1. Pediatric Psychogenic Non-Epileptic Seizures: Risk Factors, Diagnosis & Treatment
Julia Doss, PsyD, LP
Pediatric Psychology

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

3. 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”

4. 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

5. 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

6. 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.

7. Biopsychosocial Model of Conversion
Stonnington, Barry & Fisher, 2006

8. 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

9. 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%)

10. Psychiatric Diagnoses
*Significant at
p < 0.05
**Significant at p <

11. 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

12. 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)

13. 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

14. 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

15. 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

16. 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

17. 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”

18. 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

19. 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

20. 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

21. “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

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

23. 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

24. 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.

25. 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)