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Seizure metaphors differ in patients’ accounts of epileptic and psychogenic nonepileptic seizures

Seizure metaphors differ in patients’ accounts of epileptic *Leendert Plug, yBasil Sharrack, and yMarkus Reuber *Department of Linguistics and Phonetics, University of Leeds, Leeds, United Kingdom; and yAcademic Neurology Unit, University of Sheffield, Royal Hallamshire Hospital, Sheffield, United Kingdom lepsy and PNES showed preferences for different metaphoric concepts (differences p = 0.009 to Purpose: To increase understanding of the subjec- p = 0.039). Patients with epilepsy preferred meta- tive symptomatology of seizure experiences and phors depicting the seizure as an agent/force or improve differential diagnosis by studying the sei- event/situation. PNES patients more often used zure metaphors used by patients with (psycho- metaphors of space/place. Logistic regression genic) nonepileptic seizures (NES) and epilepsy.
analyses predicted the diagnosis of PNES or epi- Methods: Twenty-one unselected patients taking lepsy correctly in 85.7% of cases (based on differ- part in this study were admitted for 48 h of video- ent metaphor types in the each category) or 81.0% because of uncertainty about the diagnosis. Eight Discussion: Patients with epilepsy and PNES have were proven to have epilepsy, 13 to have psycho- different preferences in the metaphoric conceptu- genic nonepileptic seizures (PNES). During their alization of their seizures. Epileptic seizures are admission, patients were interviewed by a neurolo- described as a more external, self-directed entity gist. A linguist blinded to the medical diagnosis than PNES, which are depicted as a state or place identified and categorized all seizure metaphors in patients go through. The differentiating value of verbatim transcripts. Between-group comparisons metaphoric conceptualizations suggests that met- and logistic regression analysis were carried out.
aphor preference could form the basis of future Results: Of 382 metaphors identified, 80.8% con- diagnostic questionnaires or other diagnostic ceptualized seizures as an agent/force, event/ situation, or space/place. Most patients used meta- KEY WORDS: Epilepsy, Psychogenic nonepileptic phors from all categories, but patients with epi- seizures, Language, History-taking, Metaphors.
Epileptic seizures are caused by excessive and hyper- reduction of reactivity and (at least partial) amnesia for synchronous electrical activity in the brain. Psychogenic some aspects of the seizure process (Lesser, 1996).
nonepileptic seizures (PNES) resemble epileptic seizures Although we have now acquired a fairly detailed but are unaccompanied by ictal electroencephalographic knowledge about the origins and spread of epileptic changes. PNES are a response to psychological or social seizures in the brain, many questions about the distress, which occurs when alternative coping mecha- etiology, nosology, and treatment of PNES remain nisms are inadequate or have been exhausted. The label of unanswered (Reuber, 2008). Several previous studies PNES is sometimes applied to attacks with retained have demonstrated that it is possible to learn more consciousness, but the diagnosis usually implies an ictal about the nature of PNES and how PNESs differfrom epileptic seizures by paying attention to subjec-tive seizure symptoms (Vein et al., 1994; Goldstein Accepted July 23, 2008; Early View publication October 24, 2008.
& Mellers, 2006). In one, patients with PNES or Address correspondence to Markus Reuber, Academic Neurology epilepsy who were living in Seattle were asked how Unit, University of Sheffield, Royal Hallamshire Hospital, GlossopRoad, Sheffield S10 2JF, U.K. E-mail: they had experienced an earthquake (Richter scale6.8), which shook the city on 28 February 2001.
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ª 2008 International League Against Epilepsy Patients with epilepsy were more likely to report that they thought they were having a seizure when the Note that the opening of the interview makes no reference earthquake started (Watson et al., 2002), implying to the patient’s seizures and that the doctor is encouraged that epileptic seizures are a more unusual or external to not ask additional questions (other than for clarifica- experience and perhaps further removed from patients’ tion) or introduce new topics into the conversation.
patients’ hypnotic recall of ictal events has been found to be more impaired after epileptic (complex Verbatim transcripts of the interviews were produced partial) seizures than after PNES (Kuyk et al., 1999).
and analyzed by a linguist (LP) blinded to all additional Here we study the use of seizure metaphors by patients clinical information and the result of the ictal video-EEG with PNES and patients with epilepsy to learn more recording. The linguist searched the transcripts for all about their subjective seizure experience. In this direct references to seizures and identified those that approach we used the definition of metaphor proposed by fulfilled the definition of metaphor proposed by Lakoff Lakoff and Johnson (Lakoff & Johnson, 1980) in the and Johnson (Lakoff & Johnson,1980): a metaphor is an field of Conceptual Metaphor Theory. They consider as expression that is used in one semantic field while its core an instance of metaphor any linguistic marker of a meaning, as defined in dictionaries of contemporary correspondence between distinct conceptual domains. As an example, ‘‘your claims are indefensible,’’ ‘‘he attacked expressions such as ‘‘the seizure took place,’’ ‘‘I just let every weak point in my argument,’’ and ‘‘I demolished it run its course,’’ and ‘‘then the seizure started’’ are his argument’’ are all metaphorical expressions based on metaphorical, since the core use of take place, run its a conceptual mapping between arguing and warfare—in course, and start is in the context of events, but here they short: ‘‘Argument is war.’’ Following this approach, we are used by patients to formulate a particular part of their intended to identify the metaphors used by patients with seizure experience. Likewise, ‘‘when I came out of the PNES and patients with epilepsy in relation to their seizure’’ and ‘‘I thought the seizure was trying to force seizures, and group them into categories of the type ‘‘the itself out of me’’ are metaphorical, since the core meaning of coming out of something entails the existence of a place preferences for particular metaphoric conceptualizations or space as well as physical movement, and the core exhibited by patients with PNES and epilepsy to gain meaning of trying to do something entails a volitional new psychological and differential diagnostic insights.
agent. In all of these cases, patients are using their generalvocabulary to formulate specific subjective experi-ences for which they know little or no specialized In keeping with the method of Lakoff and Johnson Our findings are based on transcripts of first clinical (1980), and using contemporary dictionaries Anony- encounters between 21 patients with seizures and one mous (1987 & 2003), individual metaphors were grouped neurologist (MR). All patients had been admitted to the together according to the general semantic field with Royal Hallamshire Hospital in Sheffield, UK, for 48 h of which the seizure was associated. In analogy to the continuous video-EEG monitoring because a fully trained example of ‘‘Argument is war’’ given previously, ‘‘the neurologist was not certain whether they had epileptic or seizure took place,’’ ‘‘I just let it run its course,’’ and nonepileptic seizures. Patients were not included if they ‘‘then the seizure started’’ can be grouped together as had been admitted for epilepsy surgery evaluation. All instances of the conceptual mapping ‘‘the seizure is an diagnoses were confirmed by the video-EEG recording of event,’’ whereas ‘‘when I came out of the seizure’’ and a spontaneous seizure considered typical of the habitual ‘‘I thought the seizure was trying to force itself out of attacks by the patient and a seizure witness. Patients were me’’ are incompatible with this particular mapping: in included only if the recorded attack involved impairment the first case the seizure is treated as some kind of loca- tion, whereas in the second it appears to be personified.
In fact, the linguist established three common concep- tual mappings: ‘‘the seizure is an agent/force,’’ ‘‘the The interviews were audio and video recorded and event/situation,’’ and ‘‘the seizure is a lasted 15–30 min. The one-to-one interviews were con- ducted following a previously described semistandardized expressions in these categories are given in Table 2.
interview procedure encouraging the doctor to adopt an Metaphors that did not fit in the three categories were unusually passive but very attentive role (Schwabe et al., grouped together as ‘‘Other.’’ Box 1 further illustrates 2008), minimizing the risk that patients’ choices of meta- the identification and categorization of metaphors by phors would be influenced by the doctor’s questions. A showing how patients use these metaphors in their summary of the interview outline is presented in Table 1.
Box 1: Illustrative interview fragments (metaphor tokens in italics; phonetic symbols have been removed from the transcription to improve readability) David: I had to contain it, so that I was (.) within me- meself, and that’s what (0.2) huh I thought it were trying to do; (1.0) and then it came and er and then it did it again; (0.8) and I did it again, (1.2) and then I think next thing is (1.0) thing I can remember is er (3.4) I can’t (0.7) I can’t rememberwhether me mum had got (0.3) got hold of me (1.2) in the car (0.2) taking me upstairs where I were just laid on the bed upstairs Analysis: In the course of describing a particular seizure episode in some detail, David uses several metaphors that have the seizure as subject or object: he characterizes the seizure as something to be contained, and as something that came and tried to do things. All four metaphorssuggest that David has conceptualized the seizure as an agent or force.
Ken: er (1.1) it’s (–) you’d have to handle each one differently, (0.2) really; (0.3) depending on how it is, if it’s a big one you you take an extra two minutes(1.0) Doc: how do you try to handle them?Ken: erm (1.8) there’s li- if ye if you haven’t if I (1.1) if I if I’m experiencing one, (0.6) erm (1.3) i tend to (1.1) sit and (1.7) not block it out, I try to Analysis: Ken describes how he reacts to seizures of different degrees of severity. He uses three metaphors with the seizure as object: for Ken, seizures are handled, experienced, and blocked out. The latter metaphor was classified under ‘‘other,’’ but the first two suggest aconceptualization of the seizure as an event or situation.
Sue: he was talking to me (0.2) cause he always speaks to me while I’m having a seizure or (1.1) whatever; he talks to me all the way through it, cause (0.8) s- he’s hoping that it brings me out of it quicker (0.4) cause I have had (0.3) erm repeated fits Doc: mmmSue: so erm, he don’t li- he don’t like thatDoc: mmmSue: so he tries to talk to me, to stop me going back into another oneAnalysis: In the course of describing her husband’s reaction to her seizures, Sue uses three metaphors that suggest a conceptualization of the What were your expectations when you came to hospital? Can you tell me about the first seizure you can remember? Can you tell me about the last seizure you can remember?Can you tell me about the worst seizure you can remember? Inquiry or inquiries challenging the patient’s description The seizures are obviously quite distressing for you, but can you tell me about things which you enjoy doing? Avoid introducing new topicsTolerate silenceUse continuers (mmm, right, etc.) to indicate continued attentionRepeat what the patient has said to encourage elaboration particular kind of metaphorical expression. For instance a Between-group comparisons were based on counts of patient may use the expressions ‘‘the seizure comes over the number of metaphor ‘‘types’’ and ‘‘tokens’’ used by me’’ and ‘‘the seizure takes hold.’’ These are two different each patient in each conceptual mapping or category of metaphor types that can be placed in the conceptualization metaphor. A metaphor ‘‘token’’ is defined as each use of a ‘‘the seizure is an agent/force.’’ If this patient used each of metaphoric expression fulfilling the definition of meta- these two types three times he would have used six phor given previously. A metaphor type is defined as one metaphor tokens. The type count indicates the richness of Epilepsia, 50(5):994–1000, 2009doi: 10.1111/j.1528-1167.2008.01798.x patients’ metaphoric language, whereas the number of individual metaphor tokens expresses the frequency of This study was approved by the South Sheffield patients’ use of metaphorical expressions in the interview.
Research Ethics Committee. All participants gave their Demographic and clinical variables were compared by written informed consent prior to the interview with the two-tailed t-tests for independent samples or Fisher’s exact test as appropriate. Statistical analyses of differ-ences in type and token counts between the two patient groups (epilepsy/PNES) were conducted by two-tailedt-tests for independent samples after passing Levene’s test After video-EEG, 8 patients were found to have epi- for equality of variance. In view of the relatively small lepsy and 13 were found to have PNES (see Table 3 for sample size, two separate forward stepwise conditional clinical and demographic details). The video-EEG logistic regression (LR) analyses were carried out to deter- results showed that the working diagnosis was incorrect mine whether type and token counts could contribute to in 37.5% of cases in the epilepsy group and 69.2% of the discrimination between patients with epilepsy and cases in the PNES group. At the time of admission, 100% of the patients found to have epilepsy and 84.6% Table 2. Examples of metaphor types in the three most common conceptual categories Table 3. Clinical and demographic details was a higher proportion of women in the PNES group Across both diagnostic groups, we identified a total of 382 metaphors tokens. The mean token count per patientwas 18.2, the mean number of metaphor types was 8.7(demonstrating that patients who used one particular typeof metaphoric expression tended to repeat it once moreduring the course of the interview). A total of 77.6% of alltypes and 80.8% of all tokens used could be placed in oneof three common conceptual mappings or categories ofmetaphor. There were no significant differences in meantype or token counts between the PNES or epilepsygroups.
Superficially, the nature of the metaphors used by the two patient groups was similar. Most patients used meta-phors from all categories (agent/force, 15 of 21 patients; event/situation, 16 of 21; and space/place, 18 of 21). How-ever, closer analysis revealed significant differences in themetaphor profiles typically used by patients with epilepsyor PNES (see Fig. 1). Metaphors for epileptic seizureswere more commonly derived from the agent/force or event/situation categories. PNES metaphors more oftenbelonged to the space/place category. For detailed figuresand statistical comparisons see Table 4.
Only the categories agent/force and space/place con- tributed to the most highly discriminating forward condi- tional stepwise logistic regression models based either on Comparison of profiles of seizure metaphor types (A) type or token counts (type counts model: v2 = 17.97, and tokens (B) used by patients with epilepsy and p = 0.0004; 85.7% of patients correctly classified, sensi- tivity for PNES: 84.6%, specificity: 87.5%; token count model: v2 = 19.75, p = 0.0002; 81.0% of patients cor-rectly classified, sensitivity for PNES: 84.6%, specificity:75.0%).
Patients with epilepsy were 5.0 times more likely to use of the patients in the PNES group were taking antiepi- metaphor types and 3.0 times more likely to use metaphor leptic drugs. The median age was 37.5 years in the epi- tokens from the agent/force than the space/place category.
lepsy group (median duration of the seizure disorder In contrast, patients with PNES were 6.25 times more 23.5 years) and 32 years in the PNES group (median likely to use metaphor types and 5.26 times more likely to duration 10 years). The only significant demographic or use metaphor tokens from the space/place than the agent/ clinical difference between the two diagnostic groups Table 4. Overview of the mean counts of metaphor types and tokens in each category used by patients with epilepsy and patients with PNES Epilepsia, 50(5):994–1000, 2009doi: 10.1111/j.1528-1167.2008.01798.x used by patients with PNES and epilepsy suggest that the metaphoric conceptualizations could help physicians with This study shows that patients with epilepsy and the task of distinguishing between epileptic and non- patients with PNES talk differently about their seizures.
epileptic seizure disorders. The clinical data in our sample Although it is possible that the differences are explained confirm how difficult this task is: although all patients in by how patients chose to present their paroxysmal symp- our study had been referred by fully trained neurologists toms to the doctor, it is more likely that the metaphor and the mean duration of seizures in the epilepsy or PNES profiles used by the two patient groups reflect differences groups were 23.5 and 10 years respectively, approxi- in the subjective seizure experience. Patients may make a mately one-third of patients found to have epilepsy and conscious decision about what they tell a doctor, but they two-thirds of patients diagnosed as having PNES by are unlikely to have much premeditated control over how video-EEG were found to have carried an incorrect work- they are going to present their symptoms at a metaphoric ing diagnoses prior to admission. There is no suggestion that the delay in the diagnosis of PNES at our center was Our findings are broadly in line with a number of quali- exceptionally long. Similar delays have been demon- tative German studies, which reported that patients with strated in two previous studies (Reuber et al., 2002; de Ti- epilepsy are more likely than patients with PNES to mary et al., 2002). Of course, rapid and accurate describe their seizures as an opponent acting under his differentiation is of great clinical importance, because the own volition, or to use verbal imagery depicting the most appropriate treatments for epilepsy and PNES are patient as fighting against the seizure (Surmann, 2002, very different. Unfortunately, neurologists cannot rely on 2005). In grammatical terms, the seizure is the subject in tests for this. Even when attacks are frequent and video- this type of metaphor and has semantic agency.
EEG accessible, 23–47% of patients fail to have seizures Our study adds to the German results in a number of during prolonged in-patient monitoring (Mohan et al., ways. We have identified a new metaphoric category of 1996; Benbadis et al., 2004). What is more, 10–30% of seizures as an event or situation. This metaphoric concep- patients have both epileptic and nonepileptic seizures tualization was also used more often by patients with epi- (Reuber et al., 2003a). For these reasons the act of taking lepsy than by those with PNES. In these constructions, the the patient’s history remains the diagnostic ‘‘gold stan- seizure is usually still the subject, but it is not marked as dard’’ in this setting (Wolf, 2005).
having independent volition. The patient is an experiencer So far, we are unable to demonstrate that listening out rather than the ‘‘victim’’ of the seizure. We identified for the metaphoric conceptualizations can be a reliable another new category of metaphoric conceptualization, diagnostic pointer in this setting. However, the marked which was preferred by patients with PNES. This patient difference in the ratios of agent/force and space/place group was more likely to present their seizures as a space metaphors observed here may be something clinicians or place. Unlike in the conceptualizations more commonly could listen out for. It is also conceivable that our findings used by patients with epilepsy, it is the patient who is the could be incorporated into a self-report questionnaire, acting subject in most of these metaphoric constructions.
generating a probability of epileptic seizures or PNES.
The seizure is a sphere or location the patient goes into, This approach is perhaps more likely to work than inqui- travels through, or comes out of. The semantic agency in ries about factual details such as tongue biting, ictal inju- these constructions is with the patient rather than the ries, sleep seizures, or ictal incontinence, which (at least in isolation) have been shown not to distinguish reliably Notably, the metaphoric conceptualizations that dis- between epileptic and nonepileptic seizures (Geyer et al., criminated most clearly between the epilepsy and PNES 2000; Reuber et al., 2003b; Duncan et al., 2004). Notably groups were placed at the extremes of an ‘‘agency contin- the specificity and sensitivity of a diagnostic categoriza- uum’’: in metaphors most clearly preferred by patients tion based on metaphoric concepts was more encouraging with epilepsy the seizures acted on the patient, in meta- than an approach based on factual analysis of seizure phors most frequently used in the PNES group, the seizure descriptions: one study in which two experienced epilep- was a passive backdrop to the patient’s actions.
tologists (who were unaware of any other clinical informa- Having said this, the metaphoric conceptualization of tion) were asked to rate detailed written seizure the seizure as a space/place does not imply that the patient descriptions from patients with temporal lobe epilepsy or moves through this space at will. Even a patient who nonepileptic seizures found that the sensitivity of this ‘‘goes into a seizure’’ may not be doing so ‘‘deliberately.’’ approach for the detection of epileptic seizures was 96%, For instance, a train passenger might warn a person he was although the specificity was only 50% (Deacon et al., talking to on the telephone that he was ‘‘going into a tun- nel,’’ although he would not actually be driving the train.
This study has a number of limitations. Foremost, the The results of the logistic regression analyses and the relatively small sample size restricted our ability to do different ratios of agent/force and space/place metaphors more ambitious statistical analyses (such as a logistic regression analysis including all possible factors). It de Timary P, Fouchet P, Sylin M, Indriets JP, de Barsy T, Lef›bvre A, should also be pointed out that our results depend on the van Rijckevorsel K. (2002) Non-epileptic seizures: delayed diagnosisin patients presenting with electroencephalographic (EEG) or clinical relatively nondirective interview technique involving a signs of epileptic seizures. Seizure 11:193–197.
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