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A psychological perspective

PC model = explanation of the model and examples of use

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The PC model(Pressure Cooker Model, PCM; van der Hulst, 2023) is a newer and clearer psychological model that uses everyday metaphors to describe the understanding of functional neurological impairment. It has been developed based on years of clinical experience in treating patients with all forms and subtypes of functional neurological disorder. The focus of the model is on intra-individual, inter-individual, cognitive, emotional and behavioural processes. 

Layers of the model

    • Factors and history of key (psychological) events

    • Adverse childhood events (trauma, abuse, maltreatment)

    • Events that occurred closer to the onset of FND symptoms

    • Tightly closed lid (Reduced verbal expression of emotions) -

    • Blocked/disregulated/used steam valve (Abnormal activity levels)

    • Sticky food leftovers (Coping strategies from childhood that have carried over into adulthood)

    • Dissociation (A way of coping with difficult emotions)

    • Fuel (daily triggers, interactions or stressful events that stimulate FND symptoms)

    • Flames (Negative (automatic) thoughts, feelings or memories or ill-defined internal states that trigger FND symptoms)

    • Fever(Intensity of emotions in response to stressor(s))

    • Plug under too much pressure(Functional neurological disorder, pain, fatigue)

    • Potty (Acronym: FND SELF CARE = diet, sleep, medication, illness, aids, bladder function, fight or flight response, contacts, ability to take care of self, risks, physical activity, exercise and physical activity)

    • Warning light (Increased self-focus on symptoms)

    • Kitchen

      • System integration

      • family dynamics;

      • abnormal characteristics of relationships with health professionals;

      • amplification of interference on both sides;

      • Systemic re-tradmatisation;

      • prejudices/blind spots of professionals involved in the treatment of the disorder)

Ignition

Ignition represents the critical events or triggers that are most likely to have contributed to the development of a functional neurological disorder.

  • Profile 1: before-and-after

    This profile is characterised by the development of FND following a critical event, which may be either a stressful or traumatic life event (e.g. divorce, accident, death, assault) or a previous illness and/or medical intervention (e.g. surgery). Traumatic childhood experiences and/or the development of inappropriate coping strategies are also common (but not necessary!) for this profile, as are negative interpersonal dynamics in the family at the time of the development of the first symptoms.

  • Profile 2: Sudden development

    Some patients also report a sudden onset of panic attacks. This profile is strongly associated with anxiety manifestations and often results in non-epileptic or dissociative episodes.

  • Profile 3: Progressive development

    Some patients are also characterised by a long period of various abusive behaviours (e.g. violence, toxic relationships) which may make them even more vulnerable to developing FND. On the other hand, there are also patients who experience stress (e.g. from work) for long periods of time in the absence of useful coping strategies and who, after a certain period of time, reach a point where the body reacts with illness.

Pot

The pot presents a number of physical and medical-contextual factors that maintain and/or influence FND, which can be remembered by the English acronym FND SELF CARE.

Nutrition

  • Check the content and frequency of the patient's diet

  • It is also a good idea to check how stress and emotions affect their eating

  • Gut health (If there are problems, refer to a specialist for a diagnosis of irritable bowel syndrome)

  • Weight (Does the patient have weight problems that affect the course of rehabilitation?)

  • Is the patient deficient in vitamins and minerals? (In individuals where social isolation is pronounced, vitamin D deficiency is possible)

Sleep

  • Check if the patient has an associated sleep disorder

  • Ask him about the quantity and quality of his sleep

  • Check all stages of sleep (preparing for sleep, falling asleep, waking in the early hours, hypersomnia)

Medications

  • Check the combination and dose of the medicines the patient is taking

  • Check if the patient's use of the medication represents a psychological safety behaviour (e.g. ending a dissociative episode with the medication)

  • Check that he is taking his medication correctly

Disease

  • Check the patient's medical history

  • Has he/she also been diagnosed with organic diseases such as epilepsy?

Use of aids

  • What tools does he use? What role do these devices play in the patient's life?

  • Is the patient's home adapted to the FND? How?

  • What is the psychological significance of assistive devices? Have they become part of his identity? Do they represent a form of safety behaviour?

Bladder and fluid functioning

  • Does the patient have any problems with urination, bladder or incontinence?

  • When it comes to fluids, be wary of drinking too much energy drinks, alcohol and caffeine.

Fight/flight and warning signs

  • Do you often feel stressed? Where in your body do you feel stress the most?

  • Look for objective signs of stress (e.g. difficulty sleeping, eating, lack of motivation, focus)

  • Notice any warning signs?

Contact

  • Ask if they ever call the on-call clinic for FND symptoms

  • Ask about past experiences with health professionals. Has the patient been a victim of systemic re-traumatisation?

Independence

  • Is the patient independent in daily activities? Does he/she need help anywhere?

  • Is the patient no longer doing an activity they used to enjoy?

  • Check family support. How have family roles changed? Check if there are any ways in which the family maintains the symptoms of FND.

Risk assessment

  • Risk of iatrogenic harm (wrong or excessive dose of medicines; excessive medical tests)

  • Physical symptoms (pain, fatigue, etc.)

  • Use of assistive devices as a safety behaviour

  • Unintentional self-harm (falls due to balance problems, problems assessing fitness)

Exercise, movement and physical activity

  • What is the patient's mobility? (e.g. balance)

  • Do you play any sports?

  • Have you had to give up any sport because of the FND?

Fuel

Fuel presents triggers that initiate FND episodes and/or exacerbate FND symptoms

  • Emotional triggers

    Patients with FND may experience over-regulation of emotions, which can lead to avoidant behaviours, dissociation and suppression of emotional states, or a lack of emotion regulation. 

  • Physical triggers

    Patients diagnosed with psychogenic non-epileptic seizures often report physical triggers for dissociative seizures: heat, noise, intense light, pain, fatigue, etc. 

  • Interpersonal triggers

    Interpersonal triggers occur in the relationship between the patient diagnosed with FND, their symptoms and their social environment. They are often accompanied by feelings of guilt, shame and rejection (e.g. family quarrels, unmet need for belonging and affection, experience of lack of support).

  • Re-triggers

    Re-triggers are a specific type of trigger, mainly experienced by patients with a history of childhood trauma. A mundane or even neutral stimulus can activate feelings associated with the trauma experienced.

  • No triggers

    Sometimes patients report the absence of triggers, which can be extremely frustrating for both the patient and the clinical (neuro)psychologist/psychiatrist. Check if the cause is lack of awareness (e.g. alexithymia).

  • Check the A-B-A-B design (when the trigger is present, FND symptoms get worse; when the trigger is removed, symptoms FND get better).

  • Ask about symptoms/social episode they remember very well. Can they identify factors that contributed to the worsening of symptoms or triggering of the episode (e.g. argument, stressful circumstances, etc.)?

  • Ask about the variability of symptom expression and if symptoms are ever not expressed. If they are not, could the patient identify contributing factors (e.g. experiencing positive emotions, holiday-reduced or completely absent stress).

  • Ask about interpersonal triggers. Did anything happen in the partner relationship before the onset of FND symptoms?

  • Check if the trigger is an unmet social need for acceptance, belonging and love.

  • Check if there is a pattern of symptom expression (e.g. symptoms or a dissociative episode always trigger at the end of the day).

  • Check for classic negative cognition (e.g. catastrophic misinterpretation of symptoms).

  • Check if the patient is facing demands at home and/or at work/school that are beyond his/her ability to cope.

  • Check if there is a mutual reinforcement of symptoms (e.g. inappropriate reactions from family and/or partner).

Flames

The flames represent aversive beliefs about the self, others, the world or the future. They also include emotional processing problems.

Beliefs about yourself

  • Self-image

  • Beliefs about the body

    Beliefs about others

  • Negative social emotions ( shame, guilt, rejection)

  • Beliefs about interpersonal relationships

Beliefs about the world

  • Security

  • Psychological/physical threat

    Beliefs about the future

  • Fear of recovery

  • Fear of relapse

  • Fear of new functional symptoms

  • Fear of falls

    • Psychoeducation on emotions can be useful

    • You can teach patients to use different emotion regulation strategies

    • Normalisation of emotions

    • Detecting systematic re-travmatisation

    • Explain to the patient the scientific findings that health professionals do not believe patients. Explain that you will treat them differently and more positively.

  • Use mindfulness techniques to observe beliefs without judgement and reactivity. Teach the patient to distance him/herself from negative beliefs.

  • Use the 'downward pointing arrow' technique to find out what a particular belief means to the patient. E.g. if a patient believes a belief that no one believes them, the belief may result in the activation of a core fear of rejection.

  • Teach them assertiveness techniques that can help them when they need to explain the FND.

    • Alternative belief strategy

    • The pros and cons of this belief

  • Normalisation of negative beliefs and cognitions!

Heat

Heat represents the intensity of emotions. The heat can be adjusted on the pressure cooker. In the context of FND, we are talking about three settings.

Low setting = Dissociation

Dissociation in the context of FND is often triggered by intense emotions that are unbearable for the individual, both on a conscious and unconscious level. Dissociation is a defence mechanism through which the individual 'cuts off' all emotions to avoid confronting them.

High-low-high-low setting= Emotional deregulation

Rapid fluctuations between experiencing high-intensity and intense emotions and experiencing emptiness and numbness. This includes difficulties in naming and identifying emotions and difficulties in coping with and regulating emotions during stressful events, which affects interpersonal dynamics.

High-to-low setting

Characteristic mainly of functional seizures. Gradual development of a negative emotion, arousal or an unidentified internal state, leading to a climax, then gradually progressing to dissociation. 

  • Using a diary to record changes in mood and/or dissociative attacks.

  • Psychoeducation on dissociation.

  • Psychoeducation on emotions and technical emotion regulation. Grounding techniques also welcome.

Sticky foods

Sticky foods represent ineffective coping strategies that we have internalised in childhood.

  • Psychoeducation on the most common mechanisms of sticky food residues:

    • Dissociation

    • Keep things to yourself

    • Keep it up

    Helping to identify the patient's coping mechanisms and linking them to FND.

  • Exploring the formative years

    • Stability of the family environment

    • The culture in which the patient was brought up

    • How were the emotions expressed in the patient's soul?

  • Create a family genogram with the patient to get an insight into the family structure.

  • Explore the quality of family relationships.

    • Who was the closest person to the patient?

    • Have emotional needs been met?

    • How did he perceive the support in the family?

  • Explore coping strategies in the primary family.

    • What was the primary strategy for coping with difficult emotions and thoughts? Was it shared by all family members?

    • Were the problems swept under the carpet or cleared up immediately?

    • Were there a lot of conflicts, negative emotions?

    • Did patient feel psychologically safe?

    • Any traumatic events?

  • Explore your schooling period

    • Bullying

  • Critical events during growing up

    • Parental neglect

    • Traumatic events

    • Coping strategies to deal with a traumatic event

    • Link to systematic re-travmatisation

  • Explore attachment styles in the family and ask about significant losses

  • Explore current family dynamics

    • Continuous fights?

    • Primary family involvement

    • Level of expression of emotions

  • Normalise childhood coping strategies, because they had a purpose.

  • Be compassionate and patient, especially with patients who do not open up immediately about their childhood.

Cover

The cover represents the verbal expression of emotions.

Tightly closed cover

Reduced verbal expression of negative emotions in a psychologically safe and trusting relationship. Opening a tightly closed cover (verbalising and expressing difficult emotions that the patient has suppressed for a long time) often improves FND symptoms.

  • Building a trusting therapeutic relationship that allows the patient to express emotions without fear of rejection or invalidation.

  • Explore the origins of difficulties in expressing emotions.

  • Encourage the recognition and naming of emotions (e.g. anger, frustration, anxiety, feeling unwell).

  • Individuals with a tight cover have strategies that prevent them from expressing emotions. Identify them.

  • Encourage the expression of emotions and show that attempts at expression are followed by validation and normalisation of emotional states.

  • Help them to 'sit with' the feelings they experience after expressing them. Teach them coping strategies.

  • Gradually encourage them to use new emotional expression skills outside therapy.

  • When expressing emotions, praise them. This will reinforce the process of expressing emotions.

  • Learn social skills and assertiveness techniques.

Valve

The valve represents abnormal activity levels.

  • Blocked valve

    • Behavioural activation through light and relaxing activities.

    • The programme should include activities that not only create well-being, but also satisfy the need for belonging, meaning and success.

    • If the patient is socially isolated, work on expanding the social network (Social Skills and Assertiveness Training)

    • What is stopping them from maintaining a social network?

    • Explore the quality and quantity of friendships. Be compassionate as patients may experience feelings of shame.

  • Dysregulated valve

    • Psychoeducation (the pros and cons of collapse and boom)

    • Psychological barriers (Feeling lazy, unproductive)

    • Help with scheduling commitments

  • Used ventil

    • Identify relaxing and easy activities

    • Behavioural experiments with a 'reduced daily schedule'

    • Addressing negative cognition

    • Explore family valves: does everyone in the family have the same valve? Is there imitation/reinforcement?

Warning light

A warning light represents abnormal attention to physical symptoms.

Overload of physical symptoms

The patient is overwhelmed by physical symptoms, which are clearly expressed in his speech, cognition and behaviour. A large part of psychological therapy is devoted to talking about the physical symptoms. The patient minimises psychological factors and prefers physiological and organic reasons for the onset and maintenance of FND.

Hypervigilance

The patient hypervigilantly monitors FND symptoms, body functions and sensations. Systemic hypervigilance can also occur, where family members are abnormally attentive to physical symptoms and warning signs, leading to either a worsening of symptoms or a dissociative episode, which amplifies the patient's abnormal attention. Hypervigilance may also be triggered by devices in the patient's environment if they represent protective behaviours.

Identity

The patient's identity is defined by a functional neurological disorder.

  • Resolving the dichotomy between physiological and psychological factors of FND.

  • Explore the deeper psychological causes of the dichotomy. Does the patient have negative and incorrect assumptions about the psychological treatment?

  • Normalise the psychological treatment and listen to the patient's previous (negative) experiences of psychological therapy.

  • Move from dichotomy to integration

    "FND is neither an organic nor a psychological disorder, but at the intersection of mind and body. We need to treat both aspects: the physical symptoms as well as the psychological symptoms."

    "Let's leave aside the question whether FND is of psychological or organic cause. The fact is that you do not feel well. What can we do together to make you feel better?"

  • Avoid a war with the patient if he or she persistently refuses the psychological formulation. If you fight with him, he will get the feeling that you don't believe him, and you may lose the patient.

Overpressured plug

A plug that is under too much pressure represents the symptoms of FND and the pain and fatigue that result from FND

  • Check understanding of the diagnosis and explain that the disorder has been called many names in the past

  • Keep in mind the wide range of potential symptoms and comorbid disorders and/or symptoms. Also bear in mind that the patient may develop additional functional neurological symptoms.

  • Assess the level of risk.

  • Using the remaining layers, try to address associated symptoms such as sleep disturbances, pain and fatigue, headaches, etc.

Kitchen

The kitchen represents the social function of the FND

Bronfenbrenner's ecological system model

The Kitchen represents the external regulatory function of a functional neurological disorder and explores the influence of the social environment and interpersonal relationships, with the aim of identifying factors that potentially maintain and trigger FND symptoms. The PC model assumes a dynamic interaction between the FND diagnosed individual and the environment, the product of which is emotional deregulation that serves to establish psychological safety for both the patient and the environment. Based on modern research and clinical work, it is assumed that FND is maintained by biological, psychological and social factors. The complex interaction between the individual and the environment can also be explained using Bronfenbrenner's ecological system model.

Ecological theory illustrates the intricate interplay between the social environment and the individual, suggesting that understanding the connection between them can elucidate dysfunctional behavior and relationships. This model encompasses various social systems that reflect the varying levels of direct interaction an individual has with the environment. 

  • Explore your current family system. Make a genogram to explore the strength and quality of relationships and how care is distributed among family members.

  • What is systemic/family cohesion?

  • What does a typical family day look like?

  • What are the coping strategies of individual members and of the family as a unit?

  • Who is allied with whom? Does anyone not get along?

  • What are the family roles of each member?

  • What is the patient's current social network? Look out for signs of social isolation.

  • Assess the wider social situation. What social stressors does the patient face? Are they active on social networks? Do they find them validating?

  • Assess the presence of systemic re-travmatisation. Investigate past experiences with health professionals.

  • Assess if there is systemic amplification of symptoms in the immediate environment. What are the feelings, thoughts and attitudes of family members/friends towards FND?

  • How do the patient's relatives understand the FND? What are their beliefs/stereotypes about patients with FND?

Explaining the psychologist's perception of the treatment of FND patients using the PC model

  • Insisting on a psychological formulation reduces the psychologist's anxiety about his or her abilities

  • E.g. a clinical psychologist rarely or never sees a patient with FND

  • Clinical psychologists have been working with FND patients for some time, but the resistance to psychology is becoming more pronounced, the patient is very focused on his symptoms and insists on physical explanations only.

  • Fear of failure, frustration, low work self-esteem. "They'll think I'm not a good enough clinical psychologist!"

    Vročina: high levels of situational stress

  • Childhood coping strategies, "I'm not good enough!"

  • E.g. sleepless nights

  • Excessive focus on resistance to psychological treatment and attempts to convince the patient that psychological treatment is important

  • Avoiding talking about resistance to avoid losing the patient

    Boom and Boost cycle: feeling tired after treatment; no planning for other patients that day

  • Resistance to patient resistance: insisting on a psychological formulation

Explanation of the patient's resistance to psychology using a PC model

  • A clinical psychologist meets an FND patient For the first time and notices a reluctance to psychology and an increased focus on symptoms.

  • E.g. emotional neglect in childhood, parental figure never believed the patient, emotions were not talked about and/or expressed

  • E.g. referral for psychological treatment

  • "They think it's all in my head!"

  • Coping strategies from childhood, suppression of emotions, dissociation

  • E.g. unpleasant physical symptoms such as heart palpitations, hyperventilation, feeling dizzy

  • Excessive focus on FND symptoms

  • Lack of a safe relationship in which the patient can verbally express his/her feelings.

    Blocked valve: social isolation, inability to test beliefs about psychology with others

  • Neglect of psychological factors, which is maintained by the FND