Neuropsychology and PNES Robert W. Trobliger, Ph.D. Co-Director Neuropsychology Northeast Regional Epilepsy Group

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

Possible causes: Acute anxiety/panic Impaired affect recognition/interpersonal skills Somatization/Conversion Depression PTSD Reinforced Behavior Patterns

Diagnosis based on EEG findings – the gold standard

However, NP testing an important service, aiding both diagnosis and treatment.

Neuropsychological Testing What is it? -Comprehensive testing of -Cognitive functioning -Psychological/Emotional functioning

Neuropsychological Testing How? -Cognitive -Through a series of standardized tests assessing -Attention -Memory -Language -Visuospatial/Visuomotor Skills -Executive Abilities

Neuropsychological Testing How? -Psychological/Emotional -Through self-report questionnaires which assess: -mood symptoms -anxiety symptoms -coping skills -experienced cognitive difficulties

Neuropsychological Testing Why? NP testing used to confirm the diagnois.

Which is useful for the referring neurologist.

Why? NP Testing also used to further explore the reasons behind the seizures.

Which is useful for both the client and the therapist

The client to better understand what is going on.

The therapist to better understand how to address it in working with the client.

Why? NP Testing is also important in demonstrating that the diagnosis is being taking seriously.

Because NP testing involves a great deal of time.

How much time?

Typically 4 to 5 hours, at times more.

And financial cost.

An investment of such time and cost then must be worth it.

It is.

This investment combined with a supportive atmosphere sets up some hope regarding the future, introducing the possiblity of improvement.

Which is the reason why the client is sent for NP testing – a step in getting help.

Neuropsychological Testing -The Interview -The Evaluation -The Feedback -The Report

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 acclimiate the client to an atmosphere of trust- critical in therapy.

Comprehensive review of history – developmental, medical, psychological, educational, even vocational.

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).

The interview An opportunity to explore psychological history, including prior diagnoses and treatment.

The interview Particularly any history of abuse (physical emotional or sexual) or trauma.

The interview Stressors may initially be downplayed or not even mentioned during the interview However, signs of such may come out in completed quesitonnaires.

The Interview Educational and employment history helps determine prior levels of functioning for comparison.

The Interview -Because when patients talk about changes in cognitive functioning, we need to determine where they were before.

The Evaluation NP Testing – Psychological Examining Mood (depression, anger, fear) symptoms Anxiety (including PTSD) Coping tendencies Ability to identify and articulate emotions

NP Testing – Psychological An examination of symptoms is important in determing a diagnosis.

All of these questionnaires provide a lot of data, predominantly in the form of indices that demonstrate patterns – patterns which may be significant in that they are outside the norm.

NP Testing – Psychological More than just examining index findings – at times looking at specific answers.

Which again is part of being comprehensive in examining findings.

Questions of validity

NP Testing Psychological Underreporting may be helpful- indicating a lack of awareness or denial, which can be further explored in therapy.

NP Testing – Psychological Overreporting can be helpful – indiating a cry for help. It is still worth looking at what types of symptoms are endorsed.

NP Testing – Psychological Involving emotions, determining how do I feel?

Not uncommon for those with a history of PNES to have difficulty identifying and/or articulating their emotions.

Which is important to address in therapy.

Because understanding how you feel is in important step in understanding why you feel a certain way.

Which in turn is related to understanding how to cope with these emotions and related difficulties.

NP Testing – psychological Coping tendencies can be ineffective or maladaptive.

Which can account at least in part for why these seizures are occuring.

The Evaluation NP Testing – Psychological Strategies can be practical expressive avoidant All are done by all of us.

However, for some, there is a need for help in developing practical strategies for coping with overwhelming stressors.

NP Testing- Psychological This is an important part of testing – to identify how the person deals with stressors, as the person may not be completely aware of such.

NP Testing – Psychological Examing coping strategies is also helpful for any therapist working with the person in determining what strategies need practice.

NP Testing The findings are useful not only at present but also for the future.

NP Testing Psychological Can be particualry important in setting up a baseline before treatment. Certainly a decrease or the absence of seizures as reported by the patient is an important barometer.

NP Testing Psychological But using pre and post testing measures is another means of describing real change in the person. Numbers and data can be helpful in marking the changes.

NP Testing Cognitive Why?

NP Testing Cognitive Reported difficulties typically involve problems with attention and memory, similar to those with epileptic seizures.

NP Testing – Cognitive Exploring these defictis helps underline the seriousness of the condtion.

NP Testing – Cognitive Such testing results are also supportive to the diagnosis – as deficits than cannot be accounted for by underyling organic issues (developmental history, prior TBI, ongoing chronic medical issues such as migraines, hypertension) can be attributed to PNES.

NP Testing – Cognitive Which gets back to the prior idea of hope. If the problems with attention and memory have no underlying organic causes, then changes in psychological functioning should result in changes in cognitive functioning.

NP Testing – Cognitive Results combined with the person's complaints can be used to generate recommendations

Recommendations of real, practical strategies the person can use from day one in working around their difficulties.

The Feedback An opportunity to go over the results of all the above testing.

NP Testing – Cognitive An opportunity to examine a person's strengths and weaknesses.

NP Testing – Cognitive An opportunity to examine any possible discrepancies between performances on the evaluation and the types of complaints the person has.

NP Testing – Cognitive As noted, an opportunity to discuss strategies for dealing with any experienced difficulties.

NP Testing – Psychological An opportunity to discuss how the diagnosis is confirmed (or not).

NP Testing – Psychological An opportunity to discuss the diagnosis (What does this mean?) And The prognosis (what now?)

NP Testing – Psychological An opportunity to discuss how the diagnosis was determined – based on the findings. An opportunity to discuss those findings in detail

NP Testing – Psychological As noted Signs of depression, anxiety (including PTSD), conversion tendencies, anger issues, coping problems, difficulty articulating feelings

The Report

Who is it for? - The referring neurologist - Any therapist working with the person - The individual

Conclusion

Neuropsychological Testing -Why? Confirm diagnosis Examine psychological/emotioning functioning Examine coping strategies Provide compensatory strategies Provide information for therapist

A great of time on both parts which yields a great deal of useful results.

Thank you.