Patients with psychological trauma, PTSD and PNES: treatment approaches

1. Patients with psychological trauma, PTSD and PNES: treatment approaches Lorna Myers, Ph.D.

2. What is the connection between PNES and trauma? • Psychological trauma and life adversities are the most common risk factor found in PNES

3. Trauma in the general population • About 10% of women develop PTSD sometime in their lives • About 4% of men develop PTSD sometime in their lives . • About 7 or 8 out of every 100 people (or 7-8% of the population) will have PTSD at some point in their lives and about 3.5% have it now in the US. https://www.ptsd.va.gov/understand/common/common_adults.asp

4. PNES, trauma and PTSD • History of trauma: 45 out of 61 (73.8%) patients • 47%: sexual abuse43%: physical abuse34.4%: had suffered loss/death24.6% had psychological abuse • Single type of trauma reported in 15 patients (31.91%)2 types of trauma were reported in 14 patients (31.11%)3 or more types of trauma were reported by 16 out of 61 patients (26%). • Epilepsy & Behavior 2013: Psychological trauma in patients with psychogenic nonepileptic seizures: Trauma characteristics and those who develop PTSD. Myers et. al.

5. PNES and post-traumatic stress disorder (PTSD) • Patients with PNES tend to present with rates of PTSD of 30%-50% (depending on the study). • Therefore, traumatic experiences may be a potential risk factor for PNES • Possibly, there is a PTSD subtype with dissociative symptoms  PNES (with PTSD) • Fiszman A, Alves-Leon SV, Nunes RG, D’Andrea I, Figueira I, Traumatic events and posttraumatic stress disorder in patients with psychogenic nonepileptic seizures: a critical review.  Epilepsy Behav. 2004 Dec;5(6):818-25.

6. Today’s topics • Trauma and post traumatic stress disorder (PTSD) • Association between PTSD and PNES • Treatments for PTSD • Treatments for PTSD can be used to treat patients dually diagnosed with PNES and PTSD • Resources

7. Trauma • After experiencing a traumatic event some people develop PTSD. • A traumatic event is something terrifying and overwhelming that you see, hear about, or that happens to you or others that shatters your sense of safety.

8. Examples of traumatic events? • Childhood abuse (sexual, physical, neglect, bullying) • Combat experiences • Being a victim of crime, accident, torture • Natural disaster • Witnessing a loved one (e.g. mother, sibling) being hurt. • Death of a loved one (e.g. child)

9. What happens during a traumatic event? • During the traumatic event, the person who experiences it: • May be: • Completely caught off guard • Feel intense fear • Feel no control over what is happening • Not able to fight or flee

10. How do we go from experiencing Trauma to developing PTSD? • Depends on how: • Intense the trauma was or how long it lasted • If you or someone important to you were injured • How close you were to the event • How strong your reaction was • How much you felt in control of event • Whether you dealt with it by trying to forget and not process • How much support you had after

11. How do we determine if someone has PTSD? • After 6 months or more, symptoms last more than 1 month: • Re-experiencing trauma • Avoiding trauma reminders • Hyper-vigilance • Negative mood and thoughts

12. Re-experiencing • Nightmares: of the event or unrelated • Flashbacks: Reliving the event as if it is happening now • Sudden memories triggered by a smell, sight, experience that is similar to the trauma.

13. Avoidance • Efforts to forget: “Just forget it, push it away, move on.” • Numbing: Having difficulty feeling emotions, seeming cut off, shut down • Spotty memory: because so much energy is put into forgetting, forgetfulness spreads. • Avoid activities (the news, movies, going to places that are reminders or may be “dangerous”)

14. Hyper-vigilance • Constant state of being alert • Poor sleep • Startle response: jumpiness • Irritability, moodiness • Continuous scanning for danger, uneasiness • Fatigue and exhaustion as a result

15. Negative mood & thoughts • Cynicism: Jaded and negative view of others and life • Distrust of others and their intentions. • Negative self views: self-blame, guilt, shame, weak.

16. What else accompanies PTSD? • Depression/anxiety • Drinking or drug problems • Physical symptoms and chronic pain • Employment problems • Interpersonal problems • Psychogenic seizures in some patients

17. How can PTSD be treated? • Cognitive behavioral therapy (CBT) is the most empirically validated treatment for PTSD. • Prolonged Exposure (PE) therapy is a type of CBT • Prolonged exposure therapy is promising for patients dually diagnosed with PNES/PTSD

18. What does PE look like? • Therapists are certified therapists and supervisors are certified. http://www.med.upenn.edu/ctsa/ • 12-15 sessions, each lasts 90 minutes • The focus is on the “index trauma”-the most distressing traumatic memory the patient can recall • EXPOSURE instead of AVOIDANCE

19. What does PE look like? • 1) Education about trauma and PTSD • 2) Breathing retraining • 3) “Real Life” exposure to situations or activities that are avoided • 4) Repeated prolonged imaginal exposure

20. How PE treats PTSD • Avoidance: the short-term solution becomes the problem. Confrontation. • Intrusion: Those memories that intrude on you whenever THEY want: treatment teaches you to call forth those memories when YOU want. Retelling • Hypervigilance: comes down because you realize many of those “dangers” aren’t dangerous. Confrontation. • Negative mood and thoughts: helps process and challenge these thoughts. (e.g. “I am weak because I have this,” “I blame myself for not fighting more”). Processing

21. Benefits and risks • Benefits: PE reduces PTSD symptoms, depression and anxiety. • Risks: Discomfort and emotional distress when remembering trauma and confronting situations that were avoided before.

22. Is PE effective? • 20 + years of research has shown PE is very effective for treating PTSD. • Research studies have been conducted in the US, Israel, Japan, Australia, and Europe. • VA system officially adopted PE to treat veterans diagnosed with PTSD.

23. Caution • PE may not be possible with some patients who have complex PTSD and PNES. These patients require long term treatment. • Complex PTSD results from prolonged and extreme trauma. Examples: • Chronic abuse by caregivers • Survivors of torture • Prisoners of war • Concentration camp survivors • Survivors of some religious cults

24. How do PNES and PTSD connect? • When traumatized, the brain can use extreme defense mechanisms: • When fight or flight are not possible (e.g. intolerable experiences of near death, pain, horror), dissociation may be all that is left. • A dissociation pathway gets paved and future distress triggers this defense even when it is no longer needed.

25. Patients with PNES/PTSD are different from others with PNES • Epilepsy & Behavior 2013: Psychological trauma in patients with psychogenic nonepileptic seizures: Trauma characteristics and those who develop PTSD. Myers et. al. • Epilepsy & Behavior 2014: Cognitive differences between patients who have psychogenic nonepileptic seizures (PNESs) and posttraumatic stress disorder (PTSD) and patients who have PNESs without PTSD. Myers et. al.

26. Patients with PNES/PTSD are different from others with PNES • Zeng R; Myers L; Lancman M. "Patients with psychogenic non-epileptic seizures: Posttraumatic stress, coping, and alexithymia“, Seizure, 57:70-75. https://doi.org/10.1016/j.seizure.2018.03.011Myers L, Trobliger R, Bortnik K, Zeng R, Saal E, Lancman M (2019) Psychological trauma, somatization, dissociation, and psychiatric comorbidities in patients with psychogenic nonepileptic seizures compared with those in patients with intractable partial epilepsy. Epilepsy Behav. March; 92: 108-113.

27. PNES and PTSD • Since patients with PNES/PTSD exhibit many similarities (and are very different than others with PNES alone), it makes sense to treat patients dually diagnosed with treatments that have been shown to be successful in treating PTSD.

28. PTSD and PNES

29. IS PE effective for PNES? • AES Poster December 2015: “The utility of Prolonged Exposure Therapy (PET) in the treatment of patients who are dually diagnosed with PNES and PTSD.” • Myers L, Vaidya-Mathur U, Lancman M (2017). Prolonged exposure therapy for the treatment of patients diagnosed with psychogenic non-epileptic seizures (PNES) and post-traumatic stress disorder (PTSD). Epilepsy Behav, 2017 Jan;66:86-92.

30. IS PE effective for PNES? • Myers L & Zandberg L (2017). Case Report: Prolonged Exposure Therapy for comorbid psychogenic non-epileptic seizures (PNES) and post-traumatic stress disorder (PTSD). Clinical Case Studies.

31. Modifications to PE for PNES Keep a seizure log Ensuring Physical Safety Office safety Escort (if needed) Seizure Response Plan Obtain seizure descriptions Can you speak to patient during the episode? Grounding: texture of small object; holding ice; moving objects between hands Pressure applied (forearm; shoulder) for sensory grounding Emphasis on breathing exercise near end of episode CONTINUE session if possible, depending on the intensity or duration of the seizure. Avoid 911 if possible.

32. Pilot Data (Myers, Vaidya-Mathur, Lancman, 2017) • Design: Open clinical trial • Participants: • Dually dx PTSD and PNES (Video EEG-confirmed) • Age range: 20-66 years • Treatment: 12-15 weekly PE sessions (90 minutes) • Therapists (2): CTSA Certified in PE • Outcome measures: PTSD (PDS), Depression (BDI-II), Seizure frequency Myers, Lorna; Vaidya-Mathur, Urmi; Lancman, Marcelo. Epilepsy & Behavior Vol. 66,  (Jan 2017): 86-92.

33. Enrollment and Retention

35. PNES Outcomes • Baseline mean: 2.2 (Range 0 – 15 seizures per day) • Post treatment: 81.25% (13/16) completers reported no seizures by their final PE session • All showed significant reduction in seizure frequency (Z = − 3.413, p = 0.001). Post mean: .01 seizure per day • Gains maintained at follow-up (time interval: 1 month to 34 months): 11/14 remained seizure free • Nine of the 14 patients returned to work or continued with their education upon completing treatment and two were already retired at the outset of treatment

36. How does PE work for PNES? • When exposure through retelling of the memory starts, the distress signal that typically leads to dissociation and a seizure activates. • Patients use their breathing and grounding techniques during the episodes and gain control. • First sessions, as soon as the memory is touched upon, a seizure occurs. Through repeated exposure to the memory, the patient learns to control the seizures and fully processes the memory.

37. How does PE work for PNES? • The therapy is paced but the seizure is not allowed to stop the session. The goal: patient “learns to control” the seizure. Essentially the brain is taught to take a different pathway (direct confrontation) when it encounters stress and distress.

38. Other treatments • Stress inoculation treatment (SIT) • Cognitive processing therapy (CPT) • Eye movement desensitization and reprocessing (EMDR)

39. EMDR • Limited research exists showing the effectiveness of this treatment with patients who have PNES. • Kelley and Benbadis“Eye movement desensitization and reprocessing in the psychological treatment of trauma-based psychogenic non-epileptic seizures” Clinical Psychology and Psychotherapy, 2007. • 3 patients were treated with EMDR and 2 improved.

40. Resources on PTSD • Psychogenic Non-epileptic Seizures: A Guide available on Amazon Chapter 3 • Website: www.nonepilepticseizures.com (Services for PNES) • PTSD information: http://www.ptsd.va.gov/public/PTSD-overview/basics/what-is-ptsd.asp • PE article: http://articles.philly.com/2014-07-07/news/51110145_1_edna-foa-prolonged-exposure-therapy-ptsd