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Title: Emotion regulation in patients with Functional Neurological Disorder
Author: Williams, Isobel Anne
ISNI:       0000 0004 7428 2100
Awarding Body: University of Sheffield
Current Institution: University of Sheffield
Date of Award: 2018
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Functional Neurological Symptom Disorder (FND) is defined in the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013) as one or more symptoms of altered voluntary motor or sensory function. In the absence of any clear structural or physiological aetiology, FND has long been believed to have an emotional cause. However, the relationship between emotion regulation and FND has received relatively little attention from the scientific community. The overall aim of my project was empirically to test hypotheses concerning emotion dysregulation generated from the Extended Process Model of emotion regulation (EPM) (Gross, 2015) in patients with FND, using a combination of self-report, behavioural, and physiological measures. Additional aims were to explore other important issues, including whether emotion dysregulation is related to specific manifestations of FND, and whether changes in emotion regulation can be tracked across psychotherapeutic intervention by self-report. A systematic review of the available literature on emotion dysregulation in patients with Nonepileptic Attack Disorder (NEAD) (N = 52), suggested that this patient group exhibit impairments in the identification of their own emotional states, as well as a tendency to select and implement maladaptive regulatory strategies. Studies also suggested that patients with NEAD experience biased cognitive-affective processing of exteroceptive emotional information, which may further impede the implementation process. However, these impairments appear to be heterogeneously spread throughout the population, and linked to other clinical / aetiological factors such as psychological trauma. Study One aimed to explore whether emotion dysregulation and co-morbid psychopathology is linked to whether or not patients self-report Impairment of Consciousness (IOC) as part of their disorder. 163 patients with FND completed selfreport measures of emotion dysregulation (The Emotional Processing Scale – 25; EPS25), as well as measures of Major Depressive Disorder (PHQ-9), Generalized Anxiety Disorder (GAD-7), Somatization Disorder (PHQ-15), and Post-Traumatic Stress Disorder (PCL-5) symptomology. Patients with IOC scored significantly higher on the GAD-7 (p = .03), PHQ-15 (p = .002), and PCL-5 (p = .02) but there were no betweengroup differences on the EPS-25 (p = .45, both groups exceeding healthy norms). These results support the view that FND is associated with emotion dysregulation, but suggest that clinical presentations including IOC are related to symptoms of anxiety, Somatization disorder, and Post-Traumatic Stress Disorder. Study Two aimed to experimentally test the hypothesis that patients with FND are impaired in their ability to identify their own emotional states, and that this impairment would be further exacerbated by stress. Twenty-six patients with FND and 27 healthy controls participated in the Heart Beat Detection Task (HBDT; Schandry, 1981) at baseline and following stress-induction with the Cold Pressor Test (Lovallo, 1975). The 'impoverished emotional experience' subscale of the EPS-25 was included as a self-report measure of participants' ability to identify their own emotional states. Patients were significantly impaired on the HBDT compared to controls (p = .04) and reported significantly greater difficulties on the 'impoverished emotional experience' subscale. However, there were no significant main effects of stress-induction on HBDT performance. These results suggest that patients with FND are impaired in the identification stage of the EPM, as characterised by reduced interoceptive sensitivity and insight into their emotional experiences, but that impairments in interoception are not exacerbated by the kind of stress induced by the Cold Pressor Test. Study Three aimed to experimentally test the hypothesis that patients with FND habitually select and implement a maladaptive regulatory strategy, expressive suppression. Twenty-six patients and 28 healthy controls completed a picture viewing paradigm designed to elicit negative affect, and were instructed to either passively view the pictures or suppress their responses to the images. Facial responses to the images were measured using electromyography, implicit emotional responses to the images were measured with the Implicit Positive and Negative Affect Task (Quirin, Kazen, & Kuhl, 2009), and explicit emotional responses were measured with a selfreport scale. The Emotion Regulation Questionnaire (Gross & John, 2003) assessed self-reported habitual implementation of expressive suppression. Patients reported an increased tendency to select / implement expressive suppression on the ERQ (p = .005), and experienced less positive emotion in response to the pictures (implicitly) than healthy controls (p = .002), consistent with the hypothesis that patients with FND are 'habitual suppressors'. However, facial electromyography recordings were greater in the second (p = .02) and third (p = .04) post-stimulus second epochs for patients than controls when instructed to suppress. These results suggest that patients with FND perceive themselves to be habitual suppressors, but struggle to suppress the physiological expression of their emotions. Study Four aimed to examine emotion dysregulation in patients with FND by comparing a physiological measure of chronic autonomic arousal (resting Heart rate Variability; HRV) against healthy controls. This study also aimed to explore for associations between HRV and the other measures of emotion dysregulation and psychopathology used in this thesis. Five minute ECG recordings from 26 patients and 28 healthy controls were analysed for vagal and sympathetic HRV indices. Vagal, but not sympathetic HRV components were found to be lower in patients than controls (p = .02). Vagal tone correlated negatively with self-reported symptoms of emotion dysregulation (rs = -.27) and PTSD (rs = -.31), and positively with HBDT performance across both groups (rs = .36 - .39). These results suggest that patients with FND experience chronic autonomic arousal, associated with emotion dysregulation and psychological trauma. Finally, Study Five sought to assess whether changes in emotion regulation following Brief Augmented Psychodynamic Interpersonal Therapy for FND could be assessed with a self-report measure, i.e. The EPS-25. Self-report data from 44 patients who returned pre- and post-intervention questionnaires including the EPS-25 were analysed. EPS-25 scores were significantly lower following intervention (p = .049), suggesting that emotion dysregulation improved following psychotherapy. Treatmentassociated changes in EPS-25 scores correlated positively with change scores in psychological distress (CORE-10; partial correlation = .57) and mental health-related quality of life (SF-36 MHS subscale; partial correlation = .31) sharing 45% and 40% of variance respectively. These results suggest that this EPS-25 is sensitive to therapyassociated change in patients with FND. The question of whether FND is caused by emotion dysregulation cannot be answered by this thesis. However, the associations found in these studies suggest that patients with FND experience emotion dysregulation as defined by the EPM, that clinical presentation is linked to co-morbid psychopathological symptoms, and that emotion dysregulation might be successfully treated in this population.
Supervisor: Reuber, Markus ; Levita, Liat Sponsor: Not available
Qualification Name: Thesis (Ph.D.) Qualification Level: Doctoral
EThOS ID:  DOI: Not available