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
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