Family functioning in psychogenic nonepileptic seizures: Qualitative study

Sneha Vinay Haritsa¹, Kalapalli Jayasankara Reddy¹, Meghna Gupta^2
1 Department of Psychology, Christ (Deemed to be University), Bengaluru, Karnataka, India
² Department of Clinical Psychology, Faculty of Behavioral Sciences, Shree Guru Gobind Singh Tricentenary University, Gurugram, Haryana, India

Correspondence Address:
Sneha Vinay Haritsa,
Christ (Deemed to be University), Hosur Road, Bhavani Nagar, Bengaluru - 560 029, Karnataka
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aip.aip_153_21

Background: Psychogenic nonepileptic seizures (PNES) are understood as epileptic presentations without a neurological basis. PNES has underlying psychological stressors that manifest physiologically. However, family functioning has been poorly studied despite its potential to be one of the major stressors. Few studies on family functioning have focused on differences between PNES and epileptic seizures than an in-depth inquiry into family functioning in PNES. Methods: Patients diagnosed with PNES by a psychiatrist or neurologist through home videos were chosen to participate in the study. Participants had at least one seizure in the previous week before the interview, and those who had physical disabilities or comorbid epilepsy were excluded from the study. In-depth interviews were developed and conducted. Determined data was analyzed through latent thematic analysis. Results: Based on the determined data, nine themes were identified. They included interaction and attachment, communication, structure and system, distressful family factors, expressed emotions, cultural aspects, maladaptive coping, adaptive coping, and negative emotional experience. Approach avoidance and hints of ending relationships were the types of communication among PNES patients, attachment has been inconclusive, transgenerational trauma, disengaged boundaries, coalition, and maladaptive triangles are prevalent among families of PNES patients. Over-involvement and hostility are the expressed emotions that were found. Both maladaptive and adaptive coping strategies are found among PNES patients. Finally, superstitions and beliefs in possession exist among families of PNES patients. Conclusion: Family dysfunction is prevalent among families of PNES patients, and hence, family-based interventions are necessary.

Keywords: Cultural aspects, expressed emotions, family functioning, psychogenic nonepileptic seizures, structural aspects, systemic aspects

Introduction

Table 1: Objectives and anchor points based for development of interview schedule Click here to view

Methods

Table 2: Themes and sub-themes determined from the interview Click here to view

Results

1. Interaction and attachment - Both the ends of the interaction and attachment spectrum were found.



1. Leisure time spent - Many families had a dedicated time that they spent for recreational activities or anything that was out of the routine.
   
   “When he gets time. He will get time only on Sunday. I will be with him only on Sunday. He will not go to a job. He will be at home. He will take me outside like to temple and full Sunday we will spend time together. ” (Pt. 9)
2. Time spent only during chores - Some families spent time only doing chores for each other such as cooking or helping another with their routine activities.
   
   “I also enjoy it. Sunday Sometimes a full family will be nice. I Make something, give it to everyone.no, nothing, I will prepare food, will send children to school and all these.” (Pt. 3)
3. Primary attachment exists - Patients had primary attachment whom they considered very close and shared everything.
   
   “First father then sister and then mother. At first, I like my father. I will share everything with my father. No secret between us, we will all sit together and will discuss. ” (Pt. 9)
4. No primary attachment - Some patients had no attachment with anyone and did not share any information with anyone.
   
   “Since the beginning, this is how I have been. This problem also started like this only. This I could not tell anyone; also, there was a lockdown too, and I could not go out either. Like this only it happened. ” (Pt. 4)



2. Communication - Patterns of communication indicated poor communication.



1. Approach avoidance-approach-avoidance communication was found among some patients where one partner approached the problem, and the other constantly avoided it.
   
   “If I have stress, I scold, especially if my husband hurt me. I shout at him, and after that, I just get on with the daily life chores brooming and sweeping. So I also keep quiet, and he will also not reply. He will remain silent, thinking that I always do like this”
2. Hints of ending a relationship - The ending of conflicts was when the patient started communicating about ending the relationship.
   
   “I told him that day itself that I won't stay with you; I'll leave you.”



3. Structure and system - dysfunctional structures and systemic aspects were found



1. Maladaptive triangles - patients also mentioned maladaptive triangles where a third party was involved in the conflict, and the problems escalated.
   
   “Nothing. Any problem means my father-in-law's uncle was close with us. Close means only one bathroom, so we used to fight. I was asking for separate bathrooms and used to fight with them. I asked my father also. Will they build a bathroom or not, I asked? Before marriage, we will build, they told. Like that only I became pregnant. They told after getting pregnant, they would not put foundation, and they will not build a bathroom. I was quiet. After that, for delivery, I came here. One year I did not go there. Till they built bathroom and toilet room I will not go I told. I told my father. My father asked them, and they told me they would not build and started fighting”. (Pt. 9)
2. Transgenerational trauma - Trauma that affects some members of the family unintentionally got passed on to their offspring affecting children's relationships.
   
   “Nobody was there. He used to cry badly, saying that his mother also did not come to see him. My mother in law she is very different because she had suffered a lot with her husband, and towards the end, they used to lock her husband up in the bed. He had even got cancer, his mental illness had increased, and they used to tie him up. After going through all these, she has become somewhat different.” (Pt. 1)
3. Disengaged boundary - disengaged boundary existed and hardly any interaction or communication was present with the family.
   
   “If I am at my husband's home, I will look after my baby; I will complete my workaround at 11:30 am, and I will sleep till 3 pm. After 3 pm, I will come down and will have something and will speak a little and will start work again. I am least bothered about others. ” (Pt. 9)
4. Coalition-patients also reported coalition, where the entire family was against the patient and left them out, especially during celebrations.
   
   “My neighbor's house warming ceremony was there. Everyone went together leaving me. That time I felt bad. They all went leaving my baby and me. They are all one.” (Pt. 9)



4. Distressful family factors - Other family factors that acted as stressors to the patients were found



1. Distressful family conflicts - Distressful family conflicts were reported that sometimes lead to escalation of other problems in the family.
   
   “Every day, they fight, especially my husband, my mother-in-law. My husband will say that she is not even my mother. She is totally different. She is somewhat…. From the beginning, she has been like that only. After she came, our problems also escalated.” (Pt. 1)
2. Partner's abnormality - patients narrated several abnormal aspects of their partner that involved superstitions and possession that impacted the patient's mental health.
   
   “The next day, when we were having dinner, he started behaving differently. He started telling that he was possessed by God, the devil, etc., By then, his father had passed away, and he was sitting like the way his father used to, and his eyes and all changed. I didn't feel this was normal” (Pt. 1)
3. Abuse - abuse was another theme that was found, and physical abuse was very common that the patients faced.
   
   “Then he dragged me, hit me, and threatened to kill me. Then he brought me back, pushed me aside, and went somewhere. I didn't know the place well.” (Pt. 1)
4. Poor physical and sexual intimacy - patients reported being devoid of physical and sexual intimacy that they desired from their partners, and this added to their stress levels.
   
   “Also madam, when he comes at night, he will be somewhat. Even if I ask him to come close to me, he will not. Then if I go and hug him, he will not let me. Whatever I do, he will not like.” (Pt. 8)
5. Sexually inappropriate family member/s - Family members' sexual inappropriateness such as inappropriate behavior and dressing increased stress levels among the patients.
   
   “Even now, at night, my mother-in-law, if the first night seen is coming on the television, she will be seeing it with more enthusiasm than us. She is already 70 years old. Even now until night 2 'o'clock…. One boy is there who takes care of the temple. She wants to sleep in the hall only. We tell her to fully cover herself and but a bedsheet, but she will sleep reverse and pull her saree up. When such a scene comes, I will be there, and the boy will see me in a weird manner.”(Pt. 1)



5. Expressed emotions - These expressed emotions can act as stressors and devoid patients to adapt.



1. Over-involvement-Many patients reported over-involvement of the family members denoted by providing physical and psychological care.
   
   “They take more care. When it happened like this, I was not able to eat. They call me and wake me up to have something. No, only my mother-in-law and my husband will take care of here; my father, mother, sister, and brother everyone will take care of me. Yes, let baby eat, they say and wake me up, they hold my hand and wake me up, and they will help me to walk.” (Pt. 9)
2. Hostility - there were also families that made comments rejecting patients' condition especially, about hiding health conditions before marriage that negatively impacted patients.
   
   “They tell you have some problem before itself. Like this every time they say. But when the last time I got unconscious, they told us she had taken more stress, because of that may be like jaundice is there, they were seeing me and telling me that she has jaundice problem, her leg has become yellow, before marriage itself something is there. If I tell after marriage all these is happening then they say I am telling a lie, before marriage itself, she has some problem” (Pt. 7)



6. Cultural aspects - Cultural aspects could impact healing reinforcing denial of psychological stressors



1. Superstitious beliefs - superstitions were present in the family about the illness that reinforced denial of psychological stressors.
   
   “There was an eclipse, and since I took a bath twice and overdid it and got cold, my husband is telling me all this happened. Because I do so much all this happens.” (Pt. 1)
2. Belief in possession - patients also mentioned getting consulted by a faith healer who either mentioned possession by God or evil spirits.
   
   “I mean they put spells on kids if they have fear problems. Like this is happening, they told for that GOD…If I do pooja for that, then it will be solved.” (Pt. 9)



7. Maladaptive coping - these coping strategies used by the patients divert them from insight.



1. Distraction - patients also mentioned distractive strategies that distracted them from existing stress providing temporary relief.
   
   “Then I go above and play with the children. This or I will listen to songs on my mobile. This helps me overcome my sadness.”(Pt. 8)
2. Avoidance pattern - in this strategy, patients remained silent or shut themselves from everyone.


“I don't do anything. I'll just sit. ” (Pt. 2)

“If it is too much, then I will cry and sleep. After that, I will be silent. I will lock the door, and I will sleep.” (Pt. 6)
3. Behavior - Maladaptive behavior such as biting and beating were also found as responses to stress.
   
   “I feel like biting when I get angry, I feel like biting” (Pt. 3)
   
   “Simple fighting, he will say something that makes me angry, I will beat” (Pt. 3)



8. Adaptive coping - these strategies help the patients with insight and in daily functioning.

1. Logical Thinking - Patients also thought about existing conditions and gave themselves logical reasons to overcome the conflict.
   
   “I only become alright madam. I will think that if I am not there, both my children will become orphans. I think like this, and then I will only become alright.” (Pt. 8)
2. Solution-focused thinking - Solution-focused thinking was also seen among the patients denoted by “what they can do when faced with stress.”
   
   “No problem for money. He earns more. We earn less than him. I want to learn to cut; I need a machine, I told. He said he would buy it. But the next day, like this happened. Till now didn't buy. I should recover, and I will be fine after that I will learn” (Pt. 9)
3. Politely requesting - Patients requested their partners to stop the behavior without using any physical or emotional methods to forcefully control the other.
   
   “Because he is the one who behaves in a hyper manner. I tell him that it's enough, do not talk. ” (PT.1)

Discussion

Conclusion

• Family dysfunction can act as a significant stressor for PNES patients. Poor communication, disengaged boundaries, maladaptive triangles, coalition, transgenerational trauma, and other distressful family factors can act as significant stressors
• Adaptive coping also exists among PNES patients that can be used as an asset in psychotherapy.

• Although this article highlights the existence of family dysfunction, resolving the same has not been pointed out
• The sample size is very small, and hence, it is advised to duplicate the study with a larger sample and in different countries.

• Family-based interventions are very important to patients with PNES for holistic well-being
• Cultural beliefs and expressed emotions should be paid attention to by clinicians to increase awareness of the patient and the family members
• Adaptive coping should be analyzed among patients by the clinicians, and it should be used as a strength during the therapy.

References

1.	Perez DL, LaFrance WC Jr. Nonepileptic seizures: An updated review. CNS Spectr 2016;21:239-46.
2.	Anzellotti F, Dono F, Evangelista G, Di Pietro M, Carrarini C, Russo M, et al. Psychogenic non-epileptic seizures and pseudo-refractory epilepsy, a management challenge. Front Neurol 2020;11:461.
3.	Kanemoto K, LaFrance WC Jr., Duncan R, Gigineishvili D, Park SP, Tadokoro Y, et al. PNES around the world: Where we are now and how we can close the diagnosis and treatment gaps-an ILAE PNES Task Force report. Epilepsia Open 2017;2:307-16.
4.	Reuber M. The etiology of psychogenic non-epileptic seizures: Toward a biopsychosocial model. Neurol Clin 2009;27:909-24.
5.	Reuber M, Howlett S, Khan A, Grünewald RA. Non-epileptic seizures and other functional neurological symptoms: Predisposing, precipitating, and perpetuating factors. Psychosomatics 2007;48:230-8.
6.	Krawetz P, Fleisher W, Pillay N, Staley D, Arnett J, Maher J. Family functioning in subjects with pseudoseizures and epilepsy. J Nerv Ment Dis 2001;189:38-43.
7.	LaFrance WC Jr., Alosco ML, Davis JD, Tremont G, Ryan CE, Keitner GI, et al. Impact of family functioning on quality of life in patients with psychogenic nonepileptic seizures versus epilepsy. Epilepsia 2011;52:292-300.
8.	Ramanujam B, Dash D, Tripathi M. Can home videos made on smartphones complement video-EEG in diagnosing psychogenic nonepileptic seizures? Seizure 2018;62:95-8.
9.	Gerhardt C, Hamouda K, Irorutola F, Rose M, Hinkelmann K, Buchheim A, et al. Insecure and unresolved/disorganized attachment in patients with psychogenic nonepileptic seizures. J Acad Consult Liaison Psychiatry 2021;62:337-44.
10.	Asadi-Pooya AA, Bahrami Z. Sexual abuse and psychogenic nonepileptic seizures. Neurol Sci 2019;40:1607-10.
11.	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.
12.	Beghi M, Zhang L, Beghi E, Giussani G, Erba G, Longinetti E, et al. History of violence/maltreatment and psychogenic non-epileptic seizures. Seizure 2020;81:8-12.
13.	Ismail H, Wright J, Rhodes P, Small N. Religious beliefs about causes and treatment of epilepsy. Br J Gen Pract 2005;55:26-31.
14.	Singh S, Mishra VN, Rai A, Singh R, Chaurasia RN. Myths and superstition about epilepsy: A study from north India. J Neurosci Rural Pract 2018;9:359-62.   [PUBMED]  [Full text]
15.	Obeid T, Abulaban A, Al-Ghatani F, Al-Malki AR, Al-Ghamdi A. Possession by “Jinn” as a cause of epilepsy (Saraa): A study from Saudi Arabia. Seizure 2012;21:245-9.
16.	Myers L, Fleming M, Lancman M, Perrine K, Lancman M. Stress coping strategies in patients with psychogenic non-epileptic seizures and how they relate to trauma symptoms, alexithymia, anger and mood. Seizure 2013;22:634-9.
17.	Bodde NM, Brooks JL, Baker GA, Boon PA, Hendriksen JG, Mulder OG, et al. Psychogenic non-epileptic seizures – Definition, etiology, treatment and prognostic issues: A critical review. Seizure 2009;18:543-53.
18.	Testa SM, Krauss GL, Lesser RP, Brandt J. Stressful life event appraisal and coping in patients with psychogenic seizures and those with epilepsy. Seizure 2012;21:282-7.