Treatment Challenges in Nonepileptic Psychogenic Seizures: Finding the Perfect Fit for the No-One-Size-Fits-All Group

Commentary

A Pilot Study of Reduction in Healthcare Costs Following the Application of Intensive Short-Term Dynamic Psychotherapy for Psychogenic Nonepileptic Seizures.

Russell LA, Abbass AA, Allder SJ, Kisely S, Pohlmann-Eden B, Town JM. Epilepsy Behav 2016;63:17–19.

Purpose: The purpose of this study was to examine preliminary evidence of intensive short-term dynamic psychotherapy (ISTDP) as a treatment option for psychogenic nonepileptic seizures (PNES) in terms of impact on healthcare costs, emotional wellbeing, and somatic symptoms. Method: Drawn from a sample of patients treated in a tertiary psychiatric service over a nine-year period, this naturalistic pilot study compared within-group changes from pretreatment with each year up to three years posttreatment, in physician visits, physician costs, hospital admissions, and overall hospital costs. Results: Twenty-eight patients with PNES received ISTDP with average treatment duration of 3.6 sessions. Healthcare costs significantly reduced in follow-up compared with those in baseline, with patient costs falling below the healthy population means, and reductions in healthcare costs compared with those in baseline by 88% in year one, 90% in year two, and 81% in year three. This was accompanied by significant reductions in symptoms and interpersonal problems. Conclusion: These preliminary findings indicate the potential for short-term and long-term healthcare savings and improvements in emotional wellbeing, for patients with PNES from the application of ISTDP. Further research evaluating the impact of ISTDP on seizure reduction and comparing this approach with control conditions is warranted.

A Multicenter Evaluation of a Brief Manualized Psychoeducation Intervention for Psychogenic Nonepileptic Seizures Delivered by Health Professionals with Limited Experience in Psychological Treatment.

Wiseman H, Mouse S, Howlett S, Reuber M. Epilepsy Behav 2016;63:50–56.

Rationale: The aim of this study was to add to our understanding of the impact of psychoeducation on patients' acceptance of the diagnosis of psychogenic nonepileptic seizures (PNESs), the frequency of their seizures, and their quality of life. The study also aimed to evaluate the effectiveness of brief manualized psychoeducation interventions for PNESs, delivered by a more diverse range of clinicians and in a wider range of treatment settings. Method: The final sample consisted of 25 patients diagnosed with PNESs by a neurologist specializing in the treatment of seizure disorder and referred to the psychotherapy service. The study included patients from four centers, using a manualized psychoeducation intervention delivered over 4 sessions by specialist epilepsy nurses and assistant psychologists. All patients completed self-measure questionnaires for Seizure Frequency, Impaired Functioning (WSAS), Psychological Distress (CORE-OM), Illness Perception (BIPQ), Health-Related Quality of Life: general (ED-QOL) and epilepsy-specific (NewQOL-6D), Symptom Attribution, and patient's perception of usefulness and relevance of the intervention. All measures were collected at baseline and after the completion of the fourth session. Results: All measures improved from baseline to postintervention, but this improvement was only significant for CORE-OM(p b .05) and BIPQ (p b .01). Out of the 25 patients who completed the intervention information, 6 out of 25 (24%) had been seizure-free for the past month, and an additional 6 out of 25 (24%) had achieved seizure frequency reduction. Consequently, upon completion of the intervention, 12 out of 25 patients (48%) were either seizure-free or experienced fewer seizures compared with the start of the intervention. Conclusion: The evidence suggests that brief manualized psychoeducation intervention can reduce PNES frequency, improve the psychological distress, and have an effect on patients' illness perceptions that should help them engage with a more extended psychotherapy program if that was necessary. The intervention was carried out successfully by staff with relatively little training in delivering psychological interventions. Further controlled studies are required to provide proof of efficacy.

There exists a steadily growing ground swell of support in the scientific and clinical communities for developing cost-efficient and creative treatment approaches for persons with nonepileptic psychogenic seizures (1, 2). This challenging condition has been a conundrum for medical and mental health professionals for many years, repeatedly described as crossing the traditional diagnostic and treatment boundaries of both psychiatry and neurology (3, 4). In this vein, much has been written on the difficulties for establishing who are best qualified for treating this “in-between” group with a common theme in these discussions that a multidisciplinary team approach is required. However, this has not been commonly achieved.

Persons with a diagnosis of nonepileptic psychogenic seizures have met with a variety of obstacles in finding effective and empirically established treatment tools for improving their condition, including limited funding sources for development of randomized clinical treatment trials, inadequate access to private insurance pay and community mental health services, and continued limited understanding of the condition in the broader medical community. However, despite these challenges, researchers and clinicians have continued to come forth with efforts that expand our understanding of this complex condition within a comprehensive biopsychosocial model (5). Exciting developments continue as exemplified by recent publications that examine multiple aspects of the nonepileptic condition, including neurobiological underpinnings (e.g., brain network abnormalities, electrophysiological differences) (6, 7) and advance our understanding of psychological factors, such as the impact on coping and emotional reactivity to abuse histories (8).

Also promising in the literature are continued efforts at developing treatment interventions for this population, despite various degrees of perplexity and avoidance in the broader medical and mental health communities. As pointed out many times in the past, persons who present with nonepileptic seizures have a complicated set of both psychological and physical symptom presentations; these are typically thought to reflect severe psychopathology and often considered within the challenging diagnostic constellation of somatic symptoms and related disorders group (i.e., functional neurological symptom disorders, conversion disorder), dissociative categories, or even possible feigned symptom presentations. Even when event-positive video/EEG monitoring provides diagnostic certainty and excludes a neurological etiology, many mental health practitioners become apprehensive when asked to provide counseling/therapy for a person with nonepileptic “seizures.” Despite this, as comprehensively reviewed recently by both Smith (2014) and Wiseman and Markus (2014), many studies from various theoretical perspectives have been published and have produced varying but promising degrees of beneficial treatment outcome results.

Over the past year, two studies have been published that represent commendable examples of these continued efforts at developing effective, accessible, and affordable treatment approaches for persons with nonepileptic psychogenic seizures. The first study, authored by Russell et al. (2016), was described as a preliminary look at the potential impact of a short-term psychodynamic therapy approach upon aspects of emotional well-being, interpersonal relationship status, and healthcare cost/utilization outcomes in a small retrospectively collected sampled group with nonepileptic psychogenic seizures.

The authors approached their study with the viewpoint that no study to date had examined the impact of the presented therapy approach on long-term outcomes in this patient group, as well as the impact upon post-treatment healthcare costs. The treatment group consisted of 28 persons with nonepileptic seizures who were selected from a larger study that had examined the impact of short-term psychodynamic therapy on long-term healthcare cost/utilization across a large range of psychiatric groups (N = 1182). The nonepileptic diagnosis in the selected participants had been well-established via neurological and electrophysiological procedures.

The authors highlighted that seven therapists were involved in the treatment sessions for the enrolled patients across several clinic sites. The sessions ranged from 1 to 25 per participant, with increased session numbers often reflecting impacts from patient readiness for therapy as well as symptom severity. Patient outcome was assessed at upwards of 3 years post-treatment completion. Analyses revealed group level improvements on measures of psychiatric symptom severity (Brief Symptom Inventory) and on the Inventory of Interpersonal Problems. It was also noted that of the 28 patients, only a portion completed pre-therapy measures (54–68% depending on measure) and fewer completed post-therapy measures (39%). It is therefore important to point out that while the authors noted improvements in areas such as depression and psychoticism in those persons completing the measures, they acknowledged that the small numbers of patients completing the measures was a limitation that precluded any generalizations regarding impact to nonepileptic seizure patient psychological outcome.

In terms of total combined healthcare costs (i.e., physician costs, hospital days and costs), substantial reductions were reported over the three-year study period in comparison to baseline cost estimates, with reductions of over 80 percent across each year. Regarding the economic outcomes data, Russell and colleagues highlighted other study limitations, including the wide variability of the hospital cost expenditures, absence of a control group, and having no access to post-treatment seizure outcome data (e.g., seizure frequency).

Another recent study, authored by Wiseman et al. (2016), highlighted ongoing efforts at expanding mental health treatment to persons with nonepileptic psychogenic seizures and provided a continuation of their prior work towards developing a stepped-care model of post-diagnostic care. This stepped-care approach required that a neurologist initially lead the communication with the patient and family regarding diagnosis. This was followed by an invitation for participation in a brief manualized psychoeducational intervention in which the therapy providers followed step-by step session instructions and guidelines. More in-depth individualized psychotherapy sessions was offered for some patients with more severe psychopathology. .

The study involved 36 patients who agreed to participate in the psychoeducational intervention that was conducted by a range of medical/mental health professionals (e.g., psychologists, occupational therapists, or epilepsy nurses). The authors' goals were to examine the impact of their psychoeducational session on diagnostic acceptance, seizure frequency rates, and on quality of life ratings post-diagnosis. It was the authors' expressed hope that a brief intervention could be demonstrated as practical and effective towards improving aspects of patient outcomes.

The psychoeducational intervention included an outline of 4 weekly 1-hour sessions. Each participant was asked to complete a number of self-report psychological/quality-of-life measures that were completed pre-session and following intervention completion. Measures assessed aspects of illness perceptions, adjustment, and quality of life. The authors found that this brief four-session psychoeducational intervention achieved some benefit towards seizure-frequency reduction (and, in a few cases, elimination), improved understanding of illness, reduced psychological distress, and increased willingness to proceed to individualized psychotherapy. However, at the same time, the authors acknowledged the challenges that accompany intervention efforts in this patient population. Many individuals were reluctant to engage in any form of intervention, others dropped out along the way, and some were additionally nonadherent to completing the requested study questionnaire measures. Of the 25 participants completing all sessions, 19 (76%) were noted to have completed the outcome questionnaire. The authors also reported that psychoeducational programs as described likely require complementary individualized psychotherapy.

Both the Russell et al. (2016) and the Wiseman et al. (2016) studies highlight ongoing efforts in the neurology and mental health scientific and clinical communities towards developing a diversity of cost-effective and patient-accepted treatment approaches that work to improve the quality of life in persons with nonepileptic seizures. While considerable challenges will continue from multiple fronts—including socioeconomic resource limitations (e.g., limited access to mental health providers)—it remains heartening to see the number of continuing efforts at treatment development (9, 10).

There exists an ongoing need for treatment approaches that can demonstrate some degree of positive impact, not only to seizure outcome but also on a personal level, medical level, and the larger healthcare level. Obviously, these are complex and difficult goals that mostly reach only partial resolution or improvement, despite best treatment provider intentions. However, as healthcare systems evolve towards more evidence-based metrics to determine what types of services will receive coverage, such efforts as those described can provide evidence for improvements across multiple levels of patient outcome.