Stephanie Howlett

Acceptability and effectiveness of a strategy for the communication of the diagnosis of psychogenic nonepileptic seizures

Purpose:  Communicating the diagnosis of psychogenic nonepileptic seizures (PNES) is a challenging task. This study was carried out to assess the acceptability and effectiveness of a new communication procedure consisting of a patient information leaflet and a communication strategy for neurologists.

Long-term outcome of brief augmented psychodynamic interpersonal therapy for psychogenic nonepileptic seizures: Seizure control and health care utilization

Purpose:  Most neurologists endorse psychotherapy as the treatment of choice for psychogenic nonepileptic seizures (PNES), but its effectiveness remains unproven, and there are no previous reports of long‐term outcome after psychotherapy. This study aimed to establish the outcome of brief augmented psychodynamic interpersonal therapy (PIT) for 47 patients with PNES in terms of seizures and health care utilization 31–65 months (median 50 months) after diagnosis.

Functional symptoms in neurology: questions and answers

Between 10 and 30% of patients seen by neurologists have symptoms for which there is no current pathophysiological explanation. The objective of this review is to answer questions many neurologists have about disorders characterised by unexplained symptoms (functional disorders) by conducting a multidisciplinary review based on published reports and clinical experience. Current concepts explain functional symptoms as resulting from auto-suggestion, innate coping styles, disorders of volition or attention. Predisposing, precipitating, and perpetuating aetiological factors can be identified and contribute to a therapeutic formulation. The sympathetic communication of the diagnosis by the neurologist is important and all patients should be screened for psychiatric or psychological symptoms because up to two thirds have symptomatic psychiatric comorbidity. Treatment programmes are likely to be most successful if there is close collaboration between neurologists, (liaison) psychiatrists, psychologists, and general practitioners. Long term, symptoms persist in over 50% of patients and many patients remain dependent on financial help from the government. Neurologists can acquire the skills needed to engage patients in psychological treatment but would benefit from closer working relationships with liaison psychiatry or psychology.

Measuring Outcome in Psychogenic Nonepileptic Seizures: How Relevant Is Seizure Remission?

Summary:  Purpose: To examine whether seizure remission is a comprehensive marker of outcome in psychogenic nonepileptic seizures (PNESs).

Short-term outcome of psychogenic non-epileptic seizures after communication of the diagnosis.

We previously described a communication strategy for the delivery of the diagnosis of psychogenic non-epileptic seizures (PNES) that was acceptable and effective at communicating the psychological cause of PNES. This prospective multicenter study describes the short-term seizure and psychosocial outcomes after the communication of the diagnosis and with no additional treatment. Participants completed self-report measures at baseline, two and six months after the diagnosis (seizure frequency, HRQoL, health care utilization, activity levels, symptom attributions and levels of functioning). Thirty-six participants completed the self-report questionnaires. A further eight provided seizure frequency data. After six months, the median seizure frequency had dropped from 10 to 7.5 per month (p=0.9), 7/44 participants (16%) were seizure-free, and an additional 10/44 (23%) showed greater than 50% improvement in seizure frequency. Baseline questionnaire measures demonstrated high levels of impairment, which had not improved at follow-up. The lack of change in self-report measures illustrates the need for further interventions in this patient group.

ENGAGEMENT IN PSYCHOLOGICAL TREATMENT FOR FUNCTIONAL NEUROLOGICAL SYMPTOMS—BARRIERS AND SOLUTIONS

This naturalistic study explores how many patients with functional neurological symptoms referred for specialist psychotherapy engage with and complete treatment, and whether routinely recorded demographic or clinical features predict engagement. Of 77 consecutive patients referred, 14.3% were considered unsuitable for therapy and excluded from between group comparisons, 23.4% did not attend any appointments, 20.8% unilaterally discontinued therapy, and 41.6% completed treatment. 66.6% of patients starting therapy completed. Older patients were more likely to engage in or complete therapy (p = .05). There were no significant differences between groups in terms of specific functional symptoms, comorbidity, predisposing, precipitating and perpetuating, or social factors. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

Psychologic treatment of patients with psychogenic nonepileptic seizures

Psychogenic nonepileptic seizures are relatively common, often disabling and costly to patients and society. Most authorities consider psychologic treatment as the therapeutic intervention of choice. This review is intended primarily for psychologists and therapists who treat patients with psychogenic nonepileptic seizures, and for neurologists who make the diagnosis and wish to find out more about psychologic treatment options. The first section describes the nature and etiology of psychogenic nonepileptic seizures. General questions regarding the psychologic treatment of patients with psychogenic nonepileptic seizures are addressed, before discussing specific therapeutic approaches. The final part summarizes the authors’ views on optimal treatment and the direction of future research.

Psychogenic nonepileptic seizures and health-related quality of life: The relationship with psychological distress and other physical symptoms

This study explores the relationship between the frequency of psychogenic nonepileptic seizures (PNES) and health-related quality of life (HRQoL), as well as the effect of psychological distress and other physical symptoms on this relationship. Data were collected on 96 patients with PNES. Correlations of seizure frequency with HRQoL, psychological distress, and physical symptoms were computed. Partial correlations of seizure frequency with HRQoL while controlling for psychological distress and physical symptoms were also computed. Seizure frequency was found to be significantly related to subjective HRQoL, although the relationship with HRQoL was rendered nonsignificant when the effects of psychological distress and the number of other physical symptoms were taken into account. The results of this study suggest that summary scores of HRQoL are not independently related to frequency of PNES and that there is a close association between PNES frequency, levels of psychological distress, and number of other physical symptoms experienced.

A feasibility study of a brief psycho-educational intervention for psychogenic nonepileptic seizures

PURPOSE We have previously reported that one in six patients stops experiencing psychogenic nonepileptic seizures (PNES) following our communication protocol. This prospective multicentre study describes a psycho-educational intervention for PNES building on the initial communication of the diagnosis and examines the feasibility of its delivery by healthcare professionals with minimal experience in psychological therapies. METHOD Three healthcare professionals with minimal training in psychological therapies took part in a one-day training course. 20 participants attended for a four-session manualised psycho-educational intervention delivered at three different clinical neuroscience centres. Participants completed self-report measures prior to the intervention at baseline (n=29) and seven months after diagnosis (n=13) measures included seizure frequency, health related quality of life, healthcare utilisation, activity levels, symptom attributions and levels of functioning. Therapy sessions were audiorecorded and manual adherence assessed. RESULTS Of 29 patients enrolled into the study, 20 started and 13 completed the intervention and provided follow-up information. At follow-up, 4/13 of patients had achieved complete seizure control and a further 3/13 reported a greater than 50% improvement in seizure frequency. After training, epilepsy nurses and assistant psychologists demonstrated sufficient adherence to the manualised psycho-educational intervention in 80% of sessions. CONCLUSION The delivery of our brief manualised psycho-educational intervention for PNES by health professionals with minimal training in psychological treatment was feasible. The intervention was associated with higher rates of PNES cessation than those observed in our previous studies describing the short-term outcome of the communication of the diagnosis alone. An RCT of the intervention is justified but a significant proportion of drop-outs will have to be anticipated.

Emotion processing and psychogenic non-epileptic seizures: A cross-sectional comparison of patients and healthy controls

PURPOSE This exploratory study aimed to examine emotion-processing styles in patients with psychogenic non-epileptic seizures (PNES), compared to healthy individuals, and to explore associations of emotion processing with other psychological measures and seizure frequency, using the new Emotional Processing Scale (EPS-25), which had not previously been used in this patient group. METHODS Fifty consecutive patients with PNES referred for psychotherapy completed a set of self-report questionnaires, including the Emotional Processing Scale (EPS-25), Clinical Outcome in Routine Evaluation (CORE-10), Short Form-36 (SF-36), Patient Health Questionnaire (PHQ-15), and Brief Illness Perception Questionnaire (BIPQ). Responses on the EPS-25 were compared to data from 224 healthy controls. RESULTS Patients with PNES had greater emotion processing deficits across all dimensions of the EPS-25 than healthy individuals (suppression/unprocessed emotion/unregulated emotion/avoidance/impoverished emotional experience). Impaired emotion processing was highly correlated with psychological distress, more frequent and severe somatic symptoms, and a more threatening understanding of the symptoms. Emotion processing problems were also associated with reduced health-related quality of life on the mental health (but not the physical health) component of the SF-36. The unregulated emotions sub-scale of the EPS was associated with lower seizure frequency. CONCLUSION The results showed clear impairments of emotion processing in patients with PNES compared to healthy individuals, which were associated with greater psychological distress and reduced mental health functioning. These findings seem to support the face validity of the EPS-25 as a measure for PNES patients and its potential as a tool to assess the effectiveness of psychological interventions.