Psychogenic nonepileptic seizures: Ways to win over skeptical patients
To best help them, clearly explain the diagnosis and treat underlying disorders.
Many patients with psychogenic nonepileptic seizures (PNES) dismiss the idea that their seizures are psychogenic, especially if the correct diagnosis comes after years of treatment for epilepsy.“Neurocognitive impairment: Feigned, exaggerated, or real?”).
Diagnosis is part of treatment
Outcomes in PNES are generally poor: 71% of PNES patients continue to have seizures 4 years after diagnosis, and 56% are dependent on Social Security assistance.2 Neurologic and psychiatric factors associated with poor outcome include:2,10,20,21
- history of epilepsy
- abnormal MRI
- presence of a psychiatric diagnosis
- age >30
- duration of illness (the longer the patient has been treated for epilepsy, the worse the prognosis).
Treatment begins with a secure diagnosis and clear patient communication. Diagnosis alone may be therapeutic. Studies have found that patients have significantly fewer seizures22 and use less medical services23 after PNES diagnosis. One small study, however, found that substantial reductions in PNES frequency are not maintained long term.24
One potentially modifiable factor that appears to affect outcome is whether patients accept the PNES diagnosis.25 Reuber et al2 found approximately 8 out of 10 patients do not. Protocols can help you structure how you present the diagnosis to reduce patient anger and increase acceptance of the diagnosis and treatment (Table 3).26 Explain a PNES diagnosis in unambiguous terms that patients will understand, such as “psychological” and “emotional.”
Physician attitude might negatively impact PNES treatment. Only 18% of psychiatrists report being confident of a PNES diagnosis based on VEEG.27
Successful depression treatment halts this patient’s PNES
Mrs. A, age 31, is referred for psychiatric evaluation by a neurologist who suspects she is having PNES. A teacher and mother of a young child, Mrs. A reports first experiencing a seizure after an argument during which she thought her husband was going to strike her. The neurologist prescribed phenytoin, 900 mg/d.
On clinical examination Mrs. A has moderately severe depressive symptoms. She is angry that the neurologist referred her to a psychiatrist and refuses to discuss the PNES diagnosis.
Mrs. A’s psychiatric history includes recurrent depression that has been treated with antidepressants, although she is not taking an antidepressant at this time. Her psychosocial history is consistent with early developmental deprivation.
The psychiatrist tactfully shares the results of the psychological evaluation with Mrs. A and—at her request—her husband. Both reluctantly agree to the psychiatrist’s recommendations that she begin cognitive-behavioral therapy (CBT) and resume antidepressant therapy with venlafaxine XR, titrated over several weeks to 300 mg/d. They decline couples’ therapy.
Mrs. A understands and accepts the need to treat her depression but refuses to discontinue phenytoin. She doubts the need for CBT and often cancels sessions. As the focus of therapy becomes more supportive, her PNES episodes decrease but are not eliminated, even after her mood improves.
After Mrs. A has been in treatment 14 months, her husband leaves her. Her depression is greatly ameliorated, and her seizures cease. After another 2 months of treatment, the psychiatrist transfers Mrs. A’s care to her primary care physician.
Presenting patients with a diagnosis of PNES
Review the video electroencephalography-recorded seizure with the patient and someone who has witnessed the patient’s previous events to ensure the event was typical
Explain the diagnosis in positive terms (“good news”); emphasize that the seizures are not a result of the brain firing out of control
Acknowledge that the precise cause of the seizures has not yet been established and may not be found
Suggest that in many cases the seizures may be related to psychological factors such as stress or negative emotions
State that the diagnosis does not imply the patient is “crazy”
Suggest that the seizures may resolve on their own
Source: Reference 26
Scant evidence for treatments
A recent review28 found no reliable evidence to support the use of any intervention for persons with nonepileptic seizures. Treatments are based on expert opinion, case reports, and—in some cases—open trials.
Pharmacotherapy. Based on expert opinion, psychopharmacology for patients with only PNES begins with tapering and discontinuing ineffective antiepileptic drugs (AEDs), unless a specific AED has a documented beneficial effect for that patient.29 Treat comorbid mood, anxiety, or psychotic disorders with appropriate psychopharmacologic agents. PNES may be a manifestation of other psychiatric disorders; therefore, treating the predisposing disorder will likely improve PNES. Regardless of PNES outcome, improving comorbid disorders improves PNES patients’ quality of life.21,30
The National Institute of Neurological Disorders and Stroke is supporting a prospective double-blind, placebo-controlled trial of the selective serotonin reuptake inhibitor sertraline for treating PNES. The pilot study of 50 patients with PNES and comorbid depression, anxiety, and impulsivity is expected to be completed in March.31
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.
- 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.
- Benbadis SR, Heriaud L. Psychogenic (non-epileptic) seizures. A guide for patients & families. hsc.usf.edu/COM/epilepsy/PNESbrochure.pdf.
Drug brand names
- Phenytoin • Dilantin
- Sertraline • Zoloft
- Venlafaxine • Effexor
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.
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