Prolonged exposure therapy for the treatment of patients diagnosed with psychogenic non-epileptic seizures (PNES) and post-traumatic stress disorder (PTSD)

A meta-analytic evaluation of the effectiveness and durability of psychotherapy for adults presenting with functional dissociative seizures

BACKGROUND

Psychological interventions are the most recommended treatment for functional/dissociative seizures (FDS); however, there is ongoing uncertainty about their effectiveness on seizure outcomes.

METHODS

This systematic review and meta-analysis synthesises the available data. In February 2023, we completed a systematic search of four electronic databases. We described the range of seizure-related outcomes captured, used meta-analytic methods to analyse data collected during treatment and follow-up; and explored sources of heterogeneity between outcomes.

RESULTS

Overall, 44 relevant studies were identified involving 1,300 patients. Most were categorised as being at high (39.5 %) or medium (41.9 %) risk of bias. Seizure frequency was examined in all but one study; seizure intensity, severity or bothersomeness in ten; and seizure duration and cluster in one study each. Meta-analyses could be performed on seizure freedom and seizure reduction. A pooled estimate for seizure freedom at the end of treatment was 40 %, while for follow-up it was 36 %. Pooled rates for ≥50 % improvement in seizure frequency were 66 % and 75 %. None of the included moderator variables for seizure freedom were significant. At the group level, seizure frequency improved during the treatment phase with a moderate pooled effect size (d = 0.53). FDS frequency reduced by a median of 6.5 seizures per month. There was also evidence of improvement of the other (non-frequency) seizure-related measures with psychological therapy, but data were insufficient for meta-analysis.

CONCLUSIONS

The findings of this study complement a previous meta-analysis describing psychological treatment-associated improvements in non-seizure-related outcomes. Further research on the most appropriate FDS-severity measure is needed.

Nocebo Hypothesis Cognitive Behavioural Therapy (NH-CBT) for non-epileptic seizures: a consecutive case series

BACKGROUND

Research has demonstrated that implementation of Nocebo Hypothesis Cognitive Behavioural Therapy (NH-CBT) achieved full symptom remission in 93% of people with Functional Neurological Symptoms Disorder (FNSD), most of them exhibiting motor symptoms. The basis for NH-CBT is consistent with a predictive coding aetiological model of FNSD. This idea is transparently shared with people with FNSD in the form of telling them that their symptoms are caused by a nocebo effect, usually followed by some physical activity that aims to change the person's belief about their body.

AIMS

To demonstrate that a version of NH-CBT can also be effective in eliminating or reducing non-epileptic seizures (assumed to be a sub-type of FNSD).

METHOD

A consecutive case series design was employed. Participants were treated with NH-CBT over a 12-week period. The primary outcome measure was seizure frequency. Numerous secondary measures were employed, as well as a brief qualitative interview to explore participants' subjective experience of treatment.

RESULTS

Seven out of the 10 participants became seizure free at least 2 weeks before their post-treatment assessment, and all stayed seizure-free for at least 5 months. Six of those seven remained seizure free at 6-month follow-up. There were large positive effect sizes for the majority of secondary measures assessed.

CONCLUSIONS

This case series provides evidence of feasibility and likely utility of NH-CBT in reducing the frequency of non-epileptic seizures.

Psychogenic Nonepileptic Seizures Associated with an Eating Disorder and PTSD Are Responsive to Cognitive Processing Therapy

Objective

Eating disorders (EDs) are often associated with prior histories of trauma, subsequent PTSD and related psychiatric comorbidities. There is a paucity of information about their relationship to somatic symptom disorders, specifically psychogenic nonepileptic seizures (PNES), a type of functional neurological symptom disorder or conversion disorder.

Methods

We report a case of a 39-year-old bisexual female with bulimia nervosa (BN), PTSD, recurrent major depressive disorder (MDD), cannabis use disorder, and PNES who responded to integrated trauma-focused treatment during residential ED treatment using cognitive processing therapy (CPT). Symptoms of ED, PTSD, major depression, and state-trait anxiety were measured using validated assessment instruments.

Results

During the course of CPT treatment, the patient's total scores on the PTSD Symptom Checklist for DSM-5 (PCL-5) went from 59 to 26, which is below the diagnostic threshold for PTSD. In addition, she demonstrated improvements in the Eating Disorder Examination Questionnaire (EDE-Q) Global Severity score, the Eating Disorder Inventory (EDI-2) total score, the Patient Health Questionnaire (PHQ-9) total score, the Spielberger State and Trait Anxiety Inventory scores, and the Eating Disorder Quality of Life (EDQOL) total score. Furthermore, her PNES also abated, and she remained seizure free for ∼1 year following discharge with the exception of one short seizure, per report of the patient.

Conclusion

The use of CPT as part of an integrated trauma-informed treatment approach during residential ED treatment was successful in a woman with PNES, BN, PTSD, MDD, and cannabis use disorder.

The feasibility and preliminary efficacy of narrative exposure therapy on post-traumatic stress disorder among Syrian refugees in Jordan

Objectives

Post-traumatic stress disorder (PTSD), anxiety, and depression are common mental health disorders among refugees, and all require immediate mental health support to prevent short- and long-term detrimental health outcomes. The purpose of this study was to evaluate the feasibility and preliminary efficacy of narrative exposure therapy (NET) in reducing symptoms of PTSD, depression, and anxiety among Syrian refugees residing in Jordan.

Methods

A two-arm randomized control trial was utilized. A total of 40 Syrian refugees aged 18 to 64 diagnosed with PTSD were randomly allocated to either the NET intervention group (n = 20) or the waitlist control group (n = 20) using a computer-generated allocation list with 1:1 allocation. PTSD symptoms were evaluated using the Arabic rendition of the Harvard Trauma Questionnaire, while depression and anxiety symptoms were appraised using the Arabic adaptation of the Hopkins Symptoms Checklist-25. Descriptive statistics were employed to characterize the sample and survey data. Independent t-tests were conducted to assess mean score differences in PTSD, anxiety, and depression between the intervention and control groups.

Results

Post NET intervention, significant reductions in PTSD (t = -10.00, P < 0.001), anxiety (t = -9.46, P < 0.001), and depression (t = -6.00, P < 0.001) scores were observed in the intervention group compared to the control group. Effect sizes were moderate for the trauma (Cohen's d = 0.73) and depression (Cohen's d = 0.79) symptoms and notably large for anxiety symptoms (Cohen's d = 0.97). There were no adverse events related to study participation. The intervention achieved a 100% participant retention rate.

Conclusions

The results pertaining to retention rate, adherence to the study protocol, data completeness, cultural congruence, and participants' satisfaction provided strong support for the future implementation of the full-scale RCT. NET may be a feasible and helpful approach for refugees and other patients with PTSD, anxiety, and depression.

Functional Neurologic Disorders, disorders to be managed by neurologists, or are neurologists wandering in a dangerous field with inadequate resources?

In recent years, some neurologists reconsidered their approach to Medically Unexplained Symptoms and proposed Functional Neurologic Disorders (FND) as a new entity, claiming that neurology could offer alternative treatment options to the psychotherapies provided in psychiatry settings. FNDs, for this purpose, should include only the disorders listed as Conversion from the Somatic Symptom and Related Disorders (SSRD) group. The present review analyzes the rationale of this position and challenges the arguments provided for its support. The review also discusses the systematization of these disorders as provided by public health systems. It outlines risks stemming from economic support and public funding uncertainty, given their negligible epidemiological dimensions resulting from the parcellation of SSRD. The review underlines the unresolved issue of Factitious Disorders, which are in the same SSRD category of the international classification but are, nonetheless, overlooked by the theoretical proponents of the FND entity. Comorbidity with other psychiatric disorders is also analyzed. We propose a model that supports the continuum between different SSRD conditions, including Factitious Disorders. The model is based on the emergence of feigned death reflex and deception from frontal lobe dysfunction. Finally, the paper summarizes the wealth of historical psychiatric and psychodynamic approaches and critical reviews. The study also puts in context the categorization and interpretation efforts provided by the most eminent researchers of the past century.

The clinical management of functional neurological disorder: A scoping review of the literature

OBJECTIVE

To date, there have been no reviews bringing together evidence on the clinical management of functional neurological disorder (FND) and patients', caregivers', and healthcare workers' experiences. This review provides an overview of the literature focused on the clinical management of FND.

METHODS

Four databases were searched, and a consultation exercise was conducted to retrieve relevant records dated from September 2010 to September 2020. Articles documenting diagnostic methods, treatments or interventions, or the experiences and perspectives of patients and healthcare workers in the clinical management of FND were included.

RESULTS

In total, 2756 records were retrieved, with 162 included in this review. The diagnostic methods reported predominantly included positive clinical signs, v-EEG and EEG. Psychological treatments and medication were the most reported treatments. Mixed findings of the effectiveness of CBT were found. Haloperidol, physiotherapy and scripted diagnosis were found to be effective in reducing FND symptoms. Several facilitators and barriers for patients accessing treatment for FND were reported.

CONCLUSION

The literature describing the clinical management for FND has increased considerably in recent times. A wide variety of diagnostic tools and treatments and interventions were found, with more focus being placed on tests that confirm a diagnosis than 'rule-out' tests. The main treatment type found in this review was medication. This review revealed that there is a lack of high-quality evidence and reflects the need for official clinical guidelines for FND, providing healthcare workers and patients the support needed to navigate the process to diagnose and manage FND.

Childhood trauma in patients with epileptic vs nonepileptic seizures

OBJECTIVE

Childhood trauma has been implicated as a risk factor for the etiology of psychogenic nonepileptic seizures (PNES). Relatively little attention has been paid to whether profiles of specific trauma types differ between patients with epilepsy and PNES. Investigating childhood trauma profiles in these patient groups may identify psychological vulnerabilities that predispose to developing PNES, and aid early diagnoses, prevention, and treatment.

METHODS

Data were collected from two cohorts (n_{Retrospective}  = 203; n_Prospective  = 209) admitted to video-electroencephalography (EEG) monitoring units in Melbourne Australia. The differences in Childhood Trauma Questionnaire domain score between patient groups were investigated using standardized effect sizes and general linear mixed-effects models (GLMMs). Receiver-operating characteristic curves were used to investigate classification accuracy.

RESULTS

In the retrospective cohort, patients diagnosed with PNES reported greater childhood emotional abuse, emotional neglect, physical abuse, sexual abuse, and physical neglect relative to patients with epilepsy. These differences were replicated in the prospective cohort, except for physical abuse. GLMMs revealed significant main effects for group in both cohorts, but no evidence for any group by domain interactions. Reported sexual abuse showed the best screening performance of PNES, although no psychometric scores were adequate as isolated measures.

SIGNIFICANCE

Patients with PNES report a greater frequency of childhood trauma than patients with epilepsy. This effect appears to hold across all trauma types, with no strong evidence emerging for a particular trauma type that is more prevalent in PNES. From a practical perspective, inquiry regarding a history of sexual abuse shows the most promise as a screening measure.

Nonpharmacologic Interventions and Seizure Frequency in Patients With Psychogenic Nonepileptic Seizures: An Integrative Review

BACKGROUND

Psychogenic nonepileptic seizures (PNES) pose a heavy burden on patients' lives and the health care system. The symptoms of PNES are often debilitating and cause high rates of disability and poor quality of life. Many treatment options are available, but there is no clear consensus on best practices.

AIM

To critique and synthesize the current literature on nonpharmacologic interventions and effects on seizure frequency in patients with PNES.

METHODS

An integrative review guided by the Whittemore and Knafl approach.

RESULTS

The review included 24 studies published from 2010 to 2020. Interventions for PNES included individualized psychotherapies, group therapies, multimodal psychotherapies, self-help therapies, and complementary and alternative medicine therapies. Individual psychotherapies such as cognitive behavioral therapy and psychoeducation were the most used treatment modalities. The most effective treatments for seizure frequency reduction were those that included multiple psychotherapy sessions with a health care provider and covered multiple domains (e.g., understanding of diagnosis, identifying triggers, and developing effective coping strategies).

CONCLUSIONS

Seizure frequency can be reduced in patients with PNES with multiple nonpharmacologic interventions. However, seizure frequency is not considered a comprehensive outcome measure and provides little insight into other important life domains. Further research is needed on nonpharmacologic interventions for PNES and effects on other areas of life such as sleep, employment status, global functioning, and self-efficacy.

Prolonged Exposure Therapy in the Treatment of Functional Neurological Disorder and Posttraumatic Stress Disorder

Functional neurological disorder (FND) symptoms resemble neurological symptoms but are unexplained by disease or injury to the body. Psychological trauma and posttraumatic stress disorder (PTSD) are prevalent among patients with FND. This is a case report of a 64-year-old female who began treatment 2 years after developing PTSD, generalised anxiety disorder, major depressive disorder and agoraphobia following a physical assault. She subsequently developed FND approximately 18 months later. Her FND symptomology was characterised by aphasia and paraplegia. These symptoms usually lasted for a period of hours to days and usually occurred on a weekly basis. She had not previously engaged in psychological therapy due to limited insight into the relationship between her psychological and physiological symptomology. She was treated with Prolonged Exposure for PTSD (PE), and by the last session, she no longer met the diagnostic criteria for either FND or PTSD disorder. PE successfully treated both PTSD and FND. Theoretical understandings of the mechanisms underpinning this improvement are discussed.

Functional neurological disorder: new subtypes and shared mechanisms

Functional neurological disorder is common in neurological practice. A new approach to the positive diagnosis of this disorder focuses on recognisable patterns of genuinely experienced symptoms and signs that show variability within the same task and between different tasks over time. Psychological stressors are common risk factors for functional neurological disorder, but are often absent. Four entities-functional seizures, functional movement disorders, persistent perceptual postural dizziness, and functional cognitive disorder-show similarities in aetiology and pathophysiology and are variants of a disorder at the interface between neurology and psychiatry. All four entities have distinctive features and can be diagnosed with the support of clinical neurophysiological studies and other biomarkers. The pathophysiology of functional neurological disorder includes overactivity of the limbic system, the development of an internal symptom model as part of a predictive coding framework, and dysfunction of brain networks that gives movement the sense of voluntariness. Evidence supports tailored multidisciplinary treatment that can involve physical and psychological therapy approaches.

Psychotherapeutic Tools to Enhance the Neurologist-Patient Interaction

Despite providing care for patients with "disturbances of the same organ," the brain, the therapeutic approaches used by neurologists and psychiatrists are, to some extent, distinct. With recognition of the closely coupled relationship between physical health and mental health, there is increased awareness of the need to provide an integrated, neuropsychiatric approach to the care of patients in neurology. In this review article, we provide a broad overview of how neurologists can use psychotherapeutic principles to enhance patient-physician interactions in the neurological setting (e.g., developing a therapeutic alliance; frame/boundary setting; active, empathic listening; acknowledging affect). These practices relate to a broad range of conditions, including, but not necessarily limited to epilepsy, traumatic brain injury, and functional neurological (conversion) disorder. The authors provide practical approaches that a neurologist can learn to leverage psychotherapeutic tools to enhance clinical encounters.

Neuropsychiatric Treatment Approaches for Functional Neurological Disorder: A How to Guide

There is a growing body of knowledge regarding management of functional neurological disorder (FND). The aim of this article is to guide the clinician through FND clinical management, from delivery of the diagnosis, to creation of a biopsychosocially-informed treatment plan, to troubleshooting common issues that arise throughout longitudinal care. We review the evidence and core principles of both rehabilitative therapies (physical therapy, occupational therapy, and speech and language therapy) and psychological therapies for the treatment of FND, and discuss the benefits of engaging a multidisciplinary and interdisciplinary team. The optimal timing of specific therapeutic interventions is also discussed, emphasizing a patient-centered perspective. Resources for further reading, for both patients and clinicians, are provided throughout. Additional research is needed to further optimize the therapeutic approach to patients with FND, including the need to develop novel treatments for those that do not positively respond to currently available interventions.

Diagnosis and management of functional neurological disorder

Functional neurological disorder (FND), previously regarded as a diagnosis of exclusion, is now a rule-in diagnosis with available treatments. This represents a major step toward destigmatizing the disorder, which was often doubted and deemed untreatable. FND is prevalent, generally affecting young and middle aged adults, and can cause severe disability in some individuals. An early diagnosis, with subsequent access to evidence based rehabilitative and/or psychological treatments, can promote recovery-albeit not all patients respond to currently available treatments. This review presents the latest advances in the use of validated rule-in examination signs to guide diagnosis, and the range of therapeutic approaches available to care for patients with FND. The article focuses on the two most frequently identified subtypes of FND: motor (weakness and/or movement disorders) and seizure type symptoms. Twenty two studies on motor and 27 studies on seizure type symptoms report high specificities of clinical signs (64-100%), and individual signs are reviewed. Rehabilitative interventions (physical and occupational therapy) are treatments of choice for functional motor symptoms, while psychotherapy is an emerging evidence based treatment across FND subtypes. The literature to date highlights heterogeneity in responses to treatment, underscoring that more research is needed to individualize treatments and develop novel interventions.

Attachment style of patients diagnosed with psychogenic non-epileptic seizures at a tertiary Epilepsy Center in the Czech Republic

OBJECTIVE

Quality and type of early relationships with primary caregivers is considered one of the key factors in the etiopathogenesis of many mental disorders including depression, anxiety, and conversion disorders. This study focused on the type and quality of attachment style in adult patients with psychogenic non-epileptic seizures (PNES).

MATERIALS AND METHODS

We evaluated the demographic data and profiles of PNES patients (n = 262) and group of healthy volunteers (n = 51) measured by the Parental Bonding Inventory (PBI) and Experiences in Close Relationships (ECR) and Experiences in Close Relationships-Relationship Structure (ECR-RS).

RESULTS

Significant differences in measured values between the two groups were identified; specifically, differences in the caregiver style-father and mother overprotection (PBI) was higher in the PNES group. The most frequent type of attachment in PNES was type 2 (preoccupied). Correlations between the PBI and ECR results were also found.

CONCLUSION

This study highlighted certain attachment styles in patients with PNES and statistically significant differences between patients with PNES and a healthy sample. Some correlations between the results of the questionnaires with socio-demographic factors were found. The identification of specific patterns in attachment may be useful for further use in reaching a differential diagnosis and administering tailored psychotherapy of patients with PNES.

Toward a possible trauma subtype of functional neurological disorder: Impact on symptom severity and physical health

BACKGROUND

As a group, individuals with functional neurological disorder (FND) report an approximately 3-fold increase in adverse life experiences (ALEs) compared to healthy controls. In patients with FND, studies have identified a positive correlation between symptom severity and the magnitude of ALEs. While not all individuals with FND report ALEs, such findings raise the possibility of a trauma-subtype of FND.

OBJECTIVE

This study investigated if patients with FND, with or without probable post-traumatic stress disorder (PTSD) and/or significant childhood maltreatment, differed in their symptom severity and physical health.

MATERIALS AND METHODS

Seventy-eight patients with FND were recruited (functional seizures, n = 34; functional movement disorder, n = 56). Participants completed self-report measures of symptom severity [Somatoform Dissociation Questionniare-20 (SDQ-20), Screening for Somatoform Disorders: Conversion Disorder subscale (SOMS:CD), Patient Health Questionniare-15 (PHQ-15)], physical health [Short Form Health Survey-36 (SF36-physical health)], childhood maltreatment [Childhood Trauma Questionnaire (CTQ)], and PTSD [PTSD Checklist-5 (PCL-5)]; a psychometric battery of other common predisposing vulnerabilities was also completed. To adjust for multiple comparisons, a Bonferroni correction was applied to all univariate analyses.

RESULTS

Patients with FND and probable PTSD (n = 33) vs. those without probable PTSD (n = 43) had statistically significant increased scores on all symptom severity measures - as well as decreased physical health scores. In secondary post-hoc regression analyses, these findings remained significant adjusting for age, sex, race, college education, and: pathological dissociation; alexithymia; attachment styles; personality characteristics; resilience scores; functional seizures subtype; or moderate-to-severe childhood abuse and neglect scores; SOMS:CD and SDQ-20 findings also held adjusting for depression and anxiety scores. In a separate set of analyses, patients with FND and moderate-to-severe childhood abuse (n = 46) vs. those without moderate-to-severe childhood abuse (n = 32) showed statistically significant increased SDQ-20 and PHQ-15 scores; in post-hoc regressions, these findings held adjusting for demographic and other variables. Stratification by childhood neglect did not relate to symptom severity or physical health scores.

CONCLUSION

This study provides support for a possible trauma-subtype of FND. Future research should investigate the neurobiological and treatment relevance of a FND trauma-subtype, as well as continuing to delineate clinical characteristics and mechanisms in individuals with FND that lack a history of ALEs.

Psychogenic non-epileptic seizures: Chronology of multidisciplinary team approach to diagnosis and management

While the diagnosis and management of psychogenic non-epileptic seizures (PNES) remain challenging, certain evidence-based guidelines exist, which can help to optimize patient care. A multidisciplinary team approach appears to have many benefits. Current recommendations exist for some aspects of diagnosis and management of PNES, including levels of diagnostic certainty as proposed by the International League Against Epilepsy's expert Task Force on PNES. Other aspects of clinical still care lack clear consensus, including use of suggestion techniques for recording PNES and optimal terminology, since the term "functional seizures" has recently been proposed as a possible term to replace "PNES". The present article aims to (1) review current recommendations and (2) discuss our own team's experience in managing patients with PNES. This is organized chronologically in terms of the roles of the neurologist, psychiatrist and psychologist, and discusses diagnostic issues, psychiatric assessment and treatment, and psychotherapeutic approaches.

Evidence-Based Practice for the Clinical Assessment of Psychogenic Nonepileptic Seizures: A Report From the American Neuropsychiatric Association Committee on Research

The American Neuropsychiatric Association's Committee on Research assigned the task of defining the most helpful clinical factors and tests in establishing the diagnosis of psychogenic nonepileptic seizures (PNES) during a neuropsychiatric assessment. A systematic review of the literature was conducted using three search engines and specified search terms for PNES and the predetermined clinical factors and diagnostic tests, followed by a selection process with specific criteria. Data extraction results from selected articles are presented for clinical factors (semiology, psychiatric comorbidities, medical comorbidities, psychological traits) and diagnostic tests (EEG, psychometric and neuropsychological measures, prolactin level, clinical neuroimaging, autonomic testing). Semiology with video EEG (vEEG) remains the most valuable tool to determine the diagnosis of PNES. With the exception of semiology, very few studies revealed the predictive value of a clinical factor for PNES, and such findings were isolated and not replicated in most cases. Induction techniques, especially when coupled with vEEG, can lead to a captured event, which then confirms the diagnosis. In the absence of a captured event, postevent prolactin level and personality assessment can support the diagnosis but need to be carefully contextualized with other clinical factors. A comprehensive clinical assessment in patients with suspected PNES can identify several clinical factors and may include a number of tests that can support the diagnosis of PNES. This is especially relevant when the gold standard of a captured event with typical semiology on vEEG cannot be obtained.

Using evidence-based psychotherapy to tailor treatment for patients with functional neurological disorders

Functional neurological disorder (FND) frequently presents with comorbid psychopathology (e.g., anxiety, depressive, post-traumatic stress disorders (PTSD), somatic symptom and pain syndromes, and dissociative and personality disorders). It can become chronic and lead to unemployment and disability for many patients. Psychosocial factors play an important role in the onset and perpetuation of symptoms. Consequently, psychotherapy is recommended for the treatment of FND in general, and especially for the single symptom-based subtype of functional seizures (FS). Some of the psychotherapy approaches that have been utilized for FND include cognitive-behavioral therapy (CBT), third wave approaches, and psychodynamic psychotherapies as well as group therapeutic and psychoeducational interventions. For patients with FS and PTSD, prolonged exposure therapy, a CBT-based treatment has been implemented. The purpose of this manuscript is to describe and analyze specific elements (e.g., theoretical foundations, tools, targets, definitions of success) of the main psychotherapeutic approaches used in patients with FND. Our premise is that these modalities will overlap considerably in some respects. We will conclude by discussing how discrete differences may render them more suitable for subgroups of patients with FND or for patients at different timepoints of their recovery process.

A brief cognitive-behavioural treatment approach for PTSD and Dissociative Identity Disorder, a case report

BACKGROUND AND OBJECTIVES

We described a new treatment model for Posttraumatic Stress Disorder (PTSD) and Dissociative Identity Disorder (DID), based on cognitive-behavioural principles. In this model, dissociation is seen as a maladaptive avoidant coping strategy. In addition, we stress that patients have dysfunctional beliefs about dissociation. Both elements, avoidance behaviour and dysfunctional beliefs, are challenged during the brief, intensive trauma-focused treatment. When the PTSD-symptoms decrease, the patient is offered a fare-well ritual to say goodbye to their identities in one or more additional sessions.

METHODS

We illustrate this treatment approach with a case report of a woman with PTSD as a result of sexual abuse in her childhood, and DID with four identities. Treatment outcome was measured at intake, at pre-treatment, at post-treatment and at 3 and 6 months follow-up.

RESULTS

After the short treatment of only 2 weeks, she no longer fulfilled the DSM-5 diagnostic criteria for PTSD nor DID. These results were maintained at the follow-ups.

LIMITATIONS

Although we included a baseline-controlled time phase, it was not a controlled study, and only one patient was treated.

CONCLUSIONS

This new treatment model for DID-patients is promising but results should be interpreted cautiously since we described only one patient.

Posttraumatic Stress Disorder and Persistent Somatic Symptoms During the COVID-19 Pandemic: The Role of Sense of Threat

OBJECTIVE

Persistent somatic symptoms, such as pain and fatigue, have been referred to as somatization. Somatization is commonly associated with histories of trauma and posttraumatic stress disorder (PTSD). Although previous research has demonstrated that PTSD can predict somatic problems, there has been no examination of this at the level of PTSD symptom clusters and multidimensional assessment of somatic symptoms. We examined the association between the three International Classification of Disease (11th Edition) PTSD symptom clusters (reexperiencing in the here and now, avoidance, and sense of threat), measured in relation to the COVID-19 pandemic as the stressor, and somatic symptoms while statistically adjusting for confounding variables.

METHODS

Participants were a nationally representative sample of 1041 adults from the general population of the Republic of Ireland. Physical health problems across the domains of pain, gastrointestinal, cardiopulmonary, and fatigue were assessed by the Patient Health Questionnaire, and PTSD symptoms were assessed using the International Trauma Questionnaire.

RESULTS

Sense of threat was associated with the presence of pain (β = 0.254), fatigue (β = 0.332), gastrointestinal (β = 0.234), and cardiovascular symptoms (β = 0.239). Avoidance was associated with pain (β = 0.347). Reexperiencing was not associated with any physical health variable.

CONCLUSIONS

In the context of COVID-19, the sense of threat symptoms in PTSD is most strongly related to somatic problems. Findings suggest that interventions addressing sense of threat symptoms might provide relief from somatization.

Somatoform Dissociative Symptoms Have No Impact on the Outcome of Trauma-Focused Treatment for Severe PTSD

For patients with complex or other severe forms of PTSD, particularly in cases with dissociative symptoms, different treatment approaches have been suggested. However, the influence of somatoform dissociation on the effectiveness of trauma-focused treatment has hardly ever been studied. This study aims to test the hypotheses that (1) PTSD patients reporting a low level and those reporting a high level of somatoform dissociative symptoms would both benefit from an intensive trauma-focused treatment, and that (2) somatoform dissociative symptoms would alleviate. Participants were 220 patients with severe PTSD, enrolled in an intensive treatment program combining EMDR therapy and prolonged exposure therapy, without a preceding stabilization phase. Trauma history was diversified, and comorbidity was high. PTSD symptoms (CAPS-5 and PCL-5) and somatoform dissociative symptoms (SDQ-5 and SDQ-20) were assessed at pre-treatment, post-treatment and at six months after completion of treatment. The course of both PTSD and somatoform dissociative symptoms was compared for individuals reporting low and for those reporting high levels of somatoform dissociative symptoms. Large effect sizes were observed regarding PTSD symptoms reduction for patients with both low and high levels of somatoform dissociation. Somatoform dissociation did not impact improvement in terms of PTSD symptom reduction. The severity of somatoform dissociative symptoms decreased significantly in both groups. This decrease was greater for those with a positive screen for a dissociative disorder. These results add further support to the notion that the presence of strong somatoform dissociative symptoms in patients with PTSD does not necessarily call for a different treatment approach. Clinical implications are discussed.

Psychogenic Nonepileptic Seizures and Psychosocial Management: A Narrative Review

Psychogenic non-epileptic seizure (PNES) is a common disorder that imitates epileptic seizures and has its etiological roots in psychological distress. Due to its “epileptic” similarity, it is often dealt with not only by mental health professionals but also by physicians, pediatricians and neurologists. There is a growing consensus towards the psychotherapeutic treatment of the disorder, albeit a lack of clarity in choosing a gold-standard approach. This paper seeks to serve as a compendium of different psychotherapeutic approaches and their efficacy in the management of PNES. The paper employed the search strategy by selecting the keywords: “Psychogenic Non-Epileptic Seizures (PNES) and psychosocial management”, “PNES Treatment approach”, “PNES and psychotherapy” in PUBMED, EBSCO host, PsycINFO, and SCOPUS database. Eventually, specific therapies were cross-searched with PNES for an exhaustive review. Several studies were found employing various psychotherapeutic approaches for the treatment of PNES in pilot studies, randomized controlled, or open uncontrolled trials. Cognitive Behavior Therapy was demonstrated as an efficacious treatment for PNES in a randomized controlled trial (RCT). Other approaches that were effective in ameliorating the symptoms were psychodynamic therapies or psychoeducation based group therapies. Some therapies like Novel Integrative psychotherapy, Eye Movement Desensitisation Therapy and Mindfulness-based therapies require further exploration in larger clinical trials. The findings demonstrate that psychological intervention for PNES is a promising alternative treatment approach with a need for more RCTs with a larger sample and robust methodology for better generalization.

Updated Review on the Diagnosis and Primary Management of Psychogenic Nonepileptic Seizure Disorders

Psychogenic nonepileptic seizures (PNES) are paroxystic and episodic events associated with motor, sensory, mental or autonomic manifestations, which resemble epileptic seizures (ES), but are not caused by epileptogenic activity. PNES affect between 20% and 30% of patients attending at epilepsy centers and constitute a serious mental health problem. PNES are often underdiagnosed, undertreated and mistaken with epilepsy. PNES are diagnosed after medical causes (epilepsy, syncope, stroke, etc.) have been ruled out, and psychological mechanisms are involved in their genesis and perpetuation. For psychiatry, there is not a single definition for PNES; the DSM-IV and ICD-10/11 describe the conversion and dissociative disorders, and the DSM-5 describes the functional neurological disorders. However, patients with PNES also have a high frequency of other comorbidities like depression, particularly trauma and post-traumatic stress disorder. It has been postulated that PNES are essentially dissociations that operate as a defensive psychological mechanism that use the mind as a defense to deal with traumas. With the advent of VEEG in the 90s, the recognition of PNES has significantly increased, and several psychological treatments have been developed. In this manuscript, we carried out a state-of-the-art review, with the aim to provide a critical approach to the extensive literature about PNES, focusing on diagnostic aspects, the primary management, and the available treatments that have been shown to be effective for the improvement of PNES.

Treatment of functional neurological disorder: current state, future directions, and a research agenda

Functional neurological disorder (FND) encompasses a complex and heterogeneous group of neuropsychiatric syndromes commonly encountered in clinical practice. Patients with FND may present with a myriad of neurological symptoms and frequently have comorbid medical, neurological, and psychiatric disorders. Over the past decade, important advances have been made in understanding the pathophysiology of FND within a biopsychosocial framework. Many challenges remain in addressing the stigma associated with this diagnosis, refining diagnostic criteria, and providing access to evidence-based treatments. This paper outlines FND treatment approaches, emphasizing the importance of respectful communication and comprehensive explanation of the diagnosis to patients, as critical first step to enhance engagement, adherence, self-agency, and treatment outcomes. We then focus on a brief review of evidence-based treatments for psychogenic non-epileptic seizures and functional movement disorder, a guide for designing future treatment trials for FND, and a proposal for a treatment research agenda, in order to aid in advancing the field to develop and implement treatments for patients with FND.

Explanatory factors of quality of life in psychogenic non-epileptic seizure

OBJECTIVE

Previous studies showed that patients with Psychogenic Non-Epileptic Seizures (PNES) have poor quality of life (QoL). This study explored the explicative factors of the QoL at the time of diagnosis and monitored changes over the two years of follow-up.

METHODS

We evaluated 107 participants with a diagnosis of Psychogenic Non-Epileptic Seizure (PNES), every 6 months for 24 months. Quality of life (QoL) was evaluated using the QOLIE-31 and SF-36 scales (respectively specific and generic scales of QoL). Positive evolution of QoL was defined by the increase in the score of overall QoL using QOLIE-31 sub-scale from baseline to the last interview of the patient. We also collected for each patient data on psychiatric dimensions (childhood abuse, history of traumatic events, post-traumatic stress disorder (PTSD), depression, anxiety, alexithymia, and dissociation), clinical evolution of seizures and the number of mental health consultations.

RESULTS

According to the QOLIE-31 and the SF-36, depression (p ≤ 0.001), anxiety (p < 0.001), alexithymia (p ≤ 0.001), and dissociation (p ≤ 0.004) were related to QoL at the time of the diagnosis. According to SF-36 (mental and physical), PTSD was also significantly associated with QoL (p < 0.05). The number of seizures or the co-occurrence of epilepsy did not influence QoL. Positive evolution of QoL was linked to the number of consultations for mental health issues (p = 0.02).

SIGNIFICANCE

Post-traumatic dimensions (PTSD, dissociation), alexithymia and psychiatric comorbidities (depression and anxiety disorders) seem to alter QoL in people with PNES. The current study suggests that mental health care improves QoL of patients with PNES.

Systematic review of psychotherapy for adults with functional neurological disorder

Functional neurological disorder (FND) is a common and disabling disorder that is often considered difficult to treat, particularly in adults. Psychological therapies are often recommended for FND. Outcome research on psychological therapies for FND has grown in recent years but has not been systematically evaluated since 2005. This study aims to build on that by systematically reviewing the evidence-base for individual outpatient cognitive behavioural and psychodynamic psychotherapies for FND. Medical databases were systematically searched for prospective studies of individual outpatient psychotherapy for FND with at least five adult participants. Studies were assessed for methodological quality using a standardised assessment tool. Results were synthesised, and effect sizes calculated for illustrative purposes. The search strategy identified 131 relevant studies, of which 19 were eligible for inclusion: 12 examining cognitive behavioural therapy (CBT) and 7 investigating psychodynamic therapy (PDT). Eleven were pre-post studies and eight were randomised controlled trials. Most studies recruited a single symptom-based subtype rather than all presentations of FND. Effect sizes, where calculable, showed generally medium-sized benefits for physical symptoms, mental health, well-being, function and resource use for both CBT and PDT. Outcomes were broadly comparable across the two therapy types, although a lack of high-quality controlled trials of PDT is a significant limitation, as is the lack of long-term follow-up data in the majority of identified CBT trials. In conclusion, both CBT and PDT appear to potentially offer some benefit for FND, although better quality studies are needed.

Psychological inflexibility and somatization in nonepileptic attack disorder

BACKGROUND

There is no clear understanding of what causes and maintains nonepileptic attack (NEA) disorder (NEAD), or which psychological therapies may be helpful. The relationships between variables of psychological inflexibility: experiential avoidance (EA), cognitive fusion (CF), mindfulness, and key outcome variables in NEAD: somatization, impact upon life, and NEA frequency were investigated.

METHOD

Two hundred eighty-five individuals with NEAD completed validated measures online. Linear regression was used to explore which variables predicted somatization and impact upon life. Ordinal regression was used to explore variables of interest in regard to NEA frequency.

RESULTS

Mindfulness, EA, CF, somatization, and impact upon life were all significantly correlated. Mindfulness uniquely predicted somatization when considered in a model with EA and CF. Higher levels of somatization increased the odds of experiencing more NEAs. Individuals who perceived NEAD as having a more significant impact upon their lives had more NEAs, more somatic complaints, and more EA.

CONCLUSIONS

Higher levels of CF and EA appear to be related to lower levels of mindfulness. Lower levels of mindfulness predicted greater levels of somatization, and somatization predicted NEA frequency. Interventions that tackle avoidance and increase mindfulness, such as, acceptance and commitment therapy, may be beneficial for individuals with NEAD. Future directions for research are suggested as the results indicate more research is needed.

Towards an Outpatient Model of Care for Motor Functional Neurological Disorders: A Neuropsychiatric Perspective

Functional neurological disorder (FND), a condition at the intersection of neurology and psychiatry, is a common and disabling outpatient referral to neurology and neuropsychiatry clinics. In this perspective article, we focus on the motor spectrum of FND (mFND), including individuals with functional movement disorders (FND-movt), functional limb weakness/paresis (FND-par) and functional [psychogenic non-epileptic/dissociative] seizures (FND-seiz). Over the past several decades, there have been dedicated efforts within the neurologic and psychiatric communities to create "rule-in" diagnostic criteria, as well as thoughtful approaches to the clinical interview, delivery of the diagnosis and the development of a patient-centered treatment plan. These advances allow the promotion of good clinical practices in the outpatient assessment and management of mFND. Informed by the literature and our prior clinical experiences, we provide suggestions on how to evaluate individuals with suspected functional motor symptoms - including conducting sensitive psychiatric and psychosocial screenings. Additional sections discuss common "rule-in" neurological examination and semiologic signs of motor FND, as well as approaches to deliver the diagnosis and formulate a treatment plan based on individual patient needs. To aid the development of shared (partially overlapping) expertise that catalyzes an interdisciplinary approach to mFND, the use of physiotherapy for therapeutic motor retraining and cognitive behavioral therapy to examine relationships between symptoms, thoughts, behaviors and emotions are also discussed. Additional clinical research is needed to further refine and operationalize the assessment and management of mFND, across clinics, healthcare settings and countries.

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.

Psychogenic nonepileptic seizures in children-Prospective validation of a clinical care pathway & risk factors for treatment outcome

PURPOSE

The purpose of this study was to prospectively validate a care pathway for psychogenic nonepileptic seizures (PNES) in a pediatric setting. The pathway was developed based on a previous study of patients at our center, which demonstrated positive treatment outcomes of 80% full or partial remission. Sequentially referred patients with PNES in the validation cohort received care prospectively according to the pathway algorithm. It was hypothesized that the validation cohort would achieve outcomes similar to that of the development cohort as a result of standardized care.

METHOD

We performed a retrospective chart review of 43 children sequentially referred, assessed, and treated within a specialized neurology psychology service for suspected PNES over a 5-year period. The majority of patients (n = 41, 95%) met diagnostic criteria for probable, clinically established, or documented PNES, according to the International League Against Epilepsy (ILAE) criteria.

RESULTS

Ages ranged from 6 to 18 years of age at time of diagnosis, with the majority of patients being female (n = 29, 67%) and adolescent (n = 31, 72%). There was a high level of adherence to the care algorithm (n = 34, 84%). The development and validation cohorts were similar across demographic, clinical, and psychological characteristics. Standardized care resulted in high rates of full (n = 27, 63%) and partial (n = 12, 28%) remission, as self-reported at discharge. A 96% decrease in mean monthly frequency of total PNES events was also observed at discharge, as was a significant reduction in healthcare utilization related to PNES (74% fewer ambulance calls and 85% fewer emergency department (ED) visits). Post hoc analyses demonstrated that duration of PNES illness longer than 12 months (at diagnosis) increased odds of not achieving full remission by discharge (odds ratio = 5.94, p = 0.02). Developmental period of onset (child versus adolescent), having abnormal electroencephalogram (EEG) result, previous concussion, chronic versus acute stressor, more than one PNES event type, or additional functional neurological symptoms did not significantly impact treatment response.

CONCLUSIONS

This study demonstrates, for the first time prospectively in a pediatric setting, that standardized care for PNES leads to improved clinical outcomes and reduced healthcare utilization. Delayed diagnosis and treatment of PNES longer than 12 months also appears to be associated with less favorable outcomes in children.

A Novel Integrative Psychotherapy for Psychogenic Nonepileptic Seizures Based on the Biopsychosocial Model: A Retrospective Pilot Outcome Study

BACKGROUND

Psychogenic nonepileptic seizures (PNES) represent one of the most sizable treatment challenges in neuropsychiatry. Although the underlying mechanism is far from being understood, several interventions have been suggested. However, patients with comorbid psychiatric diagnoses and epilepsy are excluded from most intervention studies.

OBJECTIVE

To To present a within-group posttreatment vs pretreatment study representing the retrospective clinical results of an integrative psychotherapy model.

METHODS

We present the clinical results of 22 patients with PNES diagnosed in an epilepsy center and treated in our neuropsychiatry clinic using an integrative rehabilitative psychotherapy. Therapy included presenting the diagnosis, psychoeducation, seizure reduction behavioral techniques, and coping with past and present stressors. Insomuch as integrative biopsychosocial psychotherapy is based on an individualized treatment protocol for each patient, treatment was individualized and case specific.

RESULTS

By the end of treatment, 36% of patients had become seizure free and a further 54% achieved a major seizure reduction (reduction of more than 70%). Seventy-two percent of patients kept at least 70% seizure reduction at follow-up. Global Assessment of Functioning scores improved from a mean of 43.09 to a mean of 72.81 at the end of treatment and 69.72 at follow-up. In addition, we present 3 case descriptions that emphasize the individualized nature of psychotherapeutic decisions.

CONCLUSIONS

Our results support the feasibility and effectiveness of biopsychosocial based integrative psychotherapy for PNES and set principles for future treatment and prospective clinical trials in the field of individualized psychotherapy.

Epilepsy Benchmarks Area IV: Limit or Prevent Adverse Consequence of Seizures and Their Treatment Across the Life Span

Epilepsy represents a complex spectrum disorder, with patients sharing seizures as a common symptom and manifesting a broad array of additional clinical phenotypes. To understand this disorder and treat individuals who live with epilepsy, it is important not only to identify pathogenic mechanisms underlying epilepsy but also to understand their relationships with other health-related factors. Benchmarks Area IV focuses on the impact of seizures and their treatment on quality of life, development, cognitive function, and other aspects and comorbidities that often affect individuals with epilepsy. Included in this review is a discussion on sudden unexpected death in epilepsy and other causes of mortality, a major area of research focus with still many unanswered questions. We also draw attention to special populations, such as individuals with nonepileptic seizures and pregnant women and their offspring. In this study, we review the progress made in these areas since the 2016 review of the Benchmarks Area IV and discuss challenges and opportunities for future study.

Cognitive-emotion processing in psychogenic nonepileptic seizures

BACKGROUND

Previous literature suggests that cognitive-emotion processing contributes to the pathogenesis of psychogenic nonepileptic seizures (PNES). Characterization of alterations in cognitive-emotion processing in PNES could inform treatment.

METHODS

In this descriptive, cross-sectional study, 143 patients with video electroencephalogram (EEG) confirmed PNES were prospectively recruited. Patients completed self-report questionnaires on emotion perception (Trait Meta-Mood Scale (TMMS) attention and clarity subscales) and coping style (Affective Styles Questionnaire [ASQ] concealing, adjusting, and tolerating subscales) at the time of their initial evaluation for PNES. Demographic, clinical data and measures of psychopathology severity were also obtained. The TMMS and ASQ subscale scores were compared to available normative data and between PNES subgroups (based on presence of trauma-related factors). Correlation coefficients were obtained to evaluate associations between subscale scores and measures of psychopathology.

RESULTS

Mean scores on both TMMS subscales (attention 47.0 [SD 7.4] and clarity 37.5 [SD 8.0]) and the ASQ adjusting subscale (22.2 [SD 6.3]) were significantly lower than available normative data (p < .001). Among patients with PNES, those with a history of childhood abuse or active posttraumatic stress disorder (PTSD) were found to have significantly lower scores on emotion clarity, adjustment, and tolerance subscales than those without such histories (p < .05). Degree of clarity of emotions correlated negatively with severity of depression, anxiety, stress, and illness perception (p ≤ .001). Adjustment to and tolerance of emotional states correlated negatively with severity of depression and stress (p < .01).

CONCLUSIONS

Patients with PNES, especially those with active PTSD and childhood trauma, have lower clarity of their emotions and lower ability to adjust to emotional states than healthy individuals. These cognitive-emotion processing deficits are more pronounced in patients with more severe depression and reported stress. This study characterizes alterations in cognitive-emotion processing in PNES that are well-suited therapeutic targets and can therefore inform treatment interventions.

Suicidal Ideation and Traumatic Exposure Should Not Be Neglected in Epileptic Patients: A Multidimensional Comparison of the Psychiatric Profile of Patients Suffering From Epilepsy and Patients Suffering From Psychogenic Nonepileptic Seizures

Introduction: Patients with psychogenic nonepileptic seizures (PNESs) have often been exposed to traumatic events, which is a risk factor for suicidal behavior. This would suggest that the severity of suicidal ideation is greater in PNES than in patients suffering only from epileptic seizures (ESs). However, these psychiatric symptoms may be underestimated in the ES population. The specific features or similarities between the psychiatric clinical profiles of these two groups should be elaborated to improve therapeutic management. Our study is the first to compare suicidal ideation, suicide risk, posttraumatic stress disorder (PTSD), and depression disorder simultaneously in both groups, in a tertiary care epilepsy center. Material and methods: We prospectively enrolled patients hospitalized for video-electroencephalography (EEG) monitoring to assess repeated seizures before an ES or a PNES diagnosis was made. During the psychiatric consultation that accompanied the video EEG, we rated the severity of suicidal ideation and depressive symptoms, suicidal risk, traumatic exposure history, and PTSD symptoms. Results: Eighteen subjects were enrolled and diagnosed with PNES, and 42, with ES. The PNES group reported more exposures to traumatic events and more intense PTSD symptoms (median: 17 vs. 27; p = 0.001). The severity of suicidal ideation did not differ significantly between the two groups. Conclusion: It is the severity of PTSD symptoms in PNES patients that differentiates them from ES patients, although exposure to traumatic events is also frequent in ES patients. We demonstrated that suicidal ideation and suicide risk are equally high in the ES and PNES groups. Therefore, both groups require extreme vigilance in terms of suicidal risk.

An Overview of Psychogenic Non-Epileptic Seizures: Etiology, Diagnosis and Management

The purpose of this review is to provide an update of the research regarding the etiology, diagnosis and management of psychogenic non-epileptic seizures (PNES). A literature search using Pubmed, Ovid MEDLINE and EMBASE database was performed from 2000 up to August 2017. We have evaluated the different factors leading to PNES as well as the diagnostic approach and management of this disorder which continue to be very difficult. The coexistence of epilepsy and PNES poses special challenges and requires the coordinated efforts of the family physicians, psychiatrists, psychologists and neurologists. Although this condition has an overall poor prognosis, a multidisciplinary approach in the diagnosis and management of this disorder would likely improve the outcomes. We have proposed a diagnostic and treatment algorithm for PNES and suggested a national registry of patients suffering from this condition. The registry would contain data regarding treatment and outcomes to aid in the understanding of this entity.

Pediatric Psychogenic Nonepileptic Seizures: A Concise Review

Psychogenic nonepileptic seizures is a complicated biopsychosocial disorder with significant morbidity and high cost in children's social, emotional, family, and academic functioning as well as health care service utilization. Misdiagnosis and diagnostic delay, resulting from both lack of access to approved standards for diagnosing and service providers comfortable with diagnosing and treating this disorder, impact prognosis. Treatment in close proximity to symptom onset is thought to provide the best chance for remission.

Prolonged Exposure Therapy for Comorbid Psychogenic Nonepileptic Seizures and Posttraumatic Stress Disorder

Psychogenic nonepileptic seizures (PNES) superficially resemble epileptic seizures but are not associated with epileptic discharges in the brain. Instead, these episodes, which tend to occur with alterations in consciousness and body movements, are thought to be the result of mechanisms of conversion and dissociation. Psychological trauma and PTSD are very prevalent among patients with PNES. PNES can be conceived of as an extreme avoidance mechanism that serves the function of modulating distress and, in some cases, eliminating the precipitant stressor. Avoidance is also an essential component of PTSD. In patients who carry a dual diagnosis of PNES and PTSD, it is sensible that an empirically validated treatment for PTSD such as prolonged exposure (PE) therapy which targets avoidance by promoting exposure might be a useful approach to treat these patients. In this report, we present the case of a 52-year-old male with a 7-year history of PNES. His seizures, which were characterized by intense body shaking and loud guttural outbursts, were occurring up to 15 times per day. Because of these symptoms, he lost his employment and was ostracized by his family. Upon completion of a course of intensive outpatient PE, he achieved full remission of all psychogenic symptoms. Except for three brief seizures, he has maintained his health for 2 years. This constitutes the first detailed report of PE therapy used to effectively treat comorbid PNES and posttraumatic stress symptoms.

Postdiagnosis neurological care for patients with psychogenic nonepileptic spells (PNES)

OBJECTIVE

This study investigated continuity of neurological care for patients discharged from the epilepsy monitoring unit (EMU) with a diagnosis of psychogenic nonepileptic spells (PNES). Because PNES are seizure-like episodes that cannot be explained by abnormal electrical brain activity, they are challenging for patients to understand and accept. Consequently, after diagnosis, patients commonly fail to start recommended psychotherapy and instead pursue redundant medical care. As consistent relationships with healthcare providers may help, we instituted standard follow-up for patients diagnosed with PNES.

METHODS

We performed a retrospective observational cohort study of adults diagnosed with PNES in our EMU. In November 2013, we began routine scheduling of postdischarge follow-up neurology appointments. We compared preintervention (November 2010-October 2013) and postintervention (November 2013-May 2016) cohorts with regard to clinic attendance, understanding the diagnosis, compliance with recommendations, and event frequency.

RESULTS

We identified 55 patients in the preintervention cohort and 123 patients in the postintervention cohort. We successfully implemented the intended practice changes; more patients had follow-up scheduled by discharge (preintervention 2% vs. postintervention 36%, p<0.001), time to follow-up decreased (46days vs. 29, p=0.001), and providers more consistently queried understanding of diagnosis (38% vs. 67%, p=0.03). Explicit planning for continued care did not produce the anticipated patient-provider relationships, as follow-up in clinic was low (38% vs. 37%). For patients who attended clinic, the intervention did not improve establishment of psychiatric care, compliance with medication recommendations, understanding of diagnosis, or event frequency. The odds of reduced event frequency were nonsignificantly increased with understanding the diagnosis (OR 3.75, p=0.14). Recommending antiepileptic drug (AED) discontinuation was associated with increased odds of event freedom (OR 6.91, p<0.01).

SIGNIFICANCE

Scheduling follow-up for patients diagnosed with PNES did not facilitate ongoing patient-provider relationships due to poor clinic attendance. As follow-up is unreliable, the inpatient visit is a critical window of opportunity for intervention.