Shame in the treatment of patients with psychogenic nonepileptic seizures : the elephant in the room

Previous research has established a link between psychogenic nonepileptic seizures (also known as dissociative or functional seizures) and abnormal emotion processing. In a companion article to this multidisciplinary narrative review, we have argued that, in the context of a biopsychosocial understanding of the condition, the emotion of shame is particularly likely to contribute to the aetiology, manifestation, semiology and perpetuation of psychogenic non-epileptic seizures (PNES). Here we demonstrate how unrecognised and unaddressed shame may cause difficulties when clinicians explain the diagnosis, attempt to engage patients in psychological treatment, construct a diagnostic formulation and undertake psychotherapy. Case vignettes are used to bring theoretical considerations to life and to illustrate the complex interactions which may be observed between high shame proneness, chronic and dysregulated shame, stigma and PNES. The particular focus on shame does not mean that recent explanatory models of PNES are obsolete. Rather, we demonstrate how the inclusion of shame helps to embed the emotional, cognitive and behavioural aspects of the Integrative Cognitive Model (ICM) of PNES in a social / interpersonal context. While we describe how a number of different psychotherapeutic approaches can help to address shame-related processes we conclude that specific modalities are less important than the eventual enhancement of emotional literacy and tolerance through a healing relationship with the psychotherapist.