Transcript Neuropsychology and PNES Robert W. Trobliger, Ph.D. Co-Director Neuropsychology Northeast Regional Epilepsy Group.

Neuropsychology and PNES
Robert W. Trobliger, Ph.D.
Co-Director Neuropsychology
Northeast Regional Epilepsy Group
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PNES:
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Psychogenic Non-epileptic Seizures
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paroxysmal behavioral events without
cerebrum-based electroencephalogram (EEG)
changes, associated with a psychological rather
than a physiological etiology.
Zaroff, Myers, Barr, Luciano, & Devinsky, 2004
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Possible causes:
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Acute anxiety/panic
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Impaired affect recognition/interpersonal skills
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Somatization/Conversion
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Depression
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PTSD
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Reinforced Behavior Patterns
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Diagnosis based on EEG findings – the gold
standard
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However, NP testing an important service,
aiding both diagnosis and treatment.
Neuropsychological Testing
What is it?
-Comprehensive testing of
-Cognitive functioning
-Psychological/Emotional functioning
Neuropsychological Testing
How?
-Cognitive
-Through a series of standardized tests assessing
-Attention
-Memory
-Language
-Visuospatial/Visuomotor Skills
-Executive Abilities
Neuropsychological Testing
How?
-Psychological/Emotional
-Through self-report questionnaires which assess:
-mood symptoms
-anxiety symptoms
-coping skills
-experienced cognitive difficulties
Neuropsychological Testing
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Why?
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NP testing used to confirm the diagnois.
Which is useful for the referring neurologist.
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Why?
NP Testing also used to further explore the
reasons behind the seizures.
Which is useful for both the client and the
therapist
The client to better understand what is going on.
The therapist to better understand how to address
it in working with the client.
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Why?
NP Testing is also important in demonstrating
that the diagnosis is being taking seriously.
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Because NP testing involves a great deal of
time.
How much time?
Typically 4 to 5 hours, at times more.
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And financial cost.
An investment of such time and cost then must be
worth it.
It is.
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This investment combined with a supportive
atmosphere sets up some hope regarding the
future, introducing the possiblity of
improvement.
Which is the reason why the client is sent for NP
testing – a step in getting help.
Neuropsychological Testing
-The Interview
-The Evaluation
-The Feedback
-The Report
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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 acclimiate
the client to an atmosphere of trust- critical in
therapy.
Comprehensive review of history –
developmental, medical, psychological,
educational, even vocational.
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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).
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The interview
An opportunity to explore psychological history,
including prior diagnoses and treatment.
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The interview
Particularly any history of abuse (physical
emotional or sexual) or trauma.
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The interview
Stressors may initially be downplayed or not
even mentioned during the interview
However, signs of such may come out in
completed quesitonnaires.
The Interview
Educational and employment history helps
determine prior levels of functioning for
comparison.
The Interview
-Because when patients talk about changes in
cognitive functioning, we need to determine
where they were before.
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The Evaluation
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NP Testing – Psychological
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Examining
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Mood (depression, anger, fear) symptoms
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Anxiety (including PTSD)
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Coping tendencies
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Ability to identify and articulate emotions
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NP Testing – Psychological
An examination of symptoms is important in
determing a diagnosis.
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.
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NP Testing – Psychological
More than just examining index findings – at
times looking at specific answers.
Which again is part of being comprehensive in
examining findings.
Questions of validity
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NP Testing Psychological
Underreporting may be helpful- indicating a lack
of awareness or denial, which can be further
explored in therapy.
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NP Testing – Psychological
Overreporting can be helpful – indiating a cry
for help. It is still worth looking at what types of
symptoms are endorsed.
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NP Testing – Psychological
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Involving emotions, determining how do I feel?
Not uncommon for those with a history of PNES to
have difficulty identifying and/or articulating their
emotions.
Which is important to address in therapy.
Because understanding how you feel is in
important step in understanding why you feel a
certain way.
Which in turn is related to understanding how to
cope with these emotions and related difficulties.
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NP Testing – psychological
Coping tendencies can be ineffective or
maladaptive.
Which can account at least in part for why these
seizures are occuring.
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The Evaluation
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NP Testing – Psychological
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Strategies can be
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practical
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expressive
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avoidant
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All are done by all of us.
However, for some, there is a need for help in
developing practical strategies for coping with
overwhelming stressors.
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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.
NP Testing – Psychological
Examing coping strategies is also helpful for any
therapist working with the person in determining
what strategies need practice.
NP Testing
The findings are useful not only at present but
also for the future.
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NP Testing Psychological
Can be particualry 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.
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NP Testing Psychological
But using pre and post testing measures is
another means of describing real change in the
person. Numbers and data can be helpful in
marking the changes.
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NP Testing Cognitive
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Why?
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NP Testing Cognitive
Reported difficulties typically involve problems
with attention and memory, similar to those with
epileptic seizures.
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NP Testing – Cognitive
Exploring these defictis helps underline the
seriousness of the condtion.
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NP Testing – Cognitive
Such testing results are also supportive to the
diagnosis – as deficits than cannot be
accounted for by underyling organic issues
(developmental history, prior TBI, ongoing
chronic medical issues such as migraines,
hypertension) can be attributed to PNES.
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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.
NP Testing – Cognitive
Results combined with the person's complaints
can be used to generate recommendations
Recommendations of real, practical strategies the
person can use from day one in working around
their difficulties.
The Feedback
An opportunity to go over the results of all the
above testing.
NP Testing – Cognitive
An opportunity to examine a person's strengths
and weaknesses.
NP Testing – Cognitive
An opportunity to examine any possible
discrepancies between performances on the
evaluation and the types of complaints the
person has.
NP Testing – Cognitive
As noted, an opportunity to discuss strategies for
dealing with any experienced difficulties.
NP Testing – Psychological
An opportunity to discuss how the diagnosis is
confirmed (or not).
NP Testing – Psychological
An opportunity to discuss the diagnosis (What
does this mean?)
And
The prognosis (what now?)
NP Testing – Psychological
An opportunity to discuss how the diagnosis was
determined – based on the findings.
An opportunity to discuss those findings in detail
NP Testing – Psychological
As noted
Signs of depression, anxiety (including PTSD),
conversion tendencies, anger issues, coping
problems, difficulty articulating feelings
The Report
Who is it for?
- The referring neurologist
- Any therapist working with the person
- The individual
Conclusion
Neuropsychological Testing
-Why?
Confirm diagnosis
Examine psychological/emotioning functioning
Examine coping strategies
Provide compensatory strategies
Provide information for therapist
A great of time on both parts which yields a great
deal of useful results.
Thank you.
[email protected]