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REVISION Final version published online: 19-JAN-2016 Full bibliographic details: Epilepsy & Behavior (2016), pp. 5-14 DOI information: 10.1016/j.yebeh.2015.12.010 Emotion and dissociative seizures: a phenomenological analysis of patients’ perspectives Susannah Pick a , John D.C. Mellers b , & Laura H. Goldstein a,* a. King’s College London, Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, De Crespigny Park, London SE5 8AF, United Kingdom. (emails: [email protected]; [email protected]) b. Neuropsychiatry Department, Maudsley Hospital, South London and Maudsley NHS Foundation Trust, London SE5 8AZ, United Kingdom. (email [email protected]) *Correspondence to: Prof Laura H Goldstein. King’s College London, Department of Psychology, PO77, Institute of

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REVISION

Final version published online: 19-JAN-2016 Full bibliographic

details: Epilepsy & Behavior (2016), pp. 5-14 DOI information:

10.1016/j.yebeh.2015.12.010

Emotion and dissociative seizures: a phenomenological analysis

of patients’ perspectives

Susannah Pick a , John D.C. Mellers b , & Laura H. Goldstein a,*

a. King’s College London, Department of Psychology, Institute of

Psychiatry, Psychology and Neuroscience, De Crespigny Park, London SE5

8AF, United Kingdom. (emails: [email protected];

[email protected])

b. Neuropsychiatry Department, Maudsley Hospital, South London and

Maudsley NHS Foundation Trust, London SE5 8AZ, United Kingdom. (email

[email protected])

*Correspondence to: Prof Laura H Goldstein. King’s College London,

Department of Psychology, PO77, Institute of Psychiatry, Psychology and

Neuroscience, De Crespigny Park London, UK, tel ++44 220 7848 0218.

Email: [email protected]

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Abstract

Quantitative research has indicated that patients with dissociative

seizures (DS) show altered responses to emotional stimuli, in addition to

considerable emotional distress and dysregulation. The present study

sought to further explore emotional processes in this population, to

extend previous findings and provide a phenomenological insight into

patients’ perspectives on these issues. Semi-structured interviews were

carried out with 15 patients with DS and the principles of interpretative

phenomenological analysis (IPA) were adopted in data analysis. Key

themes elicited included: i) general emotional functioning; ii) adverse

(stressful/traumatic) life experiences; iii) the role of emotions in DS; (iv)

relating to others; and v) resilience, protective factors and coping

mechanisms. The clinical and theoretical implications of the findings are

discussed.

Key words: dissociative seizures, non-epileptic seizures, psychogenic

seizures, emotion, qualitative, phenomenological

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1. Introduction

Dissociative (non-epileptic, psychogenic) seizures (DS) are paroxysmal

phenomena classified as a dissociative disorder in ICD-10 [1] and a

conversion (somatic symptom) disorder in DSM-5 [2]. DS are superficially

similar to epileptic seizures (ES) in many respects but tend not to exactly

mimic the stereotypies of ES, often being of longer duration, with waxing-

and-waning symptom severity and unusual configurations of symptoms

[3,4]. Diagnostic investigations yielding an absence of epileptiform

electrophysiological activity contiguous with seizure occurrence (i.e.

video-encephalography; video-EEG), or a lack of significant neurological

abnormalities characteristic of epilepsy are indicative of a DS diagnosis.

Moreover, a diagnosis of DS requires the exclusion of any other potential

underlying psychiatric or physical illness, such as psychosis, substance-

withdrawal, or transient ischaemic attacks.

Much of the previous psychological literature on DS has depended on

quantitative data obtained through self-report measures (i.e. interviews,

questionnaires), and clinical case note reviews. This literature has

provided important insights into possible aetiological factors in the

disorder. Possible contributory factors include adverse life experiences

(i.e. trauma, stress, relationship disturbances), dysfunctional personality

profiles and coping techniques, subtle neurocognitive abnormalities,

comorbid psychopathology, and frequent somatoform and psychological

dissociative experiences [5-15]. However, an important limitation in the

extensive use of quantitative methods is the lack of insight gained into Abbreviations: DS = dissociative seizures; ICD-10 = International Classification of Diseases (10th ed); DSM-5 = Diagnostic and Statistical Manual of Mental Disorders (5th ed); ES = epileptic seizures; IPA = Interpretative Phenomenological Analysis

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the phenomenological experience of the patients, and their important

perspectives on the research questions under investigation.

Abbreviations: DS = dissociative seizures; ICD-10 = International Classification of Diseases (10th ed); DSM-5 = Diagnostic and Statistical Manual of Mental Disorders (5th ed); ES = epileptic seizures; IPA = Interpretative Phenomenological Analysis

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Qualitative techniques can be used to provide a richer understanding of

the unique meanings that individuals ascribe to their experiences [16].

Increasing numbers of investigators have adopted qualitative techniques

in studies of DS in the last decade. For example, several investigators

have used semi-structured interviews or linguistic analysis to examine

patients’ reactions to receiving the diagnosis [17-20]. These studies

highlighted several themes in patients’ responses to the diagnosis,

particularly feelings of confusion about the nature of the disorder, relief

and feeling like a ‘normal’ person again (i.e. due to not having a chronic

neurological condition). Issues relating to provision and patients’

experiences of treatment have also been examined qualitatively [20-24].

Other authors have adopted qualitative techniques when investigating DS

patients’ experiences and understanding of their disorder. Carton et al.

[17] , for example, reported themes relating to patients’

conceptualisations of their seizures. Some patients experienced their

seizures as a release of accumulated emotion, stress, or as in some way

related to previous traumatic experiences. In addition, many of the

sample reported considerable negative consequences of DS on other

areas of life, such as employment, self-esteem, social isolation and

anxiety. Furthermore, Dickinson and colleagues [25] used thematic

content analysis to explore patients’ perspectives on their disorder and

noted that some patients linked their disorder to both early (e.g. head

injury, physical assault, exposure to epilepsy) and recent (e.g. divorce,

bereavement, legal proceedings) adverse life events. Others [26] noted

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that DS patients tended to discuss the disorder dualistically as either

organic or psychological, rather than acknowledging the possibility that

psychological factors can interact with physical processes. Clearly,

qualitative techniques have much to offer in enhancing our understanding

of the experiences of individuals with DS, and may also serve to generate

hypotheses for further quantitative testing.

Historically and contemporarily, abnormal emotional processes have been

posited to play a crucial role in triggering or underlying DS [27-30].

Recent experimental research has yielded findings supportive of the

hypothesis that patients with DS exhibit altered emotional functioning [31-

34], including differences in attentional, behavioural and subjective

responses to affective stimuli. Moreover, patients with DS report altered

emotional states prior to and/or during the seizures, such as autonomic

arousal and/or panic symptoms [28,35,36], in addition to dissociative

symptoms [35,36]. However, patients’ perspectives on their emotional

processing styles and responsivity have not yet been examined

specifically with qualitative methods, neither have patients’ reports of

emotional experiences during their seizures. Qualitative investigation of

emotional processes in this patient group is, therefore, an important

supplement to quantitative studies in this area, as a means of providing a

more detailed account of patients’ experiences.

This study sought to explore the following research questions, using

qualitative methods:

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1. How do patients with DS perceive their general emotional

functioning?

2. To what extent can patients with DS reflect on and understand

the possible role of emotions in the onset of the disorder and/or

ongoing seizure generation?

3. How do patients with DS perceive their ability to recognise and

understand the emotions of others?

2. Materials and methods

Semi-structured interviews were conducted with a small sample of

patients recently diagnosed with DS, prior to undergoing psychological

therapy for the disorder. The research followed as closely as possible the

recommendations made by proponents of IPA [37].

2.1. Participants

Recruitment for the study took place between January 2011 and August

2012. Ethical approval was granted by the Joint South London and

Maudsley and Institute of Psychiatry NHS Research Ethics Committee

(reference 08/H0807/82). Eligibility criteria for inclusion in the study

were: i) having received a diagnosis of DS based on video-EEG monitoring

and/or consensus clinical opinion (the shared opinion of at least two

consultant neuropsychiatrists, neurologists, or epileptologists), ii) being

18-65 years of age iii) having an estimated intelligence quotient (IQ) of 70

or greater, iv) being fluent in English, and v) not having documented

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epilepsy, significant medical illness, current major depression, anxiety,

substance dependence, or psychosis. All patients were recruited from

tertiary referral neuropsychiatry services at the South London and

Maudsley NHS Foundation Trust. Prior to participation, participants

provided written informed consent.

2.2. Procedure

The interviews lasted approximately 30 to 90 minutes. Fourteen

interviews took place in a psychology laboratory, and one in the patient’s

home. The same interviewer (SP) carried out all interviews; at the time, a

female postgraduate student with no personal experience of

dissociative/conversion disorders but with a good knowledge of relevant

empirical and theoretical literature. The interviews were recorded

digitally, with patients’ permission.

The same interview schedule was used flexibly for all patients (Appendix

1). The questions focused on the following topics: general emotional

functioning, responses to emotionally upsetting events/situations,

understanding of others’ emotions, involvement of emotions at the time of

initial seizure onset, involvement of emotions in ongoing seizure

occurrence, peri-ictal emotions, and more general ideas about the links

between DS and emotions.

2.3. Data analysis

Interviews were transcribed verbatim and the transcriptions were

anonymised. In IPA, the analyst engages actively with the transcript and

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aims to interpret the meanings implicit in the data. The following steps

were taken in analysing the data: i) identification of themes in the first

transcript, ii) theme connection within the first transcript, iii) adding

additional transcripts to the analysis, and iv) developing the final

classification scheme. More detail is provided in Supplementary File 1.

During data analysis, notes were made when there was a possible

influence of the analyst’s background or characteristics on interpretation

of the data; efforts were made to minimise the influence of such

characteristics on the interpretations made. A second member of the

research team (LG) examined a subsample of transcripts independently,

blind to the themes that had been identified by the interviewer (SP). The

themes identified by the second rater were very similar to those identified

by the first; however, some small modifications were subsequently made

to the hierarchy of themes where minor disparities had emerged.

Furthermore, a preliminary summary of the main findings was sent to two

patients who had participated in the study. One of the patients

responded, confirming that the summary was understandable, acceptable

and reflected her viewpoints on the topics discussed.

3. Results

3.1. Participant characteristics

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Fifteen participants took part in the study. The demographic

characteristics and duration of DS disorder for each participant are

presented in Table 1.

Table 1 near here

3.2. Overview of themes

Several superordinate themes emerged during the analysis, partially

reflecting the topics covered in the interview schedule. These were

themes relating to: i) general emotional functioning; ii) adverse

(stressful/traumatic) life experiences; iii) the role of emotions in DS; (iv)

relating to others; and v) resilience, protective factors and coping

mechanisms. The themes and subthemes are presented with

representative quotations in Tables 2 to 6.

3.3. General emotional functioning

One cluster of themes related to patients’ perceptions of their general

emotional functioning (Table 2). For some, the phenomena described

seemed to represent long-term tendencies rooted in development. Other

patients indicated that the experiences were more specific to a given time

in their lives.

Table 2 near here

3.3.1. Negative affect

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The experience of aversive affective states was common to almost all

patients. Patients often felt that this was exacerbated by, or a direct

consequence of the symptoms of DS or other somatic concerns

(statement 1). Others described previous periods of depression in relation

to stressful/traumatic life events or circumstances (statement 2). Some

patients described a specific lack of positive affect that appeared to be

relatively long-standing (statement 3).

3.3.2. Affect dysregulation

Lability of mood state was also common, with patients describing

extremes of emotion occurring within short periods of time (i.e. a day),

labelled ‘ups and downs’ (statements 4 – 5). One patient felt that this

tendency had worsened since the onset of DS. Discrete episodes of

excessive emotional expression were also a commonality, including

weeping, aggression, and destructive behaviours (statement 6-7). Some

patients also recognised that they experienced difficulties in calming

down once upset (statements 8-9), and that these patterns might be

linked to the ongoing ‘bottling-up’ of their emotions.

3.3.3. Inhibited experience and expression of negative affect

A very common theme was the marked inhibition of the experience of

negative emotion. This was referred to as ‘closing down’ or ‘shutting off’

unwanted feelings or mood states (statements 10-11). This theme was

linked to another coping strategy involving behavioural/social ‘shutting

down’ (see section 3.7.3). Patients frequently talked of “bottling-up”

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unpleasant emotions, that is, inhibiting expression of such emotions to

others (statements 12-13). A related feature was that of “putting on a

brave face”, presenting an artificially positive/confident persona to others,

despite this being incongruent with internal affective states. This sub-

theme was connected to a belief that the expression of feelings and

emotions might be a burden to others (see section 3.6.3).

Experiential or expressive emotional inhibition was often described as

long-standing, and attributed to events/situations that had occurred

during childhood/adolescence in some cases (statements 14-15). Some

patients referred to a possible relationship between these tendencies and

the occurrence of seizures, and/or indicated awareness of the maladaptive

nature of these patterns (statements 16-17).

3.3.4. Rumination

Rumination about unpleasant emotions or upsetting experiences was

commonly described (statement 18). For some, these ruminative

thoughts were referred to as somewhat intrusive and not within voluntary

control. For others, this tendency was described as being more of a

controlled analysis of emotional episodes.

3.3.5. Emotions linked to physical feelings

Many patients perceived strong interconnections between emotional

states and physical experiences. For example, emotion was described as

causing physical discomfort or pain, motor symptoms, and/or

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tiredness/exhaustion (statements 19-21). Several patients also

experienced sleep disturbances such as insomnia and night-terrors as a

result of stress or anxiety (statements 22-23), which were also linked to

more general sleep problems in some cases (section 3.4.4). Some

patients were able to describe acute awareness of physiological changes

(e.g. heat, shaking, heart-racing) during acute emotional arousal,

particularly anger (statement 24).

3.4. Stressful/adverse life experiences or circumstances

Patients reported a wide range of stressful and/or adverse events and

circumstances (Table 3).

Table 3 near here

3.4.1. Relationship/interpersonal problems

Some patients described current relationship problems, including conflict,

intimate relationship breakdown and difficulties in forming relationships

with others (statements 25-26). Other patients referred to relationship

problems that had affected them in the past (statements 27-28).

3.4.2. Abuse

A recurrent theme was the experience of interpersonal abuse, often

during childhood (statements 29-30). Some patients described having

‘locked away’, buried or suppressed these experiences (statement 29).

For some patients, abusive experiences had also occurred during

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adulthood (statements 31-32), including domestic abuse, physical assault,

and workplace bullying.

3.4.3. Generally stressful circumstances

Some patients tended to describe their lives as generally stressful, and/or

traumatic. For some, there was a chronic or long-term nature to the

stressors and often multiple stressors or traumas were reported

(statements 33-34).

3.4.4. Somatic concerns and symptoms

Almost all patients described additional somatic illness, symptoms or

concerns (statements 35-38). The most commonly reported were pain

and sleep disturbances.

3.5. The role of emotions in DS

Themes relating to the role of emotion in DS (Table 4) included the

linkage of DS occurrence to life stressors/traumatic events, viewing DS as

a release of emotion, and an inconsistent temporal relationship between

emotional triggers and DS. Several patients described

emotions/experiences that commonly occurred post-ictally.

Table 4 near here

3.5.1. DS onset linked to stress / trauma

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Stressful circumstances or elevated stress levels were often described as

having occurred at onset of the disorder, or immediately preceding this

(statements 39-48). Such experiences included medical/somatic crises or

procedures, traumatic life events (i.e. physical/sexual assault), and

relationship breakdown or crises. Other stressors included moving home,

occupational stress, bereavement and physical/mental exhaustion. Some

patients described multiple life stressors occurring prior to DS onset.

3.5.2. DS as emotional ‘relief’ after a ‘build up’

DS were associated with switching off from emotional distress or strong

emotions by several patients (statement 49). Some patients felt that their

seizures had originally been triggered by a build-up of emotional distress

(statement 50). Feelings of well-being or relief following a seizure were

also described (statement 51).

3.5.3. Inconsistent emotional triggers for DS

The relationship between DS occurrence and emotional states was

perceived as unpredictable by the majority of patients (statement 52).

One patient mentioned that her DS used to be preceded by fear

consistently, but that now they seemed to be triggered by the experience

of any strong emotion (statement 53).

3.5.4. Post-ictal emotions / experiences

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A total lack of emotion was most often described during DS, during which

patients reported not feeling anything at all. On the other hand,

emotional reactions and experiences after DS were more common

(statements 54-56), including frustration, tiredness, weeping, but also

relief in some cases (see section 3.5.2).

3.6. Relating to others

Relationships with others were discussed frequently by patients (Table 5).

Table 5 near here

3.6.1. Interpersonal sensitivity

Most patients reported being sensitive to other people’s mental states.

Some viewed this as a positive trait (statement 57). However, some

suggested that it could at times lead to misinterpreting social signals, or

that it might be better not to be so aware of others’ mental

states/emotions (statement 58). Some patients linked their interpersonal

sensitivity to developmental experiences (statement 59).

3.6.2. Caring for and supporting others

Patients described being caring and supportive of other people. Several

patients reported being the person that ‘people come to with their

problems’, despite rarely sharing their own concerns and issues

(statements 60 – 61).

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3.6.3. Being a burden to others

Several patients described their emotions or seizures as a possible burden

on others, and clearly avoided disclosing their difficulties (e.g. statements

62-63). This was also connected to a need for independence and control,

and viewing themselves as strong and resilient (see section 3.7).

3.7. Resilience, protective factors and coping strategies

A range of factors were discussed that were perceived as being positive in

patients’ functioning or that facilitated coping with their difficulties (Table

6).

Table 6 near here

3.7.1. Resilience

Several patients described themselves as being emotionally ‘strong’, a

‘fighter’, tough and able to cope with adversity (statements 64-65).

Moreover, some perceived themselves as positive/optimistic, with a ‘glass

half full’ outlook on life (statements 66-67). Several patients referred to a

high need for control and independence in, and found that the occurrence

of DS had significantly reduced their experience of confidence and

autonomy in this regard (statement 68).

3.7.2. Protective factors

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A range of protective factors were mentioned. Spouses, family members

and friends were often discussed in positive terms, as sources of support

and encouragement (statement 69). Additionally, some patients

described academic and occupational success (statements 70-71). For

some patients, work provided a relief from difficult life circumstances or

emotions (statement 72).

3.7.3. Coping strategies

The use of coping strategies was evident in most of the sample. These

strategies most commonly involved attentional and behavioural

distraction techniques, in addition to relaxation strategies such as

meditation, martial arts, and enjoyment of music or nature (statements

73-75). A common, but less adaptive strategy was self-isolation and

behavioural avoidance of social situations during times of acute emotional

distress (statements 76-77), labelled ‘shutting down’ by several patients.

4. Discussion

The aim of the study was to gain further insight into the emotional

experiences of patients with DS, and how patients perceive their emotions

to relate to the onset and recurrence of their seizures. It was hoped that

examining these issues qualitatively would enrich and extend previous

quantitative findings suggestive of aberrant emotional processing in this

population.

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It is known that patients with DS often present with significant emotional

distress (e.g. depression, anxiety) and emotional dysregulation [9,38].

The current study suggests that the frequent experience of negative

affect and mood state oscillation are a cause of distress and reduced

quality of life in this group. This finding concurs with quantitative studies

[39, 40]. In the present study, several patients directly attributed their

emotional difficulties to the occurrence of DS, or felt that DS at least

exacerbated these problems. Furthermore, the described episodes of

excessive emotional expression seemed to occur when patients’

perceived ability to cope with their emotions had reached a limit (i.e.

when ‘things had gotten too much’). It may be informative to consider

whether DS may serve a similar function to these episodic losses in

emotional control, as another response to stress or negative affect

reaching a threshold, as proposed by some authors [29].

It is particularly interesting that the above emotional difficulties were

described alongside a general tendency to exert excessive control over

the experience and/or expression of negative emotion. Phenomena

described within this theme can accurately be summed up by the two

phrases ‘shutting down’ negative emotions and ‘putting on a brave face’.

The reported tendency towards inhibited experience of negative emotion

could be conceptualised as a dissociative mechanism (e.g. emotional

constriction, depersonalisation), in those patients who experienced this as

relatively automatic and involuntary. For these patients, this type of

detachment response seemed to have developed into a habitual

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tendency, similar to that seen in depersonalisation disorder, for example.

The observed pattern has also been reported quantitatively [40]. These

tendencies could possibly have developed in the context of early life

stressors such as traumatic experiences, family dysfunction and/or

parental modelling of excessive emotional control and inhibition, as

suggested by patients’ reflections.

Some patients also avoided expressing genuine emotions to others,

and/or referred to displaying an overtly positive façade even when this

was incongruent with their internal emotional state. For some, this was a

voluntary coping strategy, and seemed to represent intentional cognitive

avoidance of some emotions, linked to beliefs regarding the necessity for

complete independence, autonomy, personal control and ‘emotional

strength’. These general patterns accord with the quantitative findings

[41], where patients with DS reported exerting greater control over

emotional expression and more negative beliefs about emotions (e.g.

shameful, irrational, useless), relative to healthy controls. Novakova et al.

[40] also observed significantly higher scores for self-reported emotion

suppression and avoidance in their sample of patients with DS, compared

to non-clinical controls. Together, the findings indicate the presence of

maladaptive beliefs about emotional functioning, alongside a tendency to

avoid, inhibit, or ‘mask’ the experience/expression of negative affect.

Cognitive therapies for DS might seek to focus on such beliefs, and

associated schemas.

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The strong links between emotions and bodily experiences described by

many patients also suggested that negative affect was associated with an

exaggerated focus on somatic symptoms and experiences, in this sample.

This is in line with the previous findings that have shown high levels of

somatic symptoms and somatoform dissociation in patients with DS

[12,42-45]. It seems, then, that difficult emotions may manifest as a

variety of somatic symptoms in individuals with this diagnosis. The

specific mechanisms by which emotion may give rise to somatoform

symptoms is a fascinating and important area for further neurobiological

studies [46,47], but the currently available literature indicates possible

abnormalities in functioning and connectivity between neural regions

involved in emotion, agency, motor control and attention/awareness[48-

51].

The themes pertaining to stressful and traumatic life events, once again,

generally reflected and extended the findings of previous studies [52,53].

The qualitative findings described here confirm that patients with DS

experience a wide range of adverse life events. Abuse (physical,

emotional, sexual) was disclosed by several patients, further suggesting

the aetiological importance of these types of experience in DS. Several

patients described ‘locking these experiences away’ or suppressing them,

which indicates that the trauma and psychological consequences may not

have been fully processed. Again, this shows considerable insight into

mechanisms that can be conceptualised as dissociative (i.e. fractionation

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of autobiographical memories and emotions relating to traumatic life

events).

These findings are suggestive of a complex and unresolved response to

traumatic experiences that may contribute significantly to the

development of DS, and corresponds with observations of high rates of

post-traumatic stress disorder and associated symptoms in this patient

group [52]. These findings are also indicative of the potential importance

of identifying and addressing traumatic experiences in clinical

interventions for some patients with DS, perhaps utilising techniques

aimed at emotional processing of the index trauma. However, the

currently available literature indicates that whilst trauma/abuse are

significant risk factors for the later development of DS, these experiences

are reported by only a proportion of patients with the diagnosis and so

seem to represent just one of many life events that might predispose

towards the condition, in individuals with possible additional cognitive and

emotional vulnerabilities.

Relationship disturbances were also clearly present for many patients,

particularly involving problems with significant others that appeared

longstanding and difficult to resolve. Family and relationship dysfunction

has been reported in this group in studies utilising other methodologies

[8,15,53-55]. Several patients described dysfunctional family dynamics in

childhood, and relationship crises occurred immediately prior to DS onset

in several cases. Therefore, significant relationship difficulties may act as

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predisposing, precipitating or perpetuating factors for DS, and are

suggestive of the possible benefits of including significant others within

psychological interventions for the disorder. Addressing current

relationship dysfunction might either take place within CBT protocols or

other approaches such as systemic family interventions or interpersonal

psychotherapy However, it should be noted that there is currently a

paucity of controlled studies of the efficacy of the latter two approaches in

this population, so this is a potentially valuable avenue for further

research.

Whilst many patients found it difficult to understand the processes by

which stressors might have brought about the initial onset of DS, some

patients seemed to have a better understanding of how emotional states

might contribute to the ongoing occurrence of DS. The theme of DS being

a form of emotional release or ‘shut-down’ following a build-up of emotion

was reminiscent of those previously reported in other qualitative studies

[17,20]. Together, this lends support to the proposal that DS are

dissociative phenomena. Hendrickson et al. [35,36] have also reported

elevated dissociative experiences during seizures in patients with DS.

Moreover, Stone and Carson [56] report a series of DS cases who

described ‘wilful submission’ to seizure onset, akin to voluntarily

dissociating from the present situation or mental state.

The inconsistency with which DS were associated with particular

emotional states indicates that, if triggered by emotion, the relationship is

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not specific to any one emotional state. A recent study [35], nevertheless,

reported that peri-ictal emotions were more commonly reported in DS

patients than in those with ES. As many patients presently described DS

occurring during times of relative happiness or relaxation, it might be that

the emotional ‘shut-down’ or ‘release’ does not necessarily occur in direct

response to one emotional episode, but might well occur after a gradual

build-up, when the individual is in a ‘safer’ situation for the seizure to

occur. It is also possible that seizures might be triggered by emotions

taking place at a preconscious level, triggered by previously neutral cues

that have been associated with trauma-related affect [28].

The lack of consistency between conscious emotion and seizure

occurrence most likely underlies the perceived unpredictability of the

seizures and may make attempts at control or prevention more difficult.

Identifying possible preconscious triggers and/or patterns in accumulating

distress may well be beneficial in increasing patients’ ability to predict

and/or control the occurrence of their seizures. Patients who identify

stress as a precipitant for their seizures also report being better able to

predict their seizures, relative to patients who do not report stress as a

precipitant [57].

The finding that patients generally described sensitivity to others’

emotional states was noteworthy, in light of previous research. Patients

reported being very much aware of and responsive to others emotions

and some described this as having a negative impact on their functioning.

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This accords well with findings [31] that patients with DS show

exaggerated preconscious vigilance for outward signs of others’ emotional

states (i.e. from facial expressions). Moreover, other studies have

indicated that experimentally presented facial emotional expressions lead

to higher levels of cognitive interference in patients with DS compared to

controls [33,58]. The findings described here suggest that at least some

patients are aware of this tendency and so it may not be operating

entirely outside conscious awareness.

Patients often referred to their resilient personality traits, which suggested

that they perceived themselves as proficient in coping with adversity.

This seemed to be closely associated to the high levels of control and

independence preferred by these patients, and the ability to exert high

levels of regulation over their emotions. It is possible that an exaggerated

emphasis on being resilient in the face of adversity and maintaining a

relatively positive perspective may be crucially linked with the tendency

to not tolerate the experience or expression of negative affect. Therefore,

these beliefs and expectations could be an important mediator of the

relationship between traumatic/stressful life events and the development

of somatoform/dissociative symptoms, including DS. Put simply, patients’

psychological resistance to processing and expressing trauma- or stress-

related negative affect (i.e. the belief that acknowledging negative affect

or accepting support is a weakness) could directly increase the tendency

towards dissociation (psychological/somatoform) and thus, the

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development of DS or other medically unexplained symptoms / functional

neurological symptoms.

The common reports of behavioural/social avoidance as a coping strategy

indicated that some patients manage their difficulties in ways that could

be detrimental to their general functioning. The excessive use of

behavioural avoidance reported presently, for some, included prolonged

periods of self-imposed isolation, which would necessarily lead to reduced

socialisation, physical exercise, among other consequences. Once again,

though, these reports are in accordance with previous literature which has

indicated a tendency towards avoidant coping in this group [7,10,14,59].

These findings suggest that this is an important area for clinical

intervention, perhaps as one element within cognitive behavioural

approaches to treating the disorder [60].

Finally, the presence of protective factors (e.g. supportive relationships,

education, employment) seemed to limit the impact of DS for some

patients. Indeed, findings have previously shown that outcomes tend to

be better for patients with DS who are in employment [61], those with

more years of education [62], and those who are accompanied by a

supportive other to their first clinic appointment [63]. It is possible that for

patients out of employment, with less education or fewer positive social

contacts, social interventions aimed at the development of occupational,

educational and interpersonal skills might provide considerable benefits.

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4.1. Limitations

It is possible that some of the phenomena described here may not be

specific to individuals with DS and might be present in other clinical

disorders. The current study aimed to provide an in-depth

phenomenological exploration of emotional processes in patients with DS

only; however, future studies may seek to explore differences and

similarities between patients with DS and other functional neurological

disorders, for example. Another comparison group might include those

diagnosed with epilepsy, to examine whether such individuals understand

the role of emotions in their seizures differently to those with a diagnosis

of DS.

Furthermore, the current study aimed to identify themes that were

common to most/all patients in the sample, thereby representing patients

with DS more generally. Additional studies might provide comparisons of

the perspectives of subgroups of patients with DS, such as those with

higher and lower educational achievement, varying levels of social

support, an absence versus presence of psychological trauma (e.g. abuse)

and/or those with chronic versus recent-onset DS.

As previously discussed, the key goal of this study was to explore

patients’ understandings of their emotional functioning, rather than to

specifically assess causal relationships or disorder-specific phenomena.

The current study, therefore, utilised a narrative phenomenological

approach to exploring the role of emotions in DS, with the central

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objective being to better understand patients’ unique subjective

emotional experiences. Whilst the study identified several factors that

patients viewed as important sources of distress and/or of possible

relevance to the onset/occurrence of their seizures, the study did not

include manipulation of variables under controlled conditions, so it is

important to note that causal relationships between specific aetiological

factors (e.g. somatoform symptoms, trauma/abuse) and DS

occurrence/diagnosis are not supported by the current study. Instead, the

findings here provide an indication as to which symptoms and life

experiences are perceived as most important from the patients’

perspective only. Quantitative studies including experimental and/or

between-group designs are better suited to the elucidation of causal

relationships.

Another possible limitation is that this study aimed to examine patients’

subjective experiences of the links between emotions and DS. According

to most theoretical models of the disorder, the mechanism underlying this

relationship is likely to occur below the level of conscious awareness.

Therefore, it could be argued that an attempt to examine patients’

conscious access to these processes is unlikely to be informative.

However, the study has shown that this sample of patients with DS were

able to reflect on their general emotional functioning and processing

styles, which in itself provides important insights into possible aetiological

processes. Moreover, several patients were able to formulate a possible

mechanism by which their emotions might be linked to their DS, in the

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form of an emotional release or shut-down. Therefore, it seems that at

least some patients with DS are able to demonstrate insight into a

possible emotional mechanism underlying their seizures.

It should be noted, however, that an important possible influence on

patients’ responses in this study was any formulation provided by the

participants’ clinicians. All patients included in the sample had received a

diagnosis of DS, and are likely to have received verbal and/or written

explanations as to how the seizures might be related to psychological

factors. In addition, some patients may have been directed towards

internet-based resources for individuals with functional neurological

symptoms. It is not possible to conclude, therefore, that the views

expressed by patients in this study had not been in some way influenced

by clinician’s or other experts’ theoretical viewpoints. Nevertheless, one

of the exclusion criteria for the study was having completed psychological

interventions for DS. Therefore, it can be assumed that none of the

patients had experienced extensive therapeutic input that focused on

seizure- or emotion-related beliefs or processes.

It is also important to note that within IPA, the investigator actively

interprets the data provided by participants and as such, this

interpretation may be in some ways biased by the sociocultural and

professional background of that investigator. Indeed, whilst efforts were

made to ‘bracket’ such influences when interpreting patients’ responses,

bias cannot be excluded. Nevertheless, every effort was made to ‘stay

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close to the data’ and avoid making significant theoretical assumptions

that were not consistently supported by patients’ statements.

5. Conclusions

Patients with DS appear to have considerable insight into their emotional

functioning and how their life events and emotional responses might

relate to ongoing seizure occurrence. Almost all patients taking part in

this study could identify life events that may have contributed towards the

initial onset of DS, although understanding of the processes underlying

this relationship was limited. The findings indicated the experience of

considerable emotional distress and dysregulation that was often long-

standing, but also exacerbated by the development of DS. Despite these

difficulties, patients were generally aware of others’ emotions and needs,

and invested effort in caring for and supporting others.

However, there was a clear tendency for patients to place high value on

emotional resilience, control and independence, and to exert excessive

levels of control over the experience and expression of negative emotions.

This excessive emotional control can be conceptualised as dissociation

(involuntary, automatic) or cognitive avoidance (intentional, controlled) of

negative affect and it could contribute to intermittent episodes of

excessive emotional dysregulation. Indeed, DS may represent a

consequence of this unprocessed and ‘bottled up’ negative affect,

allowing the individual to release or ‘shut-off’ from the resultant emotional

experience. Future research might seek to explore further some of these

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hypotheses with experimental or self-report measures. The findings of the

study have a number of clinical implications, which if applied in practice,

could allow interventions to target specific emotion-related processes in

this group (e.g. emotion regulation, maladaptive emotion-related beliefs),

in addition to seizure-related cognitions.

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Appendix 1 – Semi-structured interview schedule

33

Can you describe to me, in general terms, what sort of a person you are emotionally?

Prompts:- Do your emotions/feelings change much over time?- Do you ever try to change your feelings?- Would you say that you generally experience more positive or

negative emotions, or roughly the same amount of each?- Do your emotions ever affect aspects of your life? (e.g. your

relationships, work/college)- Do you find it easy to name or label what you are currently

feeling?-

How do you tend to respond when you are faced with an emotionally upsetting event or situation?

Prompts:- For example, if somebody does something to upset or anger

you? - Do you always know straight away when something has upset

you?- Do you experience any physical changes when you are upset

emotionally? - Do you tend to express your feelings? - Do you find it easy to calm down, once you are upset?-

How easy do you find it to understand other people’s emotional responses to things (feelings)?

Prompts:- Can you usually tell if somebody is upset, happy, sad, angry,

etc?- If someone is upset or angry, can you generally understand why

they may feel that way?- Do you ever feel confused by other people’s reactions to things?-

Do you feel that your emotions/feelings were involved when your seizures/attacks started?

Prompts:- If yes, can you give me any ideas about what sort of events or experiences were most important in this?- If no, what are your views on the reasons for why you started to have your seizures?

In your view, are emotions/stress involved in the fact that you are having your seizures?

Prompts:- If so, can you describe how you think this may be happening?- Do you feel that you have any control over this?- If emotions and stress are not reasons why you have seizures,

why do you think that you are having seizures?

During, just before, or straight after your seizures, can you tell me if you regularly experience any specific emotions (have any particular feelings)?

Prompts:- E.g. joy, anger, or fear- Do you experience a sudden shift in the strength of your

feelings/emotions?

Do you think that Dissociative Seizures are related to emotions/stress in general?

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Acknowledgements

We wish to thank all patients who completed the study. The research was

funded by a postgraduate studentship awarded to SP from the

Department of Psychology, Institute of Psychiatry, Psychology and

Neuroscience (King’s College London), and a grant from the Central

Research Fund (University of London). This paper also represents

independent research part-funded (LHG) by the National Institute for

Health Research (NIHR) Dementia Biomedical Research Unit at South

London and Maudsley NHS Foundation Trust and King’s College London.

LHG and JDCM are in receipt of further funding from the NIHR. The views

expressed are those of the authors and not necessarily those of the NHS,

the NIHR or the Department of Health.

Conflict of interest: The authors have no conflict of interest to declare.

Supplementary information

Supplementary file 1 – Further details on data analysis

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Table 1. Participant characteristics

Participant number

Age

Gender(M/F)

Ethnic background

Occupational history

Educational background

Time since DS onset (months)

1 40s

F White British

Self-employed/homemaker

GCSEs / O levels

48

2 40s

F White British

Homemaker/professional

Undergraduate degree

84

3 50s

F White British

Homemaker None 120

4 30s

M White British

Professional Postgraduate degree

33

5 30s

F White British

Administration Undergraduate degree

192

6 50s

F Mixed Professional Postgraduate degree

84

7 20s

F Black African

Professional Postgraduate degree

84

8 30s

F White British

Homemaker GCSEs / O levels

120

9 50s

F White British

Professional Undergraduate degree

44

10 30s

M White British

Intermediate occupation

GCSEs 15

11 50s

M White British

Unemployed/disability

None 276

12 30s

M Mixed Intermediate occupation

Diploma 168

13 30 M White Service None 192

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s British occupation14 20

sF White

BritishUnemployed/disability

None 120

15 50s

F White British

Intermediate occupation

GSCEs / O levels

30

M = male; F = female

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Table 2. Themes relating to general emotional functioning

Theme Sub-theme Typical statementsNegative affect Current negative

affect related to somatic symptoms (including DS)

Previous depression related to difficult life events / circumstances

Long-term lack of positive affect

1. “I get…especially since all my health issues started, I get very depressed, due to all the things that are going on with me.” (P12)

2. “I used to be in huge emotional pain...my life was really hard emotionally...I went through a very difficult time, I was depressed…” (P6)

3. “I wouldn’t say I’ve ever felt really happy…I wouldn’t say, for the past like 15 or 20 years, I’ve been happy, I can’t remember a time in my life...” (P7)

Affect dysregulation ‘Ups and downs’ 4. “My bad moods are...they’re really bad...When I’m in a bad mood, I’m really unhappy. It’s severe. When I’m in a good mood...nothing can go wrong.” (P14)5. “…before my attacks, I was quite wavy anyway....as opposed to a calm sea...but since the attacks...my emotions have changed, are much more dramatic...the wavy lines are much higher and much lower, at either end of the spectrum…” (P1)

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Episodic excessive emotional expression

Difficulties calming down

6. “I kind of, blow up at inappropriate things at home. Well not inappropriate, but really small things at home.” (P5)7. “You know, it comes out of me…in a sense where, I’ll smash a plate or a cup.” (P11)

8. “I’m not good at calming down. It takes me forever…when I hold things in, and think what I’m saying, and I have to hold back a little bit, that’s when I can’t calm down.” (P8)9. “Once I cross the line, then it’s avalanche...and I think that’s because I bottle it all up…so, there is a line. The point of no return I suppose.” (P2)

Inhibited experience / expression of negative emotions

Shutting off difficult emotions

Bottling-up emotions and putting on a ‘brave face’

10. “I have to accommodate certain negative influences, so I think they leave me flat, rather than down. Numb. Shutting it off. Like, blocking it.” (P2)11. “I very much compartmentalise stuff…with very strong emotions, be it very good ones or very bad ones, I tend to close off from them... (P4)

12. “Throughout my entire life and throughout any stresses and strains I’ve had, the way I’ve always dealt with it, is – the worse I’m actually feeling, the happier I will be to people around me. I hide my feelings very much so…I just, you know, put on this sort of happy face...” (P15)

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Inhibition of emotions rooted in development

Insights into links with seizures / negative consequences

13. “But even my best friends, you know, they’ve come to see me, so I don’t have to be completely, you know ‘painted smile’, but there’s still an element of that.” (P1)

14. “I think, one of the things about my family life, and my upbringing, was that very strong emotions are not ok, and they’re not shown. Which I guess ties into the seizures in some way.” (P4)15. “I feel myself, it’s about how I was emotionally as a child…because I was very sensitive and the problems that I faced, I suppressed that. I forget about that for many many years. You know, it went out of my mind completely.” (P6)

16. “Sometimes...I want to hold things back...but I know, because of the seizures and everything, I know that’s the worst thing you can do, to keep it all in to yourself. You’ve got to speak to someone about it.” (P8)17. “So it was all about carrying on, covering up, not being able to say anything. Particularly in some very stressful situations…I know that was internalising the emotions, and...I know how it affected me too.” (P2)

Rumination / intrusive thoughts

18. “I have to keep processing it. I keep processing it, over and over and over...it’s like a little nag, and it won’t go away, no matter what I try to do, it won’t go away. It’s like I have to keep thinking about it...” (P9)

Emotions and Pain 19. “I’m always getting the pain…it’s just like all of the time, even

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physical symptoms (non-DS)

Motor symptoms

Exhaustion

Sleep disturbance

Physiological responses to affective arousal

for small things, if I get angry or something like that....it’s just like very quick, and then I feel very tense....it can take days before the pain goes....” (P7)

20. “I get these jerks, you know, and I recognise if I’m feeling a bit anxious, it’s like a build-up, and my body will jerk, and then the anxiety goes.” (P9)

21. “...if something’s upset me…perhaps the day after, or the day after that, I will feel very exhausted…and you know, if I allow myself time enough, then it will make me feel physically not well...” (P15)

22. “If I’m upset I won’t sleep...and then when I do sleep I have really strange weird dreams that are sort of connected to what I’m upset about...” (P5)23. “I mean night-times, there’s the night traumas, the nightmares, night sweats…there is a connection with the nightmares with the bullying.” (P13)

24. “Sometimes I get hot, and I tend to, it’s sometimes like the anger is boiling up inside me, and my heart races a bit, if it’s something really bad...If I get really angry, I shake, which is quite embarrassing.” (P5)

P = participant number

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Table 3. Themes relating to adverse life experiences

Themes Sub-theme Typical statementsRelationship / interpersonal problems

Relationship dysfunction / interpersonal problems (current)

Relationship dysfunction (previous)

25. “I know for example that there is an ongoing situation with me, where conversations are being misrepresented...and it feels terribly unjust and terribly unfair...and this has gone on for several years.” (P2)26. “I find it hard to actually make friendships. I mean I try and get out there, around people, and I just can’t do it.” (P13)

27. “…when my parents got divorced…it’s quite a wounding thing…you know, I was very cross and very bitter, and I carried that for a long time.” (P1)28. “…for the first five or maybe six years of my marriage, I cried constantly because it was so awful…it just destroyed me….” (P15)

Abuse Childhood abuse 29. “I think...when I was a child, I went through quite a bit of child abuse...and I think I locked that away, and I know because I just got on with it...my way was to kind of get on with it...I don’t think on it at all, sometimes I’m kind of, not angry, I’ll be upset that I had to suffer that, and now it’s still affecting my adult life.” (P10)30. “So, when she, when I was beaten, I hate her, I hate the pain, and I hate not being able to express my pain, my physical pain, my emotional pain, I hate not being able to cry, I thought that was, you know, pure cruelty.” (P6)

31. “...he’ll shout and he’ll scream, and throw things...last week I was making a drink and I’d got the boiling kettle in my hand…and

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Adulthood abuse he just walked up behind me and pushed me.” (P5)32. “…and then the intimidation started and the mental bullying started…and that was it.” (P13)

Generally stressful circumstances

33. “…currently my situation at the moment is quite stressful…” (P2)34. “I’ve had so many things happen, to me, during my life…” (P1)

Somatic symptoms and concerns

Pain

Sleep disturbance

35. “Most days, I end up with a bad headache throughout the day…I’ve been to the neurologists and I’ve told them about it, and I’ve had brain scans, and they’re just not finding anything.” (P13)36. “I have pain all the time. Like in my leg, it’s just like, all the time. Nobody can do anything about that...” (P7)

37. “I don’t go more than probably three, three and a half hours a night...the mind’s constantly active.” (P10)38. “Sleep, that’s the main thing at the moment....I keep waking up constantly, for no reason, and sometimes you think it’s time to get up...and then I can’t get back to sleep again.” (P8)

P = participant number

Table 4. Themes relating to the role of emotions in DS

Theme Sub-theme Typical statements

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DS onset linked to stressful / traumatic life events

Medical/somatic crises

Physical/sexual assault

Multiple stressors

39. “…they followed a long period of intense physical pain. The pain came first, the attacks came after.” (P2)40. “I had to go into hospital for minor surgery, I had general anaesthetic, I came out of the anaesthetic, and ended up staying in for a week...they hadn’t a clue what it was, and it kind of all went from there...” (P1)41. “I got sick, and I was told I had meningitis...and so, they started around then....” (P5)42. “In 2004 I had a major physical failure. I had the seizures, I had the stomach, I had to have surgery, I had breast cysts, I had cysts on my uterus….” (P6)

43. “I’d been attacked, shortly before that…” (P5)44. “I was ok-ish then. I just went out for that walk…got beaten up...it all stemmed from there...” (P11)

45. “Prior to all that, I lost my wife, my daughter, er, I gave up the alcohol…yeah so I was sort of, I’d had a few sad moments, bereavements, before the actual…erm, the first seizure.” (P11)46. “I had a lot going on...moving home, getting married, and all that sort of thing, so...it was stressful, at that time.” (P8)47. “For me, they came at a time when my body was under a huge amount of strain from stress, and also I ran the marathon...my relationship broke down in the March, I ran the (marathon) in the April, and I was scheduled for the surgery in

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Relationship crises

June...physically, there was a lot of stuff going on…”(P4)

48. “I can remember my first day, my first seizure started…the problem I was facing at home had just got to a point where I just couldn’t deal with it any more…I got to my limit…something had to give, and for me, it obviously manifested in a seizure.” (P15)

DS as emotional ‘relief’ or ‘shut-down’

DS related to switching off from emotions

DS originally triggered by a build-up of emotion/stress

Relief after DS

49. “So it would seem like to have a seizure would take me out of my surrounding problems…Switched off, emotionally switched off, I don’t feel anything…I don’t feel unhappy or I don’t feel happy, I just feel as though somebody has literally switched me off and I’m not worried about anything.” (P15)

50. “…if you don’t get things off your chest, and you’re holding certain things back, that keeps running round in your mind, then that is like stressing you out, then it’s building up and making you more and more agitated, and I think that’s possibly one of the causes that triggered it off.” (P8)

51. “I used to feel exhausted (after a seizure), but it was almost like all that fear had gone, almost like a relief feeling, funnily enough, that it had gone.” (P9)

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Inconsistent relationship between emotional triggers and DS occurrence

52. “At times when I’m stressed and fairly anxious I can have lots of seizures, but then at the same time I can have none at all...” (P12)53. “...before, I’d always feel like fear. I was just like really scared...now, I just feel like every kind of big emotion, just triggers it, that’s the thing.” (P7)

Post-seizure emotions / experiences

Frustration

Tiredness / exhaustion

Weeping

54. “So…they bring on a completely different emotion of ‘Oh god, it’s happened again’ and ‘I haven’t done this and I haven’t done that’…there can be a feeling of that, after one, which is ‘Oh god, here we go, another day lost, another day wasted.” (P2)

55. “I feel very very tired, and sort of like, more worn out, then I was before…” (P11)

56. “When I come out of it, all I want to do is cry, and that’s it...I’m always crying after them, I’m just not myself, if you know what I mean?” (P14)

P = participant number

Table 5. Themes about relating to others

Theme Sub-themes Typical statementsInterpersonal Interpersonal sensitivity 57. “I’m very sensitive to other people’s feelings, and I have a

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sensitivity as positive

Interpersonal sensitivity as negative

lot of empathy.” (P6)

58. “I’m going back to what I said about being sensitive to people, I just wish I didn’t do that, I just wish I didn’t understand it so well. Because sometimes, you just don’t want to know...” (P2)59. “I remember when I was younger…I was very susceptible to other people’s emotions…I think having a fairly volatile home-life makes you that way. You’re consciously looking out for stuff.” (P4)

Caring for and supporting others

60. “I’ve never had no-one look after me, I’ve always looked after other people….but it’s not like that now.” (P3)61. “I think I have this thing where...in work...most people will come to me...I’m like an agony aunt. Which is ironic…” (P7)

Fear of burdening others

62. “I don’t want to burden anybody else with it…I don’t want to burden anybody else with what I’ve been feeling.” (P3)63. “I tend to refuse people’s help, I tend to not want to take anything.” (P2)

P = participant number

Table 6. Themes relating to resilience, protective factors and coping

Theme Sub-theme Typical statements

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Resilience Emotional strength

Positivity

Control

64. “I had to toughen up, to be strong…so I was a fighter, I fight for things that I want...” (P6)65. “I’ve always been able to cope with everything… because if you don’t help yourself, nobody will help you…” (P3)

66. “I think I’m quite a positive person. I always look, I look positively on anything, I try to be optimistic, no matter what comes my way…” (P15)67. “I’ve always been more of a glass half full than glass half empty person....” (P9)

68. “…I was, I did everything. I was in charge and that was it, full stop. But now, I’ve lost it, I just haven’t got the confidence I had...With the seizures, since I’ve been having these turns...I was always independent, always. But I’ve lost it…I can’t cope with this, because it’s not me, I’m not in control, and I don’t like that.” (P3)

Protective factors Supportive relationships

Educational/occupational achievements

69. “I know, even on my worst days, that fundamentally I am actually really lucky, and I’m actually very happy…I know that I’m lucky with my lot, and everything I’ve got in my world, my family, my friends, and everything...” (P1)

70. “I did excellently at school, I made sure I did excellently at college, I did excellently in jobs...” (P2)71. “…sometimes I just think ok yeah, stop complaining...you can have a job, some people don’t have jobs, they don’t have

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Work

qualifications, or they are very sick and things like that.” (P7)

72. “...it’s the one place that I always feel that I can be myself, but even if I don’t feel well, if I go into (work), then I immediately feel well, because it’s like a feel-good factor.” (P15)

Coping strategies Distraction and relaxation

Behavioural / social avoidance (‘shutting down’)

73. “I’ve had to sort of force myself to get out of the depressions and try to find things to do to take my mind off it....anything to take my mind off it.” (P12)74. “I might go over the beach for a while…that’s nice, it helps, it don’t get me completely calm, but it’s a nice relaxing atmosphere and that’s what I try and do, I try and put myself in a situation where I go and do something relaxing, and try and calm down.” (P13)75. “...when I was young I did a lot of martial arts, so I learned how to do meditation and breathing exercises and things, and I use them now.” (P12)

76. “So I kind of withdraw, I don’t phone call, I don’t pick up my phone, I don’t go out, I just stay in my room...it can go on for days…I tend to...shut down.” (P7)77. “...sometimes I have a tendency to shut down. You know, erm, switch off….you know, me mobile phone, and not answer the door….I mean, shut off from society, you know, where I won’t come out, you know I’ll I stay in…this is how I find my way of dealing with it.” (P11)

P = participant number

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