PNES/pseudoseizure case formulation

[Evidence Based]

In my last med school rotation before starting residency, I spent a couple of weeks in an outpatient epilepsy clinic, and encountered a fair amount of PNES/pseudoseizures. The neurologists I was working with didn't have much advice for the patients besides "go see psychiatry" or "go get some therapy," but I found myself wondering how I would formulate a case like this if it came in front of me. Obviously one would look to treat any underlying psychiatric disorder (MDD, anxiety, etc), but I was curious about how one would think about non-epileptic seizures from a psychiatric PoV.

Most of the literature I've come across has been neurologically focused (and has mostly been on differentiating PNES from epileptic seizures), but I'd love recs for any good psychiatric writing on the subject. Thanks!

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[deleted736562]

You want to get a sense of the dynamics underlying the current behavior. What is making the patient "resort" (of course most of the time it is unconscious) to this kind of behavior. It would be helpful to establish what could be a primary or a secondary gain. Once you have something to latch on, at least you can get started with addressing the issue. This is perhaps where being more psychodynamically oriented might give you an edge.

 

[MacDonaldTriad]

I like the way neurologists don't mess with the factious vs conversion thing like we do. No one has been able to tell me how we are supposed to tell if this is consciously or subconsciously driven anyhow. I agree with the above, the key is to look for rewards and stressors. Somatic people express stress with somatic symptoms, but stress is stress.

 

[AcronymAllergy]

There's been some work in developing protocols for psychotherapy in PNES/PNEE; up to this point, most of it has been CBT-oriented. Future work will probably incorporate mindfulness-based components. And yes, if you're able to actually conduct a true functional analysis of the behavior, that'd be great. In my experience, it's been something that develops over a number of years, is intermittently reinforced (frequently unknowingly), and often involves absent or underdeveloped healthy coping skills and distress tolerance.

 

[splik]

This is probably my favorite paper on the topic

 

[LadyHalcyon]

In my last med school rotation before starting residency, I spent a couple of weeks in an outpatient epilepsy clinic, and encountered a fair amount of PNES/pseudoseizures. The neurologists I was working with didn't have much advice for the patients besides "go see psychiatry" or "go get some therapy," but I found myself wondering how I would formulate a case like this if it came in front of me. Obviously one would look to treat any underlying psychiatric disorder (MDD, anxiety, etc), but I was curious about how one would think about non-epileptic seizures from a psychiatric PoV.

Most of the literature I've come across has been neurologically focused (and has mostly been on differentiating PNES from epileptic seizures), but I'd love recs for any good psychiatric writing on the subject. Thanks!

I have a client who had those as a child. He has very severe PTSD from repeated sexual abuse as a child.

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[witzelsucht]

EM resident checking in. Any tips from our perspective? A recent podcast suggested IM zyprexa in the acute phase.

 

[Evidence Based]

Thanks for all the recs! I actually had one patient whose chief complaint was "non-epileptic seizures," and she told us that she knew these seizures were "from stress" and that she didn't have epilepsy. However, she was still having them, so it was interesting to know one could have these attacks even though she accepted they weren't "real" seizures.

Incidentally, after her 3rd or 4th presentation to the medical ED, she was transferred to the Psych ED and put on depakote. No convulsions since, and her mood is better too.

 

[nitemagi]

As above, in the primary/secondary gain examination -- ask yourself "What need might this symptom solve?"

In hypnosis, namely something called hypno-analysis (an approach borrowed from David Cheek, an Ob/Gyn who was a pioneer in using hypnosis therapeutically), most psychogenic/functional conditions exist due to a list of causes.
1. It gets the person out of an unsolvable dilemma (being pulled in two directions at the same time, but not being able to choose either). An example might be picking between two parents.
2. A metaphorical manifestation based on that body part. AKA Organ Language. "That guy has no backbone." It happens at an unconscious level, often as a child.
3. It solves a different problem. It gives attention to those that aren't getting enough, gets them out of a test, etc. Primary or secondary gain.
4. They have identified with someone with a similar problem (unconsciously). A sick relative with seizures, and want in some way to be like them.
5. They were sensitized from some traumatic experience, which set them up for the problem or might have even started the problem for a first time.
6. The symptom is a way of punishing themselves for something they believe they've done wrong. Again, this is all unconscious.
7. They took in a suggestion from someone that they manifested. Essentially someone told them to have the symptom, either directly or (usually) indirectly. Again consider that often this happens to a child that can take things too literally, or in an emotionally vulnerable (or suggestible) person.

There are then a host of techniques for figuring out which (or many) are the causes, and then treating them.

 

[Amygdarya]

As above, in the primary/secondary gain examination -- ask yourself "What need might this symptom solve?"

In hypnosis, namely something called hypno-analysis (an approach borrowed from David Cheek, an Ob/Gyn who was a pioneer in using hypnosis therapeutically), most psychogenic/functional conditions exist due to a list of causes.
1. It gets the person out of an unsolvable dilemma (being pulled in two directions at the same time, but not being able to choose either). An example might be picking between two parents.
2. A metaphorical manifestation based on that body part. AKA Organ Language. "That guy has no backbone." It happens at an unconscious level, often as a child.
3. It solves a different problem. It gives attention to those that aren't getting enough, gets them out of a test, etc. Primary or secondary gain.
4. They have identified with someone with a similar problem (unconsciously). A sick relative with seizures, and want in some way to be like them.
5. They were sensitized from some traumatic experience, which set them up for the problem or might have even started the problem for a first time.
6. The symptom is a way of punishing themselves for something they believe they've done wrong. Again, this is all unconscious.
7. They took in a suggestion from someone that they manifested. Essentially someone told them to have the symptom, either directly or (usually) indirectly. Again consider that often this happens to a child that can take things too literally, or in an emotionally vulnerable (or suggestible) person.

There are then a host of techniques for figuring out which (or many) are the causes, and then treating them.

Thanks so much for the summary! Could you recommend any literature on this?

 

[nitemagi]

In terms of technique or on the theory? If you want to just focus on hypnosis approaches (theoretically any of these could be approached through other therapy modalities), I'd recommend starting with some basic hypnosis training. Go to Asch.net and look for an approved course. A fine manual on approaching these particular issues would then be Ideomotor Signals for Rapid Hypnoanalysis by Ewin & Eimer.

Other relevant therapy or hypnosis books to consider:
The Symptom-Context Method by Luborsky
The Application of Ideomotor techniques by David Cheek (out of print)
Trance and Treatment by Spiegel & Spiegel (which includes an easy scale for measuring suggestibility)
How Psychotherapy Works by Weiss - a good book on Control Mastery Theory which includes the idea about how people (children especially) internalize ideas based on their situation, but not necessarily in a direct 1:1, often in a complement/viewing the world through a lens of omnipotence (as if I am causing what's happening around me) -- and how that plays out in regular therapy. And it's an evidence based approach.

OF course there are TONS of other valuable therapy texts, but it depends on your therapeutic lens (what modality, what conditions) to give more recommendations. Strategic family therapy books, for example, can get into a systems approach to the primary/secondary gain issues (such as Cloe Madanes).

 

[NickNaylor]

Our hospital has a PNES-specific group that I co-lead on a weekly basis. It's fairly structured and essentially introduces basic CBT principles to give folks a framework to begin thinking about how thoughts, emotions, and behaviors are linked and to try and identify patterns in those things and the onset of their symptoms. For those patients that are fairly high functioning it's pretty effective. For those who are not the group just ends up being a support group.

There are no clear recommendations for pharmacotherapy in PNES. Obviously treating any underlying disorders is probably helpful. I have no idea where these thoughts about IM olanzapine - much less VPA - come from. I would be interested in seeing what evidence those strategies are based off of.

@nitemagi's points are a good way to conceptualize a conversion disorder case. In terms of treatment, oftentimes these sorts of things require regular, individual therapy. One of my therapy cases is a young woman who was diagnosed with conversion disorder who I have been seeing for weekly psychodynamic work for about 8 months now. When she initially presented, she was having conversion disorder episodes daily for minutes to hours. She has now returned to work and only has very brief episodes (a few seconds, maybe a minute at most) every few weeks. It became clear that she had several internal conflicts that she was having - and, for some of them, still has - trouble working through.

The key for identifying these conflicts and the "reward" that comes from the behaviors is obtaining a very detailed psychosocial history - from childhood to the present - and looking out for conflicts. I've found that motivation and a desire to improve and having something to aspire to (in the case of this woman, she wanted to return to work, has aspirations to return for additional post-graduate education, etc.) that the symptoms are getting in the way of is critical for both a positive prognosis and a positive outcome.

 

[nitemagi]

Yes the time to improvement will depend on the severity of the case, the approach used, the rigidity of the system to change, and the flexibility of the therapist in approach. Plus a little luck.

I've seen the range be from hours to months (years if you're doing psychoanalysis), depending on approach and the fit of your approach to the patient.

Good for you, NickNaylor, for doing a therapy case on this in training. I think it can be one of the most rewarding therapy cases to do because the benefits are so clearly tangible, and quite often these cases go untreated by other specialties for years.

 

[Amygdarya]

In terms of technique or on the theory? If you want to just focus on hypnosis approaches (theoretically any of these could be approached through other therapy modalities), I'd recommend starting with some basic hypnosis training. Go to Asch.net and look for an approved course. A fine manual on approaching these particular issues would then be Ideomotor Signals for Rapid Hypnoanalysis by Ewin & Eimer.

Other relevant therapy or hypnosis books to consider:
The Symptom-Context Method by Luborsky
The Application of Ideomotor techniques by David Cheek (out of print)
Trance and Treatment by Spiegel & Spiegel (which includes an easy scale for measuring suggestibility)
How Psychotherapy Works by Weiss - a good book on Control Mastery Theory which includes the idea about how people (children especially) internalize ideas based on their situation, but not necessarily in a direct 1:1, often in a complement/viewing the world through a lens of omnipotence (as if I am causing what's happening around me) -- and how that plays out in regular therapy. And it's an evidence based approach.

OF course there are TONS of other valuable therapy texts, but it depends on your therapeutic lens (what modality, what conditions) to give more recommendations. Strategic family therapy books, for example, can get into a systems approach to the primary/secondary gain issues (such as Cloe Madanes).

Thanks a lot for the recommendations!

For anyone who’s interested in the topic, a review on functional neurologic symptom disorders just came out in AJP: https://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.2017.17040450

 

[FlowRate]

EM resident checking in. Any tips from our perspective? A recent podcast suggested IM zyprexa in the acute phase.

I would not recommend this a priori, not sure what the reasoning in the podcast was.

 

[clausewitz2]

I would not recommend this a priori, not sure what the reasoning in the podcast was.

I mean, it's an excellent way of enacting some pretty strong countertransference, so there's that.

 

[witzelsucht]

Pseudoseizures (PNES) - ercast.org

at 4:40

"i usually give haldol or olnazepine. ativan will make them tired, and it does work, but its off the mark. Binding gaba does not address the underlying issue. antagonizing dopamine and serotonin receptors is much more appropriate. its safer and more effective than benzos. last thing i want to do is convert a psychogenic seizure into a crashing airway."

not arguing one way or another, we still give IM ativan for PNES but it does make sense that a respiratory depressant is more dangerous than an antipsychotic, especially since you dont know if they have some benzos or alcohol on board

 

[nitemagi]

Pseudoseizures (PNES) - ercast.org

at 4:40

"i usually give haldol or olnazepine. ativan will make them tired, and it does work, but its off the mark. Binding gaba does not address the underlying issue. antagonizing dopamine and serotonin receptors is much more appropriate. its safer and more effective than benzos. last thing i want to do is convert a psychogenic seizure into a crashing airway."

not arguing one way or another, we still give IM ativan for PNES but it does make sense that a respiratory depressant is more dangerous than an antipsychotic, especially since you dont know if they have some benzos or alcohol on board

Historically sodium amytal was used to reverse conversion symptoms (though PNES can be as much factitious as anything). But keep in mind that medicating without treating the underlying causational issues has risks, too. There are case reports of suicide following this. Symptoms can be a coping strategy. Be mindful before just yanking it away and not at least getting them into a therapist.

 

[SmallBird]

antagonizing dopamine and serotonin receptors is much more appropriate.

The choice should be based on a clinical decision; receptor level analysis is not informative here (or almost anywhere...)

 

[FlowRate]

Pseudoseizures (PNES) - ercast.org

at 4:40

"i usually give haldol or olnazepine. ativan will make them tired, and it does work, but its off the mark. Binding gaba does not address the underlying issue. antagonizing dopamine and serotonin receptors is much more appropriate. its safer and more effective than benzos. last thing i want to do is convert a psychogenic seizure into a crashing airway."

not arguing one way or another, we still give IM ativan for PNES but it does make sense that a respiratory depressant is more dangerous than an antipsychotic, especially since you dont know if they have some benzos or alcohol on board

I would argue that no treatment is indicated if you're able to differentiate between PNES and convulsive status. The IM ativan treats the team's anxiety (the patient is having a seizure!) more than it treats the patient symptoms, although it may abort the not-epileptic-convulsions.

Saying that IM antipsychotics should be given presupposes that, indeed, you can differentiate PNES and convulsive status. In that case, antipsychotic medications will definitely have more potential for harm and longer-lasting effects than an appropriate (LOW) dose of a benzodiazepine.