Editors' note: Adherence with psychotherapy and treatment outcomes for psychogenic nonepileptic seizures

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In the article “Adherence with psychotherapy and treatment outcomes for psychogenic nonepileptic seizures,” Tolchin et al. reported that among 105 participants with documented psychogenic nonepileptic seizures (PNES), adherence with psychotherapy was associated with reduction in PNES frequency, improvement in quality of life, and decrease in emergency department visits at 12–24 months of follow-up. In response, Dr. Sethi notes that psychiatrists and psychologists may be reticent to accept care for patients with PNES when neurologists do not equivocally confirm the diagnosis. He encourages neurologists to sincerely attempt to rule in or rule out coexisting epilepsy in such cases. In their reply, the authors agree that making a definitive diagnosis is possible and that clear communication to both patients and behavioral specialists is essential to facilitate appropriate treatment and adherence. They emphasize the importance of capturing all typical spells on video-electroencephalography and suggest that neurologists review previous EEGs when there is suspicion that a previous “abnormal” EEG may have been overread to avoid clouding an otherwise clear diagnosis of PNES. Dr. Benbadis, who wrote the accompanying editorial for the article, responds in agreement with Dr. Sethi and like the authors notes that only 10%–15% of patients with PNES truly have evidence of coexisting epilepsy. He suggests that including “psychogenic” in the diagnosis is critical, unless there is doubt that there is another nonepileptic diagnosis. He wonders whether mental health professionals may not believe the diagnosis. In addition to encouraging tracking down previous EEGs of concern, he also argues that coexisting epilepsy should not be a reason to deny patients with PNES access to treatment by psychiatrists and psychologists. In the article “Adherence with psychotherapy and treatment outcomes for psychogenic nonepileptic seizures,” Tolchin et al. reported that among 105 participants with documented psychogenic nonepileptic seizures (PNES), adherence with psychotherapy was associated with reduction in PNES frequency, improvement in quality of life, and decrease in emergency department visits at 12–24 months of follow-up. In response, Dr. Sethi notes that psychiatrists and psychologists may be reticent to accept care for patients with PNES when neurologists do not equivocally confirm the diagnosis. He encourages neurologists to sincerely attempt to rule in or rule out coexisting epilepsy in such cases. In their reply, the authors agree that making a definitive diagnosis is possible and that clear communication to both patients and behavioral specialists is essential to facilitate appropriate treatment and adherence. They emphasize the importance of capturing all typical spells on video-electroencephalography and suggest that neurologists review previous EEGs when there is suspicion that a previous “abnormal” EEG may have been overread to avoid clouding an otherwise clear diagnosis of PNES. Dr. Benbadis, who wrote the accompanying editorial for the article, responds in agreement with Dr. Sethi and like the authors notes that only 10%–15% of patients with PNES truly have evidence of coexisting epilepsy. He suggests that including “psychogenic” in the diagnosis is critical, unless there is doubt that there is another nonepileptic diagnosis. He wonders whether mental health professionals may not believe the diagnosis. In addition to encouraging tracking down previous EEGs of concern, he also argues that coexisting epilepsy should not be a reason to deny patients with PNES access to treatment by psychiatrists and psychologists.