Psychological intervention for non-epileptic attack disorder

Dr Katy Collinson

• Durham has a specialist service coming

• No specialist services commissioned for Newcastle, Northumberland or Tyneside

• Provision variable around the region in local mental health services

• IAPT are now being trained in working with medically unexplained symptoms, but not with complex trauma

• People with non-epileptic attacks / psychogenic non-epileptic seizures have a higher incidence of adverse childhood experiences than other conversion or somataform disorders

• Common comorbidities are PTSD, anxiety, dissociative disorders, depression, borderline personality disorder.

Challenges intrinsic to disorder for RCTs

• Emotional lability

• Approach-avoidant behaviour

• Presents in crisis but not to follow up

• Poor motivation – learned helplessness

• Driving restrictions

• Dependency on family

Systemic challenges for RCTs

• “Orphaned” by neurology and psychiatry• Heterogeneous presentation• No single etiological mechanism

• Variable outcome measures used

– Baslet 2012 Neuropsychiatric Disease and Treatment

• This is not voluntary fabrication!

• Non-empathic approach to patient will reinforce reluctance to accept diagnosis

• Although no neurobiologial evidence for NEAD established yet, brain basis is indicated for psychogenic tremor and paralysis (difference between feigned and psychogenic)

Traumatised patients:

• Poor history - they can’t remember, deferring to family members

• Poor attendance, missing appointments

• Owing to dissociation, seeking a physical solution to physical symptom

• Don’t dig for trauma history – they need to be safe and ready (and be in therapy)

Signs of trauma

• Intrusions – nightmares, flashbacks, recurring panic

• Avoidance – emotionally numb, isolated, poor memory, alcohol or drug use to cope

• Hyperarousal – anxious, agitated, restless

• Hypoarousal – physically numb, detached, unable to think or speak

How to explain this disorder

• Window of tolerance model was created by Daniel Siegel – Child Psychiatrist in LA

• Developed in trauma work by Pat Ogden and Peter Levine (see previous slides) who use body focussed psychotherapy

• Is relevant for understanding the emotional and physiological dysregulation in non-epileptic attack disorder

• Specialist therapists with experience in both neurological conditions (eg. neuropsychology) and trauma treatment are required

• Treatment duration can vary

• Outcomes are good: 63% cessation or significant reduction in seizures but more importantly the processing of trauma