ARTICLE IN BRIEF
A form of cognitive behavioral therapy alone produced a 51.4 percent reduction in seizures, as well as improvement in quality of life, social interactions, and comorbidities such as depression and anxiety.
With and without the use of a selective serotonin reuptake inhibitor (SSRI), a form of cognitive behavioral therapy reduced psychogenic non-epileptic seizures (PNES), according to the results of a pilot randomized clinical trial reported in the July 2 online edition of JAMA Psychiatry.
The participants all had a diagnosis confirmed by video EEG telemetry, and they were excluded if the results were equivocal, or if they had any signs of epileptic activity.
In the trial, 38 patients were divided into four groups. One received only sertraline (Zoloft), a common SSRI. Another received only cognitive behavior therapy-informed psychotherapy (CBT-ip), which was devised for this study. A third group received a combination of sertraline and CBT-ip, and a fourth received treatment as usual, which usually involved tapering antiepileptic medication and referral to a psychiatrist or psychologist.
CBT-ip alone produced a 51.4 percent reduction in seizures (p=.01) — the primary outcome measure — as well as improvement in quality of life, social interactions, and comorbidities such as depression and anxiety (p<.001). CBT-ip combined with sertraline produced the largest reduction in seizures — 59.3 percent (p=.08) — as well as improvements in secondary outcome measures, including global functioning (p=.007). Neither sertraline alone nor treatment as usual produced a significant reduction in seizures.
THE CBT TECHNIQUE
The participants received 12 one-hour sessions of CBT-ip from therapists who followed a treatment workbook designed to promote more effective behaviors.
“Before the therapy the participants would communicate only in a passive or an aggressive manner,” said the study's lead author W. Curt LaFrance, Jr., MD, MPH, FAAN, director of neuropsychiatry and behavioral neurology at Rhode Island Hospital, and an assistant professor of psychiatry and neurology at Brown University's Alpert Medical School in Providence, RI. “They learned to practice assertive communication, which improves their relationships with others. Some learned to identify the aura that precedes a seizure so they could take action to avoid it. Some kept a thought record so they could look at their thoughts and moods from a different perspective.”
The CBT-ip also was used to teach mindfulness techniques to patients with a history of trauma and abuse. The patients in this group showed significant reductions in their seizures and improvement in other symptoms, as well as in quality of life.
“It's more than just supportive talk therapy,” said Dr. LaFrance. “I think the power of this version of psychotherapy is that it gets down to the core beliefs, and helps people go from feeling like a victim to feeling empowered, and they take control of their seizures. It's really exciting to see this transformation occur in patients.”
The treatment workbook used in the study, Taking Control of Your Seizures: A Workbook, will be published by Oxford University Press later this year, he added.
OTHER RESEARCH IN PNES
The results reported in JAMA Psychiatry support previous work by Dr. LaFrance and colleagues, as well as a landmark 2010 study led by Lynn H. Goldstein, PhD, a professor of psychology with the Institute of Psychiatry at King's College London, who detected an almost 20 percent decline in seizures among 33 PNES patients who received cognitive behavioral therapy compared with 31 controls who received standard medical treatment only.
Taken together, this recent work suggests the first effective strategy for treating PNES, a puzzling condition that produces seizures, but no detectible EEG evidence of seizure activity in the brain. With the advent of video-EEG telemetry, which provides reliable evidence of PNES, the condition now accounts for 20- to 30-percent of patients referred for refractory seizures, according to Selim R. Benbadis, MD, a professor of neurology at the University of South Florida, and director of the university's Comprehensive Epilepsy Program.
“Right now these patients are caught between psychiatrists, who barely believe in psychogenic non-epileptic seizures, and neurologists, who are not trained in treating the condition,” he said. “If we can provide some evidence that a treatment works, then maybe we will see improvement on the neurology diagnostic side and the mental health treatment side.”
Neurologists can improve treatment of PNES simply by suspecting the condition earlier, Dr. Benbadis said.
“The patient who is diagnosed one or two years after the onset of these seizure-like episodes does much better than the patient who goes 15 years without a diagnosis,” he said. “Sadly, the average delay is currently about seven to ten years. We neurologists can do better by having patients get EEG video monitoring earlier so we can make a diagnosis earlier, instead of just refilling seizure medications.”
In fact, treating PNES with antiepileptic medications often makes the condition worse, according to Dr. Benbadis. If a combination of an SSRI and CBT-pi helps, as the research reported in JAMA Psychiatry suggests, “let's get going with earlier diagnosis and earlier treatment,” he said.
Jon Stone, PhD, FrCP, one of the principal investigators of a multicenter trial in the United Kingdom — www.codestrial.org — comparing CBT with standardized care for PNES, was impressed by the JAMA Psychiatry study, although he expressed some reservations.
“It's a pilot study, so [it is] not really powered to show convincing effects of treatment, but it's nonetheless encouraging that there appeared to be a signal from CBT,” said Dr. Stone, a consultant neurologist and honorary senior lecturer in the department of clinical neurosciences at Western General Hospital of the University of Edinburgh. “To have another randomized trial in this area is very welcome. There have been so few.”
“This trial uses a CBT model in which you don't necessarily have to detect recent stress or address it for seizures to resolve,” Dr. Stone said. “Often the most stressful thing for patients is the fact they have had a seizure, in the same way that someone who has had a panic attack tends to worry most about having another panic attack. Once you have one it becomes a self-perpetuating problem.”
John T. Langfitt, PhD, a neuropsychologist in the School of Medicine and Dentistry at the University of Rochester Medical Center, believes that psychogenic disorders clearly have a physiological basis. Dutch researchers, for example, have shown that patients with non-epileptic seizures have higher levels of cortisol circulating in their blood, especially if they report a history of childhood abuse. Also, fMRI studies of patients who feel numb in half of their body but don't have a clear physical reason for this show that the brain areas that normally register this sensory information are underactive. When the symptoms go away, those brain areas start to respond again.
“When you look at studies like this it's more supportive of the argument that these patients are not faking it to get attention, which is how patients with conversion disorder have been viewed by the medical establishment for a long time,” Dr. Langfitt said. He hopes that studies like the one in JAMA Psychiatry will “begin to educate the public and physicians that these are real diagnoses, that these patients have real problems.”
•. LaFrance WC Jr, Baird GL, Barry JJ, et al. for the NES Treatment Trial (NEST-T) Consortium. Multicenter Pilot Treatment Trial for Psychogenic Nonepileptic Seizures: A randomized clinical trial. JAMA Psychiatry. 2014; Epub 2014 Jul 2.
•. Reiter J, Andrews D, Reiter C, LaFrance WC Jr.. Taking Control of Your Seizures. : A Workbook. New York, NY: Oxford University Press. In press.
•. Goldstein LH, Chalder T, Chigwedere C, et al. Cognitive-behavioral therapy for psychogenic nonepileptic seizures: A pilot RCT. Neurology. 2010; 74:(24):1986–1994.