Evidence-Based Reviews

Psychogenic nonepileptic seizures: Ways to win over skeptical patients

Current Psychiatry. 2008 January;7(1):21-34

References

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6. Szaflarski J, Szaflarski M, Hughes C, et al. Psychopathology and quality of life: psychogenic nonepileptic seizures versus epilepsy. Med Sci Monit 2003;9(4):CR165-70.

7. Reuber M, Pukrop R, Bauer J, et al. Multidimensional assessment of personality in patients with psychogenic non-epileptic seizures. J Neurol Neurosurg Psychiatry 2004;75:743-8.

8. Cragar DE, Berry DT, Schmitt FA, Fakhoury TA. Cluster analysis of normal personality traits in patients with psychogenic nonepileptic seizures. Epilepsy Behav 2005;6:593-600.

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Psychotherapy. A recent review²⁸ found only 3 studies of psychotherapy for PNES treatment—2 assessing hypnosis, 1 examining paradoxical therapy—that were randomized or quasi-randomized. All 3 studies were methodologically poor, and none provided detailed data regarding PNES frequency or severity. A 6-month randomized trial of cognitive-behavioral therapy (CBT) vs family therapy is underway at Rhode Island Hospital; data from this study are not yet available (LaFrance WC, personal communication, November 2007).

Single case reports, case series, and retrospective chart reviews have reported various psychotherapies to be successful for PNES, including CBT, eye movement desensitization and reprocessing, group psychoeducation, group psychotherapy, operant conditioning, occupational therapy, and nonspecific psychotherapy.³²

Psychotherapy for PNES is similar to the pharmacotherapy approach:

Evaluate the patient for comorbid Axis I or Axis II disorders.
Provide evidence-based treatment for those disorders.

Goals of treatment. Despite a lack of systematic trials evaluating psychotherapy for PNES, patients continue to present for treatment. Seizure remission as a treatment goal is debatable and likely unrealistic.³³

Although data supporting any specific PNES treatment are scant, very strong evidence supports treating the most common comorbid illnesses. In our experience, engaging patients in therapy and providing evidence-based treatment for psychiatric comorbidity often reduces PNES and nearly always improves patients’ quality of life (Box 2).

CASE CONTINUED: A rejected diagnosis

Ms. P’s psychotherapy focuses on her tendency to isolation of affect, dysfunctional interpersonal relations, and maladaptive coping. She participates in 5 sessions but has limited insight and never accepts the diagnosis of PNES. She withdraws from therapy after the therapist shares with her results of the psychometric testing and plans for psychiatric treatment.

Related Resources

Clinician resource

LaFrance WC Jr, Kanner AM, Barry JJ. Treating patients with psychological nonepileptic seizures. In: Ettinger AB, Kanner AM, eds. Psychiatric issues in epilepsy: a practical guide to diagnosis and treatment. 2nd ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2007:461-88.

Patient resource

Benbadis SR, Heriaud L. Psychogenic (non-epileptic) seizures. A guide for patients & families. http://hsc.usf.edu/COM/epilepsy/PNESbrochure.pdf.

Drug brand names

Phenytoin • Dilantin
Sertraline • Zoloft
Venlafaxine • Effexor

Disclosure

Drs. Marsh and Benbadis report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Dr. Fernandez receives research support from Cyberonics, Dainippon Sumitomo Pharma, Pfizer, the Florida Department of Elder Affairs, and the National Institutes of Health. He is a speaker for Wyeth.