Editor's Choice


Seizure 45, 2017: Psychological interventions for psychogenic non-epileptic seizures: A meta-analysis

From its foundation 25 years ago, Seizure has not just been a journal about epilepsy but a journal about seizure disorders. Psychogenic Nonepileptic Seizures (PNES) are one of the three most common causes of transient loss of consciousness [1]. They typically present to the same health care professionals who also deal with epilepsy. However, PNES are relatively neglected in many undergraduate and postgraduate training programs. Even experts in the management of seizures often have a much better understanding of epilepsy than PNES. And even if they are knowledgeable about the diagnostic process and how PNES can be distinguished from epilepsy, they are often very uncertain about how to treat PNES.

To be fair to the wider health care community, there are still many questions about the best treatment of PNES disorders that those who have specialized specifically in this area have to answer conclusively. Unfortunately, one of these questions is whether the treatment modality which is widely considered the intervention of choice – individual psychotherapy – is definitely effective.

The authors of my Editor’s Choice article from the current volume of Seizure, Carlson & Nicholson Perry, conclude that the combined evidence from 13 psychotherapy studies describing treatment outcomes in a total of 228 patients is that this psychological treatments may well work for PNES: almost one half of all patients were seizure free upon completion of a psychological intervention. An additional meta-analysis based on ten studies describing outcomes in a total of 137 patients with PNES revealed that four out of five who complete psychological treatment experienced a PNES frequency reduction of at least 50% [2]. This is promising and seems better than the “natural history” of PNES, when patients have not received any treatment specifically targeting their seizures [3].

Fortunately, a more definitive answer to the question whether one particularly widely available form of psychotherapy works for PNES should be available within the next two years when the “Cognitive Behavioural Therapy vs Standardised Medical Care to treat Dissociative Seizures” (CODES) trial reports its findings. To date, well over 500 patients have been recruited to this trial across the United Kingdom. If the new standards for PNES research set by this study are replicated we should soon have more definitive answers to many of the unresolved questions about PNES disorders.

(1) LaFrance Jr., W. C.; Baker, G.A.; Duncan, R.; Goldstein, L.H.; Reuber, M. Minimum requirements for the diagnosis of psychogenic nonepileptic seizures: a staged approach. A report from the International League Against Epilepsy Nonepileptic Seizures Task Force. Epilepsia 2013;54(11),2005-18.

(2) Carlson, P., Nicholson Perry, K.; Psychological interventions for psychogenic non-epileptic seizures: A meta-analysis. Seizure 2017; 45, 142-150.

(3) Reuber, M., Pukrop, R., Bauer, J., Helmstaedter, C., Tessendorf, N., Elger, C. E. Outcome in psychogenic nonepileptic seizures: 1 to 10 year follow-up in 164 patients. Annals of Neurology 2003;53,305-11.

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