PTSD AND PNES:
PROLONGED EXPOSURE
TREATMENT
POST TRAUMATIC STRESS DISORDER
AND PNES
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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
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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 hypervigilance
• 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/2014-0707/news/51110145_1_edna-foa-prolonged-exposuretherapy-ptsd