Lorna Myers, Ph.D. Trauma and PNES: Prolonged exposure - PowerPoint Presentation

Slide1

Lorna Myers, Ph.D.

Trauma and PNES: Prolonged exposure Slide2

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).Slide3

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

ResourcesSlide4

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.Slide5

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)Slide6

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. Slide7

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 afterSlide8

How do we determine if someone has PTSD?

1 Month



Re-experiencing trauma

Avoiding trauma reminders

Hyper-vigilance

Negative mood and thoughtsSlide9

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.Slide10

Avoidance

Efforts

to

forget: “Just forget it, push it away, move on.”

Numbing: Having difficulty feeling emotions, seeming cut off, shut down

S

potty 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”Slide11

Hyper-vigilance

Constant state of being alert

Poor sleep

Startle response: jumpiness

Irritability, moodiness

Continuous scanning for danger, uneasiness

Fatigue and exhaustion as a resultSlide12

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.Slide13

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 patientsSlide14

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.Slide15

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.Slide16

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

. Slide17

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/PTSDSlide18

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. Slide19

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”).Slide20

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. http

://www.med.upenn.edu/ctsa/Slide21

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. Slide22

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.Slide23

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.”Slide24

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.Slide25

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.Slide26

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

.Slide27

Other treatments

Stress inoculation treatment (SIT)

Cognitive processing therapy (CPT)

Eye movement desensitization and reprocessing (EMDR)

Medications: Zoloft and PaxilSlide28

Resources on ptsd

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

Website:

www.nonepilepticseizures.com

(Services for PNES)

PTSD information: http://www.ptsd.va.gov/public/PTSD-overview/basics/what-is-ptsd.asp

PE article: http

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