Treatments for non-epileptic attack disorder

Psychosocial interventions for conversion and dissociative disorders in adults

BACKGROUND

Conversion and dissociative disorders are conditions where people experience unusual neurological symptoms or changes in awareness or identity. However, symptoms and clinical signs cannot be explained by a neurological disease or other medical condition. Instead, a psychological stressor or trauma is often present. The symptoms are real and can cause significant distress or problems with functioning in everyday life for the people experiencing them.

OBJECTIVES

To assess the beneficial and harmful effects of psychosocial interventions of conversion and dissociative disorders in adults.

SEARCH METHODS

We conducted database searches between 16 July and 16 August 2019. We searched Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and eight other databases, together with reference checking, citation searching and contact with study authors to identify additional studies.  SELECTION CRITERIA: We included all randomised controlled trials that compared psychosocial interventions for conversion and dissociative disorders with standard care, wait list or other interventions (pharmaceutical, somatic or psychosocial).  DATA COLLECTION AND ANALYSIS: We selected, quality assessed and extracted data from the identified studies. Two review authors independently performed all tasks. We used standard Cochrane methodology. For continuous data, we calculated mean differences (MD) and standardised mean differences (SMD) with 95% confidence interval (CI). For dichotomous outcomes, we calculated risk ratio (RR) with 95% CI. We assessed and downgraded the evidence according to the GRADE system for risk of bias, imprecision, indirectness, inconsistency and publication bias.

MAIN RESULTS

We included 17 studies (16 with parallel-group designs and one with a cross-over design), with 894 participants aged 18 to 80 years (female:male ratio 3:1).  The data were separated into 12 comparisons based on the different interventions and comparators. Studies were pooled into the same comparison when identical interventions and comparisons were evaluated. The certainty of the evidence was downgraded as a consequence of potential risk of bias, as many of the studies had unclear or inadequate allocation concealment. Further downgrading was performed due to imprecision, few participants and inconsistency. There were 12 comparisons for the primary outcome of reduction in physical signs. Inpatient paradoxical intention therapy compared with outpatient diazepam: inpatient paradoxical intention therapy did not reduce conversive symptoms compared with outpatient diazepam at the end of treatment (RR 1.44, 95% CI 0.91 to 2.28; 1 study, 30 participants; P = 0.12; very low-quality evidence). Inpatient treatment programme plus hypnosis compared with inpatient treatment programme: inpatient treatment programme plus hypnosis did not reduce severity of impairment compared with inpatient treatment programme at the end of treatment (MD -0.49 (negative value better), 95% CI -1.28 to 0.30; 1 study, 45 participants; P = 0.23; very low-quality evidence). Outpatient hypnosis compared with wait list: outpatient hypnosis might reduce severity of impairment compared with wait list at the end of treatment (MD 2.10 (higher value better), 95% CI 1.34 to 2.86; 1 study, 49 participants; P < 0.00001; low-quality evidence). Behavioural therapy plus routine clinical care compared with routine clinical care: behavioural therapy plus routine clinical care might reduce the number of weekly seizures compared with routine clinical care alone at the end of treatment (MD -21.40 (negative value better), 95% CI -27.88 to -14.92; 1 study, 18 participants; P < 0.00001; very low-quality evidence). Cognitive behavioural therapy (CBT) compared with standard medical care: CBT did not reduce monthly seizure frequency compared to standard medical care at end of treatment (RR 1.56, 95% CI 0.39 to 6.19; 1 study, 16 participants; P = 0.53; very low-quality evidence). CBT did not reduce physical signs compared to standard medical care at the end of treatment (MD -4.75 (negative value better), 95% CI -18.73 to 9.23; 1 study, 61 participants; P = 0.51; low-quality evidence). CBT did not reduce seizure freedom compared to standard medical care at end of treatment (RR 2.33, 95% CI 0.30 to 17.88; 1 trial, 16 participants; P = 0.41; very low-quality evidence). Psychoeducational follow-up programmes compared with treatment as usual (TAU): no study measured reduction in physical signs at end of treatment. Specialised CBT-based physiotherapy inpatient programme compared with wait list: no study measured reduction in physical signs at end of treatment. Specialised CBT-based physiotherapy outpatient intervention compared with TAU: no study measured reduction in physical signs at end of treatment. Brief psychotherapeutic intervention (psychodynamic interpersonal treatment approach) compared with standard care: brief psychotherapeutic interventions did not reduce conversion symptoms compared to standard care at end of treatment (RR 0.12, 95% CI 0.01 to 2.00; 1 study, 19 participants; P = 0.14; very low-quality evidence). CBT plus adjunctive physical activity (APA) compared with CBT alone: CBT plus APA did not reduce overall physical impacts compared to CBT alone at end of treatment (MD 5.60 (negative value better), 95% CI -15.48 to 26.68; 1 study, 21 participants; P = 0.60; very low-quality evidence). Hypnosis compared to diazepam: hypnosis did not reduce symptoms compared to diazepam at end of treatment (RR 0.69, 95% CI 0.39 to 1.24; 1 study, 40 participants; P = 0.22; very low-quality evidence). Outpatient motivational interviewing (MI) and mindfulness-based psychotherapy compared with psychotherapy alone: psychotherapy preceded by MI might decrease seizure frequency compared with psychotherapy alone at end of treatment (MD 41.40 (negative value better), 95% CI 4.92 to 77.88; 1 study, 54 participants; P = 0.03; very low-quality evidence). The effect on the secondary outcomes was reported in 16/17  studies. None of the studies reported results on adverse effects. In the studies reporting on level of functioning and quality of life at end of treatment the effects ranged from small to no effect.

AUTHORS' CONCLUSIONS

The results of the meta-analysis and reporting of single studies suggest there is lack of evidence regarding the effects of any psychosocial intervention on conversion and dissociative disorders in adults. It is not possible to draw any conclusions about potential benefits or harms from the included studies.

Reliability of reported peri-ictal behavior to identify psychogenic nonepileptic seizures

PURPOSE

Differentiating psychogenic non-epileptic seizures (PNES) from epileptic seizures (ES) can be difficult, even when expert clinicians have video recordings of seizures. Moreover, witnesses who are not trained observers may provide descriptions that differ from the expert clinicians', which often raises concern about whether the patient has both ES and PNES. As such, quantitative, evidence-based tools to help differentiate ES from PNES based on patients' and witnesses' descriptions of seizures may assist in the early, accurate diagnosis of patients.

METHODS

Based on patient- and observer-reported data from 1372 patients with diagnoses documented by video-elect roencephalography (vEEG), we used logistic regression (LR) to compare specific peri-ictal behaviors and seizure triggers in five mutually exclusive groups: ES, PNES, physiologic non-epileptic seizure-like events, mixed PNES plus ES, and inconclusive monitoring. To differentiate PNES-only from ES-only, we retrospectively trained multivariate LR and a forest of decision trees (DF) to predict the documented diagnoses of 246 prospective patients.

RESULTS

The areas under the receiver operating characteristic curve (AUCs) of the DF and LR were 75% and 74%, respectively (empiric 95% CI of chance 37-62%). The overall accuracy was not significantly higher than the naïve assumption that all patients have ES (accuracy DF 71%, LR 70%, naïve 68%, p > 0.05).

CONCLUSIONS

Quantitative analysis of patient- and observer-reported peri-ictal behaviors objectively changed the likelihood that a patient's seizures were psychogenic, but these reports were not reliable enough to be diagnostic in isolation. Instead, our scores may identify patients with "probable" PNES that, in the right clinical context, may warrant further diagnostic assessment.

The impact of receiving a diagnosis of Non-Epileptic Attack Disorder (NEAD): A systematic review

BACKGROUND

Clinicians have reported observations of the immediate cessation of non-epileptic attacks after the diagnosis of NEAD is presented.

OBJECTIVE

The purpose of this systematic review was to examine the impact of receiving a diagnosis of NEAD.

SEARCH STRATEGY

A literature search across the databases Medline, PsycINFO, EMBASE, and CINAHL, and additional hand searching, identified six original studies meeting criteria for the review.

SELECTION CRITERIA

Included studies were original peer-reviewed articles investigating the impact of receiving a diagnosis of NEAD on adult populations with at least one outcome measured pre- and post-diagnosis.

ANALYSIS

The studies were assessed for methodological quality, including biases. This assessment was developed to include criteria specific to research regarding NEAD and diagnosis.

RESULTS

Six identified studies, with a total of 153 NEAD participants, examined the impact of receiving a diagnosis on seizure frequency. Two of the six also examined the impact on health-related quality of life. The findings were inconsistent, with approximately half the participants experiencing seizure reduction or cessation post-diagnosis. Diagnosis appeared to have no significant impact on health-related quality of life. The overall evidence lacked quality, particularly in study design and statistical rigour.

CONCLUSIONS

Mixed results and a lack of high quality evidence were found. Concerns are considered regarding the appropriateness of seizure frequency as the primary outcome measure and the use of epilepsy control groups. Indications for future research include: measuring more meaningful outcomes, using larger samples and power calculations, and ensuring consistent and standard methods for communicating the diagnosis and recording outcomes.

Psychogenic non-epileptic seizures in an Irish tertiary referral centre for epilepsy

Objectives: To examine the prevalence, psychiatric co-morbidity and management of psychogenic non-epileptic seizures (PNES) in patients admitted to a tertiary referral Epilepsy Monitoring Unit (EMU).

Methods: Medical records of patients admitted to the EMU between 2003 and 2005 were examined and data from neurological, neuropsychiatric and neuropsychological assessments were analysed.

Results: Over a three year period 224 patients were referred to the EMU and 44 (20%) were diagnosed with psychogenic non-epileptic seizures (PNES). A total of 13 people (6%) were diagnosed with both PNES and epilepsy. Of those diagnosed with PNES 34 (75%) were referred to psychology services for cognitive behavioural therapy (CBT) and 26 (58%) were followed-up by psychiatry services.

Conclusions: The prevalence rates for PNES and co-existing PNES and epilepsy are consistent with previous reports. Rates of psychiatric co-morbidity were less than would be expected in this clinical population. Clear evidence-based guidelines to manage people with PNES are required.

Closing the Major Gap in PNES Research: Finding a Home for a Borderland Disorder

Psychogenic nonepileptic seizures (PNES) are events commonly encountered by primary care physicians, neurologists, pediatricians, and emergency medicine physicians in their practices, yet there continues to be significant variability in the way they are evaluated, diagnosed, and treated. Lack of understanding this condition and limited data on long-term outcome from current treatment paradigms have resulted in an environment with iatrogenic injury, morbidity, and significant costs to the patient and healthcare system. This article will review the current state of research addressing PNES treatment both in the adult and pediatric populations.

Psychological and behavioural treatments for adults with non-epileptic attack disorder

BACKGROUND

Psychogenic non-epileptic seizures, also known as non-epileptic attack disorder (NEAD), have the outward appearance of epilepsy in the absence of physiological or electroencephalographic correlates. Non-epileptic seizures can occur in isolation or in combination with epileptic seizures. The development and maintenance of non-epileptic seizures has been well documented and there is a growing literature on the treatment of non-epileptic seizures which includes non-psychological (including anti-anxiety and antidepressant pharmacological treatment) and psychological therapies (including cognitive behavioural therapy (CBT), hypnotherapy and paradoxical therapy). Various treatment methodologies have been tried with variable success. The purpose of this Cochrane review was to establish the evidence base for the treatment of non-epileptic seizures with behavioural and psychological therapies only.

OBJECTIVES

To assess whether behavioural or psychological treatments for non-epileptic seizures or NEAD result in a reduction in the frequency of seizures or improvement in quality of life, or both, and whether any treatment is significantly more effective than others.

SEARCH METHODS

We searched the Cochrane Epilepsy Group's Specialised Register (4 February 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 1) (January 2013), MEDLINE (1946 to 4 February 2013), PsycINFO (4 February 2013) and SCOPUS (4 February 2013). No language restrictions were imposed. We checked the reference lists of retrieved studies for additional reports of relevant studies

SELECTION CRITERIA

Randomised controlled trials (RCTs) and before and after controlled and non-controlled studies were eligible for inclusion. Studies were required to assess one or more types of behavioural or psychological interventions, or both, for the treatment of non-epileptic seizures. Studies of childhood non-epileptic seizures were excluded from our review.

DATA COLLECTION AND ANALYSIS

Two review authors (JM, JP) independently assessed the trials for inclusion and extracted data. Outcomes included reduction in seizure frequency and improvements in quality of life.

MAIN RESULTS

Twelve studies, with a total of 343 participants, met our inclusion criteria (four RCTs and eight before and after non-controlled studies). Of the four RCTs, one examined patients with non-epileptic seizures and three had a mixed diagnosis (pseudoseizures, conversion disorder and somatisation disorder). Most of the non-randomised studies used non-epileptic seizure patients exclusively. Overall, five studies examined the effectiveness of psychotherapy, three examined CBT, two investigated hypnosis, one assessed paradoxical intention and one had a mixed intervention design. We classified two included studies as low risk of bias, one as unclear and nine as high risk of bias. Meta-analysis could not be undertaken due to the heterogeneity of design and interventions. Most included studies reported improved outcomes for the intervention under investigation. One RCT investigating the effectiveness of CBT in this patient group found a significant reduction in seizure frequency compared to controls (P < 0.001).

AUTHORS' CONCLUSIONS

There is little reliable evidence to support the use of any treatment, including CBT, in the treatment of non-epileptic seizures. Further randomised controlled trials of CBT and other interventions are needed.

The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-analyses

Cognitive behavioral therapy (CBT) refers to a popular therapeutic approach that has been applied to a variety of problems. The goal of this review was to provide a comprehensive survey of meta-analyses examining the efficacy of CBT. We identified 269 meta-analytic studies and reviewed of those a representative sample of 106 meta-analyses examining CBT for the following problems: substance use disorder, schizophrenia and other psychotic disorders, depression and dysthymia, bipolar disorder, anxiety disorders, somatoform disorders, eating disorders, insomnia, personality disorders, anger and aggression, criminal behaviors, general stress, distress due to general medical conditions, chronic pain and fatigue, distress related to pregnancy complications and female hormonal conditions. Additional meta-analytic reviews examined the efficacy of CBT for various problems in children and elderly adults. The strongest support exists for CBT of anxiety disorders, somatoform disorders, bulimia, anger control problems, and general stress. Eleven studies compared response rates between CBT and other treatments or control conditions. CBT showed higher response rates than the comparison conditions in 7 of these reviews and only one review reported that CBT had lower response rates than comparison treatments. In general, the evidence-base of CBT is very strong. However, additional research is needed to examine the efficacy of CBT for randomized-controlled studies. Moreover, except for children and elderly populations, no meta-analytic studies of CBT have been reported on specific subgroups, such as ethnic minorities and low income samples.

Epilepsy, mental health disorder, or both?

Temporal lobe epilepsy (TLE), a subset of the seizure disorder family, represents a complex neuropsychiatric illness, where the neurological presentation may be complemented by varying severity of affective, behavioral, psychotic, or personality abnormalities, which, in turn, may not only lead to misdiagnosis, but also affect the management. This paper outlines a spectrum of mental health presentations, including psychosis, mood, anxiety, panic, and dissociative states, associated with epilepsy that make the correct diagnosis a challenge.

Prognosis and outcome predictors in psychogenic nonepileptic seizures

It is estimated that one in five patients referred to specialist epilepsy clinics for refractory seizures have psychogenic nonepileptic seizures (PNES). Despite the high prevalence, little is known about the prognosis of patients with PNES. In this paper we set out to systematically assess published original studies on the prognosis and outcome predictors of patients with PNES. Our literature search across the databases Medline, PsycINFO, and EMBASE generated 18 original studies meeting the search criteria. Prognosis was found to be poor in adults, but good in children. Predictors of poor outcome included the presence of coexisting epilepsy or psychiatric comorbidities, violent seizure phenomenology, dependent lifestyle, and poor relationships. Overall, too much reliance is placed on seizure remission as an outcome measurement for patients with PNES, and the impact of many of the outcome predictors requires evaluation using larger studies with longer followup.

Pilot pharmacologic randomized controlled trial for psychogenic nonepileptic seizures

OBJECTIVE

There have been few treatment trials for psychogenic nonepileptic seizures (PNES). Some psychotherapies have been shown to improve PNES and comorbid symptom outcomes. We evaluated a pharmacologic intervention to test the hypothesis that sertraline would reduce PNES.

METHODS

We conducted a pilot, double-blind, randomized, placebo-controlled trial in an academic medical hospital with epilepsy center outpatients. Subjects aged 18 to 65 years diagnosed with video-EEG-confirmed PNES were treated with flexible-dose sertraline or placebo over 12 weeks. Seizure calendars and symptom scales were charted prospectively. Secondary outcome measures included psychiatric symptom scales and psychosocial variables.

RESULTS

Thirty-eight subjects enrolled, and 26 (68%) completed the trial. Thirty-three subjects with nonzero nonepileptic seizure rates at baseline were included in intent-to-treat analysis of the primary outcome. Subjects assigned to the sertraline arm experienced a 45% reduction in seizure rates from baseline to final visit (p = 0.03) vs an 8% increase in placebo (p = 0.78). Secondary outcome scales revealed no significant between-group differences in change scores from baseline to final visit, after adjustment for differences at baseline.

CONCLUSIONS

PNES were reduced in patients treated with a serotonin selective reuptake inhibitor, whereas those treated with placebo slightly increased. This study provides feasibility data for a larger-scale study.

LEVEL OF EVIDENCE

This study provides Class II evidence that flexible-dose sertraline up to a maximum dose of 200 mg is associated with a nonsignificant reduction in PNES rate compared with a placebo control arm (risk ratio 0.51, 95% confidence interval 0.25-1.05, p = 0.29), adjusting for differences at baseline.

Cognitive-behavioral therapy for psychogenic nonepileptic seizures: a pilot RCT

OBJECTIVE

To compare cognitive-behavioral therapy (CBT) and standard medical care (SMC) as treatments for psychogenic nonepileptic seizures (PNES).

METHODS

Our randomized controlled trial (RCT) compared CBT with SMC in an outpatient neuropsychiatric setting. Sixty-six PNES patients were randomized to either CBT (plus SMC) or SMC alone, scheduled to occur over 4 months. PNES diagnosis was established by video-EEG telemetry for most patients. Exclusion criteria included comorbid history of epilepsy, <2 PNES/month, and IQ <70. The primary outcome was seizure frequency at end of treatment and at 6-month follow-up. Secondary outcomes included 3 months of seizure freedom at 6-month follow-up, measures of psychosocial functioning, health service use, and employment.

RESULTS

In an intention-to-treat analysis, seizure reduction following CBT was superior at treatment end (group x time interaction p < 0.0001; large to medium effect sizes). At follow-up, the CBT group tended to be more likely to have experienced 3 months of seizure freedom (odds ratio 3.125, p = 0.086). Both groups improved in some health service use measures and on the Work and Social Adjustment Scale. Mood and employment status showed no change.

CONCLUSIONS

Our findings suggest that cognitive-behavioral therapy is more effective than standard medical care alone in reducing seizure frequency in PNES patients.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that CBT in addition to SMC, as compared to SMC alone, significantly reduces seizure frequency in patients with PNES (change in median monthly seizure frequency: baseline to 6 months follow-up, CBT group, 12 to 1.5; SMC alone group, 8 to 5).

Depression and symptoms affect quality of life in psychogenic nonepileptic seizures

BACKGROUND

In patients with active epilepsy, adverse medication effects and severity of depression are correlated with health-related quality of life, but seizure frequency is not. We sought to examine if the same pattern exists in patients with psychogenic nonepileptic seizures (PNES).

METHODS

We administered seizure calendars, quality of life (QOL) scales, depression scales, and symptom checklists to 49 patients with video EEG-confirmed PNES. Data analysis consisted of performing Pearson correlation coefficients, scatter plots, and t tests.

RESULTS

Depression and symptom scores significantly increased as health-related QOL scores decreased (partial correlation coefficient r = -0.73 for both comparisons), whereas seizure count was nonsignificant (partial correlation coefficient r = -0.19).

CONCLUSIONS

As is seen in epilepsy, patients with psychogenic nonepileptic seizures demonstrate that higher depressive symptoms and somatic symptoms are independently related to worsening quality of life (QOL); however, seizure frequency is not. Seizure frequency is an important focus in patient care and treatment trials. The findings underscore the importance of, along with seizure counts, also examining QOL, depression, and somatic symptoms in patients with seizures.

Psychogenic nonepileptic seizures

Neurological, neurodiagnostic, and neuropsychological aspects of psychogenic nonepileptic seizures (PNES) are reviewed, including psychosocial, psychiatric, cognitive, and MMPI-2 findings.