|BRIEF RESEARCH COMMUNICATION
|Year : 2020 | Volume
| Issue : 1 | Page : 76-80
Sexual and physical abuse among patients with psychogenic nonepileptic seizures: A comparative study
Anand Thaman1, Naina Sharma2, Rajeev Gupta1
1 Manas Psychology, Epilepsy and Deaddiction Centre, Ludhiana, Punjab, India
2 Department of Psychology, Punjabi University, Patiala, Punjab, India
|Date of Submission||05-Sep-2019|
|Date of Decision||19-Sep-2019|
|Date of Acceptance||04-Oct-2019|
|Date of Web Publication||30-May-2020|
Dr. Anand Thaman
Manas Psychology, Epilepsy and Deaddiction Centre, Ludhiana, Punjab
Source of Support: None, Conflict of Interest: None
Introduction: Psychogenic nonepileptic seizures (PNES) are the events with altered state of consciousness, sensations, perceptions, and involuntary motor activities which look similar to epilepsy but in the absence of any electrical discharges in the brain. The etiology of PNES is generally associated to psychosocial factors. Earlier traumatic life experiences, especially sexual abuses are considered as an important predisposing cause among PNES patients. Aims and Objectives: The aim of the current study was to survey various aspects of sexual and physical abuse in PNES patients and to compare it with epilepsy and healthy control group. Materials and Methods: Three groups (PNES, epilepsy, and healthy control) with 50 patients/participants in each were compared for the incidents of sexual and physical abuse. Semi-structured interview was conducted to explore the experiences of those patients/subjects who acknowledged about their traumas and consented to talk about it. Results: Incidents of sexual and physical abuse were found higher in the PNES group as compared to epilepsy and healthy controls. Other aspects of traumas such as nature, severity, frequency, psychological and physical consequences were found also comparable. Conclusion: PNES patients experienced more traumatic events which need to be explored for its therapeutic management.
Keywords: Physical abuse, psychogenic nonepileptic seizures, sexual abuse
|How to cite this article:|
Thaman A, Sharma N, Gupta R. Sexual and physical abuse among patients with psychogenic nonepileptic seizures: A comparative study. Ann Indian Psychiatry 2020;4:76-80
|How to cite this URL:|
Thaman A, Sharma N, Gupta R. Sexual and physical abuse among patients with psychogenic nonepileptic seizures: A comparative study. Ann Indian Psychiatry [serial online] 2020 [cited 2020 Oct 30];4:76-80. Available from: https://www.anip.co.in/text.asp?2020/4/1/76/285506
| Introduction|| |
Psychogenic nonepileptic seizures (PNES) are the paroxysmal events with altered state of consciousness, sensations, perceptions, and involuntary motor activities which otherwise look similar to epilepsy but in the absence of any abnormal electrical discharges in the brain. About 20% of the cases of seizures referred to epilepsy specialty centers get the final diagnosis as PNES. Psychological factors are mostly recognized behind the onset and maintaining causes of PNES. Among the multidimensional etiologies for PNES, earlier life's traumatic incidents are consistently reviewed. It has been found that up to 90% of patients with PNES experienced at least one traumatic life event before the first episode of seizure. Traumas of sexual and physical abuses are common in females and put them on risk for PNES. Available literature suggests that PNES patients are three times more likely to report such incidents as compared to the general population.
PNES is presumed to be a psychological defense to cope up with traumatic life experiences. According to this notion, when painful memories of traumas intrude into the conscious experience and create frequent hyperarousal in the body, PNES serves as a protecting agent by the route of dissociation and regulatory mechanisms. There are strong evidences of sexual and physical abuses among those having features of dissociative disorders. Psychodynamic view considers PNES as a manifestation of emotional distress (emerge from earlier negative life experiences) into somatic or physical symptoms without acknowledging its affective component. Therefore, traumatic events may act as predisposing factors for PNES.
Incidents of sexual and physical abuses have also been reported in few Indian studies on PNES patients., However, due to cultural factors, these incidents are either underreported or remained unexplored and even forced to be suppressed by their victims. Domestic and physical violence, especially after marriages related to demands of dowry or lack of a male child, is still very common. Thus, treating PNES while ignoring these issues and without providing psychological support to patients give poor outcomes and prognosis. Hence, the aim of the present study was to explore in detail the nature of sexual and physical abuse among PNES patients and how they relate it to their current diagnosis.
| Materials and Methods|| |
The present study was conducted at one of the reputed neuropsychiatric centers of Ludhiana. It was a comparative study consisting of three groups, i.e., PNES, epileptic seizures (ES), and healthy controls with 50 patients/participants in each group. Only new cases who had confirmed the diagnosis of PNES/ES through electroencephalography (EEG) or video EEG/ICD-10 and with no major coexisting medical or psychiatric condition were included in the study. All participants in current study were above 18 years, minimally 10th passed and were able to provide written consent. Healthy controls were recruited from the community after matching their sociodemographical profile (age, sex, education, nature of habitat, and socioeconomic status) with PNES group and whose score was below 10 on PGI health questionnaire.
All patients and participants in the three groups were interviewed and enquired about sexual and physical abuse experiences during the case history session through semi-structured pro forma. On the basis of available literature, sexual abuse for the current study was operationally defined as “forceful sexual act, i.e., intercourse/insertions/oral/anal or simple touching, rubbing, kissing, hugging, or showing or seeing private parts.” Similarly, physical abuse was defined as “an intentional act of violence resulted in trauma, bruise, concussion, and internal or external injury to any part of body.” Those who acknowledged sexual and physical abuse and gave consent to talk were further interviewed through specially designed session as per the procedure given below. Data was analyzed manually through frequency calculations and percentages. Chi-square test was used to calculate group differences for the number of cases of sexual and physical abuse. This study was approved by the university ethical committee.
Procedure for interview
A female counselor was assigned to interview all trauma victims during one-to-one session in secured/threat-free safe environment. A precounseling session was provided keeping in view the possibilities for reoccurrence of painful memories, distressed emotions, and anxiety. These patients were assured of their confidentiality and necessary psychological support. A semi-structured interview pro forma was designed, consisted of seven questions each for sexual and physical abuse to record nature of abuse, age at which it occurred, frequency, physical and psychological consequences, and victims' representation about its link with current illness. Mental state examination was carried out for all patients and participants before filling up the pro forma. Post counselling sessions were also provided to these patients as per the outcomes of the interview which included – guidance for safety seeking behaviour, cognitive behaviour therapy (CBT) to modify faulty coping mechanisms (self blaming, generalized social avoidance, magnification of traumatic memories) and enumerating useful strategies for affect regulation (acknowledging triggers, psychological discomfort, self re-assurance) and stress management (relaxations therapy etc.).
| Results|| |
In the first part of [Table 1], overall characteristics and number of cases for sexual and physical abuse in three groups, i.e., PNES, ES, and healthy control, are given. The results indicate higher number of females as compared to males in all three groups. However, three groups were statistically equal (P = 0.593) for gender distribution. The results of survey revealed that only female patients/participants reported incidents of sexual and physical abuse in all three groups. Further significantly higher number of patients in PNES group reported sexual and physical abuse incidents as compared to ES and healthy control groups (P < 0.001). Similarly, significantly more number of patients in PNES group experienced both types of abuses as compared to ES and controls (P = 0.03).
|Table 1: Comparative profile of patients/participants reported sexual and physical abuse|
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In part 2 of [Table 1], various aspects of sexual and physical abuse are described. About two-third of the PNES patients reported act of sexual intercourse (or oral) than inappropriate touching of genitals or private parts. All patients in ES and half of the patients in control group reported intercourse, whereas other half described inappropriate touching during sexual abuse. More than half of the PNES patients experienced childhood sexual abuse, i.e., before the age of 13 than in later years of life. No patient in ES group but one participant in control group reported childhood sexual abuse. Multiple incidents of sexual abuse were reported by three-fourth of the PNES, all ES patients and half of participants in control group.
Close family relatives, cousins, known family friends, and employer/boss/colleague were the perpetrators for sexual abuse in PNES, close family relatives and cousins were perpetrators in case of ES and control groups. Medical emergency after the incidents was reported by about two-third of the patients in PNES and one of the participants in control, whereas ES group described only minor injuries.
Severe-to-extreme psychological distress after incident(s) was experienced by all PNES and ES patients, whereas only half of the participant in control group perceived severe distress and other half as minor distress. Nearly half of the patients in PNES group linked their sexual abuse trauma to the current diagnosis, whereas this was not in case of ES.
During physical abuse, about four-fifth of the patients in PNES group reported the use of weapons (bat, rod, knife, bottle, utensil, etc.) for attack, whereas this was not reported in ES and control groups. Single incident of physical abuse was described by two-third of the patients in PNES and half of the patients in ES. One participant in the control group reported physical abuse more than single time.
PNES patients were victimized by their spouses, parents/step parents-in-laws, and ex-partners, whereas physical abuse was done by in-laws and spouses in case of ES and healthy controls. About two-third of the patients in PNES group reported medical emergency and one patient described permanent damage to body organs, whereas other two groups reported only minor physical injuries after the incident. Severe-to-extreme psychological distress after physical abuse was reported by all of the patients in PNES and ES groups. One patient in the control group described moderate psychological distress after physical abuse. About half of the PNES patients admitted that their current diagnosis was related to physical abuse, whereas no ES patients linked it to their illness.
| Discussion|| |
The current study was designed to explore the prevalence and nature of sexual and physical abuse in PNES patients and its comparison with ES and healthy controls in Indian settings. Many points emerged out of this survey. As expected, incidents of sexual and physical abuse were significantly higher in PNES patients as compared to ES and healthy control groups. This prevalence was somewhat lower than the prevalence reported in international studies but similar to the Indian researches. For example, Sharpe and Faye  in a review of 32 studies reported the rate of sexual abuse range from 5.9% to 84.6%, with a mean of 33.2% as compared to 16.6% in the general population. Similarly, physical abuses were reported between 0% and 52.3%, with a mean as 31.1%. A study from India by Patidar et al. reported sexual abuse in 17.46% and physical abuse in 7.93% of PNES cases. In another study by Khandelwal and Sharma, 37.83% of the cases reported for sexual abuse, whereas 25.67% reported for physical abuses. These differences may be due to the definition used for sexual and physical abuse in different studies or sociocultural factors/taboos which restricted them to open up or to disclose about their traumas.
Further, various aspects of abuses explained about the severity of the trauma, for example, majority of the victims reported sexual acts (insertion, intercourse, or oral), which could be more traumatic than mere touch only. The current study also revealed that incidents of childhood sexual abuse were higher in PNES patients that have long-term psychological consequences and linked with psychopathologies in later life. Similarly, a more number of PNES patients reported the use of weapon during physical assault that indicated the graveness of attack and could be more traumatic.
Most of the PNES patients experienced sexual traumas multiple times by their close relatives including incestuous relationships, which could be distressing in the Indian culture. These traumas are generally repressed and in many cases never been reported. On the other hand, physical traumas in PNES patients mostly occurred single time after marriages and generally committed by spouse or ex-spouse. This could explain the correlation between the higher incidents of PNES episodes in married women.
These victims also faced medical emergencies even a permanent damage to body part and above all severe psychological distress which make these patients vulnerable for the onset of PNES. Finally, PNES patients had partial insight about their stressors as majority of the patients admitted that their traumas could have a link with their current diagnosis. As these patients were already psychoeducated about the etiology of PNES during the communication of diagnosis, they could able to correlate their traumas with current illness. The insight about the ongoing stressors and disturbed emotions would be an important determinant in predicting the outcomes of PNES, i.e., acceptance of diagnosis by the patients, treatment-seeking behavior, compliance, and prognosis of illness.
Current research also has many limitations, as it conducted on a small sample and based on subjective reports of victims who were asked to recollect memories from the past. These trauma-related memories are difficult to recall thus vulnerable to distortions or magnifications while reporting the incidents. Further various questions such as the severity of the psychological distress and perception about their trauma which they linked with the present diagnosis need to be explored in more objective way. Despite these limitations, findings of the current study gave useful information about the nature and severity of traumas in PNES patients. Exploring traumas in secured and empathetic environment may serve as catharsis for these patients and can be helpful in processing their frozen emotions. Further, this information can be used for psychological intervention to PNES patients in devising suitable therapies for resolving their painful emotions which ultimately will be helpful in controlling seizures.
| Conclusions|| |
PNES patients experienced more incidents of sexual and physical traumas as compared to ES and the general population. These traumas inflicted both physical and psychological consequences on their victims which can be associated with current seizures. Exploring these traumas within secure insecure environment may help these patients therapeutically.
This study was approved by Institutional Ethics Committee with reference number IEC /03 -2018 /05 obtained on 13th August, 2018.
Declaration of patient consent
Patient consent statement was taken from each patient as perinstitutional ethics committee approval along with consenttaken for participation in the study and publication of thescientific results / clinical information / image withoutrevealing their identity, name or initials. The patient is awarethat though confidentiality would be maintained anonymitycannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kotsopoulos IA, de Krom MC, Kessels FG, Lodder J, Troost J, Twellaar M, et al.
The diagnosis of epileptic and non-epileptic seizures. Epilepsy Res 2003;57:59-67.
Baslet G, Seshadri A, Bermeo-Ovalle A, Willment K, Myers L. Psychogenic non-epileptic seizures: An updated primer. Psychosomatics 2016;57:1-7.
Reuber M. Psychogenic non-epileptic seizures: Answer & questions. Epilepsy Behav 2008:23;68-70.
Oto M, Conway P, McGonigal A, Russell AJ, Duncan R. Gender differences in psychogenic non-epileptic seizures. Seizure 2005;14:33-9.
Brown RJ, Reuber M. Psychological and psychiatric aspects of psychogenic non-epileptic seizures (PNES): A systematic review. Clin Psychol Rev 2016;45:157-82.
Baslet G. Psychogenic non-epileptic seizures: A model of their pathogenic mechanism. Seizure 2011;20:1-3.
Brown RJ, Reuber M. Towards an integrative theory of psychogenic non-epileptic seizures (PNES). Clin Psychol Rev 2016;47:55-70.
Dhanaraj M, Rangaraj R, Arulmozhi T, Vengatesan A. Nonepileptic attack disorder among married women. Neurol India 2005;53:174-7.
] [Full text]
Patidar Y, Gupta M, Khwaja GA, Chowdhury D, Batra A, Dasgupta A. Clinical profile of psychogenic non-epileptic seizures in adults: A study of 63 cases. Ann Indian Acad Neurol 2013;16:157-62.
] [Full text]
Suman LN. Domestic violence, psychological trauma and mental health of women: A view from India. Women Health Open J 2015;1:e1-2.
Gorden PC, Marchetti RL. A review of the clinical approach and challenges to psychogenic non-epileptic seizures. Mol Cell Epilepsy 2014;1:e369.
Wig NN, Verma SK. PGI health questionnaire: A simple neuroticism scale in India. Indian J Pscyhiat 1973;15:80-8.
Kooiman CG, Ouwehand AW, ter Kuile MM. The sexual and physical abuse questionnaire (SPAQ). A screening instrument for adults to assess past and current experiences of abuse. Child Abuse Negl 2002;26:939-53.
Sharpe D, Faye C. Non-epileptic seizures and child sexual abuse: A critical review of the literature. Clin Psychol Rev 2006;26:1020-40.
Khandelwal D, Sharma NK. The clinical, psychological and neurological profile and assessing of outcome predictors of patients with psychogenic nonepileptic seizures: A study of 74 cases. Int J Sci Res 2018;7:24-9.
Lange A, de Beurs E, Dolan C, Lachnit T, Sjollema S, Hanewald G. Long-term effects of childhood sexual abuse: Objective and subjective characteristics of the abuse and psychopathology in later life. J Nerv Ment Dis 1999;187:150-8.
Singh MM, Parsekar SS, Nair SN. An epidemiological overview of child sexual abuse. J Family Med Prim Care 2014;3:430-5.
] [Full text]
Beghi M, Cornaggia I, Magaudda A, Perin C, Peroni F, Cornaggia CM. Childhood trauma and psychogenic nonepileptic seizures: A review of findings with speculations on the underlying mechanisms. Epilepsy Behav 2015;52:169-73.
LaFrance WC Jr., Reuber M, Goldstein LH. Management of psychogenic nonepileptic seizures. Epilepsia 2013;54 Suppl 1:53-67.