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Neuropsychology and PNES

Robert W. Trobliger, Ph.D. Director Clinical Neuropsychology Northeast Regional Epilepsy Group. Neuropsychology and PNES. PNES: Psychogenic Non-epileptic Seizures

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Neuropsychology and PNES

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  1. Robert W. Trobliger, Ph.D. Director Clinical Neuropsychology Northeast Regional Epilepsy Group Neuropsychology and PNES Neuropsychology and PNES

  2. PNES: Psychogenic Non-epileptic Seizures • paroxysmal behavioral events without cerebrum-based electroencephalogram (EEG) changes, associated with a psychological rather than a physiological etiology. Zaroff, Myers, Barr, Luciano, & Devinsky, 2004 Neuropsychology and PNES

  3. PNES: Psychogenic Non-epileptic Seizures Still real Psychological causes compared to physical causes

  4. Possible causes: • Anxiety/panic • Impaired affect recognition/interpersonal skills • Somatization/Conversion • Depression • PTSD • Reinforced Behavior Patterns Neuropsychology and PNES

  5. Diagnosis based on EEG findings – the gold standard Neuropsychology and PNES

  6. Neuropsychological Testing NP testing important, aiding both diagnosis and treatment. Neuropsychology and PNES

  7. Neuropsychological Testing What is it? Comprehensive interview Comprehensive testing of • Cognitive functioning • Psychological/Emotional functioning Neuropsychology and PNES

  8. Neuropsychological Testing How? For cognitive functioning, through a series of standardized tests assessing • Attention • Memory • Language • Visuospatial/Visuomotor Skills • Executive Abilities Neuropsychology and PNES

  9. Neuropsychological Testing Cognitive tests involve comparisons of results to norms, which allow the examiner to determine if scores are at, above, or below expected levels given the person’s age and background.

  10. Neuropsychological Testing How? For Psychological/Emotional functioning, through self-report and observer report questionnaires which assess: • mood symptoms • anxiety symptoms • other psychiatric symptoms including tendency for somatization • coping skills • experienced levels of cognitive difficulties Neuropsychology and PNES

  11. Neuropsychological Testing Why? NP testing used to confirm the diagnosis. Neuropsychology and PNES

  12. Neuropsychological Testing Which is useful for the referring neurologist. Neuropsychology and PNES

  13. Neuropsychological Testing Why? NP Testing also used to further explore potential factors behind the seizures. Neuropsychology and PNES

  14. Neuropsychological Testing Which is useful for both the client and any therapist who is or will be working with the person. Neuropsychology and PNES

  15. Neuropsychological Testing The client • to better understand what is going on. Neuropsychology and PNES

  16. Neuropsychological Testing The therapist • to better understand what is going on and • how to address it in working with the client. Neuropsychology and PNES

  17. Neuropsychological Testing NP Testing is also important in demonstrating that the diagnosis is being taking seriously. Neuropsychology and PNES

  18. Neuropsychological Testing Because NP testing involves a great deal of time. Neuropsychology and PNES

  19. Neuropsychological Testing How much time? Neuropsychology and PNES

  20. Neuropsychological Testing Typically 3 to 5 hours of testing, at times more. As well as more time for scoring, writing up findings, and reviewing findings with the patient and, possibly, their family. Neuropsychology and PNES

  21. Neuropsychological Testing Because NP testing involves a great deal of time. And financial cost. Neuropsychology and PNES

  22. Neuropsychological Testing An investment of such time and cost then must be worth it. Neuropsychology and PNES

  23. Neuropsychological Testing It is. Neuropsychology and PNES

  24. Neuropsychological Testing This investment combined with a supportive atmosphere sets up some hope regarding the future, introducing the possibility of improvement – that this is treatable. Neuropsychology and PNES

  25. Neuropsychological Testing Which is the reason why the client is sent for NP testing – a step in getting help. Neuropsychology and PNES

  26. Neuropsychological Testing • The Interview • The Evaluation • The Feedback • The Report Neuropsychology and PNES

  27. Neuropsychological Testing The Interview • A safe place, maybe one of the first opportunities to bring up prior stressors and trauma. • Which indicates how important it is for the provider to make it a safe place, to acclimate the client to an atmosphere of trust - critical in therapy. Neuropsychology and PNES

  28. Neuropsychological Testing The Interview Not the last opportunity – as it is not uncommon for patients who initially deny any difficulties, stressors, trauma, or abuse to bring such up at the time of feedback, at times believing that such was “not important.”

  29. Neuropsychological Testing The Interview Comprehensive review of history • Developmental • Medical • Psychological • Cognitive • Educational • Vocational Neuropsychology and PNES

  30. Neuropsychological Testing The Interview An opportunity to explore developmental and medical history – factors which might contribute to issues with cognitive functioning (which is assessed in NP testing). Neuropsychology and PNES

  31. Neuropsychological Testing The interview An opportunity to explore psychological history, including prior diagnoses and treatment. Neuropsychology and PNES

  32. Neuropsychological Testing The interview Particularly any history of abuse (physical emotional or sexual) or trauma. Neuropsychology and PNES

  33. History of sexual abuse among children with PNES - 15 - 35% versus History of physical/sexual abuse among adults with PNES - 25 - 45%

  34. Neuropsychological Testing The interview With children, the interview will include questions about potential stressors which may include: - a history of abuse - bullying - academic difficulties - family difficulties such as separation or divorce - legal difficulties Neuropsychology and PNES

  35. For 93% of patients there was a significant life stressor Of those, 76% were determined to be chronic Sawchik & Buchhalter 2015

  36. In most, the seizures did not immediately follow a specific psychosocial stressor but instead occurred months or years after sexual or physical abuse or against the backdrop of chronic family dysfunction Wyllie et al 1999

  37. Neuropsychological Testing The interview At times parents will bring up these issues without the child in the room. Older children may address their psychiatric history on their own.

  38. Neuropsychological Testing The interview Stressors may initially be downplayed or not even mentioned during the interview However, signs of such may come out in completed questionnaires. Neuropsychology and PNES

  39. Neuropsychological Testing The Interview Educational and employment history helps determine prior levels of cognitive functioning for comparison. Neuropsychology and PNES

  40. Neuropsychological Testing The Interview When patients talk about changes in cognitive functioning, we need to determine where they were before. Certain tests allow us to estimate premorbid levels of functioning when prior testing results are not available or when the patient simply has never had testing before. Neuropsychology and PNES

  41. Neuropsychological Testing NP Testing – Psychological Questionnaires examining: • Mood (depression, anger, fear) symptoms • Anxiety (including PTSD) • Other Psychiatric symptoms (bipolar, OCD, schizophrenia, somatization) • Coping tendencies • Ability to identify and articulate emotions Neuropsychology and PNES

  42. Neuropsychological Testing NP Testing – Psychological Self-Report questionnaires Observer Report questionnaires

  43. Neuropsychological Testing Similar to those with epilepsy, patients with PNES often have co-morbid psychiatric diagnoses including: • depression • anxiety Salpekar et al., 2009 Sawchuk & Buchhalter 2015 Neuropsychology and PNES

  44. Neuropsychological Testing No significant difference between PNES and epilepsy groups of children regarding psychopathology on the CBCL – but both had more than controls. Chinta et al, 2008 Neuropsychology and PNES

  45. Neuropsychological Testing Other diagnoses with PNES • Depression/Dysthymia • Anxiety • Behavioral problems • ADHD Szabo et al 2012 Neuropsychology and PNES

  46. Neuropsychological Testing • Bipolar disorder • Separation anxiety • Brief reactive psychosis • Schizophreniform disorder • Panic disorder Neuropsychology and PNES

  47. Neuropsychological Testing • Post Traumatic Stress Disorder (PTSD) • Overanxious disorder • Adjustment disorder with mixed emotional features • Oppositional Defiant Disorder • Impulse control disorder Neuropsychology and PNES

  48. Neuropsychological Testing • Dependent traits • Borderline personality disorder • Mixed personality disorder • Histrionic personality disorder Wyllie et al 1999 Reilly et al 2013 Neuropsychology and PNES

  49. Neuropsychological Testing Somatization Salpekar et al (2009) findings Three instruments differentiated the PNES group from the epilepsy group: Neuropsychology and PNES

  50. CSI (Childhood Somatization Inventory) - High score approximates diagnostic criteria for somatization disorder headaches, faintness/dizziness, weakness in part of the body, losing voice, trouble walking

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