T R E AT M E N T

PTSD AND PNES: PROLONGED EXPOSURE

POST TRAUMATIC STRESS DISORDER AND PNES

• What is PTSD?• What is the connection between PTSD and PNES?• Is there an effective treatment for PTSD?• Could this treatment help those diagnosed with

PNES and PTSD?

WHAT IS POST TRAUMATIC STRESS DISORDER?

• Category: Anxiety disorder• Origin: Psychological Trauma as a result of

a horrific, terrifying, life threatening, experience that shattered your sense of safety.

WHAT CAN BE TRAUMATIC?

• Subjective: what is for one person, may not be…• Childhood abuse (sexual, physical, neglect)• Battlefield experiences• Being involved in a crime, accident, torture• Natural disaster• Witnessing the victimization of a loved one (e.g.

mother, sibling).• Death of a loved one (e.g. child)• Being shunned by family and society

TRAUMA

WHAT IS PTSD?

•1 Month Re-experience trauma

•Avoidance of trauma reminders•Hyper vigilance•Negative mood and thoughts

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.

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”• Short-term solution but it makes it worse in the

long run

SEE NO EVIL, HEAR NO EVIL, SPEAK NO EVIL

HYPER-VIGILANCE

•Constant state of being alert and revved• Poor sleep• Startle response: jumpiness• Irritability, moodiness•Continuous scanning for danger, uneasiness• Fatigue and exhaustion as a result

NEGATIVE MOOD & THOUGHTS

•Cynicism: Jaded and negative view of others and life•Distrust of others and their intentions. Great care to not open yourself to getting hurt again•Negative self views: self-blame, guilt, weak, disabled, crazy.

PTSD AND THE BRAIN

• Trauma can transform the brain: • Limbic system (emotion center): fear and vigilance• Memory center is near limbic system: intense reaction to

memories and forgetfulness of others• Prefrontal cortex: problem solving and emotion control• Left hemisphere: language dominant in most and could

explain word finding problems and verbal memory weaknesses.

• Increased Stress hormones: fight or flight response, increased glucose levels and heart rate, panicky feelings

THE BRAIN

DIAGNOSTIC CRITERIA

•1 or > intrusive symptoms•3 or > avoidance symptoms•1 or > symptoms of hyper-vigilance•3 or > negative changes in mood and thoughts•Symptoms intrude on daily life and become disabling.

ASSOCIATION BETWEEN PNES AND PTSD?

•@75% PNES patients have a history of trauma.•@23-77% have a history of childhood sexual/physical abuse.•@25% fulfill criteria for post traumatic stress disorder (PTSD).

DISSOCIATION

• Why are PNES and PTSD connected?• When traumatized the brain uses extreme

defense mechanisms. Dissociation• Intolerable experiences of near death and

horror that can’t be escaped-the brain saves you by dissociating.• A dissociation pathway gets paved and

future distress triggers this defense even when it is no longer needed.

PNES AND PTSD

• Patients with PNES/PTSD are different than 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.

HOW TO TREAT PTSD

• Intrusion: Those memories that intrude on you whenever THEY want: treatment teaches you to call forth those memories when you want. Retelling• Avoidance: the short-term solution becomes the

problem. Do the opposite.• 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”).

PROLONGED EXPOSURE TREATMENT FROM UPENN

WHAT DOES PET LOOK LIKE?

• 1) education about common reactions to trauma• 2) Breathing retraining• 3) “Real Life” exposure to situations of activities avoided because they are reminders• 4) Repeated prolonged imaginal exposure (revisit the trauma by retelling the trauma memory in session.

WHAT DOES PET LOOK LIKE?

• Session 1: Overview of treatment program and rationale, trauma interview and breathing retraining.• Session 2: Common reactions to the trauma.

“Real Life” hierarchy is constructed. • Session 3: Retelling your most disturbing trauma

memory for the first time.• Session 4-9: trauma processing and hot spots.• Session 10: Discussion about your experiences

with “real life” and imaginal exposure, progress and future.

CONFRONTATION

• Confronting the memory:• 1) Helps process the free-floating and intrusive memory.

Putting into words brings the primitive memory to higher brain levels.

• 2) You learn that thinking and remembering is not dangerous.

• 3) You learn that relatively safe situations are not dangerous.

• 4) Beliefs about self, others, and the world change for the better.

• 5) You learn that habituation will help you in other situations to reduce anxiety.

BENEFITS AND RISKS

• Benefits: PET reduces PTSD symptoms and problems, depression and anxiety.• Risks: Discomfort and emotional distress especially when remembering trauma and confronting situations that were avoided before. • Therapists are certified therapists and some are also certified as supervisors. http://www.med.upenn.edu/ctsa/

IS PET EFFECTIVE?

• 20 years of research has shown PET is an effective modality to treat PTSD. • Research studies have been conducted in the US, Israel, Japan, Australia, and Europe.• VA system has begun using PET with veterans and hundreds of mental health professionals from Vas have been trained.

IS PET EFFECTIVE FOR PNES?

• PTSD is a very toxic condition that results in depression, substance abuse and potentially PNES.• At NEREG we are offering PET to our PNES/PTSD patients and results are very encouraging.•Design of research project on PET with PNES/PTSD is in the works at NEREG.

PET FOR PNES IN OUR PROGRAM

OTHER TREATMENTS

•Stress inoculation treatment (SIT)•Cognitive processing therapy (CPT)•Eye movement desensitization and reprocessing (EMDR)•Medications: Zoloft and Paxil

RESOURCES AND CONTACT

• Psychogenic Non-epileptic Seizures: A Guide available on Amazon Chapter 3

• Website: www.nonepilepticseizures.com• Webinar on Psychogenic non-epileptic seizures on

YouTube• Facebook: Psychological non epileptic seizures• Lmyers@epilepsygroup.com• www.epilepsyfree.com for continuing education

scholarships and funds for educational programs• PET article:

http://articles.philly.com/2014-07-07/news/51110145_1_edna-foa-prolonged-exposure-therapy-ptsd