Randomized Trials of Psychotherapeutic Treatment for Psychogenic Seizures: Scoping Review

BACKGROUND

Psychotherapy improves seizure frequency and psychosocial aspects in psychogenic nonepileptic seizures (PNES). Although randomized controlled trials (RCTs) on different psychotherapies have been conducted for almost two decades now, no review has exclusively assessed RCTs of different psychotherapies.

METHODS

The objective was to review RCTs of psychotherapy for PNES, to understand the impact of different psychotherapies. Eligibility criteria included full-text articles, English articles, published between years 2000 and 2020, randomized trials of psychotherapy, and the adult population. Databases included PubMed, ProQuest, Google Scholar, ScienceDirect, EBSCO, PsycINFO, Cochrane, and a random google search was conducted. Rayyan software was used to include articles that met our eligibility criteria. The search was carried out independently by two researchers.

RESULTS

Based on the eligibility criteria, seven studies were found. Amongst them, cognitive behavioral therapy (CBT) was the most researched and seemed more effective when paired with standard medical care (SMC) or sertraline. Comparisons of CBT and brief psychodynamic therapy did not reveal significant differences. Other psychotherapies included motivational interview+psychotherapy, which significantly reduced seizure frequency and improved psychosocial functioning. Paradoxical intention therapy also reduced PNES symptoms; however, it has not been researched in the last 15 years. Group psychoeducation seems to have an impact only on psychosocial functioning and not on seizure frequency.

CONCLUSION

CBT paired with SMC or sertraline and MI along with psychotherapy yields the most effective results for PNES in reducing seizure frequency and improving psychosocial functioning.

Trait and state interoceptive abnormalities are associated with dissociation and seizure frequency in patients with functional seizures

OBJECTIVE

Dissociative traits represent a disturbance in selfhood that may predispose to, and trigger, functional seizures (FSs). The predictive representation and control of the internal physiological state of the body (interoception) are proposed to underpin the integrity of the sense of self ("minimal selfhood"). Therefore, discrepancies between objective and subjective aspects of interoception may relate to symptom expression in patients with FSs. Here, we tested whether individual differences in trait measures of interoception relate to dissociative symptoms, and whether state interoceptive deficits predict FS occurrence.

METHODS

Forty-one participants with FSs and 30 controls completed questionnaire ratings of dissociation, and measures of (1) interoceptive accuracy (IA)-objective performance on heartbeat detection tasks; (2) trait interoceptive sensibility-subjective sensitivity to internal sensations (using the Porges Body Perception Questionnaire); and (3) state interoceptive sensibility-subjective trial-by-trial measures of confidence in heartbeat detection. Interoceptive trait prediction error (ITPE) was calculated from the discrepancy between IA and trait sensibility, and interoceptive state prediction error (ISPE) from the discrepancy between IA and state sensibility.

RESULTS

Patients with FSs had significantly lower IA and greater trait interoceptive sensibility than healthy controls. ITPE was the strongest predictor of dissociation after controlling for trait anxiety and depression in a regression model. ISPE correlated significantly with FS frequency after controlling for state anxiety.

SIGNIFICANCE

Patients with FSs have disturbances in interoceptive processing that predict both dissociative traits reflecting the disrupted integrity of self-representation, and the expression of FSs. These findings provide insight into the pathophysiology of functional neurological disorder, and could lead to novel diagnostic and therapeutic approaches.

Written Accounts of Living With Epilepsy or Psychogenic Nonepileptic Seizures: A Thematic Comparison

This study examines the subjective experience of living with epilepsy or psychogenic nonepileptic seizures (PNES) by thematically comparing individuals' written accounts of their condition. Five key differences emerged. Theme 1: "Seizure onset" revealed differences in how individuals think about and ruminate over the possible causes of their condition. Theme 2: "Emotive tone" demonstrated that writings of those with epilepsy reflected stable emotions (no intense emotional reactions), whereas those of writers with PNES reflected anxiety and low mood. Theme 3: "Seizure symptoms" showed differences in the conceptualization of seizures. Theme 4: "Treatment" explored differences in the diagnostic journey and experiences of health care professionals. Theme 5: "Daily life" revealed that those with epilepsy perceived sequelae and seizures as something that must be fought, whereas those with PNES tended to describe their seizures as a place they enter and something that has destroyed their lives. The findings have implications for treatment and management.