How Can Neurologists Treat Psychogenic Nonepileptic Seizures?

KANSAS CITY, MO—Many neurologists see, but few treat, patients with psychogenic nonepileptic seizures (PNES) and other conversion disorders, said W. Curt LaFrance Jr, MD, MPH, at the 46th Annual Meeting of the Child Neurology Society.

W. Curt LaFrance Jr, MD, MPH

PNES may be associated with stigma in the minds of neurologists and may require a shift in perspective. Once a diagnosis is made by a neurologist or epileptologist, a patient with PNES is usually referred to a psychiatrist, he said. “Many times, however, those patients are lost, falling between the gaps at the borderlands of neurology and psychiatry.”

Because treatments for PNES, including cognitive behavioral therapy (CBT)-informed psychotherapy, have reduced seizures in randomized clinical trials, neurologists can tell patients that there are ways to help them, said Dr. LaFrance. Dr. LaFrance is a dually-boarded neurologist and psychiatrist and is Director of Neuropsychiatry and Behavioral Neurology at Rhode Island Hospital and Associate Professor of Psychiatry and Neurology at the Warren Alpert Medical School of Brown University in Providence.

Diagnosing Conversion Disorder

PNES is a common, disabling, and costly disorder. Patients may see numerous providers and try numerous medications over time. Neurologists’ ability to distinguish between epileptic and nonepileptic seizures is essential. In addition, DSM-5 allows clinicians to diagnose conversion disorder based on the new criteria, which include documenting the presence of non-neuroanatomic signs.

Once neurologists have confirmed that a patient has PNES, they should not hedge their diagnosis or unnecessarily treat the patient with antiepileptic drugs (AEDs) if the patient has lone PNES. AEDs do not treat nonepileptic seizures, and neurologists may safely withdraw AEDs in patients with confirmed nonepileptic seizures who do not have an indication for an AED. “Once the diagnosis is made, in therapy, we then begin doing the hard work of getting to what lies underneath,” Dr. LaFrance said. “The conversion seizure or the psychogenic tremor is just the tip of the iceberg.”

Many patients have comorbid depression, anxiety, or personality disorders, and there is a high prevalence of abuse and trauma among children and adults with PNES. Effective treatment of PNES requires understanding the patient’s social context, and these developmental factors are “part of the history taking that we are responsible for in our exam as neurologists,” Dr. LaFrance said.

Wyllie et al found that about 80% of children with PNES were seizure-free at three years, compared with 40% of adults with PNES. In a study by Yadav et al, a third of young patients with PNES had resolution of symptoms by six months, while a third remained symptomatic at two years. Approaches to treatment for PNES have included conventional CBT, group and individual therapy, social interventions, physical and occupational therapy, medication, and treatment by neurologists and psychiatrists.

Therapeutic Trials

Dr. LaFrance and colleagues in 2010 published results from a pilot trial of an SSRI for the treatment of PNES. Patients ages 18 to 65 with video-EEG–confirmed PNES received sertraline or placebo over 12 weeks. Among the 33 patients included in an intent-to-treat analysis, those who received sertraline had a 45% reduction in seizure rate from baseline to final visit, compared with an 8% increase among patients in the placebo group. The study gave preliminary data for addressing comorbidities with PNES but was not powered to gauge the efficacy of an SSRI for PNES.

In a separate study published in 2009, Dr. LaFrance and colleagues evaluated the effect of CBT-informed psychotherapy in patients with PNES. Researchers treated participants at 12 weekly sessions using a manualized therapy. The treatment workbook had been modified from one originally developed as a psychotherapeutic intervention for aura identification and behavioral interventions to reduce epileptic seizures. In the open-label clinical trial, CBT-informed psychotherapy significantly reduced seizures, depression, and anxiety, and improved quality of life. Seizures initially increased, however, before decreasing during the therapy, which may reflect some of the psychological issues that patients are addressing, Dr. LaFrance said. Patients who had a reduction in seizures at the end of the pilot study maintained the reduction at one year.

This treatment approach is based on a theoretical fear-avoidance model in which patients have an injury or traumatic event and then develop PNES. They catastrophize, fear the next seizure, become hypervigilant to somatic cues, and avoid external environments. These factors create a “pattern of disuse, disability, and depression, and it becomes a vicious cycle,” Dr. LaFrance said. The goal of treatment is to give patients tools to enter a “virtuous cycle of confronting the fear and moving into recovery.”

A Multisite Study

The researchers then combined aspects of the pharmacologic and CBT trials in a 2014 multisite pilot randomized clinical trial that included the following four treatment arms: CBT-informed psychotherapy, medication (ie, flexible-dose sertraline hydrochloride), CBT-informed psychotherapy plus medication, and standard medical care (ie, biweekly assessments with a treating neurologist). Significant within-group seizure reduction occurred in the two arms receiving CBT-informed psychotherapy—a 51.4% weekly reduction with CBT-informed psychotherapy alone, and a 59.3% weekly reduction with CBT-informed psychotherapy plus sertraline. Patients’ quality of life and function also improved in the two therapy-containing arms. Sertraline reduced depression and showed a trend toward seizure reduction. Standard medical care did not significantly reduce seizures or improve secondary outcomes.

The research team is now examining neurocircuitry mechanisms of seizures with a recently funded multisite study of fMRI before and after treatment in patients with epilepsy or with PNES. Elements of the one-hour, CBT-informed psychotherapy sessions use different psychotherapeutic modalities, including motivational interviewing, interpersonal therapy, psychodynamic psychotherapy, distress tolerance, and psychoeducation about medications. Providers around the country, including neurologists, are being trained to deliver the intervention. “What we do is not rocket science. It is just good therapy,” Dr. LaFrance said.

—Jake Remaly

Suggested Reading

LaFrance WC Jr, Baird GL, Barry JJ, et al. Multicenter pilot treatment trial for psychogenic nonepileptic seizures: a randomized clinical trial. JAMA Psychiatry. 2014;71(9):997-1005.

LaFrance WC Jr, Keitner GI, Papandonatos GD, et al. Pilot pharmacologic randomized controlled trial for psychogenic nonepileptic seizures. Neurology. 2010;75(13):1166-1173.

LaFrance WC Jr, Miller IW, Ryan CE, et al. Cognitive behavioral therapy for psychogenic nonepileptic seizures. Epilepsy Behav. 2009;14(4):591-596.

LaFrance WC Jr, Reuber M, Goldstein LH. Management of psychogenic nonepileptic seizures. Epilepsia. 2013;54 Suppl 1:53-67.

LaFrance Jr WC, Wincze JP. Treating Nonepileptic Seizures: Therapist Guide. New York, NY: Oxford University Press; 2015.

Reiter JM, Andrews D, Reiter C, LaFrance Jr WC. Taking Control of Your Seizures: Workbook. New York, NY: Oxford University Press; 2015.

Wyllie E, Friedman D, Lüders H, et al. Outcome of psychogenic seizures in children and adolescents compared with adults. Neurology. 1991;41(5):742-744.

Yadav A, Agarwal R, Park J. Outcome of psychogenic nonepileptic seizures (PNES) in children: A 2-year follow-up study. Epilepsy Behav. 2015;53:168-173.

Veterans Health Administration. Veterans and Epilepsy: Basic Training: Psychogenic Non-Epileptic Seizures [video]. YouTube. https://youtu.be/NlX-yNTX86w. Published February 27, 2017.