Multicenter Pilot Treatment Trial for Psychogenic Nonepileptic Seizures

Abstract

; for the NES Treatment Trial (NEST-T) Consortium IMPORTANCE There is a paucity of controlled treatment trials for the treatment of conversion disorder, seizures type, also known as psychogenic nonepileptic seizures (PNES). Psychogenic nonepileptic seizures, the most common conversion disorder, are as disabling as epilepsy and are not adequately addressed or treated by mental health clinicians. OBJECTIVE To evaluate different PNES treatments compared with standard medical care (treatment as usual). DESIGN, SETTING, AND PARTICIPANTS Pilot randomized clinical trial at 3 academic medical centers with mental health clinicians trained to administer psychotherapy or psychopharmacology to outpatients with PNES. Thirty-eight participants were randomized in a blocked schedule among 3 sites to 1 of 4 treatment arms and were followed up for 16 weeks between September 2008 and February 2012; 34 were included in the analysis. INTERVENTIONS Medication (flexible-dose sertraline hydrochloride) only, cognitive behavioral therapy informed psychotherapy (CBT-ip) only, CBT-ip with medication (sertraline), or treatment as usual. MAIN OUTCOMES AND MEASURES Seizure frequency was the primary outcome; psychosocial and functioning measures, including psychiatric symptoms, social interactions, quality of life, and global functioning, were secondary outcomes. Data were collected prospectively, weekly, and with baseline, week 2, midpoint (week 8), and exit (week 16) batteries. Within-group analyses for each arm were performed on primary (seizure frequency) and secondary outcomes from treatment-blinded raters using an intention-to-treat analysis. RESULTS The psychotherapy (CBT-ip) arm showed a 51.4% seizure reduction (P = .01) and significant improvement from baseline in secondary measures including depression, anxiety, quality of life, and global functioning (P < .001). The combined arm (CBT-ip with sertraline) showed 59.3% seizure reduction (P = .008) and significant improvements in some secondary measures, including global functioning (P = .007). The sertraline-only arm did not show a reduction in seizures (P = .08). The treatment as usual group showed no significant seizure reduction or improvement in secondary outcome measures (P = .19). CONCLUSIONS AND RELEVANCE This pilot randomized clinical trial for PNES revealed significant seizure reduction and improved comorbid symptoms and global functioning with CBT-ip for PNES without and with sertraline. There were no improvements in the sertraline-only or treatment-as-usual arms. This study supports the use of manualized psychotherapy for PNES and successful training of mental health clinicians in the treatment. Future studies could assess larger-scale intervention dissemination. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00835627

Long‐term adherence with psychiatric treatment among patients with psychogenic nonepileptic seizures

“…12,13 Our cohort was similar to those in prior studies of PNES, which were also disproportionately female (85% vs 75%-91%), with high rates of unemployment (61% vs 65%-90%), psychiatric comorbidities, and history of sexual abuse (42% vs 33%-76%). 9,11,12 Adherence at the first outpatient visit was similar to that seen in on the initial visit in prior studies (80% vs 72%-80%) but worsened significantly at each subsequent visit to a nadir of 14% adherence by the fourth visit. In addition, our results suggest that patients previously diagnosed with PNES, returning for a second opinion or | after the failure of a first treatment regimen, have significantly increased odds of long-term nonadherence.…”

“…The strongest evidence basis, including two randomized trials, demonstrates the efficacy of cognitive behavioral therapy. 9,10 Yet 20%-30%…”

Medically Hospitalized Patients With Eating Disorders and Somatoform Disorders in Pediatrics: What Are Their Similarities and Differences and How Can We Improve Their Care?

“…A recent pediatric study revealed that earlier referral to psychiatry consultation-liaison services for patients with a wide array of diagnoses, including SFD and ED, resulted in shorter lengths of stay and lower hospital charges regardless of illness severity. 7 From an evidence-based treatment perspective, randomized controlled trials have identified family-based therapy and cognitive behavioral therapy as effective outpatient treatments for ED and SFD patients, respectively 31,32 ; however, there is a lack of studies regarding effective psychosocial treatment approaches that can be implemented for patients with ED or SFD during medical admissions. With average admission lengths of .1 week for ED patients and close to 5 days for SFD patients, our study highlights opportunities for brief psychosocial interventions in the hospital setting that can improve health outcomes and reduce recurrent hospitalizations and emergency department visits.…”

Functional disorders continue to pose diagnostic and therapeutic challenges to neurologists

“…A pilot randomized controled trial of sertraline versus placebo for nonepileptic psychogenic seizures suggested a beneficial effect of the serotoninreuptake inhibitor, but the study was underpowered to prove the superiority of sertraline compared to placebo to decrease occurrence of psychogenic seizures 7 . A recent pilot randomized controlled trial showed significant seizure reduction and improved comorbid symptoms and global functioning for psychogenic nonepileptic seizure patients that underwent cognitive behavioral treatment with or without sertraline, while treatment-as-usual or sertralineonly showed no benefit 8 . In this issue of Arquivos de Neuropsiquiatria, DePaola et al provide an extensive review of historical aspects, epidemiology, clinical features, diagnosis, and prognosis of psychogenic nonepileptic seizures and psychogenic movement disorders 9 .…”

“…The authors also review recent advances in evidence-based efficacy of cognitive behavioral therapy for psychogenic nonepileptic seizures 8 . These studies should be replicated with different populations, in other cultural settings, and in patients with other types of psychogenic disorders, where evidence-based treatment data are still scarce 13 .…”