Journal Pre-proof

Insecure and unresolved-disorganized attachment in patients with psychogenic non-

epileptic seizures (PNES)

C. Gerhardt, K. Hamouda, F. Irorutola, M. Rose, K. Hinkelmann, A. Buchheim, P.

Senf-Beckenbach

PII: S0033-3182(20)30154-7
DOI: https://doi.org/10.1016/j.psym.2020.05.014
Reference: PSYM 1116

To appear in: Psychosomatics

Received Date: 24 April 2020

Revised Date: 17 May 2020
Accepted Date: 17 May 2020

Please cite this article as: Gerhardt C, Hamouda K, Irorutola F, Rose M, Hinkelmann K, Buchheim A,
Senf-Beckenbach P, Insecure and unresolved-disorganized attachment in patients with psychogenic
non-epileptic seizures (PNES), Psychosomatics (2020), doi: https://doi.org/10.1016/j.psym.2020.05.014.

This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition
of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of
record. This version will undergo additional copyediting, typesetting and review before it is published
in its final form, but we are providing this version to give early visibility of the article. Please note that,
during the production process, errors may be discovered which could affect the content, and all legal
disclaimers that apply to the journal pertain.

© 2020 Academy of Consultation-Liaison Psychiatry. Published by Elsevier Inc. All rights reserved.
 Insecure and unresolved-disorganized attachment in patients with
psychogenic non-epileptic seizures (PNES)
Gerhardt Ca, Hamouda Ka, Irorutola Fa, Rose Ma, Hinkelmann Ka, Buchheim Ab, Senf-
Beckenbach Pa,c

a
Department of Psychosomatic Medicine, Charité University Berlin, Germany
Medizinischen Klinik mit Schwerpunkt Psychosomatik
Charité Universitätsmedizin Berlin
Campus Benjamin Franklin
Hindenburgdamm 30
12200 Berlin
Germany

b
Department of Psychology, Clinical Psychology, University of Innsbruck, Austria
Institut für Psychologie
Universität Innsbruck
Bruno-Sander-Haus
Innrain 52f
6020 Innsbruck
Austria

c
Outpatient Clinic specialized on PNES, Department of Neurology and Psychosomatic
Medicine, Charité University Berlin, Germany
Psychosomatische Ambulanz
Charité Universitätsmedizin Berlin
Campus Charité Mitte (Hochschulambulanz)
Charitéplatz 1 (Geländeadresse: Sauerbruchweg 5, 2.Ebene)
10117 Berlin
Germany

Corresponding Author:
Carola Gerhardt
Medizinischen Klinik mit Schwerpunkt Psychosomatik
Charité Universitätsmedizin Berlin
Campus Benjamin Franklin
Hindenburgdamm 30
12200 Berlin
Germany
Carola.gerhardt@charite.de

Declarations of interest: none.

Abstract

Background: Psychogenic non-epileptic seizures (PNES) are still poorly understood and
difficult to treat. Attachment theory could add new aspects to the understanding of the
multifactorial genesis and maintenance of PNES and the therapeutic needs of this patient
group. Objective: The aim of the present study is to systematically assess attachment in
adult patients with PNES with a focus on the role of unresolved/disorganized attachment.
Methods: A cross-sectional design was chosen to compare patients with confirmed PNES
(n=44) and healthy controls (n=44) matched for gender, age and education. Attachment was
assessed with the Adult Attachment Projective Picture System (AAP). Psychometric
questionnaires included the Childhood Trauma Questionnaire (CTQ), Structured Clinical
Interview for DSM-IV axis II disorders, Patient Questionnaire (SCID-II-PQ), the Somatoform
Dissociation Questionnaire (SDQ-20) and the Patient Health Questionnaire (PHQ-9).
Results: We found significantly less secure (p=0,006) and more unresolved/disorganized
(p=0,041) attachment classifications in the PNES group. Among patients with PNES, 7%
were classified secure and 43% were classified unresolved/disorganized. Patients with an
unresolved attachment representation were significantly more likely to be screened positive
for personality pathology in the SCID-II-PQ (p=0,03) and to report more emotional abuse in
the CTQ (p=0,007) than patients with other attachment classifications.
Conclusion: Our findings suggest that unresolved/disorganized attachment might be the
predominant attachment style in patients with PNES and might be associated with more
severe personality pathology. This could be of therapeutic relevance. The present study is
the first to assess adult attachment with a semi-structured interview in comparison to
matched healthy controls.

Key Words
Psychogenic, seizure, attachment, psychopathology, unresolved trauma, dissociation

Introduction

Psychogenic non-epileptic seizures (PNES) are sudden and uncontrollable changes of

consciousness, movement, emotion or perception.1,2 Their paroxysmal attack-like nature
resembles epileptic seizures but in contrast to epileptic seizures, PNES are not accompanied
by electrophysiological changes in the brain.1,2 Psychopathology is high in patients with
PNES and there seems to be a consensus that psychological components play a crucial
etiological role in most patients.1-3 Until now, there is no comprehensive etiological model and
it is unclear what psychological mechanisms promote PNES.3

Psychopathology in PNES includes depression, anxiety, posttraumatic stress disorder

(PTSD) and personality disorders.2,3 PNES are associated with impaired emotion regulation,
dysfunctional coping and alexithymia.3 Patients with PNES report high rates of psychological
trauma, including childhood trauma.3-5 Dissociative symptoms are highly prevalent in PNES
and dissociation is being discussed as one possible etiological mechanism in the
multifactorial genesis of PNES for at least a portion of patients.3,6

A possible explanatory link between high rates of psychopathology and dissociation and high
rates of childhood trauma could be provided by attachment theory. Attachment disturbances
have repeatedly been linked to psychiatric illness7-9 and dissociation10,11 and can impair the
development of various neurobiological systems involved in stress coping and emotion
regulation.7,8 Furthermore, a patient´s individual attachment behaviour might be crucial to
therapy outcome and should be considered in the therapeutic process.7

According to attachment theory children develop an internal working model of secure,

insecure or unresolved/disorganized attachment very early in childhood based on their
experiences with primary caregivers.7,8,11-13 Insecure and especially unresolved/disorganized
attachment is associated with childhood trauma and maltreatment.14,15 However, attachment
disturbance is not necessarily caused by maltreatment.11,15 Disrupted, reclusive, affectively
negative or otherwise frightening behaviour of the caregiver can also be contributing
factors.11,16

Especially disorganized attachment carries a high risk of being associated with various forms
of psychopathology7,9,10 and has repeatedly been linked to dissociative
psychopathology.7,10,11,17

Despite its importance, attachment has not been studied extensively in PNES. To our
knowledge, four studies have assessed attachment in patients with PNES using
questionnaires and mostly in comparison to patients with epilepsy18-21 but attachment in
PNES has not been studied with a semi structured interview such as the Adult Attachment
Picture System (AAP)22. Further study of attachment in patients with PNES contributes to the
understanding of aetiological aspects as well as of therapeutic needs of this patient group.
The objective of the present study is to systematically assess attachment in patients with
PNES and to display the distribution of attachment classifications in this patient group,
evaluated by the interview method AAP in comparison to healthy controls matched along
relevant demographic variables. In addition, aspects of psychopathology typical to PNES
such as personality pathology, somatic dissociation and childhood trauma will be assessed
by self-administered questionnaires.

The key hypothesis is that among patients with PNES insecure and especially unresolved
attachment will be more prevalent than in the group of matched healthy controls.
In a second step, patients with unresolved/disorganized attachment will be compared to
patients with organized attachment representations to further explore the relationship
between disorganized attachment and psychopathology in our sample.

Materials and Methods

Participants
Between June 2017 and August 2019 n=44 consecutive patients with confirmed PNES and
n=44 controls were included in the study. Controls were chosen to match with patients
regarding age, gender and level of education.
Patients were recruited consecutively from the outpatient clinic specialized on PNES
affiliated to the Department of Neurology and Psychosomatic Medicine, Charité University
Berlin. Inclusion criteria were age of at least 18 years, diagnosis of PNES confirmed by
video-electroencephalography and ongoing seizures for more than six months with a
minimum of two seizures per month during the last three months. Patients were excluded in
case of a comorbid epilepsy, current psychosis, acute suicidal behaviour or insufficient
German language skills to complete testing.
Controls were recruited online in Berlin using the open access internet platform “Ebay
Kleinanzeigen” for advertisement. Study purpose and procedure were described in the
advertisement. Participants were offered study results and a compensation of 30 euros.
Inclusion criteria for controls were age of at least 18 years, no current diagnosed mental or
neurologic health impairment, no ongoing psychotherapy and a level of German language
skills sufficient to undergo testing. A past psychologic diagnosis (e.g. depressive episode or
adjustment disorder) or completed psychotherapeutic intervention did not lead to exclusion.
Controls who exceeded the cut-off scores of two or more psychometric questionnaires were
not considered as healthy and excluded from the study.
All patients and controls gave written and informed consent. The study design was fully
approved by the Ethics Committee of the Medical Faculty of Charité University Berlin
(EA1/185/16).

Adult Attachment Projective Picture System (AAP)

The AAP22 is a semi-structured interview of about 30 minutes. It is a reliable and validated
tool for the assessment of adult attachment representation.13,23 The AAP is available in
German.24
A set of theory-derived picture stimuli is used to activate the attachment system. Using
standardized questions, participants are invited to tell a short story about each picture. Story
content, defence mechanisms and linguistic patterns are analysed by trained interpreters
using a verbatim transcript of the interview.13,22 Participants are then assigned to one of four
attachment categories: secure (F), insecure dismissing (DS), insecure preoccupied (E) and
unresolved (U).13,22 In their inability to contain and reorganize their attachment fears,
unresolved individuals remain disorganized. In contrast, secure and insecure dismissing or
preoccupied individuals together form the group of organized attachment.13

The AAP has been developed in constant validation with the Adult Attachment Interview
(AAI)25, which is considered the gold standard of attachment measurement.22,24 The AAP´s
inter-judge reliability (kappa=0,85, p<0,001), test-retest reliability (kappa=0,78, p<0,001) and
concordant validity to the AAI (kappa=0,84, p<0,001) have proven to be very strong.13,22,26
Verbal intelligence and social desirability did not influence AAP classification.13,22,26

All interviews of our study were conducted by the same trained interviewer (C.G.) in the
same room after a short greeting. Interviews took place before running any other tests.
Immediately before the AAP, the interviewer reconfirmed that participants were not in a state
of mind characterised by emotional upheaval. Verbatim transcripts were rated by an external,
established and qualified AAP interpreter (A.B.) blind to any information about participants
such as study group, age, gender or level of education.

Questionnaires
Borderline, narcistic and histrionic personality disorders according to the criteria of DSM-IV
were screened for by using the corresponding extract from the SCID-II-PQ (Structured
Clinical Interview for DSM-IV axis II disorders, patient questionnaire).27,28
The SCID-II-PQ employs binary yes/no-questions. Participants choose if a certain behaviour
or personal trait is rather true (yes) or not true (no) for them.
Although it was not developed as an independent diagnostic tool29 in a study comparing the
results of the SCID-II PQ and the SCID-II interview28, the SCID-II-PQ produced diagnostic
results similar to those of the SCID-II interview with an overall kappa of agreement of
0,78.28,29
If participants exceeded the cut-off in at least one subsection, the screening was considered
positive for personality pathology.

The 28-item Childhood Trauma Questionnaire (CTQ)30,31 was used to assess early life
adversity. The CTQ is a reliable and valid tool and the most commonly used test
internationally to evaluate childhood maltreatment.31 The 28-item paper-pencil questionnaire
has also been validated for German language.31 Participants can express the extent to which
they experienced certain events from a score of one (never) to a score of five (very often).
Using 25 clinical and three validity items, five subscales of childhood maltreatment are
measured: emotional abuse, emotional neglect, physical abuse, physical neglect and sexual
abuse.30,31

The 20-item Somatoform Dissociation Questionnaire (SDQ-20)32,33 was used to assess the
physical aspects of dissociative psychopathology. Somatoform dissociation involves physical
symptoms like pain, anaesthesia, the temporary inability to move or see without medical
explanation. Participants can express the extent to which they suffer from a certain symptom
from one (not at all) to five (extremely).32,33

The 9-item Patient Health Questionnaire (PHQ-9)34 was handed out to acquire information
about depressive symptoms. The PHQ has shown good sensitivity and specificity in the
screening of depressive disorders.35

Statistical Analysis
Statistical analyses were calculated using SPSS software version 25 (SPSS Inc., Chicago,IL
60606, USA). Group differences were calculated with Pearson Chi-square-test for
dichotomous variables. For parametric continuous variables, the independent t-test was
chosen. The level of significance was set at p < 0,05.

Results

Demographic and clinical characteristics

The final sample size was n=44 in both the patient and the healthy control group. As
summarized in table 1, the two groups were similar in terms of age, gender and level of
education.

Table 1. Demographic characteristics of the total sample (by group)

Variable PNES HC p-Value
n=44 n=44
Age: mean (±SD) 37,30 (±12,03) 36,98 (±12,34) 0,90

Gender: n (%) 1,0

Male 10 (22,7) 10 (22,7)
Female 34 (77,3) 34 (77,3)

School education: mean (±SD); 11,77 (±1,59) 11,87 (±1,48) 0,84

years

p-values calculated with t-test for continuous and chi-square test for dichotomous variables.
PNES: psychogenic non-epileptic seizures; HC: healthy control; SD: standard deviation.

Table 2 shows, that the scores of healthy controls and patients differed significantly in the
expected direction in all psychometric self-report questionnaires. Four patients did not
complete the SDQ and PHQ. Means and proportions for the respective scores were
calculated only for valid values. 32 patients (80%) and one control (2,3%) obtained SDQ
scores that indicate clinically relevant somatoform dissociation.

Table 2. Questionnaire results of the total sample (by group)

Variable PNES HC p-Value Mean difference (95% Confidence
n=44 n=44 Interval)
SCID-II-PQ, positive screening:
n (%)
Yes 32 (72,73) 6 (13,64) <0,001
No 12 (27,27) 38 (86,36)

CTQ: mean (±SD); score

Total Score 52,40 (±18,79) 31,48 (±6,32) <0,001 20,92 (14,86; 26,98)
Emotional Neglect 13,69 (±5,48) 8,50 (±4,01) <0,001 5,19 (3,16; 7,23)
Sexual Abuse 8,68 (±5,11) 5,61 (±2,09) 0,001 3,07 (1,40; 7,74)
Physical Abuse 7,43 (±3,74) 5,66 (±2,77) 0,013 1,77 (0,38; 3,17)
Physical Neglect 9,39 (±4,32) 6,70 (±3,30) 0,002 2,68 (1,05; 4,31)
Emotional Abuse 13,20 (±5,76) 7,36 (±3,61) <0,001 5,84 (3,80; 7,88)

SDQ-20: mean (±SD); score 35,55 (±7,75) 21,25 (±2,00) <0,001 14,30 (11,76; 16,85)
Missing: n 4 0

PHQ-9, depression scale: mean

(±SD); score 11,55 (±6,09) 1,77 (±1,79) <0,001 9,77 (7,76; 11,29)
Missing: n 4 0
p-values calculated with t-test for continuous and chi-square test for dichotomous variables.
PNES: psychogenic non-epileptic seizures; HC: healthy control; SD: standard deviation.
SCID-II-PQ: Structured Clinical Interview for DSM-IV, Patient Questionnaire, extract: Narcistic/Histrionic/Borderline; CTQ:
Childhood Trauma Questionnaire; SDQ-20: 20-item Somatoform Dissociation Questionnaire; PHQ: Patient Health
Questionnaire-9.

Attachment status in patients and controls

The distribution of secure attachment classification differed significantly between the two
groups (χ2=7,639, df=1, p=0,006). Three individuals (7%) of the patient group and 13
individuals (30%) of the control group were classified as having secure attachment.
With a proportion of 43% versus 23% almost twice as many patients than controls were
classified unresolved/disorganized. The group difference was significant (χ2=4,166, df=1,
p=0,041). Table 3 summarizes the attachment distribution in both groups.

Table 3. Attachment classifications of the total sample (by group)

Variable PNES HC p-Value
n=44 n=44
AAP classification: n (%)
Secure 3 (6,82) 13 (29,54) 0,021
Dismissing 11 (25,00) 8 (18,18)
Preoccupied 11 (25,00) 13 (29,55)
Unresolved 19 (43,18) 10 (22,73)

Secure 3 (6,82) 13 (29,54) 0,006

Insecure/disorganized 41 (93,18) 31 (70,46)

Organized 25 (56,82) 34 (77,27) 0,041

Disorganized 19 (43,18) 10 (22,73)

p-Values calculated with chi-square test

PNES: psychogenic non-epileptic seizures; HC: Healthy Control; AAP: Adult Attachment Picture System.

Organized vs. disorganized attachment in patients

Table 4 presents a detailed display of demographic and clinical data comparing patients with
disorganized classification (unresolved, n =19) in the AAP to those with organized
attachment representations (secure, insecure preoccupied, insecure dismissing, n=25).
The groups were similar regarding their demographic variables, depressive and dissociative
symptoms (table 4) but differed significantly concerning the rate of personality pathology
screened for by the SCID-II-PQ and the CTQ sub score emotional abuse (table 4).

Table 4. Demographic and clinical characteristics of patients (by attachment organization)

Variable Disorganized Organized p-Value Mean difference (95% Confidence
n=19 n=25 Interval)
Age: mean (±SD) 36,68 (±11,62) 37,76 (±12,54) 0,770 1,08 (-6,32; 8,47)

Gender: n (%)
Male 4 (21,05) 6 (24) 0,817
Female 15 (78,95) 19 (76)

School education: mean 12,00 (±1,53) 11,600 (±1,62) 0,409 -0,40 (-1,39; 0,58)
(±SD); years

SCID-II-PQ, positive
screening: n (%)
Yes 17 (89,47) 15 (60) 0,030*
No 2 (10,53) 10 (40)

CTQ: mean (±SD); score

Total Score 56,96 (±17,72) 48,93 (±19,49) 0,162 -8,03 (-19,41; 3,35)
Emotional Neglect 14,91 (±6,13) 12,77 (±4,84) 0,219 -2,14 (-5,61; 1,34)
Sexual Abuse 8,32 (±4,56) 8,96 (±5,57) 0,675 0,64 (-2,44; 3,73)
Physical Abuse 7,58 (±2,85) 7,32 (±4,35) 0,813 -0,26 (-2,46; 1,94)
Physical Neglect 10,37 (±5,08) 8,64 (±3,57) 0,215 -1,73 (-4,52; 1,06)
Emotional Abuse 15,79 (±5,04) 11,24 (±5,04) 0,007* -4,55 (-7,79; -1,31)

SDQ-20: mean (±SD); score 35,56 (±7,55) 35,54 (±8,05) 0,993 -0,02 (-5,11; 5,06)
Missing: n 3 1

PHQ-9 depression scale:

mean (±SD); score 11,00 (±5,68) 11,92 (±6,45) 0,639 0,92 (-3,01; 4,85)
Missing: n 3 1

p-values calculated with t-test for continuous and chi-square test for dichotomous variables.
HC: Healthy Control; SD: Standard Deviation.
SCID-II-PQ: Structured Clinical Interview for DSM-IV, Patient Questionnaire, extract: Narcistic/Histrionic/Borderline; CTQ:
Childhood Trauma Questionnaire; SDQ-20: 20-item Somatoform Dissociation Questionnaire; PHQ: Patient Health
Questionnaire-9.

Discussion

Confirming our hypothesis, we found significantly less secure and more unresolved
attachment classifications in the patient group than in the group of matched healthy controls.
In contrast to the control group, only a marginal minority of the patient group was classified
secure. Unresolved/disorganized attachment was the predominant attachment classification
of the patient group.

To our knowledge, the present study is the first using the semi-structured interview AAP to
measure the attachment style of adult patients with PNES, in comparison to healthy controls
matched along relevant demographic variables. The AAP is a valid and robust tool to analyse
adult attachment and to reveal unresolved states of mind concerning attachment.22,23 The
matching of a healthy control group along relevant demographic variables reduces possible
confounders and allows to display how patients with PNES might differ from the healthy
population.

Our results are in line with the findings of Holman et al.18 who identified fearful attachment as
the predominant attachment style in a sample of 17 patients with PNES using the
Relationship Scales Questionnaire (RSQ). As the concept of fearful attachment overlaps with
the concept of unresolved/disorganized attachment,7 these findings complement each other
in a plausible way.
Reuber et al.20 also found significantly more insecure attachment representations in their
sample of patients with PNES than among controls with epilepsy and healthy controls.
However, Reuber et al. focused on personality and not attachment assessment and did not
use a tool designed for attachment assessment, but measured attachment insecurity as one
of 18 personality traits.20
In contrast, Brown et al.19 and Green et al.21 did not find significant differences concerning
attachment insecurity between patients with PNES and patients with epilepsy using self-
report questionnaires for attachment assessment. In the case of Brown et al.19, this could be
due to low power.3 All four studies assessed attachment with self-report questionnaires, did
not match control groups and only Reuber et al.20 recruited healthy controls in addition to
controls with epilepsy.

To further explore the relationship between unresolved/disorganized attachment and

psychopathology in our sample, we performed an intragroup analysis of the PNES group. As
both patient groups were similar regarding gender, age, level of education and depression,
we consider the group differences unrelated to any of these variables but to be attributable to
attachment disorganization. In our sample, unresolved/disorganized attachment seemed to
be significantly associated with higher rates of personality pathology and reported emotional
abuse in childhood. The complex interplay of disrupted maternal communication and
disorganized infant attachment is known to play an important role in the development of
borderline personality disorder.36
However, it is conceivable that dysfunctional parental behavior as well as psychopathology in
offspring partly reflect the effects of a shared genetic predisposition to emotional and
interpersonal dysfunction. For many complex traits or psychopathological constellations,
genes have been shown to contribute 30-50% to the variance.37 For attachment in infants
only modest genetic influences have been shown.37 Nevertheless, the vulnerability to
develop behavioural dysregulation in reaction to attachment distress seems to be
heritable.8,36,37 Behavioral dysregulation was found in infants with insecure attachment and at
least one short allele of the 5-HTTLR gene but not in securely attached children with short
alleles of this gene. In children with homozygous long alleles, attachment insecurity did not
affect regulatory capacity.36 Additionally, epigenetic alteration of stress and emotion
regulatory systems and learning processes influence the development of psychopathology in
reaction to parental dysfunction.8
Although we can only speculate about the underlying mechanisms, our findings suggest that
the heterogenous group of individuals with PNES might contain a sizable subgroup with
especially high rates of personality pathology. In their cluster analysis of patients with PNES,
Reuber et al.20 came to comparable conclusions and identified one subgroup with
pronounced personality pathology resembling the concept of borderline personality disorder
and high scores of insecure attachment and emotional dysregulation versus a second cluster
of more moderate personality pathology, less attachment insecurity and a better prognosis.

Attachment disorganization is not rare among healthy individuals.11,13 In our sample, more
than one fifth of the healthy control group was classified disorganized. Attachment
disorganization and other contributing factors seem to interact in a complex manner to
activate a developmental pathway to personality pathology and dissociation.36 Further
contributing factors include dysfunctional parental behaviour, family distress, childhood
maltreatment and genetic vulnerability.36

All patients with PNES in our sample scored considerably and significantly higher than the
healthy control group in all questionnaires measuring psychopathology with very small p-
values.
These findings are in line with the extensive body of literature linking PNES to elevated
personality pathology,3,38 rates of childhood trauma3,4 and depression.3
Depression, personality pathology and childhood trauma have all been shown to be
associated with attachment insecurity and especially disorganisation.9,14,36 As our study
design cannot explore causality, it remains unclear if attachment insecurity and
disorganization in our sample are side effects of psychiatric comorbidity, specific to PNES or
both. Further research could compare patients with PNES to adequate psychiatric controls to
explore specific dynamics of psychopathology and attachment in patients with PNES.

There are several limitations to our study. First, psychopathology was assessed by self-
report questionnaires and not interviews conducted by trained clinicians. Especially the
assessment of childhood trauma using a self-report measure could lead to recall biases,
including underreporting or potentially overreporting. Additionally, the assessment of
childhood trauma in adults is of a retrospective nature and therefore of a limited scope.
Furthermore, the AAP transcripts were rated by one judge. Despite the high inter-judge
reliability of the AAP, the lack of a second interpreter could slightly affect the robustness of
the results.

As studies of attachment in patients with PNES are scarce and the use of different methods
limits comparability, further research is needed. Nonetheless, our findings imply that PNES
might be associated with insecure and unresolved attachment. It is conceivable that
attachment insecurity and disorganization play a role in the multifactorial genesis and
maintenance of PNES.
Our findings can be useful to clinicians as the attachment relationship between client and
therapist is crucial to therapy outcomes.39 In a recent meta-analysis, improvement in
attachment security was found to be a predicting factor of therapy outcome in
psychotherapy.40 It is a prerequisite for an improvement in attachment security to tailor the
therapeutic strategies to the needs associated with the patient´s specific attachment
patterns.39 This might be particularly important in the treatment of patients with PNES.

Conclusion
Our findings suggest, that secure attachment representation is scarce among patients with
PNES. Disorganized attachment might be the predominant attachment style in this patient
group and could be associated with more severe personality pathology and distinct patterns
of early life trauma. This could be of high clinical importance and patients with PNES might
benefit especially from attachment-oriented therapies.
However, research on the role of attachment insecurity and disorganization in the aetiology
and prognosis of PNES remains scarce. Further research with larger sample sizes and
adequate psychiatric control groups is therefore needed.

Disclosure
The authors report no proprietary or commercial interest in any product mentioned or
concept discussed in this article.

Funding
This work was supported by the Else Kröner Fresenius Stiftung (EKFS) (grant number
2016_A178) and by the Heidehof Stiftung (grant number 59087.01.2/2. 16, 17 and 18).

Acknowledgments
Special thanks to Luisa Barleben for proof reading, Teresa and Jordan Pace who provided
language support and to Katharina von Viliez for the transcription of the interviews.

References
1. LaFrance WC, Baker GA, Duncan R, Goldstein LH, Reuber M: Minimum requirements
for the diagnosis of psychogenic nonepileptic seizures: a staged approach: a report from
the International League Against Epilepsy Nonepileptic Seizures Task Force. Epilepsia
2013;54(11):2005–18. https://doi.org/10.1111/epi.12356

2. Bodde NMG, Brooks JL, Baker GA, et al: Psychogenic non-epileptic seizures--definition,
etiology, treatment and prognostic issues: a critical review. Seizure 2009;18(8):543–53.
https://doi.org/10.1016/j.seizure.2009.06.006

3. Brown RJ, Reuber M: Psychological and psychiatric aspects of psychogenic non-

epileptic seizures (PNES): A systematic review. Clin Psychol Rev 2016;45:157–82.
https://doi.org/10.1016/j.cpr.2016.01.003

4. 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(Pt A):169–73.
https://doi.org/10.1016/j.yebeh.2015.09.007

5. Fiszman A, Alves-Leon SV, Nunes RG, D’Andrea I, Figueira I: Traumatic events and
posttraumatic stress disorder in patients with psychogenic nonepileptic seizures: a critical
review. Epilepsy Behav 2004;5(6):818–25. https://doi.org/10.1016/j.yebeh.2004.09.002

6. Pick S, Mellers JDC, Goldstein LH: Dissociation in patients with dissociative seizures:
relationships with trauma and seizure symptoms. Psychol Med 2017;47(7):1215–29.
https://doi.org/10.1017/S0033291716003093

7. Shorey HS, Snyder CR: The Role of Adult Attachment Styles in Psychopathology and
Psychotherapy Outcomes. Rev Gen Psychol 2006;10(1):1–20.
https://doi.org/10.1037/1089-2680.10.1.1

8. Chambers J: The Neurobiology of Attachment: From Infancy to Clinical Outcomes.

Psychodyn Psychiatry 2017;45(4):542–63. https://doi.org/10.1521/pdps.2017.45.4.542

9. Dagan O, Facompré CR, Bernard K: Adult attachment representations and depressive

symptoms: A meta-analysis. J Affect Disord 2018;236:274–90.
https://doi.org/10.1016/j.jad.2018.04.091

10. Green J, Goldwyn R: Annotation: Attachment disorganisation and psychopathology: new

findings in attachment research and their potential implications for developmental
psychopathology in childhood. J Child Psychol Psychiatry 2002;43(7):835–46.
https://doi.org/10.1111/1469-7610.00102

11. Liotti G: A model of dissociation based on attachment theory and research. J Trauma
Dissociation 2006;7(4):55–73. https://doi.org/10.1300/J229v07n04_04

12. Bowlby J: Attachment and loss: retrospect and prospect. Am J Orthopsychiatry

1982;52(4):664–78. https://doi.org/10.1111/j.1939-0025.1982.tb01456.x

13. George C, West M: The Adult Attachment Projective Picture System: integrating
attachment into clinical assessment. J Pers Assess 2011;93(5):407–16.
https://doi.org/10.1080/00223891.2011.594133
14. Morton N, Browne KD: Theory and observation of attachment and its relation to child
maltreatment: a review. Child Abuse Negl 1998;22(11):1093–104.
https://doi.org/10.1016/s0145-2134(98)00088-x

15. Granqvist P, Sroufe LA, Dozier M, et al: Disorganized attachment in infancy: a review of
the phenomenon and its implications for clinicians and policy-makers. Attach Hum Dev
2017;19(6):534–58. https://doi.org/10.1080/14616734.2017.1354040

16. Lyons-Ruth K, Pechtel P, Yoon SA, Anderson CM, Teicher MH: Disorganized attachment
in infancy predicts greater amygdala volume in adulthood. Behav Brain Res
2016;308:83–93. https://doi.org/10.1016/j.bbr.2016.03.050

17. Farina B, Speranza AM, Dittoni S, et al: Memories of attachment hamper EEG cortical
connectivity in dissociative patients. Eur Arch Psychiatry Clin Neurosci 2014;264(5):449–
58. https://doi.org/10.1007/s00406-013-0461-9

18. Holman N, Kirkby A, Duncan S, Brown RJ: Adult attachment style and childhood
interpersonal trauma in non-epileptic attack disorder. Epilepsy Res 2008;79(1):84–9.
https://doi.org/10.1016/j.eplepsyres.2007.12.015

19. Brown RJ, Bouska JF, Frow A, et al: Emotional dysregulation, alexithymia, and
attachment in psychogenic nonepileptic seizures. Epilepsy Behav 2013;29(1):178–83.
https://doi.org/10.1016/j.yebeh.2013.07.019

20. Reuber M, Pukrop R, Bauer J, Derfuss R, Elger CE: Multidimensional assessment of

personality in patients with psychogenic non-epileptic seizures. J Neurol Neurosurg
Psychiatry 2004;75(5):743–8. https://doi.org/10.1136/jnnp.2003.013821

21. Green B, Norman P, Reuber M: Attachment style, relationship quality, and psychological
distress in patients with psychogenic non-epileptic seizures versus epilepsy. Epilepsy
Behav 2017;66:120–6. https://doi.org/10.1016/j.yebeh.2016.10.015

22. George C, West M: The development and preliminary validation of a new measure of
adult attachment: the adult attachment projective. Attach Hum Dev 2001;3(1):30–61.
https://doi.org/10.1080/14616730010024771

23. Ravitz P, Maunder R, Hunter J, Sthankiya B, Lancee W: Adult attachment measures: a

25-year review. J Psychosom Res 2010;69(4):419–32.
https://doi.org/10.1016/j.jpsychores.2009.08.006

24. Buchheim A, George C, West M: Das Adult Attachment Projective (AAP) - Gütekriterien
und neue Forschungsergebnisse [The adult attachment projective (AAP) - psychometric
properties and new reserach results]. Psychother Psychosom Med Psychol 2003;53(9–
10):419–27. https://doi.org/10.1055/s-2003-42170

25. George C, Kaplan N, Main M: The Adult Attachment Interview. Unpublished Manuscript.
Department of Psychology, University of California, Berkely, 1996

26. Gander M, George C, Pokorny D, Buchheim A: Assessing Attachment Representations

in Adolescents: Discriminant Validation of the Adult Attachment Projective Picture
System. Child Psychiatry Hum Dev 2017;48(2):270–82. https://doi.org/10.1007/s10578-
016-0639-2

27. Wittchen HU, Zaudig M, Fydrich T: SKID. Strukturiertes Klinisches Interview für DSM-IV.
Achse I und II. Handanweisung. Göttingen, Hogrefe; 1997
28. Ekselius L, Lindström E, Knorring L von, Bodlund O, Kullgren G: SCID II interviews and
the SCID Screen questionnaire as diagnostic tools for personality disorders in DSM-III-R.
Acta Psychiatr Scand 1994;90(2):120–3. https://doi.org/10.1111/j.1600-
0447.1994.tb01566.x

29. First B, Gibbon M: The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I)
and the Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-II). In: Hilsenroth
MJ, Segal DL, editors: Comprehensive Handbook of Psychological Assessment, Volume
2: Personality Assessment. Hoboken, John Wiley & Sons, 2004:134-43

30. Bernstein DP, Stein JA, Newcomb MD, et al: Development and validation of a brief
screening version of the Childhood Trauma Questionnaire. Child Abuse Negl
2003;27(2):169–90. https://doi.org/10.1016/s0145-2134(02)00541-0

31. Klinitzke G, Romppel M, Häuser W, Brähler E, Glaesmer H: Die deutsche Version des
Childhood Trauma Questionnaire (CTQ) – psychometrische Eigenschaften in einer
bevölkerungsrepräsentativen Stichprobe [The German Version of the Childhood Trauma
Questionnaire (CTQ): psychometric characteristics in a representative sample of the
general population]. Psychother Psychosom Med Psychol 2012;62(2):47–51.
https://doi.org/10.1055/s-0031-1295495

32. Nijenhuis ER, Spinhoven P, Van Dyck R, Van der Hart O, Vanderlinden J: The
development and psychometric characteristics of the Somatoform Dissociation
Questionnaire (SDQ-20). J Nerv Ment Dis 1996;184(11):688–94.
https://doi.org/10.1097/00005053-199611000-00006

33. Mueller-Pfeiffer C, Schumacher S, Martin-Soelch C, et al: The Validity and Reliability of

the German Version of the Somatoform Dissociation Questionnaire (SDQ-20). J Trauma
Dissociation 2010;11(3):337–57. https://doi.org/10.1080/15299731003793450

34. Gräfe K, Zipfel S, Herzog W, Löwe B: Screening psychischer Störungen mit dem
“Gesundheitsfragebogen für Patienten (PHQ-D)“ [Screening for psychiatric disorders with
the Patient Health Questionnaire (PHQ). Results from the German validation study].
Diagnostica 2004;50(4):171–81. https://doi.org/10.1026/0012-1924.50.4.171

35. Levis B, Benedetti A, Thombs BD: Accuracy of Patient Health Questionnaire-9 (PHQ-9)
for screening to detect major depression: individual participant data meta-analysis. BMJ
2019;365:l1476:1-11. https://doi.org/10.1136/bmj.l1476

36. Levy KN, Beeney JE, Temes CM: Attachment and its vicissitudes in borderline
personality disorder. Curr Psychiatry Rep 2011;13(1):50–9.
https://doi.org/10.1007/s11920-010-0169-8

37. Plomin R, DeFries JC, McClearn GE, McGuffin P: Behavioral Genetics. 5th ed. New
York, Worth Publishers; 2008

38. Beghi M, Negrini PB, Perin C, et al: Psychogenic non-epileptic seizures: so-called
psychiatric comorbidity and underlying defense mechanisms. Neuropsychiatr Dis Treat
2015;11:2519–27. https://doi.org/10.2147/NDT.S82079

39. Slade A, Holmes J: Attachment and psychotherapy: Curr Opin Psychol 2019;25:152–6.
https://doi.org/10.1016/j.copsyc.2018.06.008

40. Levy KN, Kivity Y, Johnson BN, Gooch CV: Adult attachment as a predictor and
moderator of psychotherapy outcome: A meta-analysis. J Clin Psychol
2018;74(11):1996–2013. https://doi.org/10.1002/jclp.22685