Therapists Understandings of Psychogenic Nonepileptic Seizures and Their TreatmentAuthors:• Maria Quinn.PhD student, La Trobe University, Melbourne, Australia• Professor Margot Schofield.Professor of Counselling and Psychotherapy, La TrobeUniversity, Melbourne, Australia• Dr Warwick Middleton.Chair, The Cannan Institute, Brisbane, AustraliaAdjunct Professor, School of Public Health, La TrobeUniversity, Melbourne, Australia
Therapists Understandings of Psychogenic Non-epileptic Seizures and Their Treatment
Hysteria• Conversion • Dissociation failure to integrate the variousconversion of sensory, cognitive, andpsychological distress into affective aspects of anbodily manifestations experience into a person’s(American Psychiatric Association, sense of themselves (Janet,1994; Freud & Breuer, 1895). 1907; World Health Organisation, 1992).
Somatoform Dissociation• integrative failure involving the sensorimotor components of a distressing experience, resulting in symptoms such as:paralyses; heart palpitations; disturbances of vision, hearing,speech, sensation and breathing; tics; somnambulism;catatonias; and seizure like states, that have no underlyingmedical cause (van der Hart, van Dijke, van Son, & Steele, 2000).
1. Cost to scarce medical resources.• 30-60% of patients in primary care settings complain of symptoms for which no medical basis is found (Waldinger, Schulz, Barsky, & Ahern, 2006 .• Somatising patients are frequent users of outpatients, general practitioners, and specialists and the most frequent users of unwarranted medications, for no change in condition (Grabe, Baumeister, John, Freyberger, & Volzke, 2009; Stuart & Noyes, 1999).• When they are properly diagnosed and treated, the saving in health resources is considerable (Stevenson & Meares, 1999; Stevenson, Meares, & DAngelo, 2005).
2. Somatoform symptoms pose a considerable diagnostic challenge.• Differentiation of somatoform symptoms from organic illness is time consuming and expensive.• Diagnosis by elimination can result in misdiagnoses leading to unnecessary treatments with serious side effects.• Patients often find the diagnosis of a psychological disorder difficult to accept
3. Somatoform disorders have a high comorbidity with other psychiatric diagnoses including• Depression, anxiety, post traumatic stress disorder (PTSD), borderline personality disorder and dissociative disorders (Bowman, 2001)• associated with poor quality of life (Jones et al., 2010; Reuber, Mitchell, Howlett, & Elger, 2005).
Psychogenic Non Epileptic Seizures• behaviours that look like seizures but differ from epilepsy and other medical events because they have psychological rather than medical causes.• lack clinical features and simultaneous electrographic features as measured by Electroencephalogram.
1. Relative to other psychogenic symptoms, they can be diagnosed with a high degree of certainty (Benbadis, ONeill, Tatum, & Heriaud, 2005).2. They are frequently misdiagnosed, resulting in delays in appropriate treatment, or they are treated inappropriately with drugs (Benbadis, 1999).3. 19%-93% of people with PNES also experience other psychogenic symptoms, the study of PNES provides a lens through which these complex reactions and their key psychological components can be explored (Bowman & Kanner, 2007).
Factors that Contribute to Psychogenic SymptomsTrauma.• Physical, sexual and emotional trauma in childhood and across the life span is a well supported risk factor -found among 40- 100% of people who experience PNES ( see Fiszman, Alves- Leon, Nunes, DAndrea, & Figueira, 2004, for a review).• Adult relational trauma is commonly associated with the onset of somatoform symptoms including PNES (Bowman & Markand, 1996, 1999; Harden, 2003)• Correlation of trauma to psychogenic symptoms is robust across cultures (see Sar, 2006, for a review).• Extent and severity of childhood abuse correlates with complexity and severity of adult symptoms (Nijenhuis, Spinhoven, van Dyck, van der Hart, & Vanderlinden, 1998)
Factors that Contribute to Psychogenic SymptomsDeprivation, depletion and shock.• chronic sleep deprivation, exhaustion, cold, thirst, hunger, poor nutrition, lack of sanitation, exposure to high risk of disease and prolonged emotional strain (van der Hart, et al., 2000).• After loss following protracted emotional strain (Freud & Breuer, 1895, the case of Anna O.).• In adolescents with their developing emotion regulation systems who are exposed to life stressors• Neurological events such as head injury and poorly controlled epilepsy• During prolonged periods of deprivation and torment, such as war or natural disaster, resources must be directed towards survival, and are therefore not available for the integration of sensation, cognition, emotion and memory (van der Hart, Nijenhuis, Steele, & Brown, 2004; van der Hart, et al., 2000)
Factors that Contribute to Psychogenic SymptomsSilencing expression of strong emotion.• Contexts that restrict verbal expression of strong emotion and impose no-win choicesE.g. interpersonal dynamics in which childhoodabuse most frequently occurs
Australian therapist’s understanding of PNES and their treatmentAim: To explore the understandings of therapistswho successfully treated PNES in Australianclients.• Part of broader research into client and therapist understandings of PNES.• Conducted with approval of the Human research ethics Committee of La Trobe University.
Grounded IPA Document Theory researchTherapist Across Within case therapist analysis analysis of (case study) consecutively constructed interviewsClient GT not used Within case Within case due to ethical analysis longitudinal problems. (case study) case study Across client -using client analysis writing/drawingTherapist GT not used Within dyad Within dyad/client dyad due to ethical analysis longitudinal problems Across dyad case study analysis -using case notes and client writings
Grounded theory analysis• Theory construction-to identify the concepts central to therapist’s understandings of PNES• Detailed thematic analysis of each interview, prior to interviewing then next participant• Emerging themes inform questions explored with subsequent participants• After all interviews, analysis of themes across interviews
Inclusion Criteria• Australian psychotherapists (any discipline)• Treated a client with PNES in last 5 years• PNES verified by v-EEG• No recurrence of PNES in past 12 months• Record of treatment exists
FindingsTherapists• 3 female, 5 male• 7/8 > 40 years of age, >15 years experience• 1/8 in training• 7/8 provided long term therapy• 5/8 psychiatrists, 2/8 psychologists,1/8 mental health nurse• 7/8 had treated the client of interest for 2-13 years• Av. length of therapy was 6.5 years, 5 continuing
Complex- Therapists understood PNES of these clients as one of a Therapists with Clients with number of responses to chronic complex PNES presentations interpersonal trauma in formative understood they had acquired Findings relationships. norms of non verbal communication of distress in their early Simple- PNES in the absence of attachments extensive comorbidity and trauma Silencing of traumatic affect by early attachment figures Complex 7/8 Prescriptions for nonverbal communication by earlyUnderstandings of PNES attachment figures Arising out of stress Simple 1/8 immaturity, or minor skill deficits.
BPD PNES with orientation to the present A skill deficit consequent to emotional deprivation in early attachments Diagnostic criterion for In clients with complex BPD are not PTSD and othermet but there dissociative disorders butis significant at times when there is self good orientation to the impairment present.
Function of PNES when oriented to the present• Escape• Self harm/self soothing
Complex PTSD PNES in the absence of orientation to the present.DID ie. In a dissociated state. Where a trigger in the present focused the clients attention on an aspect of a past traumatic incident DDNOS
Functions of PNES in dissociated states• Re-enactment• Escape• Protection• Preservation of attachment• PNES with induced medical seizure
Implications for treatment Understanding of function of PNES, staged integration of trauma, in safe therapeutic rel’p. Orientation to present Dissociated states without orientation to present, eg PTSD, DID, DDNOS Development of self skills, eg relational, emotion PNES, attachment regulation, distress tolerancedisturbance, psychiatric comorbidity Presentations with limited Understanding of function of dissociation, good orientation PNES to the present, and limited Development of self skills in self skills safe therapeutic relationship
Significance for therapist training and resource allocation• People with psychiatrically complex presentations and PNES require long term psychotherapy• Therapists require preparation for understanding the effects of trauma and treatment of the complex array of resulting symptoms• Counter transference and confusion are a normal part of this therapy, for therapists.• Therapist and client transformations are a normal part of this therapy.