ARTICLE IN BRIEF
Investigators reported that in patients with psychogenic nonepileptic seizure, cognitive behavior therapy was associated with an almost 2 percent reduction in seizures at the end of treatment.
Patients who experience seizures without any evidence of epilepsy or other underlying neurological condition appear to respond better to cognitive therapy and standard medical care than to medication alone, according to the first randomized study comparing the two approaches.
Researchers in the United Kingdom evaluated seizure activity in 64 patients with psychogenic nonepileptic seizure disorder (PNES), 31 of whom received cognitive behavior therapy (CBT) in addition to standard medical care, and 34 who only received medical treatment. Patients in the standard medical care group received psychoanalysis and supervised withdrawal from antiepileptic drugs (AEDs). Patients in the cognitive behavior therapy met for nine one-hour sessions over four months with therapists who taught them breathing, relaxation, or distraction techniques for responding to the start of a seizure.
CBT was associated with an almost 20 percent reduction in seizures at the end of treatment, and after the first six-months, compared with standard medical care alone.
Lynn H. Goldstein, PhD, professor of psychology at the Institute of Psychiatry, King's College, in London, led the investigative team, whose findings were published in the June 15 issue of Neurology.
All of the subjects had similar demographic and seizure histories at the trial's outset, and most had epilepsy ruled out by video EEG, ictal EEG, or diagnostic consensus.
After adjusting for pre-randomization seizure frequency, there was no difference between the two groups at the start of treatment, but significantly lower seizure frequency at the end.
At baseline, the CBT group had between 12 and 33 seizures per month, and the patients in the standard medical group had between 8 and 30 seizures monthly. But at the end of the treatment, the CBT group had an average of between two and 31 seizures per month, while the standard medical care groups had an average of 6.75 and 30 seizures per month. The CBT group was more likely to be seizure-free six months after treatment (p=0.086), with a 19.5 percent reduction in absolute risk. Risk was defined as not being seizure-free at follow-up.
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“The current study lends weight to the potential contribution of CBT to the management of PNES when compared directly to another treatment,” the authors concluded, although they admitted the study had a number of limitations.
For instance, standard medical care did not control for therapist contact, which was greater in the CBT group, and conducting a blinded study involving psychological treatment was not possible because neuropsychiatrists providing standard medical care had to be informed that a patient was also undergoing CBT. The team was not able to determine if or how this influenced the number or content of standard medical care sessions.
The study was also designed to detect a large treatment effect, yet found only a medium effect size at follow-up. Moreover, in planning the trial, the researchers incorrectly assumed there would be no improvement in the standard medical care group. They also noted that because their center's clinical service is specialized, most patients are referred because they fail to respond to routine interventions in neurology clinics. Because of this, there might have been a selection bias favoring chronic, more difficult-to-treat patients, they said.
Nonetheless, the findings support additional exploration in a larger study, according to the researchers.
Neurology Professor Selim Benbadis, MD, director of the Comprehensive Epilepsy Program at the University of South Florida in Tampa, who was not involved with the study, said: “This study should send a message to psychiatrists who are in denial about these patients. Many of them don't even believe in PNES — they believe these seizures are due to some form of undiagnosed epilepsy.”
“Until now there has been no evidence that behavioral therapy of any kind is effective in PNES or other conversion disorders, so this study is encouraging. I hope many more individuals in the mental health community will now get involved. If we are to get any help with this, it must come from therapists.”
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But A. James Fessler, MD, director of the Strong Epilepsy Center at the University of Rochester Medical Center, Rochester, NY, said neurologists also have an important role in helping such patients.
“Given the results of this study, we, as neurologists, are able to do more than simply convey a diagnosis of psychogenic seizures, but can discuss effective treatment options supported by the literature and steer these patients onto a treatment path with appropriate, psychological follow-up,” he told Neurology Today.
Dr. Benbadis noted in a 2005 paper in the journal Epilepsy and Behavior that “suggestibility is a feature of somatoform disorders at large, and for example, in psychogenic movement disorders, where the diagnosis rests solely on phenomenology (i.e., there is no equivalent of the EEG), response to placebo or suggestion is considered a diagnostic criterion for definite psychogenic mechanism.
“Likewise, in most specialties, response to placebo is the only method that may allow a positive diagnosis of psychogenic symptoms, as opposed to just diagnosis of exclusion,” he wrote.
In addition to being valuable in making diagnoses, suggestibility may also be useful as a treatment, according to Dr. Benbadis, who noted that suggesting a cure often successfully treats acute conversion symptoms.
“Instead of being relegated to last and unlikely possibilities in lists of differential diagnoses, psychogenic symptoms should be the subject of education and research in all specialties,” he wrote. “If PNES are any indication, psychogenic symptoms are very common in patients with atypical and refractory conditions.”
Psychogenic nonepileptic seizure disorder has been described in the medical literature for centuries, yet no class I treatment data has yet been published, noted W. Curt LaFrance, Jr., MD, director of neuropsychiatry and behavioral neurology at Rhode Island Hospital, and assistant professor of neurology and psychiatry (research) at Brown Medical School in Providence, RI, who was not involved with the study.
“Dr. Goldstein and colleagues have added a significant piece to the PNES treatment literature with their pilot randomized controlled trial. That CBT was effective in reducing PNES was not unexpected, as prior open label CBT pilots have demonstrated,” he said in an e-mail to Neurology Today.
“One of the major points of the trial is that it challenges the notion, often taught in neurology, that if you just tell patients that it is not epilepsy, the ‘pseudoseizures’ will go away',” he said.
The small percentage of patients with PNES who have an uncomplicated past history, and no comorbidities, may benefit from simple communication of the diagnosis and referral, Dr. LaFrance explained. “However, clinical practice and the lack of improvement in the standard medical care arm of the study underscore that this population needs more than just ‘treatment as usual.’”