It is important for mental health professionals to be cognizant of this because these patients exist and are encountered in psychotherapists’ offices with certain regularity.
For decades if not centuries (if we look back to Pierre Janet and Sigmund Freud) it has been understood that psychological trauma is an important risk factor in the development of PNES and other conversion disorders. However, we can really expect that out of every 4 patients we meet who are diagnosed with PNES, only 3 will likely have psychological trauma present in their histories.
How do we know this? No matter what study you look at, you will find that psychological trauma is never (except for one older study that had 10 subjects) found in all patients diagnosed with PNES. A superb review by Fiszman et al (2004) of traumatic events and PTSD in PNES, found that depending on the study anywhere from 44-100% of patients reported trauma in their histories (https://www.sciencedirect.com/science/article/abs/pii/S1525505004002926). And please note, as I mentioned before, that the one that reported 100% had a very small number of total cases…
A more recent study our group conducted in 2013 (https://www.sciencedirect.com/science/article/pii/S1525505013001819), showed that around 25% of patients reported no trauma in their histories. This translates into 1 out of 4 patients in our sample of 61 patients diagnosed using the gold standard Video-EEG test did not report psychological trauma. And of the ones who had trauma, only around 30% fulfilled criteria to be diagnosed with post-traumatic stress disorder (PTSD).
This means that only 30% of 75% of the whole sample, had developed qualifying post traumatic symptomatology.
So, what are we to make of patients with PNES who do not report any psychological trauma? Are we to believe that they are simply repressing the traumatic memories or choosing not to share them? Or is it that PNES is a heterogenous disorder in which all the patients share one symptom (seizure-like episodes) but have an array of different psychiatric comorbidities and risk factors?
I favor the latter explanation. Currently, there are very interesting theories appearing with regard to PNES. Some are proposing that perhaps a unifying feature is that PNES is a disorder of interoception in which physiological signs and emotional cues are missed or misinterpreted. The concept of emotional dysregulation is also promising as is attachment theory.
So, what can we conclude? Clearly, we cannot conclude that trauma is CAUSAL in PNES but rather seems to have a prominent role as a RISK FACTOR in many who go on to develop this disorder.
We must also be aware that for these non-traumatized patients with PNES, a diagnosis of post-traumatic stress disorder (PTSD) is not possible, and it would be highly unusual to identify a dissociative identity disorder (DID) in them as well. These patients tend to have very different psychological mechanisms activating the seizure symptoms. As clinicians, we must be able to think in a fluid and adaptable manner and adjust our treatments to our patients’ presenting problems and characteristics.
Next topic we, as professionals, might tackle: How would you treat someone who has PNES but do not have psychological trauma in her/his list of risk factors?
Patients reading this: what are your thoughts about this topic. Does this reflect you in some way?