Epilepsy & Behavior 37 (2014) 110–115

Contents lists available at ScienceDirect

Epilepsy & Behavior

journal homepage: www.elsevier.com/locate/yebeh

Regulation of emotions in psychogenic nonepileptic seizures

Monika Urbanek a,⁎, Martin Harvey b, John McGowan a, Niruj Agrawal c
a
Salomons Centre for Applied Psychology, Canterbury Christ Church University, Runcie Court, David Salomons Estate, Broomhill Road, Tunbridge Wells TN3 0TF, UK
b
West Kent Neuro-Rehabilitation Unit, West Kent Neuropsychiatry Service, Darent House, Sevenoaks Hospital, Hospital Road, Sevenoaks TN13 3PG, UK
c
Neuropsychiatry Unit, Clare House, St George's Hospital, Blackshaw Road, London SW17 0QT, UK

a r t i c l e i n f o a b s t r a c t

Article history: Background: Despite the long history of psychogenic nonepileptic seizures (PNES), relatively little is known about
Received 26 March 2014 the mechanisms that cause and maintain this condition. Emerging research evidence suggests that patients with
Revised 25 May 2014 PNES might have difficulties in regulating their emotions. However, much remains to be learned about the nature
Accepted 4 June 2014 of these difficulties and the emotional responses of individuals with PNES. This study aimed to gain a detailed un-
Available online xxxx
derstanding of emotion regulation processes in patients with PNES by examining differences between patients
with PNES and a healthy control group with regard to intensity of emotional reactions, understanding of one's
Keywords:
Psychogenic
emotional experience, beliefs about emotions, and managing emotions by controlling emotional expression.
Nonepileptic Method: A cross-sectional design was used to compare the group with PNES (n = 56) and the healthy control
Seizures group (n = 88) on a range of self-report measures.
Emotion regulation Results: Participants with a diagnosis of PNES reported significantly poorer understanding of their emotions, more
Alexithymia negative beliefs about emotions, and a greater tendency to control emotional expression compared to the control
group. While intensity of emotions did not discriminate between the groups, poor understanding and negative be-
liefs about emotions were found to be significant predictors of PNES, even after controlling for age, education level,
and emotional distress. Furthermore, the presence of some emotion regulation difficulties was associated with
self-reported seizure severity.
Conclusions: The results of this study are largely consistent with previous literature and provide evidence for
difficulties in emotion regulation in patients with PNES. However, this research goes further in bringing together
different aspects of emotion regulation, including beliefs about emotions, which have not been examined before.
As far as it is known, this is the first study to suggest that levels of alexithymia in a population with PNES are
positively associated with self-reported seizure severity. The findings suggest a need for tailored psychological
therapies addressing specific emotion regulation difficulties in individuals with PNES.
© 2014 Published by Elsevier Inc.

1. Introduction there is no consensus with regard to the definition of emotion regula-

Psychogenic nonepileptic seizures (PNES) are episodes of sudden,
involuntary, and time-limited alteration in movement, sensation, be-
havior, or consciousness, which superficially resemble epileptic seizures
(ES) but are not associated with abnormal electrical discharges in
the brain [1]. While most authors recognize that PNES are thought to
represent an experiential or behavioral response to emotional distress
[2], the psychological mechanisms underlying PNES remain poorly
understood [3], which has negative implications for treatments and
outcomes [4].
Emotion regulation is considered to be a psychological mechanism
underlying various forms of mental and physical illness [5,6]. Although
⁎ Corresponding author at: 108A Lancaster Road, W11 1QS, UK. Tel.: +44 2075984911;
fax: +44 2073680202.
E-mail address: monikaurbanek@nhs.net (M. Urbanek).
tion (ER), a number of theories have been proposed [5,7–9], and ER
has been described as conscious and unconscious [10] processes by
which individuals influence, manage, experience, and express their
emotions [11]. Mennin et al. [9], who developed an emotion dysregula-
tion model of mood disorders, emphasized that the process of ER is dy-
namic and that regulation occurs at different points, namely generation,
understanding, reactivity, and management of emotions.
While it is widely assumed that PNES are closely tied to emotions and
even caused purely by emotions [12], only a handful of studies have ex-
amined emotion regulation (ER) difficulties, and little is known about
specific ER processes involved in PNES. Some research has shown PNES
to be associated with deficits in identifying and describing feelings
[13–15]. Furthermore, certain aspects of emotional dysregulation such
as autonomic hyperarousal, intrusive experiences, dissociation, and de-
fensive avoidance have been found to be positively associated with
alexithymia in patients with PNES [14]. It is worth noting that while pa-
tients with PNES tend to report higher levels of alexithymia than healthy

http://dx.doi.org/10.1016/j.yebeh.2014.06.004
1525-5050/© 2014 Published by Elsevier Inc.
 M. Urbanek et al. / Epilepsy & Behavior 37 (2014) 110–115
controls, the differences between patients with PNES and ES have not al-
ways been found, particularly when anxiety and depression have been
controlled for [13,15].
Increased threat vigilance [16] and avoidance behaviors [17] have
been documented in patients with PNES and might be indicative of a
particular type of emotional processing. Two studies to date provided
some evidence of emotion regulation difficulties using the Difficulties
in Emotion Regulation Scale (DERS [18]) [19,20]. The findings also
showed that patients with PNES experienced greater emotional inten-
sity when presented with neutral and pleasant pictures but not un-
pleasant pictures. They did not experience greater negativity than
those without PNES [19].
Furthermore, a mixed picture has emerged with regard to the
emotional expression in PNES. Roberts et al. [19] demonstrated a
diminished expression of positive affect in patients with PNES. Howev-
er, these findings were in contrast to the results of Stone, Binzer, and
Sharpe [21], who failed to discover differences between patients with
ES and PNES on difficulties expressing feelings, as measured by an affect
inhibition subscale of the Illness Behavior Questionnaire (IBQ [22]). The
inconsistency in findings could be due to methodological limitations of
the studies or different methods used to measure emotional expression.
It is also possible that the use of ER strategies varies, depending on spe-
cific emotions.
Research examining how patients with PNES process emotions is
still in its infancy. The aim of the current research was to extend the pre-
vious findings and to provide a comprehensive understanding of ER
processes in PNES using the conceptual framework developed by
Mennin et al. [9]. The following aspects of ER were examined: intensity
of emotional reactions, understanding of one's emotional states, beliefs
about emotions, and the extent to which individuals with PNES used
emotional control strategies. Based on previous findings regarding
PNES as well as other psychosomatic conditions, it was predicted that,
overall, patients with PNES would demonstrate poorer ER and report
heightened intensity of emotions, poorer understanding of emotions,
more negative beliefs about emotions, and a higher level of emotional
control strategies compared to controls. Finally, it was hypothesized
that ER difficulties would predict the presence or absence of PNES and
that ER difficulties would be associated with a change in seizure charac-
teristics (frequency, severity, bothersomeness).
2. Methods
2.1. Participants
Patients with PNES were recruited via outpatient clinics in the neu-
ropsychiatry services of two NHS trusts in South East England, and each
had been diagnosed by a consultant neurologist with a special interest
in epilepsy and consultant neuropsychiatrist on the basis of clinical
assessment and investigations including EEG and/or video EEG as
necessary. Patients attending the outpatient clinics were invited to par-
ticipate in the study if they (1) had a diagnosis of PNES, (2) were
experiencing at least occasional nonepileptic seizures at the time of
the study, and (3) had the capacity to give informed consent. Partici-
pants were excluded if they (1) were less than 18 years of age or
(2) had a concurrent diagnosis of learning disability, autism, dementia,
or acquired brain injury. While 181 patients with PNES were invited
to take part in this research, a total of 56 comprised the final sample,
yielding a response rate of 31%.
The healthy control (HC) group was recruited through a university
and a social networking site. Participants were included if they (1) had
no history or evidence of seizure activity. They were excluded if they
(1) were less than 18 years of age; (2) had a long-term neurological or
health condition (e.g., fibromyalgia, chronic fatigue syndrome, brain
tumor, head injury, or stroke); or (3) had a severe psychiatric disorder
(e.g., schizophrenia, bipolar disorder, or personality disorder) or a histo-
ry of self-harm. A total of 88 participants comprised the final sample.
111
2.2. Measures
2.2.1. Affect intensity
The Affect Intensity Measure (AIM) was used to examine the inten-
sity of emotional reactions. The AIM is a widely used 40-item self-report
questionnaire, which assesses the intensity of emotional responses to
both negative and positive emotionally salient life events. The items
are rated on a 6-point scale, ranging from “never” to “always”. Adequate
internal consistency and convergent and discriminate validity have
been established for this measure [23]. Test–retest reliability of 0.81
after three months has also been demonstrated [23]. The AIM had a
good internal consistency in the present study (α = .85).
2.2.2. Alexithymia
The Toronto Alexithymia Scale—20 (TAS-20) was used as a measure
of understanding one's own emotions. It is a well-established and widely
used self-report scale, consisting of 20 items, rated on a 5-point scale,
ranging from “strongly agree” to “strongly disagree”. A total score greater
than 60 represents alexithymia [24]. The TAS-20 has shown good inter-
nal consistency (Cronbach's alpha = .81 [25] and .85 [9]). Furthermore,
the TAS-20 demonstrated adequate test–retest reliability (r = .77,
p b .01) and adequate levels of convergent validity and concurrent va-
lidity [24]. In our sample, internal consistency of the TAS-20 was very
good (α = .91).
2.2.3. Beliefs about emotions
The Beliefs about Emotions Questionnaire (BAEQ) was used to mea-
sure a range of specific beliefs about feelings. The subscales examine be-
liefs about emotions as overwhelming and uncontrollable, shameful
and irrational, invalid and meaningless, useless, damaging, and conta-
gious. The scale is composed of 43 items that are rated on a 5-point
scale, ranging from “strongly disagree” to “strongly agree”. The BAEQ
demonstrated good internal consistency (0.69–0.88) and adequate
test–retest reliability. Adequate convergent validity and divergent va-
lidity were also reported [26]. In the present sample, the Cronbach's
alpha reliability was good (α = .90).
2.2.4. Control of emotional reactions
The Courtauld Emotional Control Scale (CECS) was used to measure
a tendency to control emotional reactions. The CECS consists of 21
items, scored on a 4-point scale, ranging from “almost never” to “almost
always”. An important aspect of this scale is that it has three subscales,
indicating control of different affective states, namely anger, anxiety,
and depressed mood. The CECS demonstrated good internal consistency
of 0.86 (anger subscale) to 0.88 (anxiety and depressed mood sub-
scales) and good test–retest reliability (0.84–0.95) [27]. The CECS
showed very good internal consistency in the present study (α = .93).
2.2.5. Anxiety and depression
The Hospital Anxiety and Depression Scale (HADS [28]) is a 14-item
screening tool for anxiety and depression. Items are scored on a 4-point
scale and assess feelings and behaviors during the previous week. Total
scores can fall into four categories: normal (0–7), mild (8–10), moder-
ate (11–15), and severe (16–21). The scale has been widely used in re-
search and has demonstrated good validity and reliability [29,30]. The
sensitivity and specificity for both anxiety and depression scales were
reported to be sufficient to detect caseness and symptom severity with-
in a wide range of psychosomatic, psychiatric, and healthy populations
[29]. In our sample, reliability for the HADS total score was α = .88.
2.2.6. Seizure characteristics
Self-report data with regard to seizure characteristics in three do-
mains, i.e., frequency, severity, and the degree to which seizures inter-
fered with one's life (bothersomeness), were collected. Participants
were asked about the longest time that they have had between seizures
in the past 12 months and the number of seizures that they experienced
112 M. Urbanek et al. / Epilepsy & Behavior 37 (2014) 110–115

in the past 4 weeks. They were then asked to rate how severe (intense) Table 1
the seizures in the previous 4 weeks were on a 7-point Likert scale, Demographic characteristics.

ranging from ‘very mild’ to ‘very severe’. Participants were also asked Group with PNES Control group
to rate how bothersome these seizures were or how much they inter- (n = 56) (n = 88)
fered with their life on a 7-point Likert scale, ranging from ‘no bother Age M = 39.2 (13.6) M = 27.2 (9.3)
at all’ to ‘very bothersome’. Questions regarding age at seizure onset Gender
and age at diagnosis were also included. Male 20 26
Female 36 62
Ethnicity
2.3. Procedure White British 50 69
Any other White background 3 16
Ethical approval was obtained from the NHS Ethics Committee and Asian or Asian British 2 1
the Research and Development departments within the participating Black or Black British 1 –
Any other Mixed background – 1
trusts. Typically, the information sheet, describing the study and the re-
Prefer not to state – 1
search procedure, was sent out by post. If no contact was made by a par- Education
ticipant within 2–3 weeks of receiving the letter, the researcher made a Primary, secondary school, O levels 23 –
follow-up phone call in order to give participants an opportunity to ask A levels, diploma, trade certificate 22 37
University degree 10 51
questions or discuss any issues regarding the study. Participants were
given a choice of whether they wished to come to the clinic or complete
the questionnaires at home and return them in an envelope provided.
Five participants chose to meet the researcher and complete the ques- results indicated that patients with PNES scored higher than HC partic-
tionnaires in the clinic. Once a written informed consent was obtained, ipants on both anxiety and depression subscales. These differences were
participants completed the measures described above and a demo- statistically significant (Table 3). The proportion of participants who
graphic questionnaire. were within the ‘clinical’ range (N 10) [31] for anxiety in the group
An online survey was used to collect data from the control group. with PNES (54%) was higher compared to the control group (28%).
Once permission was gained, an email inviting students to complete This difference was statistically significant (χ2(1) = 9.179, p = .002).
the questionnaires online was circulated to three university depart- Similar results were found in relation to the depression subscale, as
ments. Further, participants for the control group were recruited 23% of the group with PNES and 6% of the control group were classified
through a social networking site. as depressed. This difference was statistically significant (χ2(1) = 9.618,
p = .002).
2.4. Statistical analyses The relationship between emotional distress and ER difficulties was
examined across both groups using Spearman's correlation coefficient.
A priori power calculations were performed to ensure an adequate Symptoms of anxiety and depression were positively correlated with
sample size. Based on a medium effect size, a significance level of 0.05, the total scores on the AIM, TAS-20, BAEQ, and CECS. These associations
and a power of 0.80, the t-test sample size required for each group were statistically significant (Table 4).
was 64. The total sample size for logistic regression was 88, with 0.05
level of significance, odds ratio of 2.0, and a power of 0.80. All statistical 3.2. Group differences on ER measures
analyses were performed using SPSS software (version 18.0). A series of
independent samples t-test and Mann–Whitney U tests were conducted A series of independent samples t-test and Mann–Whitney U tests
to compare group means on ER variables. A hierarchical binary logistic were conducted to determine whether patients with PNES showed
regression was then carried out using the forced entry method to find difficulties in ER. On average, patients with PNES obtained higher
the set of predictors which best distinguished between the group with scores on the AIM (M = 146.42, SD = 23.45) than HC participants
PNES and the control group. The relationships between ER processes (M = 141.03, SD = 16.60). This difference was not significant
and seizure characteristics in the group with PNES were then explored (t(90) = 1.50, p = .069). As hypothesized, the group with PNES report-
using Spearman's correlations. ed significantly higher scores on all subscales of the TAS-20 than the
control group. Effect sizes for these comparisons ranged from moderate
3. Results to large (Table 5). The prevalence of alexithymia (TAS-20 total
score N 60) in the group with PNES (63%) was considerably higher com-
3.1. Demographic and clinical characteristics pared to the control group (14%). This difference was found to be statis-
tically significant (χ2(1) = 37.165, p b .001).
Demographic characteristics of both groups of participants are On average, patients with PNES (M = 135.2354, SD = 20.60) scored
summarized in Table 1. Both groups were predominantly female higher on the BAEQ than the control group (M = 110.86, SD =
(group with PNES: 64% female; control group: 70% female). The chi- 15.42). This difference represented a large effect size and was significant
square tests for independence indicated that gender (χ2(1) = 0.599, (t(94) = 7.6, p b 0.001). The examination of subscales showed that
p = 0.439) and ethnicity (χ2(1) = 2.822, p = 0.093) were not signif-
icantly associated with group membership. However, there was a sig-
Table 2
nificant association between group membership and education level Self-reported seizure characteristics of patients with PNES.
(χ2(1) = 31.022, p b .001). Data showed that 5% of patients with
PNES and 50% of participants in the control sample completed a uni- Seizure variable

versity degree. In addition, the patients with PNES (Mdn = 41.5) Age at onset M = 32.0 (15.2)
were found to be older than the control participants (Mdn = 25). Age at diagnosis M = 35.9 (14.6)
Average time until diagnosis (years) M = 4.6 (7.8)
This difference was significant (U = 1225, z = − 5.084, p b .001,
Seizure-free in the last 12 months Range from 9 h to 9 months
r = −.42). There was a significant variability in the self-reported fre- Seizure frequency in the last month M = 11.6 (16.0), Mdn = 5.0 (0–84)
quency and severity of seizures in the group with PNES. Seizure char- Seizure severity in the last month: M = 4.2 (1.9), Mdn = 4
acteristics are presented in Table 2. 1 (very mild)–7 (very severe)
The Mann–Whitney U test was used to determine if there were dif- Seizure bothersomeness in the last month: M = 5.0 (1.7), Mdn = 5
1 (no bother at all)–7 (very bothersome)
ferences between groups on anxiety and depression symptoms. The
 M. Urbanek et al. / Epilepsy & Behavior 37 (2014) 110–115
Table 3
Group differences on the HADS.
Group with PNES (n = 56)
Median (range)
Total 17.5 (3–34)
Anxiety 11 (2–20)
Depression 7 (0–19)
⁎ p b .001 (two-tailed).
patients with PNES had significantly higher scores on the subscales mea-
suring beliefs about emotions as overwhelming and uncontrollable,
shameful and irrational, contagious, useless, and damaging compared
to the controls. Effect sizes ranged from medium (r = −.25) to large
(r = .51). Finally, the scores on the CECS were significantly higher for
patients with PNES than HC (U = 1867.50, z = − .2.446, p = .007).
Significant differences were found for the anxiety and sadness subscales.
3.3. Emotion regulation variables predicting group membership
In order to find the set of predictors which best distinguished be-
tween the group with PNES and the control group, hierarchical binary
logistic regression was carried out using the forced entry method. In
order to control for the effect of age and education, these variables
were added as covariates in step one, while the predictor variables
were added at step two. These included the TAS-20, BAEQ, CECS, and
HADS, as they were found to be significantly correlated with group
membership.
The results showed that the addition of the predictor variables statis-
tically added to the model, which was found to be statistically signifi-
cant (omnibus χ2(8) = 120.877, p b .001). This model had a pseudo
R-square of .573 using the Cox and Snell statistics and pseudo r-square
of .780 using the Nagelkerke statistics, indicating that the predictor var-
iables explained approximately 78% (Nagelkerke, R-square) of the vari-
ance in group membership. The results of the Hosmer and Lemeshow
test indicated support for the model, as the value was larger than .05
(χ2(8) = 6.510, p = .590). The predictive capacity of the model was
good, as it correctly classified 90.8% of cases. In addition, the Wald statis-
tic indicated that of the predictors included, alexithymia and beliefs
about emotions were significant. The anxiety and depression score
and the control of emotions score were not found to be significant pre-
dictors of group membership. The strongest predictor was poor under-
standing of emotions, with an odds ratio of 1.11 suggesting that as the
score on the TAS-20 increases, the likelihood of having PNES increases
by 1.11 times. It is also worth noting that when the HADS was entered
at step one, the TAS-20 (p = .005) and BAEQ (p = .047) remained sig-
nificant predictors.
3.4. Seizure characteristics
The relationships between ER processes and self-reported seizure
characteristics were then explored in the group with PNES using
Spearman's correlations. There was a medium positive correlation
between self-reported seizure severity and BAEQ total score (r = .309,
p = .027). Similarly, medium positive correlations were found between
seizure bothersomeness and BAEQ total score (r = .372, p b .01). The
Table 4
Correlations between emotional distress and emotion regulation difficulties.
Affect Understanding Beliefs about
intensity of emotions emotions
Emotional distress .185⁎ .601⁎⁎⁎ .635⁎⁎⁎
⁎ p b .05 (two-tailed).
⁎⁎⁎ p b .001 (two-tailed).
113
Control group (n = 88) U statistic Effect size
Median (range)
11 (1–32) U = 1220⁎, z = −5.103 r = −.43
8 (1–20) U = 1187⁎, z = −3.676 r = −.31
3 (0–12) U = 1569⁎, z = −5.252 r = −.44
analysis also indicated that small positive correlations were found be-
tween seizure severity and the TAS-20 (r = 0.290, p = .039).
4. Discussion
The aim of this study was to examine a range of ER processes in a
group of patients diagnosed with PNES compared to healthy controls.
The results indicated that patients with PNES had more difficulties
with identifying and describing feelings as well as greater levels of ex-
ternally orientated thinking than controls. Furthermore, the clinical
levels of alexithymia in the group with PNES were significantly higher
compared to the control group. Poor understanding of emotions was
shown to be a significant predictor of PNES, even when age, education
level, and emotional distress were controlled for. This is in line with pre-
vious research in PNES [13] and other somatoform disorders [32,33],
suggesting deficits in emotional awareness and understanding of one's
own feelings.
As expected, patients with PNES reported more negative beliefs
about emotions. Beliefs about emotions were found to be a significant
predictor of PNES, even when age, education level, and emotional dis-
tress were controlled for. To our knowledge, this is the first time that be-
liefs about emotions have been associated with an increased likelihood
of experiencing PNES. These findings are in line with the literature on
mood disorders, indicating a relationship between negative beliefs
about emotion and emotional distress [9,34]. It is also worth noting
that levels of alexithymia and negative beliefs about emotions in a pa-
tients with PNES were positively associated with self-reported seizure
severity. Beliefs about emotions were also significantly associated with
the degree to which participants were bothered by their seizures. This
is consistent with previous findings regarding correlations between
the high level of seizure severity, somatization, and poor outcomes [35].
The results of the current study also revealed that the extent to
which people controlled their emotions was significantly greater in
the group with PNES when compared with controls, providing support
to previous findings [19,36]. There was also a significant correlation of
medium strength between the use of control strategies in managing
emotions and emotional distress. The emotional control of anxious
and depressed states was significantly higher in the group with PNES
compared to controls. It is worth noting that elevated levels of anxiety
and depression were also found in the group with PNES. This is consis-
tent with the theory and research on emotional inhibition, indicating
that controlling an emotional response often fails to decrease emotional
experience [34,37–39]. The use of emotional control strategies was not
found to be a significant predictor of PNES, which might be due to the
fact that other predictors in the analysis were more significant. Further-
more, while this study examined control strategies in relation to nega-
tive emotions, it is possible that patients with PNES control the
expression of positive emotions more than the expression of negative
emotions [19].
On average, patients with PNES had higher scores on affect intensity
than participants in the control group. However, contrary to the hypoth-
Control of esis, this difference was not statistically significant. In previous research,
emotions
patients with PNES showed greater emotional intensity when presented
.414⁎⁎⁎ with neutral or pleasant pictures but not when presented with negative
stimuli [19]. The AIM does not clearly distinguish between positive and
negative emotions, as typically one total score is calculated, which
114 M. Urbanek et al. / Epilepsy & Behavior 37 (2014) 110–115

Table 5
Group differences on measures of emotion regulation.

PNES (n = 56): mean (SD), Control group (n = 88): mean (SD), Comparison statistic Effect size (r)
median (range) median (range) t-test/Mann–Whitney U

Affect intensity 146.42 (23.45) 141.03 (16.60) t(90) = 1.50 .15

Understanding of emotions 64.94 (30–91) 41.50 (22–76) U = 594.50⁎⁎⁎, z = −7.664 −.64
Difficulty identifying feelings 25 (11–35) 13.00 (7–32) U = 478.50⁎⁎⁎, z = −8.145 −.68
Difficulty describing feelings 18 (7–25) 11.00 (5–25) U = 840.50⁎⁎⁎, z = −6.664 −.56
Externally oriented thinking 22 (9–34) 17.00 (9–28) U = 1473.50⁎⁎⁎, z = −4.068 −.34
Beliefs about emotions 135.2354 (20.60) 110.86 (15.42) t(94) = 7.6⁎⁎⁎ .62
Overwhelming 32.20 (7.58) 24.44 (6.55) t(142) = 6.51⁎⁎⁎ .48
Shameful 26.00 (12–41) 17.50 (10–38) U = 1143.00⁎⁎⁎, z = −5.420 −.45
Invalid 23.00 (15–30) 22.00 (13–27) U = 2300.00, z = −.675 −.06
Useless 27.50 (13–37) 24.50 (12–35) U = 1724.00⁎⁎, z = −3.041 −.25
Damaging 14.18 (4.43) 10.36 (3.07) t(89) = 5.65⁎⁎⁎ .51
Contagious 14.00 (8–20) 12.00 (4–19) U = 1277.00⁎⁎⁎, z = −4.898 −.41
Control of emotions 56.00 (31–84) 49.00 (27–82) U = 1867.50⁎⁎, z = −2.446 −.20
Angry 18.00 (7–28) 16.00 (8–28) U = 2144.50, z = −1.313 −.11
Anxious 20.00 (10–28) 17.00 (7–28) U = 1929.00⁎, z = −2.200 −.18
Unhappy 18.50 (12–28) 16.00 (9–28) U = 1862.50⁎⁎, z = −2.471 −.21
⁎ p b .05 (one-tailed).
⁎⁎ p b .01 (one-tailed).
⁎⁎⁎ p b .001 (one-tailed).

might account for the discrepancy in findings. While methodological is-
sues need to be considered, it is also possible that patients with PNES do
not perceive their emotional experiences as more intense than other
people do. This is consistent with somatization theories, according to
which affect is converted into somatic symptoms, bypassing cognitive
processing [40]. Research has shown that patients with PNES tend to re-
port physical symptoms and are less likely to attribute their symptoms
to stress or psychological factors [21]. It could be argued that difficulties
with identifying and describing feelings are indicative of a possible dis-
connection between physical and cognitive aspects of emotional experi-
ence and might go some way to explain the findings regarding affect
intensity.
4.1. Limitations
The findings of this study need to be considered in the context of
some methodological limitations. The cross-sectional nature of the
data limited the conclusions that could be drawn from the findings
with regard to the nature of the relationships between the variables.
Studies using a longitudinal design need to determine whether emotion
regulation difficulties are the causal or maintaining factor in PNES or the
result of having seizures. While the response rate of 31% is typical of this
type of research, the results need to be generalized with caution. Finally,
the use of self-report data could be considered a limitation, as it can be
questioned whether individuals are able to accurately self-report on the
frequency and severity of their seizures as well as ER processes. It would
therefore be important to replicate these findings using a combination
of self-report measures of ER and seizure characteristics with observa-
tional, physiological, or neuroimaging data. It would also be an impor-
tant focus for future research to replicate the current findings with
other comparison groups.
4.2. Clinical implications
In spite of the limitations, this study contributes a multifaceted ap-
proach to understanding emotion regulation in patients with PNES,
and findings have a number of clinical implications. Firstly, the results
indicated that a significant proportion of patients with PNES scored in
the clinical range for anxiety and depression. This adds to the
evidence that patients with PNES have significant psychological needs.
Although tentative, the findings of this study also contribute to the liter-
ature suggesting a possible role of ER processes in PNES. Deficits in abil-
ity to identify and describe feelings as well as negative beliefs about
emotions appear to be of particular significance. These processes appear
to be associated with personal experiences of seizure severity and have
been found to lead to experiential and situational avoidance, dissocia-
tion, as well as high levels of emotional distress [34]. The relationship
between subjective perceptions of seizures, perceptions of emotions,
and emotional distress is likely to be a complex one and requires further
exploration. However, interventions designed to help a person normal-
ize their emotional states and develop more positive beliefs about emo-
tions, while increasing adaptive emotional expression, might be
beneficial. In addition, therapy could help a person develop an under-
standing of their emotional responses by connecting cognitive and so-
matic aspects of their emotional experience. As patients with PNES
represent a heterogeneous population, it is crucial that the interven-
tions are tailored to an individual emotional style, taking into account
deficits in emotional development, traumatic life events, as well as spe-
cific ER difficulties.
While there is some evidence of the effectiveness of cognitive–
behavioral therapy in PNES [41], the current evidence base for interven-
tions for patients with PNES is limited. The present findings suggest that
therapies which specifically focus on emotion regulation processes, e.g.,
acceptance and commitment therapy [42] and dialectical behavior ther-
apy [8], might be effective for patients with PNES who present with dif-
ficulties in this area, as they help people to develop skills in tolerating
distressing emotions and regulating emotions effectively.
4.3. Future research directions
Future work in this area might focus on identifying changes in affect
regulation which are most strongly associated with the outcomes. It
would then enable the development of implicit and explicit strategies
to facilitate these changes in clinical practice. Furthermore, it would be
useful to explore the differences in regulation of positive and negative
emotions. For instance, future research might examine whether pa-
tients with PNES control the expression of positive emotions more
than the expression of negative emotions. Anger might be of particular
significance, given the previous literature on the relationship between
anger and psychosomatic symptoms [6]. It might therefore be useful
to measure the frequency and severity of anger symptoms and explore
the link between the anger symptoms and strategies of managing this
emotion in a population with PNES. Finally, a wider range of ER strate-
gies and the flexibility with which patients with PNES apply specific
ER strategies, depending on the situational demands, requires further
investigation [43].
 M. Urbanek et al. / Epilepsy & Behavior 37 (2014) 110–115
4.4. Conclusion
In conclusion, the results of the present study suggest that PNES are
associated with higher levels of alexithymia, more negative beliefs
about emotions, and more reliance on emotional control strategies.
Poor understanding of emotions and negative beliefs about feelings
were found to be significant predictors of PNES, even when age, educa-
tion level, and emotional distress were controlled for. These results are
largely consistent with previous literature, but this study goes further
in bringing together different aspects of ER, including beliefs about emo-
tions, which have not been examined before. The findings highlight the
importance of considering ER difficulties in psychological formulation
and treatment of PNES.
Disclosure
We confirm that there are no conflict of interests regarding the pub-
lication of this paper.
References
[1] Hixson JD, Balcer LJ, Glosser G, French JA. Fear sensitivity and the psychological profile
of patients with psychogenic nonepileptic seizures. Epilepsy Behav 2006;9:587–92.
[2] Reuber M, Mayor R. Recent progress in the understanding and treatment of
nonepileptic seizures. Curr Opin Psychiatry 2012;25:244–50.
[3] Baslet G. Psychogenic nonepileptic seizures: a treatment review. What have we
learned since the beginning of the millennium? Neuropsychiatr Dis Treat 2012;8:
585–98.
[4] Brown RJ, Syed TU, Benbadis S, LaFrance WC, Reuber M. Psychogenic nonepileptic
seizures. Epilepsy Behav 2011;22:85–93.
[5] Bucci W. Symptoms and symbols: a multiple code theory of somatisation. Psychoanal
Inq 1997;17:151–72.
[6] Taylor GJ, Bagby RM, Parker JDA. Disorders of affect regulation: alexithymia in
medical and psychiatric illness. Cambridge: University Press; 1997.
[7] Gross JJ, Thompson RA. Emotion regulation: conceptual foundations. In: Gross JJ, ed-
itor. Handbook of emotion regulation. New York, NY: Guilford Press; 2007. p. 3–24.
[8] Linehan M. Cognitive-behavioral treatment of borderline personality disorder.
New York: Guilford Press; 1993.
[9] Mennin DS, Holaway RM, Fresco DM, Moore MT, Heimberg RG. Delineating compo-
nents of emotion and its dysregulation in anxiety and mood psychopathology. Behav
Ther 2007;38:284–302.
[10] Boden JM, Baumeister RF. Repressive coping: distraction using pleasant thoughts
and memories. J Pers Soc Psychol 1997;73:45–62.
[11] Gross JJ. The emerging field of emotion regulation: an integrative review. Rev Gen
Psychol 1998;2:271–99.
[12] Lesser RP. Treatment and outcome of psychogenic nonepileptic seizures. Epilepsy
Curr 2003;3:198–200.
[13] Bewley J, Murphy PN, Mallows J, Baker GA. Does alexithymia differentiate between
patients with nonepileptic seizures, patients with epilepsy, and nonpatient controls?
Epilepsy Behav 2005;7:430–7.
[14] Myers L, Matzner B, Lancman M, Perrine K, Lancman M. Prevalence of alexithymia in
patients with psychogenic non-epileptic seizures and epileptic seizures and predic-
tors in psychogenic non-epileptic seizures. Epilepsy Behav 2013;26:153–7.
[15] Tojek TM, Lumley M, Barkley G, Mahr G, Thomas A. Stress and other psychosocial
characteristics of patients with psychogenic nonepileptic seizures. Psychosomatics
2000;41:221–6.
[16] Bakvis P, Spinhoven P, Zitman FG, Roelofs K. Automatic avoidance tendencies in pa-
tients with psychogenic non epileptic seizures. Seizure 2011;20:628–34.
115
[17] Goldstein LH, Mellers JDC. Ictal symptoms of anxiety, avoidance behaviour, and dis-
sociation in patients with dissociative seizures. J Neurol Neurosurg Psychiatry
2006;77:616–21.
[18] Gratz KL, Roemer L. Multidimensional assessment of emotion regulation and dysreg-
ulation: development, factor structure, and initial validation of the difficulties in
emotion regulation scale. J Psychopathol Behav 2004;26:41–54.
[19] Roberts NA, Burleson MH, Weber DJ, Larson A, Sergeant K, Devine MJ, et al. Emotion
in psychogenic nonepileptic seizures: responses to affective pictures. Epilepsy Behav
2012;24:107–15.
[20] Uliaszek AA, Prensky E, Baslet G. Emotion regulation profiles in psychogenic non-
epileptic seizures. Epilepsy Behav 2012;23:364–9.
[21] Stone J, Binzer M, Sharpe M. Illness beliefs and locus of control: a comparison of
patients with pseudoseizures and epilepsy. J Psychosom Res 2004;57:541–7.
[22] Pilowsky I, Spence ND. Manual for the Illness Behaviour Questionnaire (IBQ).
University of Adelaide; 1983.
[23] Larsen RJ, Diener E. Affect intensity as an individual difference characteristic: a re-
view. J Res Pers 1987;21:1–39.
[24] Bagby RM, Taylor GJ, Parker JD. The twenty-item Toronto Alexithymia scale: II.
Convergent, discriminant, and concurrent validity. J Psychosom Res 1994;38:33–40.
[25] Bagby RM, Parker JD, Taylor GJ. The twenty-item Toronto Alexithymia scale: I.
Item selection and cross-validation of the factor structure. J Psychosom Res
1994;38:23–32.
[26] Manser R, Cooper M, Trefusis J. Beliefs about emotions as a metacognitive construct:
initial development of a self‐report questionnaire measure and preliminary investi-
gation in relation to emotion regulation. Clin Psychol Psychother 2012;19:235–46.
[27] Watson M, Greer S. Development of a questionnaire measure of emotional control.
J Psychosom Res 1983;27:299–305.
[28] Zigmond S, Snaith P. The hospital anxiety and depression scale. Acta Psychiatr Scand
1983;67:361–70.
[29] Bjelland I, Dahl AA, Haug TT, Neckelmann D. The validity of the Hospital Anxiety and
Depression Scale: an updated literature review. J Psychosom Res 2002;52:69–77.
[30] Mykletun A, Stordal E, Dahl AA. Hospital Anxiety and Depression (HAD) scale:
factor structure, item analyses and internal consistency in a large population. Brit J
Psychiatry 2001;179:540–4.
[31] Snaith RP. The Hospital Anxiety And Depression Scale. Health Qual Life Out
2003;1:29–33.
[32] Subic-Wrana C, Beutel ME, Knebel A, Lane RD. Theory of mind and emotional aware-
ness deficits in patients with somatoform disorders. Psychosom Med 2010;72:
404–11.
[33] Waller E, Scheidt CE. Somatoform disorders as disorders of affect regulation: a devel-
opment perspective. Int Rev Psychiatry 2006;18:13–24.
[34] Leahy RL. A model of emotional schemas. Cogn Behav Pract 2002;9:177–90.
[35] Reuber M, House AO, Pukrop R, Bauerd J, Elgerd CE. Somatization, dissociation
and general psychopathology in patients with psychogenic non-epileptic seizures.
Epilepsy Res 2003;57:159–67.
[36] Prigatano GP, Kirlin KA. Self-appraisal and objective assessment of cognitive and
affective functioning in persons with epileptic and nonepileptic seizures. Epilepsy
Behav 2009;14:387–92.
[37] Gross JJ. Emotion regulation: affective, cognitive, and social consequences. Psycho-
physiology 2002;39:281–91.
[38] Goldin PR, McRae K, Ramel W, Gross JJ. The neural bases of emotion regulation:
reappraisal and suppression of negative emotion. Biol Psychiatry 2008;63:577–86.
[39] Stanton AL, Danoff-Burg S, Cameron CL, Bishop M, Collins CA, Kirk SB, et al. Emotionally
expressive coping predicts psychological and physical adjustment to breast cancer.
J Consult Clin Psychol 2000;68:875–82.
[40] Baslet G. Psychogenic non-epileptic seizures: a model of their pathogenic mecha-
nism. Seizure 2011;20:1–13.
[41] Goldstein LH, Chalder T, Chigwedere C, Khondoker MR, Moriarty J, Toone BK, et al.
Cognitive-behavioral therapy for psychogenic nonepileptic seizures: a pilot RCT.
Neurology 2010;74:1986–94.
[42] Hayes SC, Luoma JB, Bond FW, Masuda A, Lillis J. Acceptance and commitment
therapy: model, processes and outcomes. Behav Res Ther 2006;44:1–25.
[43] Hofmann SG, Sawyer AT, Fang A, Asnaani A. Emotion dysregulation model of mood
and anxiety disorders. Depress Anxiety 2012;29:409–16.