1. Psychological trauma, PTSD and PNES
Lorna Myers, Ph.D.-Director PNES Program- Northeast Regional Epilepsy Group

2. History of traumatic or adverse life experiences (including significant health events as well as physical, sexual, emotional abuse, major losses, etc.)
History of psychiatric disorders, including depression, anxiety, post-traumatic stress disorder and personality disorders
History of medically unexplained symptoms
PNES risk factors

3. Until recently there was no treatment designed specifically for PNES.
There are several treatment options now available.
If we consider all possible psychological treatments available, elimination of seizures or significant reduction in numbers has been reported in about a 1/4 to over half of cases.
Note: not all treatments are helpful to all. Some of the short term treatments may not be sufficient for those with severe psychological disorders, complex trauma, and certain personality disorders.
Treating PNES

4. First step: the conversation the patient has with her/his neurologist, diagnostic team before being discharged from the hospital.
Thorough and clear explanation about PNES: what it is, what is known about its origins, how it fits with the patient and how it can be treated. Ideally, the patient leaves the hospital with a psychological referral in hand.
Treating PNES

5. But what type of psychotherapy?
Approximately 30 to 40% of individuals presenting to epilepsy diagnostic centers have PNES.
General consensus that psychotherapy is the indicated form of treatment.
But what type of psychotherapy?
Starting point

6. PSYCHOTHERAPY should start once a diagnosis of PNES has been made
There is empirical validation and reports of utility of the following treatment approaches:
Cognitive Behavioral Therapy (CBT)
Prolonged exposure for therapy for dually diagnosed PNES/PTSD *
Psychodynamic therapy
Mindfulness-based therapy
Psychoeducational group interventions
Treating pnes

7. >90% of PNES patients report psychological trauma in their history (especially high number of childhood sexual and physical abuse) compared to control groups and healthy volunteers.
Across 10 studies, the mean percentage of PNES patients meeting criteria for PTSD was 38.9%.
Compared to PNES without PTSD:
Higher incidence of mood disorders
Alexithymia and different stress coping
Greater substance abuse
Higher incidence of suicide attempts (25%)
1Reuber, M. Psychogenic nonepileptic seizures: answers and questions. Epilepsy Behav. May 2008; 12: 622–635
2 Fiszman, A., Alves-Leon, S.V., Nunes, R.G., D'Andrea, I., and Figueira, I. Traumatic events and posttraumatic stress disorder in patients with psychogenic nonepileptic seizures: a critical review. Epilepsy Behav. Dec 2004; 5: 818–825
3Epilepsy & Behavior 2013: Psychological trauma in patients with psychogenic nonepileptic seizures: Trauma characteristics and those who develop PTSD. Myers et. al.
PNES + Trauma + PTSD

8. Types of trauma Multiplicity of adverse childhood events Adult trauma
medical illnesses
loss of caregivers
Divorce
War
Natural disasters
General instability
Adult trauma
Incarceration
Assaults
Natural disasters
Military and first responder experiences
In women, we greater numbers of sexual trauma than in men
Types of trauma

9. Why not target the dual diagnosis of PTSD and PNES?
Prolonged exposure Therapy

10. Why Prolonged exposure?
PE has been around for decades and has the largest number of studies supporting its efficacy and effectiveness
Effectiveness reported with the widest range of trauma populations, including comorbid populations (substance use disorders, BPD, psychosis, high dissociation)
PE widely disseminated
Foa, Rothbaum, & Hembree, Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide, 2007
Why Prolonged exposure?

11. Rationale for PE Three main factors prolong post-trauma problems:
Avoidance of trauma related thoughts and images
Avoidance of trauma related situations
The presence of dysfunctional cognitions: “The world is extremely dangerous”; “I am totally incompetent.”
Rationale for PE

12. The core components of exposure therapy are to replace avoidance with exposure and confrontation:
Imaginal exposure, revisiting the index trauma memory, repeated recounting it aloud, and processing the experience of memory recollection, and
In vivo exposure, the repeated confrontation with situations and objects that have become associated to the trauma and cause distress but are not inherently dangerous.
Post imaginal processing of dysfunctional cognitions associated to the trauma.
Rationale for PE

13. How does PNES fit into this picture?
Hypervigilance- intero and exteroceptive
Intrusive symptoms
Avoidance
Avoidance 2.0 PNES
Negative thoughts and mood

14. CBT treatments for PNES/PTSD-Prolonged exposure (PE)
Prolonged exposure acts on:
Avoidance symptoms (of the memory and other life aspects). Patient reconquers that which was avoided.
Intrusive symptoms because the patient learns to recollect the memory and associated thoughts voluntarily instead of being “intruded on.”
Hypervigilance because the patient learns that many “dangerous” situations are in fact safe and because intrusive symptoms come down.
Negative thoughts and mood because there is a sense of achievement and regained confidence.
CBT treatments for PNES/PTSD-Prolonged exposure (PE)

15. Pilot Data (Myers, Vaidya-Mathur, Lancman, 2017)
Design: Open clinical trial
Participants:
Dually dx PTSD and PNES (Video EEG-confirmed)
Age range: years
Treatment: weekly PE sessions (90 minutes)
Therapists (2): CTSA Certified in PE
Outcome measures: PTSD (PDS), Depression (BDI-II), Seizure frequency
Myers, Lorna; Vaidya-Mathur, Urmi; Lancman, Marcelo. Epilepsy & Behavior Vol. 66,  (Jan 2017):
Pilot Data (Myers, Vaidya-Mathur, Lancman, 2017)

16. Pilot Data (Myers, Vaidya-Mathur, Lancman, 2017)

17. Enrollment and Retention

18. PDS and BDI II
BDI post = low end of the mild range (beginning at the high end of moderate)
Seizure per day, 1.6 baseline, .02

19. PNES Outcomes Baseline mean: 2.2 (Range 0 – 15 seizures per day)
Post treatment: 81.25% (13/16) completers reported no seizures by their final PE session
All showed significant reduction in seizure frequency (Z = − 3.413, p = 0.001). Post mean: .01 seizure per day
Gains maintained at follow-up (time interval: 1 month to 34 months): 11/14 remained seizure free
Nine of the 14 patients returned to work or continued with their education.
PNES Outcomes
ITT: 68% abstinent

20. Strong, preliminary data supporting use of trauma-focused therapy in this population
Safe, feasible: 18 patients, 0 adverse events
What’s next?
RCTs to establish efficacy compared to other treatments
Replication in other settings
Mediator analyses – what’s driving change? PTSD reduction? Reduction in avoidant coping?
Conclusions
Effectiveness with clinicians outside of epilepsy centers

21. Case study: 53 year old man with PNES for 7 years (up to 15 seizures per day).
Underwent treatment for PTSD/PNES with PE. No seizures at end of treatment.
3-year follow up: 3 seizures in all. Clearly identifies triggers for these.
Myers L & Zandberg L (2017). Case Report: Prolonged Exposure Therapy for comorbid psychogenic non-epileptic seizures (PNES) and post-traumatic stress disorder (PTSD). Clinical Case Studies.
PE for PTSD/PNES

22. Important consideration for PE
It may not be possible to use PE with patients who have complex PTSD and PNES, especially if it is not possible to identify an index trauma.
Complex PTSD involves a set of symptoms resulting from prolonged trauma that was not possible to escape. Examples:
Chronic abuse by caregivers
Hostages
Prisoners of war
Concentration camp survivors
Survivors of some religious cults
Important consideration for PE

23. Eye Movement Desensitization and Reprocessing (EMDR)
Report on EMDR targeting trauma and dissociative symptoms in 3 patients, Psychogenic seizures stopped in two. Those patients remained seizure- free for 12–18 months.
Kelley & Benbadis (2007). Eye movement desensitization and reprocessing in the psychological treatment of trauma-based psychogenic non-epileptic seizures. Clin. Psychol. & Psychotherapy.
Eye Movement Desensitization and Reprocessing (EMDR)

24. >90% of patients with PNES report psychological trauma in their history & about 50% have PTSD
We have obtained strong, preliminary data supporting use of Prolonged Exposure (trauma- focused therapy) in this population.
What is next: randomized controlled trial (RCTs) to establish efficacy compared to other treatments.
Concluding remarks

25. Myers L, Vaidya-Mathur U, Lancman M (2017)
Myers L, Vaidya-Mathur U, Lancman M (2017). Prolonged exposure therapy for the treatment of patients diagnosed with psychogenic non-epileptic seizures (PNES) and post-traumatic stress disorder (PTSD). Epilepsy Behav;66: doi: /j.yebeh Epub 2016 Dec 27.
Myers L & Zandberg L (2017). Case Report: Prolonged Exposure Therapy for comorbid psychogenic non-epileptic seizures (PNES) and post-traumatic stress disorder (PTSD). Clinical Case Studies
Myers L, Perrine K, Lancman M, Fleming M, Lancman M. (2013) Psychological trauma in patients with psychogenic nonepileptic seizures: Trauma characteristics and those who develop PTSD. Epilepsy Behav. Vol. 28, Issue 1, Pages 121– 126.
References

26. Myers L, Zeng R, Perrine K, Lancman M, Lancman M (2014)
Myers L, Zeng R, Perrine K, Lancman M, Lancman M (2014). Cognitive differences between patients who have psychogenic nonepileptic seizures (PNESs) and posttraumatic stress disorder (PTSD) and patients who have PNESs without PTSD. Epilepsy Behav. Volume 37, August 2014, Pages 82– 86.
Zeng R, Myers L, Lancman M (2018). Post- traumatic stress and relationships to coping and alexithymia in patients with psychogenic non-epileptic seizures. Seizure, 57:
References