Neuropsychology and PNES Robert W Trobliger Ph D

Neuropsychology and PNES Robert W. Trobliger, Ph. D. Director Clinical Neuropsychology Northeast Regional Epilepsy Group Neuropsychology and PNES

PNES: Psychogenic Non-epileptic Seizures paroxysmal behavioral events without cerebrum-based electroencephalogram (EEG) changes, associated with a psychological rather than a physiological etiology. Zaroff, Myers, Barr, Luciano, & Devinsky, 2004 Neuropsychology and PNES

PNES: Psychogenic Non-epileptic Seizures Still real Psychological causes compared to physical causes

Possible causes: Anxiety/panic Impaired affect recognition/interpersonal skills Somatization/Conversion Depression PTSD Reinforced Behavior Patterns Neuropsychology and PNES

Diagnosis based on EEG findings – the gold standard Neuropsychology and PNES

Neuropsychological Testing NP testing important, aiding both diagnosis and treatment. Neuropsychology and PNES

Neuropsychological Testing What is it? Comprehensive interview Comprehensive testing of § Cognitive functioning § Psychological/Emotional functioning Neuropsychology and PNES

Neuropsychological Testing How? For cognitive functioning, through a series of standardized tests assessing § § § Attention Memory Language Visuospatial/Visuomotor Skills Executive Abilities Neuropsychology and PNES

Neuropsychological Testing Cognitive tests involve comparisons of results to norms, which allow the examiner to determine if scores are at, above, or below expected levels given the person’s age and background.

Neuropsychological Testing How? For Psychological/Emotional functioning, through self-report and observer report questionnaires which assess: § § § mood symptoms anxiety symptoms other psychiatric symptoms including tendency for somatization coping skills experienced levels of cognitive difficulties Neuropsychology and PNES

Neuropsychological Testing Why? NP testing used to confirm the diagnosis. Neuropsychology and PNES

Neuropsychological Testing Which is useful for the referring neurologist. Neuropsychology and PNES

Neuropsychological Testing Why? NP Testing also used to further explore potential factors behind the seizures. Neuropsychology and PNES

Neuropsychological Testing Which is useful for both the client and any therapist who is or will be working with the person. Neuropsychology and PNES

Neuropsychological Testing The client § to better understand what is going on. Neuropsychology and PNES

Neuropsychological Testing The therapist § to better understand what is going on and § how to address it in working with the client. Neuropsychology and PNES

Neuropsychological Testing NP Testing is also important in demonstrating that the diagnosis is being taking seriously. Neuropsychology and PNES

Neuropsychological Testing Because NP testing involves a great deal of time. Neuropsychology and PNES

Neuropsychological Testing How much time? Neuropsychology and PNES

Neuropsychological Testing Typically 3 to 5 hours of testing, at times more. As well as more time for scoring, writing up findings, and reviewing findings with the patient and, possibly, their family. Neuropsychology and PNES

Neuropsychological Testing Because NP testing involves a great deal of time. And financial cost. Neuropsychology and PNES

Neuropsychological Testing An investment of such time and cost then must be worth it. Neuropsychology and PNES

Neuropsychological Testing It is. Neuropsychology and PNES

Neuropsychological Testing This investment combined with a supportive atmosphere sets up some hope regarding the future, introducing the possibility of improvement – that this is treatable. Neuropsychology and PNES

Neuropsychological Testing Which is the reason why the client is sent for NP testing – a step in getting help. Neuropsychology and PNES

Neuropsychological Testing § § The Interview The Evaluation The Feedback The Report Neuropsychology and PNES

Neuropsychological Testing The Interview A safe place, maybe one of the first opportunities to bring up prior stressors and trauma. Which indicates how important it is for the provider to make it a safe place, to acclimate the client to an atmosphere of trust - critical in therapy. Neuropsychology and PNES

Neuropsychological Testing The Interview Not the last opportunity – as it is not uncommon for patients who initially deny any difficulties, stressors, trauma, or abuse to bring such up at the time of feedback, at times believing that such was “not important. ”

Neuropsychological Testing The Interview Comprehensive review of history § § § Developmental Medical Psychological Cognitive Educational Vocational Neuropsychology and PNES

Neuropsychological Testing The Interview An opportunity to explore developmental and medical history – factors which might contribute to issues with cognitive functioning (which is assessed in NP testing). Neuropsychology and PNES

Neuropsychological Testing The interview An opportunity to explore psychological history, including prior diagnoses and treatment. Neuropsychology and PNES

Neuropsychological Testing The interview Particularly any history of abuse (physical emotional or sexual) or trauma. Neuropsychology and PNES

History of sexual abuse among children with PNES - 15 - 35% versus History of physical/sexual abuse among adults with PNES - 25 - 45%

Neuropsychological Testing The interview With children, the interview will include questions about potential stressors which may include: - a history of abuse - bullying - academic difficulties - family difficulties such as separation or divorce - legal difficulties Neuropsychology and PNES

For 93% of patients there was a significant life stressor Of those, 76% were determined to be chronic Sawchik & Buchhalter 2015

In most, the seizures did not immediately follow a specific psychosocial stressor but instead occurred months or years after sexual or physical abuse or against the backdrop of chronic family dysfunction Wyllie et al 1999

Neuropsychological Testing The interview At times parents will bring up these issues without the child in the room. Older children may address their psychiatric history on their own.

Neuropsychological Testing The interview Stressors may initially be downplayed or not even mentioned during the interview However, signs of such may come out in completed questionnaires. Neuropsychology and PNES

Neuropsychological Testing The Interview Educational and employment history helps determine prior levels of cognitive functioning for comparison. Neuropsychology and PNES

Neuropsychological Testing The Interview When patients talk about changes in cognitive functioning, we need to determine where they were before. Certain tests allow us to estimate premorbid levels of functioning when prior testing results are not available or when the patient simply has never had testing before. Neuropsychology and PNES

Neuropsychological Testing NP Testing – Psychological Questionnaires examining: Mood (depression, anger, fear) symptoms Anxiety (including PTSD) Other Psychiatric symptoms (bipolar, OCD, schizophrenia, somatization) Coping tendencies Ability to identify and articulate emotions Neuropsychology and PNES

Neuropsychological Testing NP Testing – Psychological Self-Report questionnaires Observer Report questionnaires

Neuropsychological Testing Similar to those with epilepsy, patients with PNES often have co-morbid psychiatric diagnoses including: § depression § anxiety Salpekar et al. , 2009 Sawchuk & Buchhalter 2015 Neuropsychology and PNES

Neuropsychological Testing No significant difference between PNES and epilepsy groups of children regarding psychopathology on the CBCL – but both had more than controls. Chinta et al, 2008 Neuropsychology and PNES

Neuropsychological Testing Other diagnoses with PNES § § Depression/Dysthymia Anxiety Behavioral problems ADHD Szabo et al 2012 Neuropsychology and PNES

Neuropsychological Testing § § § Bipolar disorder Separation anxiety Brief reactive psychosis Schizophreniform disorder Panic disorder Neuropsychology and PNES

Neuropsychological Testing § § § Post Traumatic Stress Disorder (PTSD) Overanxious disorder Adjustment disorder with mixed emotional features Oppositional Defiant Disorder Impulse control disorder Neuropsychology and PNES

Neuropsychological Testing § § Dependent traits Borderline personality disorder Mixed personality disorder Histrionic personality disorder Wyllie et al 1999 Reilly et al 2013 Neuropsychology and PNES

Neuropsychological Testing Somatization Salpekar et al (2009) findings Three instruments differentiated the PNES group from the epilepsy group: Neuropsychology and PNES

CSI (Childhood Somatization Inventory) - High score approximates diagnostic criteria for somatization disorder headaches, faintness/dizziness, weakness in part of the body, losing voice, trouble walking

FDI (Functional Disability Inventory) – greater difficulty getting and staying asleep, getting through the school day, and doing activities in gym class.

CBCL (Child Behavior Checklist) - Somatic problems subscale of CBCL significantly higher for PNES than ES CBCL: headaches, dizziness, nausea, vision issues, hearing issues, coordination problems

Children with PNES more aware of significantly more somatic symptoms than ES Parents of PNES reported significantly more somatic symptoms than parents with ES

Sawchuk & Buchhalter 2015 Commonly used child self-report measures of: depression anxiety behavioral/emotional symptoms did not differentiate between PNES and ES groups.

§ Which does not mean that self-report measures of mood anxiety symptoms are not useful

Neuropsychological Testing NP Testing – Psychological An examination of symptoms is important in determining a diagnosis. Neuropsychology and PNES

Neuropsychological Testing All of these questionnaires provide a lot of data, predominantly in the form of indices that demonstrate patterns – patterns which may be significant in that they are outside the norm and associated with certain diagnoses. Neuropsychology and PNES

Neuropsychological Testing NP Testing – Psychological More than just examining index findings – at times looking at specific answers. Neuropsychology and PNES

Neuropsychological Testing NP Testing – Psychological Specific items on questionnaires can provide information about thoughts and behaviors that the person may not identify as unusual or that the person may not feel comfortable discussing. Neuropsychology and PNES

Neuropsychological Testing NP Testing – Psychological Comprehensiveness in examining findings Neuropsychology and PNES

Neuropsychological Testing NP Testing – Psychological Questions of validity Neuropsychology and PNES

Neuropsychological Testing NP Testing Psychological Underreporting may indicate a lack of awareness or denial, which can be further explored in therapy. Neuropsychology and PNES

Neuropsychological Testing NP Testing – Psychological Over reporting may indicate a cry for help. It is still worth looking at what types of symptoms are endorsed. Neuropsychology and PNES

NP Testing – Psychological Focus on determining how well the person can describe and identify how they are feeling Neuropsychology and PNES

Not uncommon for those with a history of PNES to have difficulty identifying and/or articulating their emotions. Neuropsychology and PNES

Which is important to address in therapy. Neuropsychology and PNES

Because understanding how you feel is in important step in understanding why you feel a certain way. Neuropsychology and PNES

Neuropsychological Testing Which in turn is related to understanding how to cope with these emotions and related difficulties. Neuropsychology and PNES

Neuropsychological Testing NP Testing – psychological Coping tendencies can be ineffective or maladaptive. Neuropsychology and PNES

Neuropsychological Testing Which can account at least in part for why these seizures are occurring. Neuropsychology and PNES

Neuropsychological Testing NP Testing – Psychological Strategies can be practical expressive avoidant All are done by all of us. Neuropsychology and PNES

Neuropsychological Testing However, for some, there is a need for help in developing practical strategies for coping with overwhelming stressors. Neuropsychology and PNES

Neuropsychological Testing increased use of passive/avoidant coping strategies Sawchuk & Buchhalter 2015 Neuropsychology and PNES

Neuropsychological Testing NP Testing- Psychological This is an important part of testing – to identify how the person deals with stressors, as the person may not be completely aware of such. Questionnaire results can quantify a person’s tendencies. Neuropsychology and PNES

Neuropsychological Testing NP Testing – Psychological Examining coping strategies is also helpful for any therapist working with the person in determining what strategies need practice. Neuropsychology and PNES

Neuropsychological Testing The findings are useful not only at present but also for the future. Neuropsychology and PNES

Neuropsychological Testing NP Testing Psychological Results can be particularly important in setting up a baseline before treatment. Certainly a decrease or the absence of seizures as reported by the patient is an important barometer. Neuropsychology and PNES

Neuropsychological Testing NP Testing Psychological Using pre and post test measures is another means of describing real change in the person. Numbers and data can be helpful in marking the changes. Neuropsychology and PNES

Neuropsychological Testing NP Testing Psychological Results are also useful for research focusing on differentiating between patients with epileptic versus non-epileptic seizures as well as differentiating between age groups and genders, which in turn can guide treatment recommendations.

Neuropsychological Testing NP Testing Cognitive Why? Non-Epileptic Psychogenic Seizures Where is the cognitive part? Neuropsychology and PNES

Neuropsychological Testing NP Testing Cognitive Reported difficulties among patients typically involve problems with attention and memory, similar to those with epileptic seizures. Neuropsychology and PNES

Neuropsychological Testing NP Testing – Cognitive Co-Morbid Epilepsy and PNES

NP Testing – Cognitive Co-morbidity of epileptic and non-epileptic seizures Adults 10 -50% Children 19 -48% http: //www. psychiatrictimes. com/articles/comorbid-medical-illnesseschildren-psychogenic-nonepileptic-seizures Neuropsychology and PNES

Neuropsychological Testing NP Testing – Cognitive Exploring these deficits helps underline the seriousness of the condition. Neuropsychology and PNES

Neuropsychological Testing NP Testing – Cognitive Such testing results are also supportive to the diagnosis – as deficits than cannot be accounted for by underlying organic issues (developmental history, prior TBI, ongoing chronic medical issues such as migraines, hypertension) can be attributed to PNES. Neuropsychology and PNES

NP Testing – Cognitive Which gets back to the prior idea of hope. If the problems with attention and memory have no underlying organic causes, then changes in psychological functioning should result in changes in cognitive functioning. Neuropsychology and PNES

NP Testing – Cognitive Results combined with the person's complaints can be used to generate recommendations Neuropsychology and PNES

NP Testing – Cognitive Recommendations of real, practical strategies the person can use from day one in working around their difficulties. Neuropsychology and PNES

NP Testing – Cognitive Examples Using notebook/phone for reminders, with alarms Focusing on organization Managing distractions Self-care

NP Testing – Cognitive Results are also useful for research focused on differentiating between patients with epileptic versus non-epileptic seizures

The Feedback An opportunity to go over the results of all the above testing. Neuropsychology and PNES

Neuropsychological Testing The Feedback An opportunity to discuss how the diagnosis is confirmed (or not) or what questions may remain. Neuropsychology and PNES

Neuropsychological Testing The Feedback Sometimes results only partially support a PNES diagnosis or do not support it at all.

Neuropsychological Testing The Feedback An opportunity to discuss the diagnosis (What does this mean? ) And The prognosis (what now? ) Neuropsychology and PNES

Neuropsychological Testing The Feedback An opportunity to discuss how the diagnosis was determined – based on the findings. An opportunity to discuss those findings in detail Neuropsychology and PNES

The Feedback An opportunity to examine a person's strengths and weaknesses, cognitively. Neuropsychology and PNES

The Feedback An opportunity to examine any possible discrepancies between performances on the evaluation and the types of complaints the person has. Neuropsychology and PNES

The Feedback For instance, findings of no difficulties in the areas of attention and memory on tests do not necessarily mean the person is not experiencing problems in daily life.

The Feedback Such findings do raise concerns regarding psychological factors behind the person’s experienced problems.

Neuropsychological Testing The Feedback As noted, signs of depression, anxiety (including PTSD), conversion tendencies, anger issues, coping problems Neuropsychology and PNES

Neuropsychological Testing The Feedback As noted, an opportunity to discuss strategies for dealing with any experienced difficulties. Neuropsychology and PNES

The Feedback Referral for therapy focused on: - Understanding the relationship between psychological stressors and physical symptoms - Developing coping strategies

Neuropsychological Testing The Report Neuropsychology and PNES

Neuropsychological Testing The Report Who is it for? § The referring neurologist § Any therapist working with the person § The individual Neuropsychology and PNES