Cognitive Behavioral Therapy Can Alleviate Nonepileptic Seizures

PNES is a condition that is marked by seizures resembling epileptic seizures. Unlike epilepsy, however, seizures in patients with PNES are not caused by the same brain cell firing that occurs with epilepsy. Estimates indicate that approximately 20 to 30 percent of patients who are seen in epilepsy centers actually suffer from PNES as opposed to epilepsy. Patients who suffer from PNES often exhibit a higher incidence of symptoms such as anxiety and depression than patients with epilepsy, along with a reduced quality of life due to the effect of the seizures themselves. It is recognized, however, that conditions such as anxiety and depression often respond well to CBT. To date, treatment trials for PNES are few, despite the disabling nature of the disorder.

With this in mind, senior author W. Curt LaFrance, Jr., MD, MPH, director of the division of neuropsychiatry and behavioral neurology at Rhode Island Hospital, developed a CBT for PNES treatment manual. Modified from a CBT for patients with epilepsy workbook, the treatment manual has been developed over the past five years to address core issues in patients with PNES. LaFrance, who is also an assistant professor of psychiatry and neurology (research) at the Warren Alpert Medical School of Brown University, worked with colleagues at Rhode Island Hospital's comprehensive epilepsy center to conduct an open, prospective clinical trial assessing the outcomes of outpatients with video-electroencephalogram (EEG)-confirmed PNES who were treated using the CBT for PNES manual.

LaFrance and the researchers have outlined a clinical model for management of PNES, where a key component is to identify precursors, precipitants and perpetuating factors of the seizures. LaFrance says, "Based on the tendency of patients with PNES to somatize (to manifest mental pain as pain in one's body), we hypothesized that identifying and modifying cognitive distortions and environmental triggers for PNES would reduce PNES."

The researchers then identified patients who were referred to the Rhode Island Hospital neuropsychiatry/behavioral neurology clinic after being diagnosed with PNES and at least one typical PNES was captured on video EEG. Of the 101 patients who were assessed for eligibility, 21 patients met the criteria or agreed to participate. Of those 21, 17 completed the 12-week session of CBT intervention and were included in the analysis.

LaFrance notes that the results of the clinical trial showed the CBT to be effective in terms of reducing the frequency of PNES. He notes, "Upon completion of the CBT, 16 of the 21 participants reported a 50 percent reduction in seizure frequency, and 11 of the 17 who completed the CBT reported no seizures per week by their final CBT session." He also points out, "treating the seizure is not the sum total of treating the patient with a seizure disorder, so we assessed other important measures, as well." The evaluation of quality of life scores, as well as assessments of depression, anxiety, somatic symptoms and psychosocial functioning also showed statistically significant improvement from baseline to final session.

The doctor concludes, "In this small clinical trial, treatment with the CBT for PNES program appears to be a beneficial approach in helping patients with PNES reduce their seizure frequency and significantly improve quality of life. We have also seen patients referred with other somatoform disorders, such as psychogenic movement disorders, respond to the treatment." The results of this trial will be used for an upcoming National Institutes of Health proposal for a multi-center randomized controlled trial for PNES.

Other researchers include Ivan W. Miller; Christine E. Ryan; Andrew S. Blum, MD; David A. Solomon, Joan E. Kelley, and Gabor I. Keitner, all of Rhode Island Hospital's department of psychiatry, department of neurology and the comprehensive epilepsy center, and the departments of psychiatry and human behavior and neurology at the Warren Alpert Medical School of Brown University in Providence, RI.