So what I'm going to be talking about is the role of clinical psychology and the clinical psychologist in psychogenic non-epileptic seizures or PNES in general. A couple of disclosures here, which you can see on this slide, none of which has anything to do directly with any of the content or recommendations that I will be making during this presentation. So our learning objectives today are fairly straightforward. The first is to identify optimal roles or role of a psychologist within PNES assessment and treatment, and then to list at least three barriers to care access for patients with PNES and methods for possibly reducing barriers to care. So I wanted to start with a little bit of a story of where we started with our PNES treatment program at Parkland in Dallas, which is our county safety and at-hospital system, where we started, where we are now, and how we sort of developed a program to help patients who are falling in the gaps between their stay at the epilepsy monitoring unit and then getting into some sort of and then getting into some form of mental health care treatment in an outpatient setting. So you can see here on the left is Old Parkland Hospital. That's the famous ER there. I think a lot of people have seen in pictures. We have now moved into this wonderful new, much bigger, much needed facility on the right. So this started about 15 years ago, this story here about PNES. I was a new faculty member on the consult liaison psychiatry psychology service. And one of the areas of need that we had was trying to figure out how to appropriately address the needs of patients who had recently been diagnosed with PNES on our Parkland epilepsy monitoring unit. And how the system was sort of breaking down for these patients was that they would get diagnosed, they would get a really good gold standard workup with our epileptologist, but then we didn't really have a great place to send them. So the consult liaison service would be called usually after the person got the diagnosis when they were ready to discharge. And at that point, there wasn't a lot that we were able to assess or treat them for because they were about to leave the hospital. And this caused sort of repeated systemic issues. And I think that when we think about the role of a psychologist or psychiatrist in PNES, I think we really have to think about their ability to look at systems, to look at patient and provider behaviors, and to plan for programs that can really meet the mental health care needs of these patients. And so 15 years ago, it's very different than we are now. I would have to say, I think attitudes about PNES have really shifted across the board. But 15 years ago, we were really struggling here to come to agreement about how to educate, triage, and where to refer these patients. So after working on these two services in the hospital repeatedly, really getting to know this patient population and understanding the perspectives of the neurology team, what we opted to do was to create an embedded program within our existing Parkland Outpatient Behavioral Health Clinic, just for patients with PNES. And this was a really important opportunity for us to bring together different stakeholders, both inpatient and outpatient, to really get buy-in from clinic management at that clinic, to incorporate the wonderful skills of our licensed clinical social worker in that clinic, and then to also use it as a really good training opportunity for both our residents in the hospital on the EMU and our psychiatry residents who were working outpatient at the time. So this is what our program ended up looking like and where we are now. We require that before patients are referred to us, they have to undergo what's called a gold standard EMU workup. So we don't take referrals from patients who are diagnosed with, let's say, a two-hour bedside EEG. We don't take referrals from patients who get diagnosed maybe in the ER, an outpatient setting. We need them to go through the whole EMU workup to have a very definite diagnosis or as close as possible. This is really important because we need to know what we're working with. We need to know if the person potentially has a mixed epileptic, non-epileptic seizure presentation. We need to really rule out a whole lot of other things that can result in a misdiagnosis of PNES before we start to treat it as if it is a psychological concern. Then the patient is phone screened by our licensed clinical social worker who actually has a background working in our outpatient epilepsy clinic before she moved to psychiatry. And so that has been just a fantastic addition for our clinic. Then if the patient has not done a basic kind of diagnostic workup or intake with a psychiatrist or psychologist that really can be used, they go through that process with one of our residents or attendings in the clinic. Those residents and the attendings at this point have received repeated education about important components of a PNES diagnostic interview. And then they are referred for either two or four months, they can do up to four months of what's called the PNES skills group. So the PNES skills group meets once a week. It is now entirely virtual post-COVID, which has been great and I'll talk about that later. And that group really focuses on two different areas. One has to do with self-care, things like self-regulation, sleep hygiene, things like that. And the other month really has to do with cognitive behavioral therapy approaches to treating PNES. So they can complete that group for up to four months. It's called an open closed group, meaning we only allow new patients during the first week of the month. And then the rest of the month is closed off. So it's the kind of the same cohort who works together for that whole month. And then we allow new patients in the next month. And then they can be referred to our routine PNES support group, which is run by either our social worker or one of the residents. We also help them get into individual therapy depending on their needs. I will also talk about the very unique and different needs of patients with PNES. And they can also continue med management in our clinic at that point. Now, psychologists have always been relatively involved in the research and diagnosis and treatment of patients with PNES, either from a conversion disorder standpoint or somatic symptom disorder, functional neurological disorder. One of the ways psychology has tried to be involved in the past is trying to figure out whether some of our standardized testing can actually help us diagnose PNES kind of earlier and faster and cheaper, to be honest, than an EMU stay. And our research hasn't been very successful in that area. So we have personality tests like the MMPI, the PAI. Those results are pretty nonspecific for patients with PNES. They're not great diagnostic tools. Same with cognitive batteries, as well as more recent studies on using biomarkers. Those studies have been relatively inconclusive in helping to differentiate patients with PNES from those without. The thing that I really wanna emphasize to this group in particular is that sometimes we overly simplify our explanation for why a patient has developed PNES. I think this is a really useful area for mental health as well, is to help other disciplines understand this link, or sometimes lack thereof, between trauma and PNES. So often, I think we wanna give patients explanations and tell them why they're experiencing what they experience, and trauma can be a fairly straightforward way to potentially explain that to a patient. One issue, though, is that trauma is really a nonspecific risk factor for every psychiatric condition that we have. And so it's really hard to be able to say specifically, because you had this trauma, that's why you're having non-epileptic seizures. So I would really caution you about relying too much on that explanation, because it simply doesn't fit for some of our patients, and a lot of our patients. In clinic, this is what we start to see. So clinically, we see that there's a multifactorial explanation, like there is with many complicated disorders and presentations, that we see a combination of these things clinically. We see a combination of adverse childhood experiences and or trauma. We see things like poor emotional coping strategies, so difficulties naming and expressing emotional difficulties. And so it tends to sort of come out somatically. We see a host of very different psychiatric symptoms. Some patients have depression, some patients have severe anxiety, some have panic attacks, some have personality pathology, some have all the above. It's a very diverse group that make up the PNES population. We also see quite a high range of patients who have history of TBI or some other neurological event as well, including things like migraines. But it's even a little more complicated than this very linear pathway. Clinically, what it tends to look more like is this. PNES and adverse childhood experiences and or trauma sometimes happening after or before. The PNES, that leading to or reinforcing poor emotional coping strategies, causing an increase in psychiatric symptoms, the combination of potentially other neurological symptoms the person has or continues to have. So they really kind of feed off of each other. And this makes for a very complicated problem to try to study from a scientific perspective. So when we think about PNES and when I'm talking to groups about PNES and learning to think about and talk about PNES, what I want you to take away from this is that there's not a singular PNES presentation from a psychological perspective in terms of their psychological presentation, their symptoms, the course, their prognosis, or even their treatment. So when you see PNES, I want you to think of it as being a symptom of another underlying biopsychosocial problem. It's not this coherent, unified mental health diagnostic category. It's really the tip of the iceberg. When we think about barriers to care, we're trying to get people into mental health care for PNES and the underlying concerns that they have, we have to think about the barriers. Mental health stigma is a big one. When you try to explain that a person's very real, very interfering physical health symptoms may likely very well be caused by underlying mental health problems, this does not always go over well with people. We tend in the U.S. culturally to want to medicalize a lot of things that people are experiencing to give it some sense of legitimacy. And so it can be difficult for patients to accept that, and you see this in your clinics, I'm sure. It's also challenging because of that to get buy-in by the patient, by the family, and even other mental health and medical treatment providers. Some of those patients are caught between providers who say, no, I think you just need an additional X, Y, and Z workup. When their neurologist is pulling their hair out saying, we've done all of the things, and so the patient can get mixed messages. They also don't often have access to care. This is a very specific type of, I think, treatment and training background, and a lot of mental health care providers don't have it. Most in the general population, unless they've worked in neurology or worked in medicine, haven't even heard of this being referred to as PNES. So it really limits the number of providers, although that is something that is growing and changing, and makes me very happy. Transportation is a huge barrier because we put driving restrictions on people who are having these symptoms for good reason, but it really limits their ability to come into clinic. And then when we take away a diagnosis, it can lead to a loss of identity or a fear that a person may lose their disability. So what do we actually do about it? Well, one thing we can do in our own practices is to really promote the idea that mental health care is health care. We can also increase buy-in by providing education through the neurologist or epileptologist. We have data that really supports that this being provided by an existing care provider in neurology or epileptology really helps a patient buy-in to that diagnosis. Also access to care, identifying good partners in the community and holding onto those relationships as a neurology practice. And then in our case, telehealth has helped tremendously reduce this burden and safety issue related to transportation. We've had a lot of success with telehealth interventions and mental health in general. We can also educate people that they may no longer have an epilepsy diagnosis, but there are other conditions or concerns that they may actually qualify for disability for if they continue to have persisting severe mental health concerns. This is a really interesting article from 2020. I'm not gonna go into all of the details, but this is what we're shooting for over and over. How do we, if we're thinking about psychology and psychologists and mental health care, how do we try to push out systems, especially in academic medicine systems that really integrate neurology, mental health, primary care, and the patient and the family to improve outcomes for people with PNES? And that's where I really think that mental health care providers, mental health leadership can help look at these systems, augment behaviors, and help promote more optimal care. So when we think about overall impact on clinical care, just to summarize for y'all, remember that PNES symptoms represent heterogeneous psychiatric conditions. There's not a singular underlying psychiatric diagnosis that's propping up the PNES symptoms. It's often buried and very unique to the patient. It's also important that you continue to educate, educate, educate your patients about this condition and about the variety of things that may be underpinning it or perpetuating those symptoms. And also, like I've kind of talked about in our case, clinics can actually create a lot of care-filling gaps with very few resources. We can do a lot with things that are already in place to help create a little bit of space to catch these patients who may be falling in the cracks. Thank you so much for your time and attention, and I hope you have a good rest of the conference.

clinical psychology

PNES treatment

biopsychosocial issues

telehealth

cognitive behavioral therapy