Transcript Trauma and PNES - Psychogenic Non Epileptic Seizures

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
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”
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.
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/PTSDoverview/basics/what-is-ptsd.asp
• PE article: http://articles.philly.com/2014-0707/news/51110145_1_edna-foa-prolongedexposure-therapy-ptsd