Therapists understood psychogenic nonepileptic seizures (PNES) in complex clients as responses to chronic interpersonal trauma. PNES functioned to communicate distress, reenact trauma, or dissociate. Treatment focused on staged trauma integration and developing self-skills. Therapists saw PNES resulting from limited skills or attachment issues as simpler, while complex PTSD presentations required long-term psychotherapy and specialist therapist training.

1. Therapists' Understandings of Psychogenic Nonepileptic
Seizures and Their Treatment
Authors:
• Maria Quinn.
PhD student, La Trobe University, Melbourne, Australia
• Professor Margot Schofield.
Professor of Counselling and Psychotherapy, La Trobe
University, Melbourne, Australia
• Dr Warwick Middleton.
Chair, The Cannan Institute, Brisbane, Australia
Adjunct Professor, School of Public Health, La Trobe
University, Melbourne, Australia

2. Therapists' Understandings of Psychogenic Non-epileptic
Seizures and Their Treatment

3. Hysteria
• Conversion • Dissociation
failure to integrate the various
conversion of sensory, cognitive, and
psychological distress into affective aspects of an
bodily manifestations experience into a person’s
(American Psychiatric Association, sense of themselves (Janet,
1994; Freud & Breuer, 1895). 1907; World Health
Organisation, 1992).

4. 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 underlying
medical cause
(van der Hart, van Dijke, van Son, & Steele, 2000).

5. 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, & D'Angelo, 2005).

6. 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

7. 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).

8. 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.

9. 1. Relative to other psychogenic symptoms,
they can be diagnosed with a high degree of
certainty (Benbadis, O'Neill, 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).

10. Factors that Contribute to Psychogenic Symptoms
Trauma.
• 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, D'Andrea, & 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)

11. Factors that Contribute to Psychogenic Symptoms
Deprivation, 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)

12. Factors that Contribute to Psychogenic Symptoms
Silencing expression of strong emotion.
• Contexts that restrict verbal expression of
strong emotion and impose no-win choices
E.g. interpersonal dynamics in which childhood
abuse most frequently occurs

13. Australian therapist’s understanding of PNES
and their treatment
Aim: To explore the understandings of therapists
who successfully treated PNES in Australian
clients.
• Part of broader research into client and
therapist understandings of PNES.
• Conducted with approval of the Human research ethics Committee of La
Trobe University.

14. Grounded IPA Document
Theory research
Therapist Across Within case
therapist analysis
analysis of (case study)
consecutively
constructed
interviews
Client GT not used Within case Within case
due to ethical analysis longitudinal
problems. (case study) case study
Across client -using client
analysis writing/drawing
Therapist 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

15. 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

16. 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

17. Findings
Therapists
• 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

18. Findings
Client Characteristics
• 2 males, 5 females, aged 27-50
• Comorbid conditions (AV. 3): epilepsy (2),
Graves disease, anxiety disorders (7),
depression (4), DID (3), BPD (3), DDNOS (2).
• Multiple A&E presentations prior to therapy

19. 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 early
Understandings of PNES attachment figures
Arising out of stress
Simple 1/8 immaturity, or minor skill
deficits.

20. 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 other
met but there dissociative disorders but
is significant at times when there is
self good orientation to the
impairment present.

21. Function of PNES when oriented to the
present
• Escape
• Self harm/self soothing

22. 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

23. Functions of PNES in dissociated states
• Re-enactment
• Escape
• Protection
• Preservation of attachment
• PNES with induced medical seizure

24. 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 tolerance
disturbance, 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

25. 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.