Psychogenic Nonepileptic Seizures

A variety of treatment strategies are employed for the management of PNES including cognitive behavioral therapy (CBT), group and family therapy, antidepressant medication, and other forms of rehabilitation [5,57,58]. A 2007 Cochrane review that identified 608 references for non-medication PNES treatments found that only 3 studies met criteria for a randomized controlled trial. One of the more recently favored treatment options for PNES that has been applied to the treatment of various somatoform disorders and other psychiatric disorders in the past is CBT [57,59,60]. This form of psychotherapy can be administered by trained personnel in a time-limited fashion using defined protocols. The basis of this treatment is that the patient learns to increase awareness of their dysfunctional thoughts and learns new ways to respond to them [57,58]. To date, several groups have reported results of nonrandomized trials as well as case reports and case series which have established the utility of this treatment. There have been reports of significant reductions in seizure frequency and this treatment strategy appears very promising [61–65]. Preliminary randomized controlled trials have also been piloted and are also suggestive that this may be a validated treatment approach [66].

Prognosis

The outcomes of patients with PNES vary. Long-term follow-up studies show that about half of all patients with PNES function reasonably well following their diagnosis. However, only approximately one-third of patients will completely stop having seizures or related problems, and approximately 50% percent have poor functional outcomes [1,2,50]. When the diagnosis of PNES is based on reliable criteria such a video EEG monitoring, misdiagnosis is unlikely. Instead, the usual cause for a poor outcome is related to a patient’s chronic psychological and social problems[1,8,22,50].

It is noteworthy that children with PNES appear to have a much better prognosis than adults [9,10]. In fact, the etiology in children may be related more to transient stress and coping disorders, while adults are more likely to have PNES within the context of more chronic psychological maladjustment, such as personality disorders [10]. Another factor that accounts for the better outcomes in children is that they are usually properly diagnosed earlier in the course of their disorder [9,10].

Patients with milder psychopathology respond better to supportive educational or behavioral therapeutic approaches. In contrast, patients with more severe psychopathology and factitious disorders more often have associated chronic personality problems and correspondingly, a poorer prognosis [1,50]. Also it appears that patients who continue to be followed by the diagnosing neurologist or center do better than patients who are not seen after diagnosis [49,67]. As knowledge about the nature of PNES and their associated psychopathology is gained, better treatment strategies can be developed that will improve the care and prognosis of these difficult and challenging patients.

A large study of 164 patients who were followed for 10 years were considered to have “poor outcome” in general but favorable factors included higher education, younger age of onset and diagnosis, and less “dramatic” attacks, defined as lack of “positive motor features, no ictal incontinence or tongue biting.” These findings were consistent with prior studies [52,68].