Abstract
Functional neurological disorder (FND) symptoms resemble neurological symptoms but are unexplained by disease or injury to the body. Psychological trauma and posttraumatic stress disorder (PTSD) are prevalent among patients with FND. This is a case report of a 64-year-old female who began treatment 2 years after developing PTSD, generalised anxiety disorder, major depressive disorder and agoraphobia following a physical assault. She subsequently developed FND approximately 18 months later. Her FND symptomology was characterised by aphasia and paraplegia. These symptoms usually lasted for a period of hours to days and usually occurred on a weekly basis. She had not previously engaged in psychological therapy due to limited insight into the relationship between her psychological and physiological symptomology. She was treated with Prolonged Exposure for PTSD (PE), and by the last session, she no longer met the diagnostic criteria for either FND or PTSD disorder. PE successfully treated both PTSD and FND. Theoretical understandings of the mechanisms underpinning this improvement are discussed.
Keywords
1 Theoretical and Research Basis for Treatment
Functional neurological disorder (FND), also referred to as conversion disorder, refers to neurological symptoms, such as psychogenic non-epileptic seizures (PNES), gait and sensory disturbances, psychogenic pain and globus pharyngeus – the sensation of having a lump or something stuck in the throat unexplained by the presence of disease of injury to the body (Cope et al., 2018). FND is referred to as functional neurological symptom disorder in the DSM-5 (American Psychiatric Association, 2013).
Previous trauma is an important predisposing factor in modern accounts of FND (Brown & Reuber, 2016), and ongoing debate exists with whether the failure of some patients to remember experiencing relevant distressing experiences means they did not occur, that they are reluctant or incapable of recalling them or that the methods used to assess this information are insufficient (Reuber, 2018). Similarly, FND symptoms have been hypothesised to be a form of ‘somatic dissociation’, with Fiszman et al. (2004) positing that FND may actually be a clinical expression of the dissociative subtype of PTSD. The aforementioned hypotheses are supported by Gray et al. (2020) who found that of 430 consecutive FND patients referred to a specialist psychology clinic (56% with PNES; 44% with other FND), 60.7% likely had a clinical diagnosis of PTSD, with no difference between PNES and FND. Similarly, Gupta (2013) hypothesised FND to being a dissociation to extreme arousal in PTSD through the hyper-inhibition of the limbic regions, necessary for emotion processing and regulation (Lanius et al., 2005). Therefore, it is not surprising that proposed treatments for FND involve modification of pathological appraisal and arousal components.
Treatment of Functional Neurological Disorders
Although there is no single model of CBT for patients with FND, the two approaches described in most detail in the literature are LaFrance et al.’s (LaFrance et al., 2014) and the approach in Goldstein et al.’s (2015, 2020) Cognitive Behaviour Therapy for adults with dissociative seizures (CODES) study. LaFrance et al.’s (2014) CBT-informed psychotherapy (CBT-ip) is based on an epilepsy therapy workbook that targets mood-cognition-environment connections, relaxation techniques, healthy communication and identification of internal and external triggers (LaFrance et al., 2014). Goldstein et al. (2004) conceptualise FND as symptoms that stem from fear avoidance, although awareness of fear may not be present (i.e. ‘panic without panic’). An initial physiological antecedent precipitates a cycle where cognitive and attributional factors drive experiential avoidance. FND is maintained by a combination of behavioural, cognitive, affective, physiological and social factors. The model is based on Lang’s (1968) escape-avoidance model which formulates FND as dissociative responses to triggers (cognitive; emotional; physiological or environmental) that may have been associated in some cases with traumatic events, such as abuse or trauma during childhood, or following emotions such as panic and which have previously produced unbearable distressing emotions (Goldstein et al., 2010). However, given the robust link between FND and unprocessed traumatic experiences, it may be that trauma-focused treatments are indicated as a primary or adjunct treatment to target the underlying unprocessed traumatic experiences perpetuating affective dysregulation.
Prolonged Exposure (PE) therapy is a frontline, trauma-focused treatment of PTSD (Powers et al., 2010). PE is indicated in treating PTSD symptoms in patients with various co-morbidities including dissociation (Rothbaum et al., 2005) and anger (Cahill et al., 2003).
Prolonged Exposure (PE) consists of two fundamental mechanisms: (1) repeated exposure (imaginal exposure) to the trauma memory (index memory) in session to promote processing of upsetting life experiences and (2) repeated, real-life approach of situations or activities (in vivo exposure) that are avoided because of their relationship to the trauma or emotions appraised as dangerous or intolerable, but that are objectively safe. The first three sessions focus on psycho-education about the treatment, common reactions to traumatic experiences and breathing retraining. Due to the focus on the repeated, prolonged, confronting of avoided distressing emotions (including bodily sensations), the patient is afforded the opportunity to learn that emotive bodily signals are not inherently dangerous and will not signal a loss of control or competence. The new re-appraisal of bodily sensations may not only occur via the process of habituation within and between exposure trials, however, may come from a sense of agency in engaging in such challenging exposures while not losing functioning or experiencing a deterioration in physical health (e.g. see Paulus & Stein, 2006).
To our knowledge, no randomised controlled research has been published for PE in patients with PTSD and co-morbid FND. However, there is some published evidence of PE being used to treat PTSD and co-morbid FND including globus pharyngeus (Neer et al., 2016), psycho and psychogenic non-epileptic seizures (Myers et al., 2021; Myers & Zandberg, 2018). A further case series with 16 patients diagnosed with both psychogenic non-epileptic seizures and PTSD showed the efficacy of PE for patients with this co-morbidity (Myers et al., 2017). Due to shared underlying mechanisms with these functional disorders, we anticipated that Prolonged Exposure would be just as efficacious for the following case study.
Functional Neurological Disorders and Alexithymia
Interestingly, FND (Williams et al., 2018) as well as PTSD (Frewen et al., 2008) are both associated with higher levels of alexithymia. Alexithymia is a sub-clinical, dimensional construct most commonly defined by (1) a difficulty in identifying feelings; (2) a difficulty in describing feelings to other people and (3) Externally Orientated Thinking (Bagby & Taylor, 1997). A hyper-inhibition of limbic regions necessary for emotion processing is also observed among those with alexithymia (Putica et al., 2021). Further, those with alexithymia exhibit hypersensitivity to interoceptive sensations (processing of internal bodily stimuli; Craig, 2015), that is, exhibit high interoceptive sensibility (Longarzo et al., 2015). Therefore, it could be that a mechanism of FND presentations may be an inability to adaptively tend to emotive and non-emotive bodily signals. Specifically, those high in alexithymia may interpret normative bodily changes as catastrophic or detach (via a process of anticipatory suppression) from autonomic physiological arousal which may impair habituation to emotive stimuli (see Panayiotou & Constantinou, 2017) – perpetuating a maladaptive interoceptive processing. Therefore, it is not surprising that emerging treatment protocols for FND involve arousal regulation and processing of internal triggers (i.e. interoceptive changes) However, to our knowledge, no work to date has explored whether established treatment protocols also lead to improved emotion regulation in FND and therefore whether adjunct treatments for these mechanisms are indicated.
The present case study is novel as it also examines the role or (1) alexithymia, (2) interoception and (3) emotion regulation in FND presentations and treatment-response. Specifically, we are interested in assessing whether PE for FND also leads to (1) a reduction in alexithymia; (2) improved awareness and tolerance of non-emotive bodily stimuli and (3) improved emotion regulation ability.
2 Case Introduction
The following de-identified case example presents a patient treated by the first author (a licenced clinical psychologist) at a university-based posttraumatic research clinic. Modifications of specific case details were made to protect patient confidentiality. At treatment initiation, Mary was a 64-year-old Caucasian married female, retired school teacher. She managed a fledgling after-school tutoring business with her husband, which was on hold due to mandatory COVID-19 lockdown orders.
3 Presenting Complaints
At the time of referral, Mary reported experiencing ongoing ruminations and re-experiencing of physical assault she endured at her home two years ago (index event), generalised difficulty when coping with stress and psychogenic aphasia and paraplegia. The perpetrator of the assault was her youngest daughter’s partner at the time, who she suspects was physically violent towards her daughter and trying to isolate her from the family. On the day of the incident, he trespassed in to Mary’s home, while she was there alone, to take her daughter’s possessions to move her into his home. Fearing her daughter would be in greater danger and isolated further, Mary attempted to intercept him. He threw Mary on the bed, while threatening ‘I can do anything I want to you…’ while holding her wrists above her head. This reminded Mary of a rape she experienced at a party in her mid-20s, where the assailant also held her hands above her head. Mary was able to break free from the perpetrator of the most recent assault (index assault) after she bit his forearm. The perpetrator then proceeded to chase Mary and physically assault her repeatedly while her daughter silently watched. Mary reported both the rape and physical assault to the police immediately after each respective event. She reported that in both instances, the police were dismissive and blaming of her parts in the event, even threatening to charge her for biting the perpetrator.
Mary reported the presence of PTSD symptoms ‘almost immediately’ post the index assault and continuing through to her referral to treatment. Mary’s current FND symptomology commenced when Mary was on the phone to a government department to dispute a taxation ruling regarding her income. She stated that when the male operator on the phone began to curtly ask her for supporting evidence of her claims, she reported having flashbacks of the physical assault, loss of speech and terminating the call. She reported that the FND symptomology has been persistent since the call, 6 months ago.
4 History
Mary reported a close relationship with her husband and eldest daughter. She cites a turbulent relationship with her youngest ‘problem’ daughter who she describes as ‘emotionally unstable’, ‘directionless’ and ‘pre-occupied with chasing toxic men’. Mary grew up in a major metropolitan city, the second youngest in a sibship of five. Her father was a plant-worker, and her mother was a homemaker. She reported that while her parents did not have formal psychiatric diagnoses, her parents would have both most likely have suffered from intermittent ‘nervous breakdowns’ – characterised by increased punitiveness, rigidity and emotional aloofness. She reported that on the whole, productivity and social graces were preferred over emotional nurturance. She reported that she and her siblings generally accommodated and conformed to their parents’ rigid and authoritarian parenting style. Mary reported generally being appreciative of her parents’ ability to provide for the family and afford her the opportunity and encouragement to pursue a tertiary education at a female-only teachers college.
5 Assessment
Mini-International Neuropsychiatric Interview (MINI)
Pre- and post-treatment evaluation outcome variable scores.
RCI = Reliable Change Index. * denotes significant change, i.e. RCI ≥ 1.9.
Clinician Administered PTSD Scale (CAPS-V; Weathers et al., 2018)
The CAPS (Weathers et al., 2018) is the gold standard in PTSD assessment. The CAPS-5 is a 30-item structured interview that was used to confirm a PTSD diagnosis and assess PTSD symptom severity. The CAPS was administered by a trained research assistant at the pre-treatment and post-treatment (scores presented in Table 1). The CAPS has demonstrated good interrater reliability (ICC = .91) and convergent validity (r = .83) in diagnosing the present and severity of PTSD (Weathers et al., 2018).
Toronto Alexithymia Scale (TAS-20; Bagby et al., 1994)
The TAS-20 (Bagby et al., 1994) was used to measure the presence and severity of alexithymia in clinical settings. The TAS-20 20 item self-report scale where patients rate their responses using a 5-point Likert scale (1 = strongly disagree and 5 = strongly agree). There are five items that are reverse scored (items 4, 5, 10, 18 and 19). The TAS-20 contains three subscales: Difficulties Identifying Feelings (DIF), Difficulties Describing Feelings (DDF) and Externally Orientated Thinking (EOT). The total alexithymia score is the sum of all 20 items, while the score for each subscale factor is the sum of the responses to that subscale. The TAS-20 was administered as part of the standard self-report booklets in the research clinic at pre-treatment and post-treatment (scores presented in Table 1). The TAS-20 has demonstrated good validity and test-retest reliability (alpha = .77) (Bagby et al., 1994).
Body Awareness Questionnaire (BAQ; Shields et al., 1989)
The BAQ (Shields et al., 1989) is an 18-item scale designed to assess self-reported attentiveness to normal non-emotive body processes, the ability to detect changes in bodily signals and the ability to predict bodily signals. The scale was used to measure interoceptive efficacy with higher scores indicating greater efficacy. Each item is rated on a seven-point Likert scale (1 = not at all true about me and 7 = very true about me). The BAQ was administered as part of the standard self-report booklets in the research clinic at pre-treatment and post-treatment (scores presented in Table 1). The scale has a good demonstrated test-retest reliability (r = .80), along with good convergent and discriminant validity (Shields et al. 1989) and has been validated in clinical settings.
Difficulties in Emotion Regulation – Short Form (DERS-SF; Kaufman et al., 2016)
The DERS-SF (Kaufman et al., 2016) is used to measure emotional regulation difficulties in clinical settings. The DERS-SF is an 18-item, self-report scale, rated on a five-point Likert scale (1 = almost never and 5 = almost always). The DERS-SF consists of six subscales: strategies, non-acceptance, impulse, goals, awareness and clarity. All items on the awareness scale are reverse scored. The score for each subscale factor is the sum of the responses to that subscale. The DERS-SF was administered as part of the standard self-report booklets in the research clinic at pre-treatment and post-treatment (scores presented in Table 1). A good internal consistency (alpha = .91), internal consistency reliability (alpha = .91) and concurrent validity with the long form measure (alpha = .87) have been reported for the DERS-SF (Victor & Klonsky, 2016).
Changes in Functioning from Pre- to Post-Treatment
Overall, Mary reported an improvement in her functional neurological symptomology. At pre-treatment, she reported these symptoms being present for hours to days and occurring on a weekly basis. At the conclusion of treatment, Mary reported that she had not experienced any such symptomology after the off protocol session prior to the seventh session of PE. The reported change in functional symptomology may have occurred as a result of Mary challenging her appraisals of her inability to cope and function during periods of increased distress. The work in approaching distress Mary had completed in the preceding PE sessions most likely acted as reinforcement and evidence of Mary’s capacity to cope and resolve stressors when she approaches, rather than avoids them – therefore undermining the perpetuants of her functional symptomology.
Potential significance of changes on self-report measures from pre- to post-PE completion was assessed with the Reliable Change Index (Jacobson & Truax, 1991). Mary reported a significant reduction in PTSD symptomology with her CAPS scores no longer being indicative of a PTSD diagnosis from pre- to post-treatment. Furthermore, Mary ceased to meet diagnostic criteria for all of her pre-treatment diagnoses including MDD, GAD and agoraphobia. Mary’s score on the TAS decreased significantly from pre- to post-treatment suggested that she was no longer experiencing alexithymia, with her biggest reduction being on the Externally Orientated Thinking subscale. The significant reduction in TAS score suggests that Mary was experiencing secondary alexithymia – a defence against negative affect secondary to psychological distress/pathology. Mary’s score on the BAQ also significantly reduced by 35 points – suggesting that her pre-occupation with normal, non-emotive, bodily sensations had decreased. The contrasting results between the EOT (pre-occupation with concrete external events over feelings, fantasies and other emotive inner experiences) scale and BAQ (attention to non-emotive bodily processes) measure is of particular interest as it suggests that while her pre-occupation with normal bodily processes reduced, her attention to emotive bodily signals increased, potentially increasing differentiation of interoceptive signalling. Anecdotally, this hypothesis was confirmed by Mary ‘I can identify what is a normal bodily signal and when my body is trying to give me a message via emotion – I’m able to lean into this without feeling like I am going to lose control of myself for days’. Mary did demonstrate improvements in overall emotion regulation abilities from pre- to post-treatment, however, her results did not reach threshold for significant clinical change. Her largest improvement was on the impulsivity subscale indicating that she had some reduction in impulsive behaviours when experiencing negative affect. The lack of significant pre- and post-changes in emotion regulation abilities may be due to Mary’s scores on the measure (including all subscales) being an average of two standard deviations below scores observed – among 427 adults presenting to an outpatient clinic diagnosed with at least one DSM-5 disorder (Hallion et al., 2018). However, her scores on the DERS-SF were also higher of an adult healthy normative sample. Another potential reason that may explain a lack of reported improvement in emotion regulation, maybe that this is not a mechanism of change in PE. As the primary treatment mechanism in PE is fear extinction learning (Graham et al., 2014), any emotion regulation intervention targets may benefit from adjunct treatments specifically targeting these mechanisms (e.g. STAIR; Cloitre & Schmidt, 2015). Given that Mary no longer endorsed criterion for pre-treatment co-morbid psychopathology, at post-treatment, emotion regulation treatment was not introduced as an adjunct treatment. However, we appreciate that this may leave Mary at risk of future psychopathology.
Overall, Mary’s assessment profile suggests that she has a strong aversion/impulsive avoidance to anticipated or experienced negative affect, as evidenced by her high TAS-20 score. However, as her PTSD severity reduced, so did her alexithymia score – suggesting her alexithymia presentation served as avoidance of affect/including bodily signals. Our post-treatment findings suggest that the course of PE was effective in treating Mary’s PTSD and induced FND, perhaps via an affective approach (overcoming affective avoidance) and fear extinction learning. However, the course of PE did not appear to improve Mary’s overall emotion regulation ability. Given the role of emotion regulation as a transdiagnostic vulnerability to psychopathology, this may be an important target of future intervention – perhaps as an adjunct to PE.
6 Case Conceptualisation
Mary’s primary presenting problem was characterised by the following: 1. Generalised low mood, appearing akin to a dysthymic disorder. 2. Intrusive memories regarding a physical assault by her youngest daughter’s ex-partner problematic stimulus-stimulus elements in fear structure. 3. Lack of efficacy/control in ability to keep herself and her family safe (problematic secondary appraisals of self, others and world). 4. Psychogenic aphasia and paraplegia when liaising with government departments or institutions of authority (problematic stimulus-response elements in fear structure).
Mary’s presentation may be predisposed by a genetic predisposition to psychopathology; untreated dysthymia; heightened trauma-load due to an unprocessed sexual assault and a rigid, authoritarian parenting style of family of origin where emotions and emotional processing where discouraged (emotions = undesirable/dangerous). Her current presentation appeared to be precipitated by a physical assault which had similar physical and psychological characteristics of the rape she suffered in her 20s. Her current presentation appears to be perpetuated by the following: 1. Avoidance of any situation in which she has little perceived control or where she may or does become overwhelmed (by re-experiencing symptoms; emotional appraisals and/or psychophysiological arousal), therefore inhibiting the opportunity for any contradictory information challenging her fear of distress or emotion and reinforcing pathological fear memory structures, for example, arousal = danger (erroneous associations of safe stimuli with threat meaning). 2. A mistrust and expectation that institutions and personnel in authority will not be able to keep her and/or her family safe and may even be punitive-dangerous, perpetuating evaluations associated with maladaptive fear memory structures: ‘others cannot be trusted to keep me safe’. 3. Generalised low sense of self-efficacy in ability to keep self-and/or others safe, only culminated by the unfolding uncertainty regarding the COVID-19 pandemic (perpetuating secondary evaluations linked to maladaptive fear structures and inhibiting opportunity to challenge this structure, therefore reinforcing the very structure perpetuating her symptomology). 4. Limited emotional literacy and differentiation (top-down emotion processing difficulties), inhibiting the opportunity for any contradictory information challenging her fear of acute emotional experience and reinforcing pathological fear memory structures, for example, arousal = danger (erroneous associations of safe stimuli with threat meaning) or emotion = inability to cope. 5. Atypical interoception (heightened anxiety sensitivity/interoceptive sensibility bottom-up emotion processing difficulties), inhibiting the opportunity for any contradictory information challenging her fear of distress or emotion and reinforcing pathological fear memory structures, for example, arousal = danger/illness (erroneous associations of safe stimuli with threat meaning).
Mary did appear to have a number of protective factors which improve her prognosis in completing and benefiting from exposure-based treatments. She presented as intelligent, accepting that her overall symptomology may be due to psychological aetiology, help seeking and motivated to engage in treatment.
7 Course of Treatment and Assessment of Progress
Below, we outline Mary’s course of treatment. A summary of her PCL-5 scores from each session are presented in Figure 1. Analysing the PCL data across treatment phases at sessions 1–3 (psycho-education), Mary’s scores were consistently in the 45–50 range. Once imaginal exposure (sessions 3–6) was introduced, Mary demonstrated a downward trend in her scores (45–20), indicating appropriate habituation. Mary’s PCL scores again increased once hotspot exposures were introduced (20–50). Mary’s PCL scores peaked at 50 between session 7 and 8 when Mary experienced a crisis/missed session. However, through persistence and engagement through this distress, Mary reported a downward trend in her PCL scores. Interestingly, her FND symptomology followed similar trends (see Figure 2). At post-treatment, Mary did not endorse PTSD criteria. Her only residual difficulties were detachment/estrangement from others, startle response and sleep difficulty. PCL scores between sessions. Course of FND symptomology during treatment.
Although PE was the primary treatment modality utilised in Mary’s care, she was also encouraged to keep a functional log including antecedent, response and consequences of FND symptoms (as recommended by Myers et al., 2017; 2021). Mary’s compliance with this log was inconsistent – however, the purpose of such was to encourage reflection on the association between her FND and emotional distress. Mary was encouraged to report FND symptomology retrospectively if she did not complete such logs. Further, a summary of Mary’s reported FND symptoms (aphasia and paraplegia) are presented in Figure 2. Mary did not endorse any such symptomology following session seven of PE.
Pre-PE Assessment/Orientation Session
During the first clinical session, Mary was socialised to the teleconferencing software client, and a risk management plan was also drafted to manage situations if connection is lost during treatment. Following this, a comprehensive clinical psychiatric assessment was completed.
PE Session 1
Session was conducted as per PE protocol and consisted of (1) psycho-education of nature and perpetuants of PTSD and how PE addresses these, (2) structured trauma interview and (3) breathing retraining.
PE Session 2
Session was conducted as per PE protocol and consisted of (1) psycho-education regarding common reactions to trauma and PTSD including functional neurological symptoms (aphasia and paraplegia) were discussed in greater depth, (2) introduction of in vivo exposures, (3) composition of her in vivo hierarchy with most of the tasks comprised of graded, behaviour activation/mastery tasks while she was experiencing undesired or intense emotion and (4) two in vivo tasks were assigned as homework for this and each subsequent PE session.
PE Session 3
Session was conducted as per PE protocol and consisted of (1) review of homework – she had attempted but not persisted with the tasks, citing days of not being able to speak or leave her bed room due to a loss of sensation in her legs. All attempts to engage in homework were reinforced, and exploration of how she can re-engage by chunking tasks down when she experiences these symptoms was discussed. (2) Rationale for imaginal exposure was introduced. (3) Mary engaged in imaginal exposure – Mary’s speech became slurred at times throughout the re-tellings, particularly around potential hotspots, she completed the imaginal exposure from the beginning to end for 40 minutes, completing two re-tellings. The therapist allowed Mary to take her time and reinforced any and continued engagement with the exposure trials. At the beginning of the exercise, she reported her SUDs were at 80 with peak SUDs of 100 (see Figure 3 for a summary of May’s SUDs across sessions 3, 4, 8 and 10). Two potential hotspots emerged (i) when she was pinned to the bed by her hands above her head and (ii) when she was being beaten repeatedly while her daughter watched on and did not intervene. (4) Homework was set; along with the in vivo exposures, Mary was instructed to listen to the taped imaginal exposures from each subsequent session. SUDs during imaginal exposures.
PE Session 4
Session was conducted as per PE protocol: (1) Review of homework, (2) imaginal exposures, (3) emotion processing of imaginal exposure and (4) homework setting.
Missed Session One
Mary did not present for her scheduled session. When the therapist phoned Mary to follow-up, she stated that she was running 60 minutes late doing her groceries. The therapist explained that she had another appointment scheduled at this time – and postponed the session to her usual time the following week.
PE Session 5
Prior to the commencement of session, the therapist took time to discuss Mary’s non-attendance the previous week. Mary stated that she knew her session was scheduled at this time but tried to do something productive prior to the distress and fatigue she would feel post-session. The therapist queried whether doing an activity which has historically been stressful, due to increased physiological arousal (being in crowds) and distress associated with this high arousal was indicated immediately prior to a scheduled session. The therapist feedback that this may have (1) increased fatigue; (2) artificially increased her SUDS – limiting information regarding habituation, and therefore potentially perpetuating hopelessness regarding her response to treatment and (3) perpetuate the belief that her somatic complaints are independent of her mental state. The therapist asked Mary to hold these hypotheses and reflect on her reasons for doing the shopping at this time, particularly if this was a form of avoidance. Mary responded well to this.
Mary completed session five of Prolonged Exposure as per protocol. During this session, Mary began to focus on her hotspots during the imaginal exposure. She identified three potential hotspots: (1) Where she is lying on her back on the bed and the perpetrator in kneeling on top of her and has her arms pinned above her head; (2) when she grabs a shovel and threatens the perpetrator’s life and (3) when the perpetrator is using a blunt instrument to repeatedly hit Mary across the torso. During this session, we focused on the first hotspot. Mary reported initial difficulty in engaging with the hotspots and she skimmed over the connection (hands above the head) between the two thematically linked traumatic events she experienced. She reported being acutely aware of feeling helpless without a point of relative safety. She completed three re-tellings of the hotspot and her SUDS were as follows: (1) 35–80; (2) 10–85 and (3) 30–50. In the processing phase of the session, we explored the theme of helplessness (vs. what she actively did and didn’t do to keep herself safe) across the two traumatic events she experienced whilst reinforcing her ability to engage in such difficult exposures, as a means of strengthening her general sense of efficacy.
PE Session 6
Session was conducted as per PE protocol: (1) Review of homework – Mary reported that while re-listening to the recording of the imaginal exposure from session five she felt detached from herself and her memory. While she was not able to identify why she felt disconnected, she did identify that she was not engaged with the re-listening. However, Mary reported more intrusive symptomology over the course of the week as a result of trying to engage with the memory. We discussed the hypothesis that this may have occurred due to Mary believing that re-listening to the recording of the hotspot would have been dangerous and her experienced dis-engagement/detachment was a result of avoidance/suppression of any emotional reactivity to the re-listening.
During the session, we again focused on hotspot (1) and completed three re-tellings of the event – Mary reported her SUDS to be slightly less than the previous week: (1) 35–75; (2) 10–70 and (3) 30–40 which may be due to habituation, however, more likely to be a result of fatigue. During the exposure, Mary realised that she was fearful during the assault that she would be raped in front of her daughter, as a means of the perpetrator signalling to the daughter – ‘look what I can do to your mother… imagine what I can do to you’… she stated that it was at this point she no longer felt helpless during the event – but rather started looking at weaknesses in her attacker to keep herself and her daughter safe. She identified that it was her role as a mother in this moment that activated her to action.
Missed Session Two
Mary logged on to the session approximately 30 minutes late and without a web-cam (a condition of engaging with the treatment). Voices, background noise was prominent during the connection. Mary stated her youngest daughter has experienced another relationship breakdown and has suddenly returned home. Mary reported that this has been disruptive as her daughter has taken up the room in which she did therapy and was presenting in ‘emotional crisis’ which Mary and her husband were needing to tend to. Continued encouraged engagement in all homework tasks until their session the following week.
Correspondence from Mary between sessions
The day prior to our next scheduled session, the therapist received correspondence from Mary stating that that since the last session, up until a day prior to her next session, she was experiencing acute pain, dis-connection from others, global SUDS of 95, insomnia, exhaustion, dysthymia, loss of speech, uncontrollable crying and not being able to engage in activities of daily living. Mary stated that she attributed these experiences to a ‘massive, undesirable side effect to the last session’. The therapist hypothesised that the deterioration in Mary’s mental state was precipitated by her daughter moving back into the home as it increased Mary’s (unwanted experiences) frustration regarding her daughter’s ongoing need for care and constant re-triggering of the fear memory structure as the daughter was involved in the index event. Therefore, it is not the session which had an undesirable effect on her experience, but rather it was the nature that she was experiencing emotion which was unsettling for Mary.
Off Protocol Session
Mary experienced a week of severe and acute distress over the course of the previous week. She appeared quite blunted and softly spoken during the session. Her reported PCL-5 score was 52. Mary reported extreme anxiety that she has had a detrimental side effect to treatment, and she will not be able to cope or function for months as a result. The therapist validated appraisal in the context of the severity of the distress, however gently reminded Mary that this was to be expected when someone starts to approach things they have been understandably avoiding thinking about/remembering and also was dealing with additional stressors (COVID lockdown and having her youngest daughter who was involved in the index trauma move back into home mid treatment). The therapist reminded Mary that she would not have her do anything dangerous, and she is a health professional with a duty of care to Mary. She also highlighted the hard work Mary had already engaged in, and that terminating treatment now would be heartbreaking to see as she would be worried that Mary would be stuck here – at the point of most severity – not affording herself the opportunity to see benefit from her hard work. Mary responded well to this – and stated that she was keen to continue with the treatment. Mary stated that she was not ready to re-engage with the re-listening of her last imaginal exposure. The therapist and Mary collaboratively discussed in vivo exposure behaviour activation activities to reinforce her sense of mastery, efficacy, coping and functioning – countering her appraisals that she will not be able to cope or continue with treatment.
The therapist asked Mary how she was feeling about her daughter moving back into the home. Although Mary exhibited frustration and displeasure that her daughter had moved back into the home, she replied to the questioning in pragmatics and fact. The therapist provided feedback regarding this to Mary, who appeared surprised and this became a therapeutic opportunity to explore Mary’s relationship to emotions. She identified that she engages in suppression and avoidance of unwanted (negatively valanced) emotions – we discussed how this creates a cost on her body, functioning and mental state in the long-term.
PE Session 7
Session was conducted as per PE protocol. Mary completed three re-tellings of hotspot and reported SUDS of 60–20; 50–20 and 40–10. Habituation to hotspot was evident and fed back to Mary.
Missed Session Three
Mary did not attend her session as she reported difficulties with speech. The therapist followed up with Mary to assess her mental state (including risk levels), reinforce progress she has made to date and coaching Mary through her in vivo exposures, structured around emotional exposures (leaning into distressing emotions and related arousal rather than avoiding to her bed room), behavioural activation and mastery. Mary attributed these increased somatic complaints and feeling overwhelmed – however, she reported ongoing attempts at compliance with her homework. All attempts to re-engage with homework were reinforced. Distressing emotions and physical sensations were framed as emotional and interoceptive exposures, respectively. Education was provided to Mary in regard to physical sensations not being harmful in the context of PTSD. Interoceptive exposures were designed and discussed for Mary to trial as part of her in vivo exposures until the following session. The interoceptive exposures chosen were initially designed to increase heartrate (aerobic activity), sense of disorientation (gentle spinning in an office chair) and a shortness of breath (holding her breath).
PE Session 8
Session was conducted as per PE protocol. During this session, she completed three imaginal re-tellings of hotspot (2) – where her daughter stands by as the perpetrator repeatedly physically assaults Mary. Her SUDS for the three re-tellings were as follows: 20–30; 20–40; 40–50. At the end of each trial when she out manoeuvres her attacker – Mary lets out a chuckle – a stark contrast to the softly spoken/defeated woman in earlier sessions. She reported that the most concerning element of this hotspot was her daughter’s inaction – it was a parallel to no one helping her during or following the rape she survived in her 20s. However, as a result of new information from the imaginal exposures, she was able to reframe this event in her keeping herself and her daughter safe, by fighting and by showing her daughter the lengths she’d go to keep her safe.
Missed Session Four
Mary cancelled the session as she did not have access to a working laptop.
PE Session 9
Session was conducted as per PE protocol. During this session, Mary completed three re-tellings on hotspot (3), her SUDS were as follows: 40–85; 50–85 and 45–65. She expressed feeling extreme shame in her action of grabbing a shovel and threatening to strike her attacker – she reported connecting with rage/anger which she was surprised she could experience and/or distress. She reported that this emotion was ‘wrong, not like her, not what a civilized person should experience or distress’. The therapist discussed anger as a helpful/adaptive response, particularly within the context of her experience, and queried whether this is one, potentially of many emotions which Mary judged as ‘bad’, ‘dangerous’ or ‘unwanted’ – which she suppresses and what the cost of this may be, rather than leaning it curiously – habituating to the emotional response itself or seeing if it is adaptive to context. The therapist queried whether it was this suppression which may be driving Mary’s somatic complaints – and highlighted that since she has begun to take the brave, difficult steps of leaning into distress, she has reported greater ability to be assertive and diminished functional symptomology. The therapist queried when the last time Mary asserted herself and connected with anger/uncomfortable emotions – she stated that she could not recall a recent time. Mary was instructed to engage with unwanted emotions, primarily anger via mood induction for the in vivo for the week.
PE Session 10 (final session)
Session was conducted as per PE protocol. Mary completed an entire re-telling of her index trauma and was animated, angry and engaged throughout. At times where she was previously silent, she was now quoting the attacker ‘I can do anything to you, and no one will help you… no one will believe you’. She was able to paraphrase what she had said to him ‘why are you doing this’. She was also able to articulate the cascading thoughts to her previous sexual assault and the moment she was able to re-orient herself in the room, orient herself to her attacker’s grip and rolled towards him while she bit his forearm, causing him to fall off her and affording her the opportunity to run to safety. At the end of the exposure, Mary smiled and reported feeling empowered in recognising that even while being in objective danger and reminded of her sexual assault – she was able to get herself to place of relative safety. Mary was also able to contextualise the event in her role as a mother – protecting her child, showing her daughter that she would always protect her and that her daughter always had a home with her. She was able to reframe the event from something that happened to her, to one where she was actively protecting her daughter. Mary also reported increased empathy towards her daughter’s helplessness in during the index event.
8 Complicating Factors
Mary’s treatment was complicated by a number of familial stressors, the primary one being her younger daughter, who was involved in the index event, moving back into home with Mary and her husband mid-treatment. Mary described her youngest daughter as ‘chaotic’ and at times verbally aggressive towards both Mary and her husband. This increased stressor when engaging in prolonged exposure treatment, during a COVID-environment may have understandably overwhelming and may have contributed to Mary’s dis-jointed treatment trajectory by limiting her ability to differentiate between the dangerous-then and safe-now. Further, Mary’s FND symptomology were also an inherent complicating factor – with the therapist needing to continuously monitor her functional symptomology while delivering the PE protocol. However, this did not appear to impact in her ability to benefit from and sustain treatment gains.
9 Access and Barriers to Care
The unfolding COVID-19 environment presented a unique challenge and access opportunity for Mary. She was not able to attend face-to-face sessions due to state-enforced restrictions. She did attend all of her sessions via telehealth. Although at times, her disruptive home environment presented as a barrier to her finding appropriate space for treatment and access to technology – this also afforded an opportunity as Mary was still able to present to session when she was experiencing FND symptoms.
10 Follow-Up
Mary was contacted at 6-month post-treatment follow-up and reported that she had maintained all of her treatment gains (nil diagnoses indicated in the MINI, and a CAPS score of 10), including absence of ongoing FND symptomology. She also anecdotally reported increased functioning in dealing with government departments for taxation grants for her business during the COVID-19 pandemic, had pivoted her business to an online format and was providing care to her two young grandchildren.
11 Treatment Implications of the Case
PE therapy was not only an efficacious treatment for Mary’s PTSD but was also pivotal in treating Mary’s FND and other psychiatric co-morbidities. The primary mechanism of this is believed to occur through the process of mastery and differentiation of and between highly emotionally distressing memories and experiences. A pathological fear structure is theorised to comprise of excessive (pathological) meaning, stimulus and response elements. For a fear structure to be modified, it must first be activated, and then, new information must be processed and incorporated into the structure to modify the pathological elements (Foa and Rothbaum). Due to repeated activations of Mary’s fear memory structure and avoided emotional states, events (including emotional states) were no longer viewed as overwhelming, uncontrollable and dangerous allowing Mary to incorporate new information into the fear memory structure.
Further, Mary was able to re-appraise her bodily signals as manageable, discrete messages for her to slowly, but continue to engage in important tasks, rather than avoiding by retreating to her bed room for days and not engaging in goal-driven behaviour. Reinforcement of gains, validation of difficulties and differentiation between experiences were imperative in fostering the aforementioned mechanisms. The therapist not only acted as cheerleader but also as emotional arousal (focussing on differentiating interoceptive signals) barometer. Specifically when working with Mary, the treater needed to be mindful that any emotive arousal would be read as foreign, overwhelming and dangerous. Therefore, instilling hope and encouraging Mary to tolerate fluctuations in experience was paramount.
During the course of PE treatment, Mary connected with the emotions (interoceptive sensations) she felt during the traumatic event(s) and gained an understanding of her PTSD symptoms including her psychogenic functional impairments. She was able to identify how emotional distress, particularly experiences where she feels overwhelmed or is confronted by authority triggered her psychogenic communication and movement functional impairments. She was particularly able to lean into these experiences and insights when engaged in in vivo exposures and did at times lose speech during these exposures. Interestingly, Mary gained communication, speech and bodily animation as she habituated to her trauma memories in later treatment sessions. Continuing the session or engaging in her in vivo exercises right after experiencing an FDN symptom, allowed her to experience a ‘corrective experience’ of distress habituation when discomfort was approached rather than avoided. This mastery and related corrective experiences were all highlighted to Mary throughout her session – and were a major focus of emotional processing, above and beyond integration of new trauma-event related information into consolidated fear memories. Grounding, self-care and relaxation exercises post therapy-related work were focused on goal-driven, active and reflective practice, that is, arts-based activities Mary enjoyed but was not engaging in. Avoidance, retreat or rest behaviours as a form of grounding were not encouraged during the treatment. However, it is important to note that Mary did not exhibit any clinically significant change in emotion regulation ability. This suggests that while PE is beneficial in addressing fear-based pathology, clients may benefit from transdiagnostic emotion regulation adjuncts if they present with co-morbid difficulties in emotion regulation, either as mechanisms or co-morbid pathology.
12 Recommendations to Clinicians and Students
As FND can look like acute physical symptomology, they can baffle the therapist witnessing the manifestation of physical symptomology. It is paramount that the therapist has a good understanding of the patient’s medical history and also is able to complete a comprehensive developmental and functional assessment of all presenting symptomology, ensuring that the patient has been medically cleared of organic origins of their presentation. If in doubt, it is recommended that the therapist contact the patient’s medical treaters for collateral information and medical clearance. This will result in more confidence in creating a formulation including hypotheses which are testable within treatment. Where possible, it is recommended that therapists work or consult with an FND specialist or neurologist who specialises in PNES prior to starting treatment presupposing that the patient has a conversion disorder. Especially in PNES, seizures can appear psychogenic and yet may be epileptic in nature. Also with FND-like symptoms, it is necessary to be as sure as possible that the symptoms do not have a neurological origin that might be best treated by a physician. If there is an FND program in the vicinity, an initial assessment via such service is recommended.
There is a growing body of literature on FND and online resources including a free downloadable learning guide (https://fndaustralia.com.au/resources/FND-Learning-guide-for-nurses.pdf or https://www.neurosymptoms.org/en_GB/) that address presentation and treatment issues for FND. Currently, if a clinician encounters a patient with an FND, it is relatively easy to access relevant clinical resources.
Our case study provides evidence showing that PE as a primary treatment modality is sufficient in treating PTSD with FND. However, the therapist must adapt the protocol based on presenting complicating factors, that is, the patient’s ability/acceptance in approaching emotional distress. Given these considerations, we argue that PE may benefit from continued adaptations (e.g. addressing fears of acute emotional experience or including emotion regulation/emotion-focused interventions as an adjunct) in increasing the patient’s emotional agency prior to the commencement of exposures. As the PE protocol stands at present, it is important for the therapist to be aware that while PE is indicated for those with PTSD and FND, they may need to think laterally away from fear-related exposure activity to those involving hypothesis testing regarding the function of the FND symptoms in context of their PTSD symptoms and general mental state; emotional and interoceptive exposures. It is also recommended that the patient complete a log on the antecedent, response and consequences of their FND symptoms during treatment. Due to the patient often having little insight into (1) the components of their emotional states and (2) link between their physical and emotional experiences creating a safe, collaborative rapport is paramount – where the client is invited to formulate and test hypothesis. The therapist is also encouraged to follow-up with the client between sessions as appropriate (e.g. when there is an expected initial escalation of distress or symptomology). Between session follow-up should focus on assessment of mental state (including risk levels) and to enhance any attempts at engagement and mastery.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
