SAN DIEGO—Patients who have been newly diagnosed with psychogenic nonepileptic seizures probably benefit from counseling and group therapy sessions before being referred to psychiatrists for treatment of their underlying mental health problem. That's what researchers from the Baylor College of Medicine in Houston found when they compared outcomes for 16 patients immediately referred to mental health services following diagnosis—the standard practice—with 19 others who first had three educational group sessions where they learned about their condition and shared coping strategies.
Following their sessions, support group patients were more likely than were control group patients to agree that "my attacks do not really bother me or affect my life that much anymore" and that "I have some control over my attacks." Perhaps most tellingly, patients in the treatment group were significantly less likely to return to the emergency department three months later (7% vs. 22%).
“Clearly, what we are seeing is that these patients need significant follow-up, perhaps with a neurologist rather than simply a mental health professional. Psychiatrists don’t feel comfortable addressing this issue; having a team approach with both a neurologist and a psychiatrist probably gives the best outcomes,” said lead investigator Atul Maheshwari, MD, Assistant Professor of Neurology and Neuroscience at Baylor, at the 66th Annual Meeting of the American Epilepsy Society.
The patients in the randomized study were adults, mostly male, and had at least one seizure per week. They were diagnosed with psychogenic nonepileptic events (PNEE) in the epilepsy monitoring unit of Houston Veterans Affairs Medical Center, where the study was conducted. Psychiatric problems included depression, post-traumatic stress disorder, and childhood abuse.
The diagnosis of PNEE is often a hard blow to patients convinced that they have epilepsy or a brain tumor and feel like doctors aren’t taking them seriously; accepting that their seizures are caused by underlying psychiatric stress is difficult, Dr. Maheshwari said.
A nurse practitioner led the group sessions with talking points and instructions from a neurologist. “The first session helped [patients] understand [that] PNEE are nonpathologic [and] don’t cause the brain to be fried or cause long-term brain damage, but still require treatment. They were also shown videos of what PNEE look like and what epileptic seizures look like so they could better understand what’s going on. The goal was to take away the negative associations people have with the diagnosis,” Dr. Maheshwari said.
“Subsequent sessions focused on finding constructive channels for stress release, focusing on the idea that [PNEE] are manifestations of inner stress,” Dr. Maheshwari continued. “Patients were allowed to discuss what strategies they found helpful. Peer-to-peer acceptance and evaluation helps.”
Identification of triggers, including those for post-traumatic stress disorder, was key, Dr. Maheshwari noted. “For some people, [that means] identifying the aura so they can use stress-release strategies to avoid the seizure,” he commented. “It’s helpful to share those things with other people who have the same symptoms so they can appreciate they are not alone.”
Dr. Maheshwari cautioned that the research is ongoing and that the trial’s results are preliminary. “We didn’t help out with the frequency and intensity of events, but there were significant improvements in the patients’ perceptions of the problem” and in their quality of life, he concluded.
—M. Alexander Otto