Pediatric Psychogenic Non-Epileptic Seizures: Risk Factors, Diagnosis & Treatment Julia Doss, PsyD, LP Pediatric Psychology jdoss@mnepilepsy.net

Objectives: Identify risk factors in the pediatric population Discuss diagnostic considerations Review treatment recommendations

PNES through History… Several hundred years ago supernatural forces and demon possession were thought to cause seizures Late in the 1800’s, Charcot and others believed certain seizures occurred after stressful events Women were thought to be more likely to have stress-induced seizures, hence the early characterization as a “hysterical disorder”

Managing the Hysterical Patient Patients were treated with a variety of apparatus that were meant to impact function and cure one of frustrating, “overactive” hormonal difficulties

Freud, where have we come from and where are we going? Hypothesized “hysterical seizures” were due to childhood incest that had been repressed Due to the mind’s need to cope with these memories, the mind “converts” these emotional conflicts into physical symptoms so that they can be expressed in some conscious way, hence the term “conversion” disorder Recent studies have shown that the risks factors are different in children

Myths Associated with Pediatric PNES: The stressors or conflicts that cause PNES are easily identified. PNES is always caused by trauma Patients present with easily identifiable psychiatric issues Patients are faking symptoms to get attention Patients can control their symptoms.

Biopsychosocial Model of Conversion Stonnington, Barry & Fisher, 2006

The Difficulty with Treating PNES: Few treatment studies, only retrospective and case- report studies on pediatric PNES PNES is a complicated disorder, with many layers that requires a multidisciplinary approach PNES remission, does not mean that the disorder is resolved MINNESOTA EPILEPSY GROUP SEIZURE CARE FOR ALL AGES

Risk Factors for Pediatric PNES: Plioplys et al. 2014 Co-Occurring Psychopathology-100% Anxiety (83%) Depression (43%) ADHD (29%) PTSD (25%) Adversities-92.7% Bullying (41%) Divorce/Bereavement (32%) Personal illness/injury (25%) Witness domestic/community violence (23%) Sexual abuse (14%) Physical abuse (12%)

Psychiatric Diagnoses *Significant at p < 0.05 **Significant at p < 0.0001

Case Study L L’s Genogram: L- Age 14 L’s Mom L’s Dad Genogram Legend Maternal Great-Grandma Maternal Great-Grandpa Maternal Grandma Maternal Grandpa Paternal Grandma Paternal Grandpa L’s Mom L’s Dad Genogram Legend History of Somatic Complaints Psychiatric Disorders Conflictual relationship Close relationship L- Age 14

Semiology: A natural place to start… Often the targeted problem at first psychotherapy assessment Discuss in detail physical symptoms, both that child is aware of experiencing and what is witnessed Manage concerns about validity of diagnosis Provide an explanation about physiological impact of stress (reference biopsychosocial model)

Individual Child Therapy/ Separate Family Therapy Stage 1: Manage symptoms Stage 2: Understand etiology of symptoms Stage 3: Change patterns of coping and relating MINNESOTA EPILEPSY GROUP SEIZURE CARE FOR ALL AGES

Stage 1:Behavioral Interventions: Reduce frequency and severity of physical symptoms through: Relaxation training Mindfulness Improve day-to-day function: Engage in life activities while managing symptoms Problem solve obstacles to function Relaxation training Mindfulness Return to function is key and often this requires consultation with school staff, parents and management of other factors that could interrupt some of this “normal” flow --In cases where there is a lot of resistance to return to school and/or other normal function– this is when we see some of the biggest challenges in gaining management of symptoms. Managing obstacles by: working with the school to create an accommodation plan etc

In Session Behavioral Interventions: Symptom reduction Body awareness Grounding techniques Relaxation strategies Manage anxieties related to symptoms Socially Academically Involve family in treatment process Understanding of symptoms Model appropriate response to symptoms and family stress

Encouraging Return to “Normal” Consultation with school staff Provide neuropsychological results Ensure that accommodations to work and schedule are made as needed Address peer-related challenges

Emotions Behaviors Beliefs Stage 2: Cognitive Behavioral Example of Conversion Process: Emotions Behaviors Beliefs Example emotions: Sad Overwhelmed Scared Hopeless Example Behaviors: Avoids exercise Does not go to school Responds to each symptom as if it indicates worsening illness Example Beliefs: “Activity makes my symptoms worse” “I am always going to feel sick” “No one can find what is wrong with me”

Stage 2: Cognitive Behavioral Interventions Explore thoughts related to symptoms How are symptoms understood in context of person’s life? What do the symptoms prevent? Discuss current/obvious stressors Problem Solving Daily stressors Difficulties coping

Child Therapy: Family Therapy Stage 3: Develop Insight Identify, understand and influence expression of negative emotion Address relationship struggles Identify communication challenges and improve them Family Therapy Problem solve Identify family stressors Discuss and modify family communication patterns MINNESOTA EPILEPSY GROUP SEIZURE CARE FOR ALL AGES

Case Therapy Timeline: EMU Admission Week 1 (Episodes >10 per day) -Relaxation training -Mindfulness -Return to school plan -Manage parental anxiety Week 2 (Episodes >5 per day) -Relaxation practice -Problem solve barriers to school return -Discuss “triggers” Week 3 (Episodes: 1-2 per day) -Reviewed triggers and what has worked -Discussed barriers at school to management -Parent engagement in treatment Week 4 (Episodes: 1 every few days) -Reinforced relaxation/ mindfulness -Discussed peer involvement -Discussed family concerns Week 5 (Episodes: 1 this week) -Reviewed relaxation -Discussed anxiety about school/family -Processed family concerns Week 6 (Episodes: none) -Problem solved coping with school/social stressors -Family conflict discussed Weeks 7-16 (No additional episodes) -Transitioned to managing anxiety in relationships with peers -Problem solving strategies for family conflict MINNESOTA EPILEPSY GROUP SEIZURE CARE FOR ALL AGES

“Roadblocks” to Treatment Symptoms as “source” of anxiety/depression Some behavioral interventions can exacerbate the somatic symptoms Strong emotional expression following remission of physical symptoms can be overwhelming When specific stressors/anxiety/depression/relationship concerns surface, family may struggle to acknowledge/accept/address. Parents may feel guilty

Preliminary Data Using this Treatment Model for Pediatric PNES: Doss, 2017 MINNESOTA EPILEPSY GROUP SEIZURE CARE FOR ALL AGES

Important Factors to Avoid “Roadblocks”: Therapist and patient must be confident in a good medical evaluation and understand physical symptoms as related in some way to psychological factors Pacing Parents must be active participants in treatment Long-term therapy, after physical symptom resolution, is often indicated Be sure to provide examples of verbal and nonverbal signs that you are pacing appropriately

The Question of “Medically Unexplained” versus “Conversion” Focus on function versus understanding the source of some of the physical symptoms Can create a barrier to the acceptance of the influence of emotional factors Patients/families can struggle with addressing other psychological factors that influence functioning or significant stressors that may be contributing.

Summary: Multiple factors contribute to the etiology of conversion disorder Semiology often brings the patient to the office but is only the “tip of the iceberg” Therapy can be thought of in stages Stage 1: Manage symptom Stage 2: Understand origin of symptoms Stage 3: Alter coping, improve communication, address individual and family stressors (including co-occurring psychopathology)