Psychogenic non-epileptic seizures: so-called psychiatric comorbidity and underlying defense mechanisms

Abstract

Massimiliano Beghi,1,2 Paola Beffa Negrini,1 Cecilia Perin,1,3 Federica Peroni,1,3 Adriana Magaudda,4 Cesare Cerri,1,3 Cesare Maria Cornaggia1,3 1Department of Surgery and Translational Medicine, University of Milano-Bicocca, 2Department of Mental Health, “Guido Salvini” Hospital, Garbagnate Milanese, Milan, Italy; 3Rehabilitation Medicine, Istituti Clinici Zucchi, Carate Brianza, Monza and Brianza, Italy; 4Epilepsy Center, Department of Neuroscience, University of Messina, Messina, Italy Abstract: In Diagnostic and Statistical Manual of Mental Disorders, fifth edition, psychogenic non-epileptic seizures (PNES) do not have a unique classification as they can be found within different categories: conversion, dissociative, and somatization disorders. The ICD-10, instead, considers PNES within dissociative disorders, merging the dissociative disorders and conversion disorders, although the underlying defense mechanisms are different. The literature data show that PNES are associated with cluster B (mainly borderline) personality disorders and/or to people with depressive or anxiety disorders. Defense mechanisms in patients with PNES with a prevalence of anxious/depressive symptoms are of “neurotic” type; their goal is to lead to a “split”, either vertical (dissociation) or horizontal (repression). The majority of patients with this type of PNES have alexithymia traits, meaning that they had difficulties in feeling or perceiving emotions. In subjects where PNES are associated with a borderline personality, in which the symbolic function is lost, the defense mechanisms are of a more archaic nature (denial). PNES with different underlying defense mechanisms have different prognoses (despite similar severity of PNES) and need usually a different treatment (pharmacological or psychological). Thus, it appears superfluous to talk about psychiatric comorbidity, since PNES are a different symptomatic expression of specific psychiatric disorders. Keywords: epilepsy, PNES, defense mechanisms, comorbidity