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

2. 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).

3. 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

4. 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.

5. 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)

6. 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.

7. 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

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

9. 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.

10. 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”

11. 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

12. 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.

13. 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

14. 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.

15. 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.

16. 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.

17. 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

18. 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.

19. 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”).

20. 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.

21. 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.

22. 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.

23. 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.”

24. 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.

25. 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.

26. 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.

27. 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

28. Resources on ptsd
Psychogenic Non-epileptic Seizures: A Guide available on Amazon Chapter 3
Website: (Services for PNES)
PTSD information:
PE article: