Ep 76 - EMDR for FND
 Hello, and welcome back to the EMDR doctor podcast. I'm Dr. Caroline Lloyd, And if you are new to this channel, you are welcome here, and please don't forget to like and subscribe because it really does make the podcast a little bit easier for other people to find it.
 So I just wanna start before I hop into my topic of today, which is FND, which is - functional neurological disorder. I just wanna give myself another little plug. So in a few weeks' time, on the 17th of September, I'm presenting a webinar about DID, which is just one of the most fascinating mental health issues that I think we can work with. And, myself and Cate Bearsley Smith, who's a wonderful psychologist who works a lot with DID, we are presenting a webinar. So it's gonna be fascinating. I'm gonna learn a lot. I'm sure you will learn a lot if you decide to come along. So hop on over to my website emdrdoctor.com.au/training, and there you can register to come along to the webinar.
So today, I am talking about FND, which is functional neurological disorder. So FND is also a really amazing thing that the brain does when it comes up with bodily symptoms which are manifestations of emotional distress. So basically, FND is medically unexplained diagnoses or symptoms, and it can present as, like, a tremor with a hand shaking, or muscle weakness, or sometimes gait abnormalities, like people can not walk properly. Or another common presentation is non-epileptic seizures. So this is when someone has what looks to be a seizure, but there's not the neurological process of the rapidly firing generalized neurological impulses that go through the brain. So the person is actually usually conscious, although often dissociated, but they're having what looks like a seizure, but there's no medical explanation for it. And sometimes it can present as muscle spasms or sometimes facial tics, that sort of thing.
So what is it not? And this is kind of an important thing to talk about. So FND is not malingering. So people with FND, they're not pretending, they're not trying to get something for nothing. They're not trying to fool the doctors. It's an unconscious process, so they are not in control of their symptoms on a conscious level. The symptoms are real, they are not imagined, but there is also no biological disorder. So oftentimes people with FND have really been through the wringer in terms of having lots and lots of tests to exclude any reversible cause. So doctors are making sure that it's not epilepsy, that it's not something like MS. So they've often had really quite a lot of investigations to make sure that there's no biological cause, and the tests are negative. And all of this seems to indicate that it is all in the mind, which by the way, by definition, FND is not all in the mind. It does exist in this kind of gray area between biology and psychology, sort of a neurology and psychiatry interface. It's where the mind meets the body in terms of symptoms. So it encompasses both physical health and mental health, and usually there are psychiatrists as well as neurologists involved in the care of people who have FND. And one more thing that I will mention here in the what FND is not basket, is that FND is not a deliberate attempt to foil or confuse or annoy doctors. So I can say this, as a doctor, I remember many times in the emergency department, people coming in with, often repeated presentations with the same sort of thing. Like they might come in with this sort of epilepsy kind of presentation, and the doctors in the emergency department would get quite irritated by their presentation. So often faced with a diagnosis of FND or functional neurological disorder, what in the past used to be called conversion disorder, doctors feel quite helpless. We feel quite redundant. We don't know what to do. We have no more tests to do. We have nothing more to offer in the emergency department or in the general practice, and so we do feel a little bit helpless and redundant. And quite often what that does is - doctors are human too, and if we feel a bit helpless, we might go towards our psychological defenses, which might be to withdraw, to blame, to minimize, or to psychologically abandon our patients as, "They're just too hard. I've got nothing to offer." So to any doctors who might be listening and maybe kind of internally wincing in recognition of this sort of response, I would encourage you to, you know, perhaps avoid blaming or shaming, recognize it as an expression of emotional distress, and refer to a trusted psychologist or psychiatrist or physiotherapists. A lot of physiotherapists are quite skilled at treating FND. And just be there for your patient when things get tough, just so that they know that they have someone in their corner, they have someone that they can chat to, and just know that your patients are doing their best and so are you. It is complex, and so many doctors do avoid this illness, recognizing that it takes more resources and more patience than a standard physical illness.
And so what is it? It is real. It causes a lot of distress. It's usually a result of high levels of emotional distress, which are unable to be expressed in a way that they should be expressed with emotionality. So FND, there is a huge impact of trauma on FND. In fact, some studies show that up to 100% of people with FND have experienced trauma. Whether that be big T trauma, childhood trauma, developmental trauma, small T trauma, it's gonna be there in some shape or form.
And FND is seen in some cultures more than others. So cultures that might shut down emotions make it impossible to actually express the emotions that are there. Maybe there's a lot of shaming in regards to emotions. Cultures that do that tend to - find that more emotions are expressed through the physical means , as a disability.
Now, I want to talk a little bit about the intersection between FND and autism. FND is much more prevalent in people with autism. So there is an overlap between these two conditions, and there are probably a few contributing reasons for this. First of all, we know that autistic people do experience more trauma than non-autistic people, and this might be a result of societal expectations, and exclusion, and bullying, otherness. There may be an element of familial trauma or intergenerational trauma here. So parents on the spectrum who are maybe not getting the help that they need and deserve, they may not have the coping skills. They may be contributing to the trauma in their children. All of these factors make trauma more common in autistic individuals. Also, autism means greater sensitivity to trauma. They may have less of a robust self-esteem. They just may be more sensitive in terms of physical sensitivity to bodily sensations, also general sensory sensitivity and emotional sensitivity. They are also more susceptible to moral injury because one aspect, and I haven't found any literature on this, I haven't done a deep dive into it, but in my experience, autistic individuals have a very strict moral code and high moral standards. It's part of the definitive thinking around how people should behave. You know, the government should do this. Individuals should do that. The rules of society are X, Y, Z. People should. So there’s definite moral expectations in people who are autistic. And so they are more sensitive to moral injury. Having to do things that they don't agree with, a perception of hurting others through their actions, or just being more injured by others' immoral actions So autistic people are not only more sensitive to trauma and experience more trauma than other people, but they also process trauma in a bit of a different way. Autistic people do have more alexithymia than non-autistic people. And alexithymia is an inability to recognize or describe, name their emotions, and express their emotions verbally or emotionally. So there may be a misinterpretation of emotions as bodily sensations or a difficulty in teasing out what is an emotion, what is a bodily sensation. You know, this feeling in my tummy, what is that? Is it anxiety? Is it fear? Is it nausea? There's a bit of an overlap in terms of experiencing bodily sensations, there may be a bit of a difficulty in telling the difference between a body sensation, a somatic sensation, and an emotional feeling. And they also have a sensory sensitivity and an interoceptive difference that makes pain syndromes more likely as well. Their bodies can perceive internal sensations like, for example, pressure or tension or increased heart rate, rapid breathing or pain, these might be interpreted differently, and perhaps this makes autistic people more likely to convert that into an ongoing physical symptom that doesn't have any biological basis. The other thing that I would mention here in terms of FND and autism, and in particular perhaps non-epileptic seizures - With autism, if there is a situation where there is emotional overload or sensory overload, the shutdown that needs to happen for that autistic person to regain a sense of safety, they need to withdraw, they need to hibernate to, in order to recover from that overstimulation and overwhelm. This kind of shutdown may actually manifest as a collapse, which could then morph into that interpretation of a pseudo seizure. So a collapse may just be a complete shutdown and a bodily withdrawal, dissociation you might want to call it, and an actual fall to the floor. So, this might be a kind of a learned behaviour perhaps, and I, there's no research on this - it's my interpretation of how this may actually kind of manifest, so don't take this as gospel. It is just opinion. That the sensory overload, emotional overload might lead to a need to collapse and withdraw in order to regain a level of composure So it might be a really effective involuntary way of coping with that overload in the short term So interestingly, one study that I did read highlighted the fact that nearly half the cohort who had both FND and autism, they were only diagnosed with autism after the FND was diagnosed, and it was part of their treatment to be investigated for autism. So those autistic individuals were definitely not getting any help for their autism prior to developing and then being investigated for their FND symptoms, and that might be a real contributing factor. Being neurodivergent without a diagnosis, having to mask and cope in a world that is not designed for difference may be a factor in developing this particular set of symptoms. So just be bearing this in mind, just considering if you have been diagnosed with FND or if you have clients, if you're a therapist and you have clients with FND, just check in with that. Just have a bit of a think. Are they autistic? Is it worth checking that out and looking for a diagnosis? A diagnosis of autism can definitely be helpful because then people know in what direction to get some help And just on a side note, all the reading that I'm doing at the moment about DID - DID also has a correlation with autism, and it would be interesting to find out if there's a correlation between - DID and FND, because I do know that personally I have a couple of clients with both. So, you know, that's just my personal experience, but, worth thinking about.
Okay, back to FND. So just another little point worth making. FND can coexist with actual physiological, biological illness. Someone can actually have epilepsy and non-epileptic seizures, just to really confuse matters a little bit.
So that brings me to what do we do about it? So first of all, I would make sure there is a good physio involved because that can be really helpful, or an exercise physiologist. Often they are really good at that invisible illness and maintaining functionality. So that's something to bear in mind.
But can we use EMDR to treat FND? I know you know the answer to this. Yes, we can. So there are a very limited number of studies done on this, and, you know, the interesting ones are actually quite old, from around 2009, some in the early 2013, I think they were. And the, scientific knowledge is really quite limited as regards EMDR and FND. But the studies that I did read were quite promising. Not conclusive, but quite promising. So they ranged between one session and I think 75 sessions of EMDR. That's a pretty unusual number of sessions to have of EMDR. Certainly when I set out to record this podcast, I was all set to kind of give a little bit of a warning about FND and say, "You know, it probably signifies quite substantial childhood trauma, and go slowly, do preparation, explore the comorbidities, and so on." And that advice is a little bit foreign for me, 'cause as you probably know if you've listened to enough of my podcasts, I'm a hop in and do it kind of a person. So I love to start treating the trauma quite quickly, get people some resolution of their symptoms in as little time as possible. And I was gonna make an exception for FND, but lo and behold, one of these studies actually showed that with one single session of EMDR, this person with their FND actually had their symptoms resolved after one session, which is very, very promising. So perhaps we can do EMDR in that model of care that I so dearly love, which is hop straight on in, resolve the trauma, and help your clients quickly. Now, of course, everyone is gonna be a little bit different, recently I did refer somebody out, because of a diagnosis of FND because I did sense that perhaps there was a little bit of preparation work to be done. But you know, everybody's an individual, so if you're an EMDR therapist, just taking it on a case-by-case basis. And the way that we would work with EMDR and FND According to the model that has been proposed in one study that I read, which is called the Modifi Protocol (because EMDR therapists love a protocol). They have suggested in their protocol what they suggest is, of course, using the three-pronged approach, the past, present, and future. The past being obviously the trauma, perhaps the earliest experiences of FND, perhaps the experiences that the client was having at around the time the FND started to become apparent. So very often it becomes apparent in a time of increased stress in somebody's life. So targeting those events that were causing the increased stress or those traumatic events that immediately preceded the onset of the symptoms of the FND, that's a really good place to go as well. So the trauma of maybe early childhood trauma, the trauma just preceding the onset of the FND. You can target present day targets, which might be the sensation of the FND. It might be noticing the tension in the forearm with the shake of the hand, if hand shaking is one of the symptoms. If it's body shaking, it might be the sensation in the middle of the body that causes the shake. So you can process those sensations as targets, and you might find that that actually resolves the FND symptoms really, really quickly. But I would encourage you to look beyond the symptoms, look for underlying vulnerability being childhood trauma, Perhaps some negative cognitions of I'm not safe, or I'm vulnerable, or my body's not a safe place to be. Those sort of things might be relevant. And then moving on to the future and installing a future template of life without the FND symptoms So this may have to be preceded by some coping skills, some DBT skills, or some of the EMDR strategies that we love to use, the attachment focus coping skills, the container and the calm place, of course. ,So, you know, each client is different, and if you're an EMDR therapist, you will know this, and you will know how to titrate your work and how to best assess your client in terms of what they're able to cope with. But if you are a client listening to this and you have FND or you know someone with FND, maybe pass this on to them, and I hope that they find it helpful as well. FND is treatable. It is one of those mental health issues that can resolve, and the better treatment that people get, the quicker it will resolve. And the more they retain their functional capacity with the help of other allied health services like physios and OTs and exercise physiologists, the more able people will be to maintain a good and, fulfilling life.
So I hope that's helpful. If you're interested in DID, please come along to my webinar on the 17th of September, and you can register for that at emdrdoctor.com.au/training. In the meantime, I hope this has been helpful to you. I look forward to talking to you again in a couple of weeks. In the meantime, take good care. Bye for now
