Child Long-Term Treatment Goal 4: Connect Negative Emotions with NES Symptoms

, Julia Doss², Sigita Plioplys³ and Jana E. Jones⁴

(1)

Department of Psychiatry, UCLA, Los Angeles, CA, USA

(2)

Department of Psychology, Minnesota Epilepsy Group, St. Paul, MN, USA

(3)

Department of Psychiatry, Northwestern University, Chicago, IL, USA

(4)

Department of Neurology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA

Keywords

NES symptomsStressNegative emotionsTherapeutic interpretations

Suggested Techniques

Whenever a child with PNES brings up any type of physical complaint, find out what the emotional triggers are using the techniques described in the following sections.

Link Between Bodily Sensations and Emotions

Gently revisit this link using the methods described in Child Long-Term Treatment Goal 3 in Chap. 7. In addition, you can describe how people might experience physical sensations when things occur that make them sad, mad, happy, or excited. Ask the child to talk about examples in the child’s life that bring up these same emotions, and ask what physical sensations accompany them. It is also helpful to remind the child about negative incidents or events that the child has told you about. Find out what physical sensations the child might have experienced then and who the child told about them. Inquire if the child also expressed the negative feelings the child experienced in these situations. If not, find out what negative repercussions might have occurred if the child verbalized those feelings.

For younger children, it can be helpful to have visuals or to draw how the body feels when experiencing different emotions (see Appendix I for example drawings of the body). On a full body or face drawing, ask the child to use colors to identify different emotions and which body parts might experience them.

To normalize the mind-body connection, share how you and children you have worked with feel and think in situations that induce negative feelings. Talk about the emotions experienced when a child gives a speech in class, participates in a competitive sports game, or performs on stage. Then find out what your patient would feel (nervous, scared, shy) in a similar situation and how the child’s body might react.

What Is Your Body Telling You?

As the child becomes more open to sharing negative emotions and experiences with you, suggest, “Was this your body letting you know that …?” Premature interpretation of the link among negative emotions, stressors, and episodes can cause the child’s discomfort and resistance. To avoid this happening, be sure the child is ready emotionally for you to make these connections.

Story Game

Chapter 6, section “Storytelling” described when and how to implement storytelling. Ask the child how what happens in the story might make the protagonist (whether imaginary or the child) feel both emotionally and physically. Initially, this may be hard for the child. But as the child progresses in therapy, it becomes easier and more spontaneous.

The Exploding Balloon Phenomenon

To help the child understand what happens when one does not express negative emotions, describe how a stuffed plastic bag or a balloon with too much air eventually bursts. Also, discuss how the body feels when people cannot express an emotion and the ways in which their bodies react or speak up. When stressed, some people get headaches, stomachaches, or backaches. Talk about the importance of the child expressing feelings, even if it is unpleasant because otherwise bad feelings do not go away. Model this for the child from your own experience or that of other children.

After Understanding the Link Between NES and Emotions

Well into therapy, if a stressful situation occurs, the child might experience stress-related physical symptoms other than NES. Gradually work on making the link between stressors and these symptoms by clarifying the emotion the child experienced and the symptoms that developed. If, in earlier stages of therapy, you used an approach that helped the child express negative feelings or make the connection between physical sensations and negative emotions, revisit those tools.

Dialogue: How to Connect Among Stressors, Negative Emotions, and Episodes

This 14-year old high school freshman cheerleader was in her sixth month of therapy with infrequent episodes that occurred mainly at school. During the first 3 months of therapy, her therapist and cheerleader coach recommended that she not resume her cheerleader activities until her episodes were controlled. Educational testing revealed language-based learning and reading difficulties. Although the patient had communicated to her parents about her learning difficulties already in third grade, they ignored her complaints and encouraged her to apply herself. The therapist worked frequently with the mother, but the father was “always too busy” to attend these sessions. The mother continued to have difficulty acknowledging her daughter’s learning difficulties and felt they were emotional and subjective.

It took about 3 months of therapy before the patient started to talk about negative feelings. At first, she expressed anxiety related to her learning difficulties. Later, she reported feeling rejected by her peers at school. Several months into therapy, she said that she was bothered by her younger brother’s intrusive behavior, particularly when her boyfriend visited her at home. The therapy focused on helping the girl gradually tune into and express negative feelings, as well as deal with her learning and social difficulties. Her episodes at school stopped. Although she was quite content not to resume her cheerleader activities, she was unable to share with the therapist what, if any difficulties she experienced during cheerleading. In fact, she repeatedly stated she loved cheerleading.

The patient was a third generation cheerleader, and her mother devoted a lot of her free time to her daughter’s cheerleader activities. She arranged for her daughter to return to cheerleading without consulting with the therapist. For the first month (the fourth month of therapy), there were no untoward events, and the patient felt comfortable doing easier routines than she had been involved in prior to her illness. In meetings with the mother, the therapist emphasized the importance of a gradual return to cheerleading activities only when her daughter felt she was ready to do this. However, about 6 weeks after resuming cheerleading, the mother and coach encouraged the teen to do the challenging routines she had been involved before onset of her episodes. Without discussing how she felt about this with her therapist or anyone else, the patient agreed to do these challenging and daring routines. Within 3 weeks, she began to have episodes again at school.

As in previous dialogues, blue balloons are comments on the therapist’s techniques and yellow balloons on the adolescents’ responses.

Therapist: So I heard from your mom that you were not feeling so good at school.

Teen: Yes, I had to leave class on Monday and go to the nurse’s office and then again on Wednesday, but today I was fine.

Therapist: That must have been tough for you.

Teen with tears in her eyes: Yes, the snobs all had something to say about this. They said that I am just trying to get everyone’s attention and not do all the work.

Therapist: I can see that really made you feel sad.

Teen starts to cry: The more episodes I have, the more work I miss. Why would I be doing this on purpose?

Therapist: You had come up with this great answer for them in our session when you were having episodes a few months ago. Were you able to say this to them?