES group included in the comparative research described
Reduced connectivity has also been shown to distinguish PNES above found that a greater recall of ictal panic symptoms is
patients from those with epilepsy with a high level of accuracy associated with more common dissociative experiences [48].
[37]. Although a study analysing whole-head surface topography of
multivariate phase synchronisation in interictal high-density EEG 2.5. Interactional representation
failed to demonstrate any significant differences between
13 patients with PNES and the same number of age- and In routine practice, subjective experiences are usually captured
gender-matched controls, a significant correlation was found by history-taking. Despite the fact that the process of eliciting and
between decreased prefrontal and parietal synchronisation and interpreting the patient’s history is, arguably, the most important
PNES frequency in the patient group [38]. contribution clinicians make to the diagnostic process, it has only
become a focus of epileptological research over the last two
2.4. Subjective experiences decades. Importantly, in the process of describing their seizures,
patients do not just tell the clinician what they experience in their
Even if a seizure has been captured by video-EEG, diagnoses of seizures, they also show how they deal with the challenge of having
epilepsy or PNES can never rely on video-EEG data alone. Patients’ to communicate about their seizure experiences interpersonally.
subjective seizure symptoms give important clues about the The latter observation may provide clinicians with insights into
nature and aetiology of the seizures. Compared to a relative wealth patients’ preferred coping behaviours more generally [49].
of publications about visible or measurable PNES manifestations, Research initially carried out in Germany but then also in the
very little research was carried out on patients’ subjective seizure United Kingdom and elsewhere showed that patients with
202 M. Reuber, R.J. Brown / Seizure 44 (2017) 199–205

epilepsy tend to focus on their subjective seizure experiences and Leaving aside questions about the quality of the studies
make considerable efforts to explain exactly how they feel in their reviewed, which had numerous limitations [58], it was evident
seizures; in contrast, those with PNES preferentially focus on the that none of the available models (which interpret PNES variously
circumstances in which their seizures occurred or the consequen- as the activation of dissociated material, a physical manifestation
ces of their seizures [50–53]. The metaphoric conceptualisations of of emotional distress, hard-wired reflex responses, or learned
seizure experiences preferred by patients with epilepsy place the behaviours [58]), could provide a complete explanation of the
linguistic agency with the seizure, which acts independently and semiology and phenomenology of PNES, or account for all of the
often in a hostile fashion (e.g. “the seizure knocked me out”). In available research data on the phenomenon. In order to address
contrast, patients with PNES prefer metaphors in which the these limitations, we described an Integrative Cognitive Model
linguistic agency is with the patient and which depict the seizure (ICM) that brings together existing theories within a single
as a space or place (e.g. “I went into the seizure”) [54]. Narratives of explanatory framework, leading to a number of novel hypotheses
patients with epilepsy typically normalise seizure experiences [5]. Based on an established theory of “medically unexplained
whereas patients with PNES often catastrophise [55]. Patients with symptoms” (MUS) [60], the ICM suggests that the observable and
epilepsy are happy to call their main symptom a “seizure” whereas subjective elements of PNES result from the automatic execution of
those with PNES often avoid labels and prefer pronouns [56]. These a learnt mental representation (broadly speaking, “idea”) of
observations concur with other data suggesting that many patients seizures (the “seizure scaffold”), typically in the context of a high
with PNES have an avoidant coping style [57,58], and that the level inhibitory dysfunction resulting from chronic stress, arousal
attacks themselves are often an anxiety-based phenomenon, albeit and other factors that compromise high level processing (Fig. 1).
not one that is always recognised as such by patients. The seizure scaffold consists of a sequence of perceptions and
motor activities initially formed by experiences such as inherent
3. An integrative aetiological model: “State of the Art” and reflexes (e.g. freeze, startle), physical symptoms (e.g. of pre-
future directions syncope/dissociation/hyperventilation/head injury), but also per-
sonal knowledge or modelling. The perceptions may be triggered
3.1. An Integrative Cognitive Model of PNES by sensory inputs but are generated by pre-existing expectations
and are at odds with the patients’ actual internal or external
At the time that Seizure first went into publication, the two environment (readers keen to convince themselves how sensory
predominant models suggested somewhat vaguely that PNES were inputs can be “trumped” by expectations are advised to look up the
either a manifestation of dissociation or somatization [1,59]. We rubber hand illusion and the McGurk effect). This sequence of
recently reviewed the evidence pertaining to these and other, more perceptions and actions is relatively stable but not completely
recent, models of PNES, encompassing research on life adversity, fixed. As such, it has much in common with the key constituents of
dissociation, anxiety, suggestibility, attentional dysfunction, fami- a conditioned reflex.
ly/relationship problems, insecure attachment, defense mecha- Like a conditioned reflex, the seizure scaffold can be triggered
nisms, somatization/conversion, coping, emotion regulation, by a range of internal or external stimuli. This often occurs in
alexithymia, emotional processing, symptom modelling, learning response to elevated autonomic arousal, although it can become
and expectancy in patients with PNES [5,58]. divorced from abnormal autonomic and emotional activity and
may be triggered by thoughts or perceptions which are,

Chronic stress, arousal and other

factors compromising inhibitory
processing

Inhibitory
processing
dysfunction

Elevated arousal Predict/anticipate Activation of Reduced arousal

Physical symptoms seizure onset seizure scaffold PNES

Threat perception

Internal/external cues
Conditioned stimuli,
trauma reminders etc.

SEIZURE SCAFFOLD

Scaffold shaping factors

e.g., Hard-wired behavioural tendencies
Seizure models from self, others, the media etc.
Experiences misinterpreted as seizures/epilepsy
Prior physical illness and injury
Loss of consciousness
Traumatic experiences

Fig. 1. Intergrative Cognitive Model of PNES. Essential components are represented in the dashed area (from Ref. [8]).
 M. Reuber, R.J. Brown / Seizure 44 (2017) 199–205 203

objectively, quite neutral. Triggering of the seizure scaffold often PNES group showed discrepancies between explicitly reported
disrupts the individual’s (full) awareness of distressing material. high anxiety and the implicitly recorded measures. One possible
The seizure scaffold is more likely to be triggered in the presence of explanation of these findings is that PNES enable patients to
dysfunctional inhibition, which could be due to chronic stress but dissociate “successfully” from adverse emotions and not to think of
also have “physical” causes such as illness or the effects of themselves as anxious individuals [67].
medication. The launch of the seizure scaffold is usually experi- While it would be premature to draw any firm conclusions from
enced as non-volitional although patients may be able to inhibit it these small experimental studies (or the physiological research
by willed action. This is in keeping with the observation that there mentioned above), the ICM provides a basis for hypothesis-driven
may be times when patients “wilfully submit” to the dissociation research. These small studies demonstrate how we can use
associated with their PNES by a withdrawal of active inhibition experimental methods to further our understanding of PNES in the
subjectively perceived as volitional [61]. future.
The reflex-like nature of PNES described in this model is
consistent with the observation of a limited number of PNES-types 4. Conclusions
and the relatively stable experiential and behavioural semiology of
seizures in individual patients. However, the ICM can accommo- Over the last 25 years we have gained a much better
date the clinical and psychological heterogeneity evident from so understanding of the clinical phenomenology of PNES as well
many of the studies discussed above, while indicating how factors as the physiological and psychological factors characterising and
such as previous traumatic experiences, current life adversity and contributing to this disorder. This research has demonstrated that
physical health problems may contribute to PNES. Importantly, patients do not only have PNES, but also more persistent
however, none of these factors is essential for the development or problems likely to affect their emotional well-being, social
maintenance of the disorder, even though they may be of central functioning and ability to cope with life challenges in between
importance in specific cases. seizures. Although the PNES patient population is aetiologically
and experientially heterogeneous it may be possible to define a
3.2. Testing the ICM moderate number of different subtypes and clinical subpopula-
tions characterised by differences in seizure experience and
To date, the vast majority of studies of psychological mecha- semiology, psychological and psychiatric profile. Physiological
nisms relevant in PNES have used self-report methods, although and hypothesis-driven experimental studies have begun to make
there are obvious conceptual limitations to using self-report in contributions to a better-grounded understanding of the neuro-
research about a process that evidently involves some unconscious biological foundations to this disorder, although the evidence
elements. Having said that, our understanding of psychological emerging from studies using relatively novel methods (such as
mechanisms underpinning PNES has also been enhanced by resting state fMRI or quantitative EEG analysis) currently remains
experimental approaches, such as those used by Bakvis and inconclusive.
colleagues mentioned already. Although relatively small in scale, Although the ICM embraces the evidence discussed above
these studies have provided important corroborating evidence that better than traditional accounts, it is important to point out that
differences between patients with PNES and healthy controls (or the model is intrinsically a psychological theory. While invoking
controls with epilepsy) are not limited to the seizure state, and the processes such as threat perception or response inhibition, which
first objective demonstration of heightened avoidance tendencies are clearly linked to neurobiological mechanisms, it does not map
and abnormal working memory in patients with PNES [62,63]. directly onto particular anatomical structures in its current form.
What is more, the heightened arousal, and the experimental Indeed, many of the factors included in the model could involve
cognitive findings likely to be associated with impaired inhibition different centres or networks in the brain. However, the lack of
are in keeping with the ICM. anatomical or mechanistic precision is a strength and not a
Several more recent experimental studies have focussed on weakness of the ICM. The representation of PNES as the result of
aspects of emotion processing. In one study, PNES patients dysfunction of a range of interacting neuronal networks allows the
reported greater emotional intensity of neutral pictures but less model to account for the numerous interindividual differences
positive emotional behaviour in response to pleasant pictures than described above, as well as for changes in the relative importance
a control group without seizures but with similar levels of previous of different factors in one particular patient as a PNES disorder
trauma [64]. Another study testing affect perception and theory of turns from an acute to a chronic problem, or as PNES stop in
mind demonstrated that, compared to healthy controls, patients response to therapeutic intervention. What is more, the ICM can
with PNES were characterised by increased alexithymic traits and, help psychotherapists put together individualised formulations of
impaired mentalising skills while basal facial expression recogni- the aetiology of a particular patient’s PNES disorder and devise
tion were found to be normal [65]. Finally, in an experimental effective treatment strategies targeting specific elements of the
study focussing on attention to emotion, patients with PNES model.
reappraised their cognitions less frequently and showed im- Last but not least, the ICM provides a clear basis for future
pairment in their ability to switch attention between emotion and hypothesis-driven phenomenological, psychological and experi-
non-emotion face categorisations [66]. mental research. If the model is correct, future research will have to
There is also some initial experimental evidence demonstrating combine phenomenological data with methods probing particular
how PNES may serve a functional purpose. One of the studies of PNES mechanisms to account for the heterogeneity of the disorder.
HRV changes during PNES already mentioned above suggested that Researchers can make the most of the phenomenological
the preictal rise of sympathetic activation was stopped by the variability of PNES by pursuing correlational approaches or by
dissociation from the adverse experience causing PNES or selecting subgroups of patients, but our understanding of PNES is
associated with having a seizure and replaced by parasympathetic unlikely to advance much further without a more differentiated
activation in the ictal and postical phase of a PNES [27]. If approach to disorder. This means that future aetiological research
confirmed in larger studies, this findings would provide strong will need to involve larger numbers patients with PNES. The
support for the ICM. Another study compared explicit (self-report) impressive recruitment success of the multicentre CODES study in
and implicit (reaction-time dependent) psychological measures in the United Kingdom (a randomised controlled Cognitive Behaviour
patients with PNES or epilepsy and in healthy controls. Only the Therapy treatment trial to which over 500 patients have been
204 M. Reuber, R.J. Brown / Seizure 44 (2017) 199–205

recruited so far [68]) demonstrates that these sort of studies are [29] Bakvis P, Roelofs K, Kuyk J, Edelbroek PM, Swinkels WAM, Spinhoven P.
feasible if researchers collaborate and funders can be persuaded to Trauma, stress and preconscious threat processing in patients with
psychogenic non-epileptic seizures. Epilepsia 2009;50:1001–11.
invest in the improvement of a common, costly and under- [30] Bakvis P, Spinhoven P, Giltay EJ, Kuyk J, Edelbroek PM, Zitman FG, et al. Basal
researched disorder. hypercortisolism and trauma in patients with psychogenic nonepileptic
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Conflict of interest statement vigilance in patients with psychogenic nonepileptic seizures. Epilepsy Behav
2009;16:558–60.
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