Nondrug treatments for psychogenic nonepileptic seizures: What’s the evidence?
Introduction
Although much research has been devoted to the etiology of psychogenic nonepileptic seizures [1], [2], little attention has been given to the systematic evaluation of treatment programs, although there have been various reviews of the research literature over the years [3], [4], [5], [6], [7]. Patients with psychogenic nonepileptic seizures represent a heterogeneous group with diverse psychological problems against a background of long-standing physical, psychological, or sexual abuse, inadequate social skills, and chronic adjustment problems [1], [2], [8]. Consequently, psychogenic nonepileptic seizures (PNES) represent a serious problem for the patient, the family, and the treating clinician. The costs to society can be significant, with reported costs in the United States of US$100,000 per year per patient [9]. The challenge for the treating clinician relates to providing an accurate diagnosis and an effective treatment. The evidence for how best to manage and treat patients with this condition, however, is scarce. The available evidence relies on clinical case studies or studies that lack scientific rigor. In addition, there is no overall theoretical framework for the understanding of PNES on which to base the development of treatment strategies and research protocols. Various psychological and nonpsychological interventions, such as cognitive behavior therapy (CBT) [4], [10], [11], eye movement desensitization and reprocessing [13], and neurofeedback [14], have been used alone or in combination in the treatment of PNES to reduce attack frequency and improve quality of life.
In the studies, there was variable detail provided regarding how the diagnosis of PNES was given, although diagnosis is usually through exclusion of epilepsy and other paroxysmal conditions. Expert analysis of video-telemetry recordings can result in identification of PNES as the result of seizurelike physical activity in the absence of any EEG correlates. More details regarding how these diagnoses are made are given in Reuber’s 2005 article [15]. In some cases, because the diagnosis of conversion disorder was the focus, rather than the more specific PNES, DSM-IV criteria were used [16].
Several studies have attempted to document the treatment outcomes of various types of intervention. McDade and Brown reported on the outcomes of treatment using psychotherapy, occupational therapy, and minimal attention within an inpatient setting. The authors concluded that prognosis for PNES is good when management takes place in a specialist unit with a multidisciplinary approach and a team familiar with this patient group [17]. In the same year, Betts and Boden reported on a group of 128 patients diagnosed with PNES over a 5-year period [18]. A variety of management strategies were offered; these included anxiety management, abreaction, psychotherapy/counseling, family therapy, and medication (major tranquillizers). At discharge it was reported that 63% (76) of patients no longer had PNES and 24% (29) had a partial resolution; the remainder had either no change or were worse. At 2-year follow up, seizures had returned in 34% (41) and partially returned in 14% [17], while 31% (37) were still seizure free. In 8% [10], the diagnosis of PNES was found to be incorrect. The authors commented that inpatient treatment results may be misleading. Once the patient returns to the community and the stresses that may have led to the attack disorder, PNES may return [18].
Confrontation with diagnosis, psychotherapy, and continuing clinical care were the main components of a study by Buchanan and Snars, who reported that 9 of 32 became seizure free, 11 of 32 significantly improved, and 8 of 32 exhibited no change at all [19]. A later study involved combining neurofeedback with psychotherapy [14]. The author concluded that reductions in the theta/SMR ratio brought about by neurofeedback were associated with reductions in seizure behavior. Swingle also added the use of EEG feedback training. He commented on the absence of a control group and the limitations this puts on the generalizability of his findings.
In their retrospective study, Aboukasm et al. divided 61 patients into four groups: (A) those receiving comprehensive epilepsy program (CEP) psychotherapy; (B) those only under a CEP neurologist’s care; (C) those receiving non-CEP psychotherapy; and (D) those with no feedback or intervention. There were no details about the type of psychotherapy used. The authors reported that Group D had significantly less desirable PNES clinical outcomes than the other three groups and less improvement in quality of life (QOL). They concluded that psychotherapy and feedback by CEP professionals experienced in epilepsy and PNES were beneficial compared with other or no interventions [20]. Rusch et al. described how the psychotherapeutic interventions focused on one of six symptom patterns: acute anxiety/panic; impaired affect regulation and interpersonal skills; somatization/conversion; depression; posttraumatic stress disorder; and reinforced behavior pattern. Patients were treated according to the symptom pattern; for example, those in the acute anxiety/panic group received cognitive therapy with exposure; those in the reinforced behavior pattern group received behavioral management strategies involving family or significant other participation to directly modify reinforcement patterns. Twenty-six of thirty-three patients completed treatment, and of those, 21 were event free by the end of treatment, the remaining 5 showing a significant reduction in frequency [3].
An open-ended group psychotherapy program was published by Zaroff et al. This treatment was given to 10 patients with PNES and included a “disorder-specific psychoeducation treatment component.” Only 7 of the 10 completed the majority of psychoeducational sessions. Seizure frequency was measured pre- and posttreatment. Four patients had no change in seizure frequency, but three of these were seizure free at treatment initiation. Two patients had a reduction in seizure frequency, and one, an increase. The authors concluded that there was a nonsignificant trend toward improved QOL (as measured by the Quality of Life in Epilepsy—31 Inventory [QOLIE-31]). They also note that seizure remission following diagnosis supports the hypothesis that education about the disorder is effective in its treatment [22].
Many of these studies, however, were plagued by methodological difficulties, and none were randomized controlled clinical trials. Randomized controlled clinical trials (RCTs) represent the gold standard for evaluating the clinical effectiveness of treatment. The aim of this article is to systematically review RCTs that have evaluated the outcomes of treatment for patients with PNES. The excluded studies are summarized in Table 1.
The main objectives of the review were to assess whether RCTs of treatments for PNES result in a reduction in frequency of seizures and/or improvement in QOL and to assess if any treatment is significantly more effective than others. Treatments included CBT, hypnotherapy, and paradoxical therapy. Medication trials were not included specifically in this review as our focus was noninvasive, nondrug treatments for PNES. Primary outcome measures were seizure frequency and percentage change in seizure frequency. Secondary outcome measures were QOL and seizure severity measures.
A formal systematic review has been completed as part of The Cochrane Library series.
Section snippets
Methods
Studies were included in the review if they were RCTs or quasi-randomized studies (e.g., where randomization is according to the day of the week or date of birth). The studies may be single or double blind or unblinded. Participants were described as adult male or female with any type of nonorganic PNES, with or without learning disabilities. With respect to interventions, any psychological or behavior modification therapies, such as CBT, relaxation therapy, biofeedback, counseling,
Results
We reported the results of each intervention separately. As only three RCTs were found, no meta-analysis was undertaken, but results for individual studies are given. Results have been tabulated rather than combined in a meta-analysis.
Discussion
This review, in line with previous reviews [3], clearly highlights that there is a lack of well-designed trials to inform treating physicians as to what therapeutic treatments exist and how effective they may be for this condition. An overall theoretical framework for understanding the development of PNES would provide a foundation on which to develop treatment strategies and research protocols. Various frameworks have been proposed in an effort to elucidate the development of PNES. They
Acknowledgments
We are grateful to Dr. Rusch for sending a copy of his article, “Psychogenic Treatment of Nonepileptic Events,” to assist in the preparation of this review.
This article is based on a Cochrane Review published in The Cochrane Library 2007, Issue 2 (see www.thecochranelibrary.com for information). Cochrane Reviews are regularly updated as new evidence emerges and in response to feedback, and The Cochrane Library should be consulted for the most recent version of the review.
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