Trauma and PNES: Prolonged exposure Lorna Myers, Ph.D.

What is the connection between PNES and trauma? @75-90% patients with PNES report a history of trauma. @23-77% have a history of childhood sexual/physical abuse. @25% fulfill criteria for post traumatic stress disorder (PTSD).

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

trauma After experiencing a traumatic event some people develop PTSD. A traumatic event is something terrible and scary that you see, hear about, or that happens to you that shatters your sense of safety and is well outside of your normal experiences.

Examples of traumatic events? Childhood abuse (sexual, physical, neglect, bullying) Battlefield 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)

What happens during trauma During a traumatic event, the person who experiences it: May be completely caught off guard May feel intense fear May feel that no control over what is happening.

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 events Whether you dealt with it by trying to forget and not process How much support you had after

How do we determine if someone has PTSD? 1 Month Re-experiencing trauma Avoiding trauma reminders Hyper-vigilance Negative mood and thoughts

Nightmares: of the event or unrelated 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.

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”

Constant state of being alert Poor sleep Startle response: jumpiness 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

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.

What else accompanies PTSD? Depression/anxiety Drinking or drug problems Physical symptoms and chronic pain Employment problems Relationship problems, including divorce Psychogenic seizures in some patients

How do PNES and PTSD connect? When traumatized, the brain can use extreme defense mechanisms: Dissociation Intolerable experiences of near death, pain, horror that can’t be escaped- brain may defend by dissociating. A dissociation pathway gets paved and future distress triggers this defense even when it is no longer needed.

PNES and PTSD We are finding that patients with PNES/PTSD exhibit differences from other patients 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.

PNES and PTSD American Psychological Association Convention 2015 (Division 56 Trauma Psychology). "Patients with psychogenic non-epileptic seizures: Posttraumatic stress, coping, and alexithymia" Zeng R; Myers L; Lancman M.

How can PTSD be treated? Cognitive behavioral therapy (CBT) is the most effective treatment for PTSD. Prolonged Exposure (PE) therapy Prolonged exposure therapy is offered at our program for patients dually diagnosed with PNES/PTSD

What does PE look like? 1) education about common reactions to trauma 2) Breathing retraining 3) “Real Life” exposure to situations or activities previously avoided 4) Repeated prolonged imaginal exposure (revisit the trauma by retelling the trauma memory in session.

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. Negative mood and thoughts: therapy helps process and challenge these thoughts. (e.g. “I am weak because I have this,” “I blame myself for not fighting more”).

Benefits and risks Benefits: PE reduces PTSD symptoms and problems, depression and anxiety. Risks: Discomfort and emotional distress when remembering trauma and confronting situations that were avoided before. Therapists are certified therapists and supervisors are certified. http://www.med.upenn.edu/ctsa/

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 and 100’s of mental health professionals from VAs have been trained.

PNES and PTSD Since patients with PNES/PTSD are exhibiting many similarities, it makes sense to treat patients dually diagnosed with treatments that have been shown to be successful in treating PTSD.

IS PE effective for PNES? At NEREG we have been offering PE to our patients dually diagnosed with PNES/PTSD for 2 years. AES Poster December 2015: “The utility of Prolonged Exposure Therapy (PET) in the treatment of patients who are dually diagnosed with PNES and PTSD.”

How does PE work for PNES? Our first sessions involve extensive teaching and learning about PTSD and PNES. The patient uses a log to keep track of triggers and stressors outside of the office. The patient listens to taped sessions between office visits. The patient practices breathing and in vivo exposure between office visits.

How does pe work for PNES? When we begin to use exposure through retelling of the memory, we activate the distress structure that typically leads to dissociation and a seizure. 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 confrontations of the memory, the patient learns to control the seizures and fully processes the memory.

How does pe work for pnes? We pace the therapy but we don’t allow a seizure to stop the session. The goal: patient “conquers” the seizure. At the end, the patient has taken back many lost parts of life (activities, people) and can file away the memory. We essentially teach the brain to take a different pathway when it encounters stress and distress. You take this lesson with you for the rest of your life.

Stress inoculation treatment (SIT) Cognitive processing therapy (CPT) Other treatments Stress inoculation treatment (SIT) Cognitive processing therapy (CPT) Eye movement desensitization and reprocessing (EMDR) Medications: Zoloft and Paxil

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