Psychogenic Nonepileptic Seizures Frequency Research Articles

Outcome of psychogenic non-epileptic seizures following diagnosis in the epilepsy monitoring unit.

To study the outcome of patients with psychogenic non-epileptic seizures (PNES) after their diagnosis in the epilepsy monitoring unit (EMU). Patients diagnosed in our EMU with definite PNES between January 2009 and May 2023 were contacted by phone, and those who agreed to participate were asked a set of predetermined questions. Comparative analyses were carried out on several variables before and after diagnosis: number of participants with daily PNES, number of visits to the emergency department, number of participants who consulted their general practitioner or a neurologist outside of a scheduled follow-up, number of participants who took antiseizure medications (ASMs) or psychotropic drugs, and employment status. Out of the 103 patients with a definite diagnosis of PNES, 61 patients (79% female) accepted to participate in our study. The median age at PNES onset was 35 years, and the median delay to diagnosis was 3 years. Almost two-thirds (62%) were receiving ASMs and 40% psychotropic drugs. The mean stay at the EMU was 5 days. PNES diagnosis was explained to almost all patients (97%) by the end of their EMU stay and was well-accepted by most (89%). When contacted, 46% of participants no longer had PNES; 32% mentioned that their PNES had ceased immediately upon communication of the diagnosis. The median follow-up duration was 51 months. Fewer patients had daily seizures after the diagnosis (18 vs. 38%; p < 0.0455). Similarly, the median number of emergency department visits was significantly lower (0 vs. 2; p < 0.001). Only 17 patients consulted their general practitioner (vs. 40, p < 0.001) and 20 a neurologist (vs. 55, p < 0.001) after a PNES attack outside of a scheduled follow-up. The use of ASMs was also significantly reduced from 70 to 33% (p < 0.01), with only one still taking an ASM for its antiseizure properties. Significantly more participants were working at last follow-up than at PNES diagnosis (49 vs. 25%; p < 0.001). Our study revealed a relatively favorable long-term outcome of definite PNES diagnosed in the EMU that translated in significant reductions in PNES frequency, health care utilization and ASM use, as well as a significant increase in employment rate.

The influence of transient loss of consciousness in children on the health-related quality of life indicators

Abstract. Any acute, recurrent or inflammatory disease can cause numerous changes in various areas of a child's life from daily duties to emotional and cognitive development, self-esteem, and relationships with other people, as well as can negatively affect his/her contacts with peers, functioning in school or family. The aim of the study was the search for modern scientific achievements in the field of research on the quality of life among children with transient loss of consciousness and their families for a better understanding of the state of the possibilities of using this indicator in the evaluation of the effectiveness of the carried-out treatment and prevention measures. Materials and methods. The following terms were used for the search: «syncope», «epilepsy», «psychogenic transient loss of consciousness», and «quality of life», and «children» in the PubMed Medline and Scopus databases. Only English-language full-text articles published between January 2013 and December 2022 were included in the search. Results. During the past 10 years numerous studies have been published on health-related quality of life in children with epilepsy, and there was only one study among children with vasovagal syncope. Given the typically benign etiology of this disease, children are at high risk of psychological health worsening after experiencing a syncope episode. A diagnosis of epilepsy in early childhood has a profound effect on the child's psychological and physical development. It is important that epilepsy slows down the achievement of children's independence and complicates social relationships and cognitive processes. A number of authors drew attention to the lack of relationship between the quality of life and the frequency of psychogenic non-epileptic seizures in children and proved the key influence of depression and somatoform disorders on the reduction of quality of life. Conclusions. Health-related quality of life study is an important tool for the understanding of disease impact on child’s daily life and family members, which allows you to effectively recognize symptoms for the purpose of their timely correction, and is the final point in assessing the effectiveness of treatment and prevention measures, as well as quality of public health services. The relevance of further quality of life studies in children under the various types of syncope is due to the extremely limited results of observations in this group of patients.

Cognitive behavioural therapy for psychogenic nonepileptic seizures (PNES) in an adult with a learning disability: A case study

AbstractBackgroundPsychogenic nonepileptic seizures (PNES) are attacks that often look like epileptic seizures (ES). Unlike ES, PNES are not triggered by underlying neurological factors. PNES are relatively rare in the general population; however, their prevalence in people with learning disabilities is much higher—up to 10%. Individuals with PNES and learning disabilities often have psychiatric comorbidities, such as anxiety disorders, depression and posttraumatic stress disorder. There are currently no treatment guidelines for PNES in people with or without learning disabilities. However, talking therapies, such as cognitive‐behavioural therapy (CBT), are recommended. This study explores the effectiveness of CBT for the treatment of PNES in a woman (Susan) with PNES and learning disabilities.MethodsWe used a single‐case experimental design (SCED) to investigate the effectiveness of CBT intervention. Specifically, the withdrawal (also known as ABA) design was applied. The patient's average PNES frequency, as well as idiosyncratic mood measure and standardised outcome measures for people with learning disabilities (Glasgow Anxiety Scale for People with an Intellectual Disability and Mini‐Maslow Assessment of Needs Scale‐Learning Disabilities), were used to assess the effectiveness of treatment.FindingsResults show that Susan's monthly PNES frequency reduced from phase A1 (assessment phase) to phase B (treatment phase), and this persisted to the follow‐up phase (phase A2). However, the reduction was not statistically significant. The intervention was associated with improvements in Susan's mood, anxiety and quality of life. Reduction of Susan's anxiety was clinically significant.ConclusionsThis SCED study demonstrates that CBT might be associated with reduction of PNES frequency and improvements in general functioning in people with PNES and learning disabilities; however, further research, especially around confounding variables is needed.

Frequency and economic burden of psychogenic non-epileptic seizures in patients applying for disability benefits due to epilepsy.

Psychogenic non-epileptic seizures (PNES) resemble epileptic seizures and are often misdiagnosed as epilepsy. To investigate the frequency of PNES and to calculate the economic burden of the patients who admitted to video-electroencephalographicmonitoring (VEM) to obtain a diagnosis of epilepsy in order to apply for disability retirement. The present retrospective study included 134 patients who required disability reports between 2013 and 2019 and had their definite diagnoses after VEM. Following VEM, the patients were divided into three groups: epilepsy, PNES, and epilepsy + PNES. In total, 22.4% (n = 30) of the patients were diagnosed with PNES, 21.6% (n = 29) with PNES and epilepsy, and 56% (n = 75), with epilepsy. The frequency of PNES among all patients was of 44% (n = 59). In patients with PNES alone, the annual cost of using anti-seizure medication was of 160.67 ± 94.04 dollars; for psychostimulant drugs, it was of 148.3 ± 72.48 dollars a year; and the mean direct cost for diagnostic procedures was of 582.9 ± 330.0 (range: 103.52-1601.3) dollars. Although it is challenging to determine the qualitative and quantitative total cost in these patient groups, early diagnosis and sociopsychological support will reduce the additional financial burden on the health system and increase the quality of life of the patients.

Characterizing the driving dilemma among patients with psychogenic nonepileptic seizures: A single-center prospective cohort study

ObjectiveDriving is a critical topic to counsel among patients with epileptic seizures (ES) and psychogenic nonepileptic seizures (PNES), with significant legal and public health implications. This prospective cohort study examined the frequency of ES and PNES in a single institution’s Epilepsy Monitoring Unit (EMU) and assessed driving-related issues between each group. MethodsAdult patients from the Mayo Clinic Arizona Epilepsy Monitoring Unit (EMU) were given comprehensive surveys addressing driving history. Descriptive analysis and statistics were used to summarize differences between patients with ES and PNES. Differences between patients with epilepsy and PNES were determined by Pearson chi-square. ResultsNearly half (n = 75/163) of all patients admitted to the EMU were diagnosed with PNES. Although the PNES group had a statistically significant higher frequency of events (p = 0.01), 87.7% of these patients reported compliance with the driving law recommendations, suggesting a trend that patients who have been counseled regarding fitness-to-drive are likely to follow the recommendation. One-third of patients with PNES reported an event while operating a motor vehicle and 8% (n = 2/25) resulted in a motor vehicle collision severe enough to require hospitalization. In contrast to those with ES, 25% of patients reported a typical event while driving and 25% (n = 2/8) of those resulted in a collision requiring hospitalization. The incidence of habitual events while driving is higher in the population with PNES (n = 25) when compared to those with ES (n = 8); however, it appears that patients with PNES were less likely to become involved in an accident resulting in seriously bodily injury than in ES. ConclusionsCompared to patients with PNES, patients with ES have less frequent events but more severe collisions. This study reinforces the need for diligent driving counseling to help prevent driving-related injuries in patients with PNES and ES.

Sustained improvement with mindfulness-based therapy for psychogenic nonepileptic seizures

BackgroundWe previously reported on the efficacy of a manualized 12-session mindfulness-based therapy (MBT) for psychogenic nonepileptic seizures (PNES). Completion of MBT provided improvements in weekly PNES frequency and self-rated intensity. ObjectivesIn this study, we aimed to determine sustainability of improvement of seizure-related measures at 3- to 6-month follow-up after treatment completion. We also examined changes at treatment end and at follow-up on therapeutic targets of the MBT program. MethodsPatients with documented PNES were recruited from 2014 to 2018. Baseline measures were collected at time of diagnosis (T0) and at first follow-up post-diagnosis (T1). Outcomes are reported at MBT treatment completion (T3) and 3- to 6-month follow-up (T4). The Wilcoxon signed-rank test was used for pair-wise comparisons of PNES frequency; linear mixed models were used for other outcomes. ResultsFourteen of the 26 MBT completers (54%) attended follow-up (median 147.5 days between T3 and T4). PNES frequency, intensity, and number of days/week with PNES remained reduced at T4 (p < 0.01 for all; median frequency reduction 1.3/week from T1). Illness perception and feeling understood remained improved at T4 (p < 0.001 for both) as did worry about PNES (p < 0.05). Illness attribution (physical, mental or both) changed from T0 to T3 (p < 0.01), but not to T4. Psychological flexibility did not change over time. ConclusionPreviously reported improvements in seizure-related measures with MBT at treatment conclusion were maintained at 3- to 6-month follow-up. There were sustained improvements in some underlying processes (illness perception, feeling understood, and symptom worry) over the course of treatment and at follow-up. Long-term benefits of MBT need to be established with randomized controlled trials.

The COVID-19 outbreak and PNES: The impact of a ubiquitously felt stressor

ObjectiveWe aimed to assess frequency of functional seizures or psychogenic nonepileptic seizures (PNES) during the COVID-19 outbreak and to recognize possible factors associated with worsening in this population. MethodsIn this cross-sectional study conducted during the second phase of the pandemic, adult patients with PNES documented by video-EEG and followed up in two tertiary epilepsy centers responded to a structured telephone survey. Data were gathered on demographics, clinical features and frequency of PNES, history of psychiatric comorbidity, access to treatment, as well as on anxiety (GAD-7 items) and depressive symptoms (NDDI-E). ResultsFifty-four patients (78% female; mean age of 31.36 years [SD = 10.6]) were contacted and 15 (28%) reported increased frequency of PNES during the pandemic. Higher scores of GAD-7 items (p < 0.001) and NDDI-E (p < 0.001) were associated with PNES worsening. There was strong evidence of a correlation between higher stress levels (p < 0.001) and poor sleep quality (p 0.005) with PNES aggravation. After regression, stress was the strongest predictor of PNES increased frequency. SignificancePatients with functional neurological disorders are vulnerable during ubiquitously felt stressors. However, the atmosphere of uncertainty did not affect these patients equally. Patients with PNES showing symptoms of anxiety and depression are at higher risk of seizure worsening. Early identification of this subset of patients may prevent this detrimental outcome.

A South African review of routinely-collected health data of psychogenic nonepileptic seizure patients referred to psychiatrists in Johannesburg

Patients with psychogenic nonepileptic seizures (PNES) are often referred to psychiatrists for treatment of functional neurological symptom disorder (FNSD). However, not all patients with FNSD have an identified psychiatric comorbidity [1].The aim of this observational study was to characterize the clinical and psychiatric features of patients with PNES from Johannesburg, South Africa, where a high frequency of PNES has been reported [2], and compare these findings to other reports. We hypothesized that patient outcomes regarding treatment adherence and episode frequency would improve when treated within a closed multidisciplinary team. The data included a retrospective record review of patients diagnosed with PNES from an epilepsy monitoring unit and referred for psychiatric assessment and treatment between November 2013 and July 2017.Fifty-nine cases met the criteria for the study. There were 7 male and 52 female participants, aged between 14 and 72 years (M = 33.76, SD = 13.88). The most frequently reported comorbid symptoms were anxiety (90%); dissociative symptoms (51%); headaches (76%) and gastrointestinal symptoms (36%). Important patient characteristics included past substance abuse (76%); impaired attachment (86%); past trauma (69%) and sexual trauma (29%). Generalized anxiety disorder (76%), major depressive disorder (64%) and PTSD (22%) were the most prevalent psychiatric diagnoses. After receiving psychiatric treatment, 47% of patients experienced a decrease in the frequency of episodes, while 86% became aware of the precipitants of their episodes.Psychiatric data can valuably inform current theories of PNES management. This study contributes to the understanding of comorbid, aetiological, and prognostic factors that are crucial to refining coherent models that will guide practice.

Auricular acupuncture for the treatment of nonepileptic seizures: A pilot study

ObjectiveThe aim of this pilot study was to examine the safety and tolerability of an eight-week treatment of twice weekly auricular acupuncture as a therapeutic intervention for the treatment of psychogenic nonepileptic seizures (PNES). The secondary aim was to determine if auricular acupuncture was effective at reducing PNES event frequency. Psychogenic nonepileptic seizures are as common as multiple sclerosis and are highly resistant to intervention. Unfortunately, there is no standard of care therapy, although mental health treatment referrals are commonly made. Acupuncture is felt to be a safe and cost-effective treatment for many diseases and symptoms including mental health disorders such as posttraumatic stress disorder (PTSD), anxiety, and conversion disorders. We propose to examine auricular acupuncture as a treatment for PNES. MethodsA single-center, 16-week trial of auricular acupuncture was designed: a four-week baseline period, followed by an eight-week active treatment period during which subjects received twice weekly auricular acupuncture, then followed by a four-week washout period. Tolerability was defined as completion of 12 of 16 treatments. Successful compliance with seizure diary was defined as >80%, or 100 of 120 days completed. Safety profile was established and seizure count per week was also calculated. ResultsA total of 29 subjects enrolled from a consecutive sample of 73 PNES diagnoses discharging from our epilepsy unit. Twenty-two subjects entered the study with 91% completing more than 12 of 16 treatments, 91% meeting the endpoint of completing >80% of diary entries. Adverse events were mild, and only two subjects were withdrawn due to increased PNES frequency. Although short-term in design, using one-way repeated measures analysis of variance (ANOVA), we observed a statistically significant reduction in seizure count from baseline at treatment month one, treatment month two, and at the washout period (p = 0.0083). Eleven of 12 subjects (52.3%) who received at least one treatment recorded a 50% frequency reduction. Three of 21 subjects (14%) were PNES-free at the end of the study. SignificanceAuricular acupuncture is well-tolerated in a population with PNES and exhibits similar event frequency reductions as cognitive behavioral therapy (CBT). We believe that this is the first literature report examining auricular acupuncture for the treatment of PNES.

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

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.

Mindfulness-based therapy for psychogenic nonepileptic seizures

BackgroundMindfulness-based therapies (MBTs) are effective in many neuropsychiatric disorders, and represent a potential therapeutic strategy for psychogenic nonepileptic seizures (PNES). ObjectiveThe objective of this study was to investigate the clinical effect of a manualized 12-session MBT for PNES in an uncontrolled trial. We hypothesized reductions in PNES frequency, intensity, and duration, and improvements in quality of life and psychiatric symptom severity at treatment completion. MethodsBetween August 2014 and February 2018, 49 patients with documented PNES (with video electroencephalography [EEG]) were recruited at Brigham and Women's Hospital to participate in the MBT for PNES treatment study. Baseline demographic and clinical information and self-rating scales were obtained during the diagnostic evaluation (T0). Baseline PNES frequency, intensity, and duration were collected at the first follow-up postdiagnosis (T1). Frequency was obtained at each subsequent MBT session and analyzed over time with median regression analysis. Outcomes for other measures were collected at the last MBT session (T3), and compared to baseline measures using linear mixed models. ResultsTwenty-six patients completed the 12-session MBT program and were included in the analysis. Median PNES frequency decreased by 0.12 events/week on average with each successive MBT session (p = 0.002). At session 12, 70% of participants endorsed a reduction in PNES frequency of at least 50%. Freedom from PNES was reported by 50% of participants by treatment conclusion. Seventy percent reported a 50% reduction in frequency from baseline and 50% reported remission at session 12. By treatment end, PNES intensity decreased (p = 0.012) and quality of life improved (p = 0.002). Event duration and psychiatric symptom severity were lower after treatment, but reductions were not statistically significant. ConclusionsCompletion of a manualized 12-session MBT for PNES provides improvement in PNES frequency, intensity, and quality of life. The high dropout rate is consistent with adherence studies in PNES. Possible reasons for dropout are discussed. Randomized controlled trials and longer-term outcomes are needed to demonstrate the efficacy of MBT in PNES.

Treatment Works, So Who's Afraid of PNES?

Adherence With Psychotherapy and Treatment Outcomes for Psychogenic Nonepileptic Seizures Tolchin B, Dworetzky BA, Martino S, et al. Neurology. 2019;92(7):e675-e679. doi:10.1212/WNL.0000000000006848.Objective:We conducted a prospective cohort study of patients with psychogenic nonepileptic seizures (PNES) to examine the association between adherence to psychotherapy and outcomes, including significant (≥50%) reduction in PNES frequency, PNES freedom, improvement in quality of life, and reduction in emergency department (ED) utilization.Methods:A total of 105 participants were referred to receive psychotherapy either at Brigham and Women’s Hospital or with a local therapist. We called participants at 12 to 24 months of follow-up and obtained detailed follow-up data from 93 (89%) participants. Participants were considered adherent to psychotherapy if they attended at least 8 sessions within a 16-week period starting at the time of referral.Results:Adherence to psychotherapy was associated with reduction in seizure frequency (84% in adherent group vs 61% in nonadherent; P = .021), improvement in quality of life (P = .044), and reduction in ED utilization (P = .040), with medium effect sizes; there was no difference in PNES freedom. The association between adherence and ≥50% reduction in PNES frequency persisted when controlling for potential confounders in a multivariate model. Psychotherapy nonadherence was associated with baseline characteristics of self-identified minority status (odds ratio: 7.47; P = .019) and history of childhood abuse (odds ratio: 3.30; P = .023).Conclusions:Our study is limited in that it cannot establish a causal relationship between adherence to psychotherapy and outcomes, and the results may not generalize beyond the single quaternary care center study site. Among participants with documented PNES, adherence to psychotherapy was associated with reduction in PNES frequency, improvement in quality of life, and decrease in ED visits.

Randomized controlled trial of motivational interviewing for psychogenic nonepileptic seizures.

We conducted a randomized controlled trial of motivational interviewing (MI) as an intervention to improve psychotherapy adherence and outcomes, including frequency of psychogenic nonepileptic seizures (PNES), quality of life, and emergency department utilization, among participants with PNES. Sixty participants were randomized to receive either psychotherapy alone or MI plus psychotherapy. Participants and therapists were contacted at 16-week follow-up. Participants were considered adherent with psychotherapy if they attended at least eight sessions within 16 weeks following referral. Among control participants, 31.0% were adherent, whereas among MI participants, 65.4% were adherent (P = 0.015, absolute risk reduction = 34.4%, number needed to treat = 2.9). In the control arm, PNES frequency decreased by 34.8% (standard deviation [SD] = 89.7%), whereas in the MI arm, PNES frequency decreased by 76.2% (SD = 39.2%; P = 0.034, Cohen's d=0.59). Among control participants, 10.7% achieved PNES freedom versus 30.8% of MI participants (P = 0.095). Quality of Life in Epilepsy-10 scores (a 40-point scale) improved by an average of 1.8 (SD = 7.9) points among control participants, and by 7.2 (SD = 10.0) points among MI participants (P = 0.047, Cohen's d=0.60). Monthly emergency department visits increased by 0.06 (SD = 0.47) visits per month among control participants versus a decrease of 0.15 (SD = 0.76) among MI participants (P = 0.23). Motivational interviewing improved treatment adherence, PNES frequency, and quality of life among our participants with PNES. Our study is limited in that it was conducted at a single quaternary care medical center, and MI was provided by a single neurologist, which may limit generalization of results.

Adherence with psychotherapy and treatment outcomes for psychogenic nonepileptic seizures.

We conducted a prospective cohort study of patients with psychogenic nonepileptic seizures (PNES) to examine the association between adherence with psychotherapy and outcomes, including significant (≥50%) reduction in PNES frequency, PNES freedom, improvement in quality of life, and reduction in emergency department (ED) utilization. A total of 105 participants were referred to receive psychotherapy either at Brigham and Women's Hospital or with a local therapist. We called participants at 12-24 months follow-up and obtained detailed follow-up data from 93 participants (89%). Participants were considered adherent with psychotherapy if they attended at least 8 sessions within a 16-week period starting at the time of referral. Adherence with psychotherapy was associated with reduction in seizure frequency (84% in adherent group vs 61% in nonadherent, p = 0.021), improvement in quality of life (p = 0.044), and reduction in ED utilization (p = 0.040), with medium effect sizes; there was no difference in PNES freedom. The association between adherence and ≥50% reduction in PNES frequency persisted when controlling for potential confounders in a multivariate model. Psychotherapy nonadherence was associated with baseline characteristics of self-identified minority status (odds ratio 7.47, p = 0.019) and history of childhood abuse (odds ratio 3.30, p = 0.023). Our study is limited in that it cannot establish a causal relationship between adherence with psychotherapy and outcomes, and the results may not generalize beyond the single quaternary care center study site. Among participants with documented PNES, adherence with psychotherapy was associated with reduction in PNES frequency, improvement in quality of life, and decrease in ED visits.

The Effect of Therapy Psychodynamic and Cognitive Behavioral Therapy on Quality of Life in Patients with PNES

Objective: In the search for effective therapeutically tools for Psychogenic Non-epileptic Seizures (PNES), in the present study we analyzed the effect of two different psychotherapeutic approaches, Brief Psychodynamic Therapy (BPT) and Cognitive Behavioral Therapy (CBT) on the frequency of PNES as well as on quality of life in these patients. Methods: 23 patients displaying PNES were randomly assigned to a group receiving BPT for 6 months, a group receiving CBT for 6 months and a control group no receiving psychotherapy. Presence of PNES was confirmed by electroencephalography (EEG). To assess self-perception quality of life, the QOLIE-31 questionnaire was applied before and every three months including a six months’ follow-up after treatment ended. Results: PNES frequency decreased significantly after the first three months of both therapies compared to control group. No differences were observed when the two therapies were compared. The significant decrease of PNES frequency remains until six months after the end of psychotherapy. Concerning self-perceived quality of life, QOLIE-31 results indicate a significant improvement since the first three months. At the beginning all the patients report a poor quality of life. After three months of psychotherapy most of them improve to a normal quality of life. After 6 months of therapy patients showed values reflecting an excellent quality of life, remaining at these levels six months after therapies ended. Conclusion: The present results support the notion that both psychotherapeutic approaches are reliably procedures for decrease PNES frequency and improve quality of life in these patients.

A multicenter evaluation of a brief manualized psychoeducation intervention for psychogenic nonepileptic seizures delivered by health professionals with limited experience in psychological treatment.

The aim of this study was to add to our understanding of the impact of psychoeducation on patients' acceptance of the diagnosis of psychogenic nonepileptic seizures (PNESs), the frequency of their seizures, and their quality of life. The study also aimed to evaluate the effectiveness of brief manualized psychoeducation interventions for PNESs, delivered by a more diverse range of clinicians and in a wider range of treatment settings. The final sample consisted of 25 patients diagnosed with PNESs by a neurologist specializing in the treatment of seizure disorder and referred to the psychotherapy service. The study included patients from four centers, using a manualized psychoeducation intervention delivered over 4 sessions by specialist epilepsy nurses and assistant psychologists. All patients completed self-measure questionnaires for Seizure Frequency, Impaired Functioning (WSAS), Psychological Distress (CORE-OM), Illness Perception (BIPQ), Health-Related Quality of Life: general (ED-QOL) and epilepsy-specific (NewQOL-6D), Symptom Attribution, and patient's perception of usefulness and relevance of the intervention. All measures were collected at baseline and after the completion of the fourth session. All measures improved from baseline to postintervention, but this improvement was only significant for CORE-OM (p<.05) and BIPQ (p<.01). Out of the 25 patients who completed the intervention information, 6 out of 25 (24%) had been seizure-free for the past month, and an additional 6 out of 25 (24%) had achieved seizure frequency reduction. Consequently, upon completion of the intervention, 12 out of 25 patients (48%) were either seizure-free or experienced fewer seizures compared with the start of the intervention. The evidence suggests that brief manualized psychoeducation intervention can reduce PNES frequency, improve the psychological distress, and have an effect on patients' illness perceptions that should help them engage with a more extended psychotherapy program if that was necessary. The intervention was carried out successfully by staff with relatively little training in delivering psychological interventions. Further controlled studies are required to provide proof of efficacy.

Psychogenic non-epileptic seizures (PNES) on the Internet: Online representation of the disorder and frequency of search terms

PurposeThe nature of the symptoms associated with PNES require a multidisciplinary health team. There are too few professionals with an adequate understanding of PNES and therefore many are not able to provide patients with necessary information. In the age of the internet, it is not surprising that patients or caregivers might look for answers online. The purpose of this project was to investigate the online representation of PNES and search frequency for PNES and its associated terms. MethodsTo determine online representation, searches of: Google®, twitter®, YouTube®, and Instagram® for “PNES” and associated terms were conducted. Websites, tweets, and films were classified by host and exclusivity of information. PNES and associated terms search frequency was determined through Google Trends®. ResultsProfessional and patient sites exclusively about PNES were outnumbered by sites that only mentioned PNES in fewer than three posts. Patients tended to favor less traditional hosting options than did professionals. On twitter®, different keyword preferences were identified for professionals and patients. On YouTube® there was a substantial selection of videos of which 22 were professionally produced. Google Trends®, revealed the terms most commonly used to search for this topic were in order: (1) “PNES;” (2) “NEAD;” and (3) “pseudoseizure.” ConclusionA variety of professional and patient internet content about PNES can be found online. Professional sites offered accurate and empirically-validated information on the disorder and tended to use traditional hosting options. Future professional initiatives might consider novel hosting options and higher-frequency terms to reach their audience more effectively.

A standardized diagnostic approach and ongoing feedback improves outcome in psychogenic nonepileptic seizures.

Psychogenic nonepileptic seizures (PNES) are episodic alterations in behavior presumed to reflect a physical manifestation of underlying psychological distress. Standardized treatment approaches for PNES care are lacking. We evaluated common approaches to PNES management that do not require significant commitment of time and resources. Patients with PNES established with video-EEG monitoring were randomized to one of the following three groups: 1) PNES diagnosis delivered per the discretion of the attending physician with advice to seek mental health assistance in the community (n=12), 2) scripted PNES diagnosis provided and inpatient psychiatry consult obtained (n=10), and 3) weekly follow-up phone calls made in addition to scripted diagnosis and inpatient psychiatry consultation (n=15). Reduction in event frequency measured at 8weeks following hospital discharge represented the primary outcome variable. Secondary variables analyzed included exploration of change in self-reported mood, quality of life, and healthcare utilization. No significant improvements were noted in patients simply given a PNES diagnosis and advised to seek outside care on any measure. In contrast, patients receiving a scripted diagnosis and psychiatric consultation demonstrated decreased PNES frequency accompanied by improved quality of life (QOL). Patients also receiving weekly phone calls not only demonstrated decreased PNES frequency and improvements in QOL but also exhibited improved mood. These findings demonstrate that providing diagnostic information regarding PNES is insufficient by itself to meaningfully affect patient outcome. Structured feedback and psychiatric consultation appeared adequate to significantly reduce PNES frequency and improve aspects of quality of life, while the addition of a weekly phone contact also led to improved mood.

Altered regional activity and inter-regional functional connectivity in psychogenic non-epileptic seizures.

Although various imaging studies have focused on detecting the cerebral function underlying psychogenic non-epileptic seizures (PNES), the nature of PNES remains poorly understood. In this study, we combined the resting state fMRI with fractional amplitude of low-frequency fluctuations (fALFF) and functional connectivity based on the seed voxel linear correlation approach to examine the alterations of regional and inter-regional network cerebral functions in PNES. A total of 20 healthy controls and 18 patients were enrolled. The PNES patients showed significantly increased fALFF mainly in the dorsolateral prefrontal cortex (DLPFC), parietal cortices, and motor areas, as well as decreased fALFF in the triangular inferior frontal gyrus. Thus, our results add to literature suggesting abnormalities of neural synchrony in PNES. Moreover, PNES exhibited widespread inter-regional neural network deficits, including increased (DLPFC, sensorimotor, and limbic system) and decreased (ventrolateral prefrontal cortex) connectivity, indicating that changes in the regional cerebral function are related to remote inter-regional network deficits. Correlation analysis results revealed that the connectivity between supplementary motor area and anterior cingulate cortex correlated with the PNES frequency, further suggesting the skewed integration of synchronous activity could predispose to the occurrence of PNES. Our findings provided novel evidence to investigate the pathophysiological mechanisms of PNES.

Implicit and explicit self-esteem discrepancies in people with psychogenic nonepileptic seizures

PurposeSelf-esteem (SE), or one's sense of competence and worth, is reduced in many mental and physical disorders. Low SE is associated with perceived stigma and disability and poor treatment outcomes. The present study examined implicit and explicit SE (automatic and deliberate views about the self) in people with epilepsy and people with psychogenic nonepileptic seizures (PNESs). Discrepancies between implicit SE and explicit SE have been found to correlate with psychological distress in disorders often associated with PNESs but are relatively unexplored in PNESs. We hypothesized that, compared with epilepsy, PNESs would be associated with lower self-reported SE and greater discrepancies between implicit SE and explicit SE. MethodsThirty adults with PNESs, 25 adults with epilepsy, and 31 controls without a history of seizures were asked to complete the Rosenberg Self-esteem Scale as a measure of explicit SE and an Implicit Relational Assessment Procedure as a measure of implicit SE. The State–Trait Anxiety Inventory and Patient Health Questionnaire—15 (a somatic symptom inventory) were also administered. ResultsWe found significant group differences in explicit (p<0.001) but not implicit SE. Patients with PNESs reported lower SE than the other groups. No group differences were found in implicit SE. Implicit–explicit SE discrepancies were larger in the group with PNESs than in the other groups (p<0.001). Higher frequency of PNESs (but not epileptic seizures) was associated with lower explicit SE (rs=−.83, p<0.01) and greater SE discrepancies (i.e., lower explicit relative to implicit SE; rs=.65, p<0.01). These relationships remained significant when controlling for anxiety and somatization. ConclusionPatients with PNESs had lower explicit SE than those with epilepsy or healthy controls. In keeping with our expectations, there were greater discrepancies between implicit SE and explicit SE among patients with PNESs than in the other groups. Our results, including the strong relationship between PNES frequency, anxiety, and explicit–implicit SE discrepancies, support the interpretation that PNESs serve to reduce cognitive dissonance, perhaps protecting patients' implicit SE.