Table 1.
Therapeutic modalities used to treat PNES: number of sessions, theoretical foundation, rationale, treatment targets, tools and results.
| Treatment modality | Structure (# of sessions, duration) | Theoretical foundation | Targets | Tools | Results |
|---|---|---|---|---|---|
| CBT-ip for PNES (LaFrance et al, 2014), for functional tremor (Espay et al, 2019) | 1 initial encounter + 11 sessions + 1 final reading (Taking control: an ongoing process) | Fear Avoidance Model: trigger → distorted thinking → maladaptive behavior (recurring cycle) | Emotional dysregulation, distorted views of world and self, avoidance behavior, environmental factors | Seizure/symptom record, workbooks, thought record, trigger charts, relaxation training, goal-setting exercises, medication logs, support person | ↓ seizure frequency/severity of functional symptoms, ↓depression and anxiety, improved QOL, global functioning |
| CBT for PNES (Goldstein et al, 2020) | 12 | Fear Avoidance Model (“panic without panic”) - classical and operant conditioning: physiological trigger → cognitive and attributional factors → avoidant behavior (recurring cycle) | Behavioral, cognitive, affective, physiological and social factors | Seizure record, relaxation training, distraction techniques, handouts | No improvement in seizure frequency at 1 year (except first 6 months) Improved QOL, ↓ impairment in psychosocial functioning, ↓ psychological distress, ↓ somatic symptoms and seizures less bothersome |
| CBT for FMD (Dallochio et al, 2016) | 12 | Somatic signal misinterpretation and incorrect illness beliefs maintain FMD | Distorted thoughts, physical activity | Distraction techniques, coping strategies, physical exercise prescription | Improved FMD symptoms (self-assessment of incapacitation), depression, anxiety |
| CBT for FND (Sharpe et al, 2011) | Paced through guided self-help workbook Maximum contact: 4 sessions for guidance (30 minutes) | Functional symptoms are explained as “changes in nervous system functioning that were influenced by psychological and behavioral factors:” avoidance behaviors and distorted thoughts perpetuate symptoms | Lack of information on FND, avoidance behaviors, distorted thoughts | Workbook and self-management techniques | Improved FND symptoms (based on global impression) and less symptom burden. |
| Mindfulness-based therapy for PNES (Baslet et al, 2020) | 5 modules (12 sessions) | Mixes elements of ACT, DBT, MBSR and MBCT. By creating increased awareness and acceptance of internal states, patients purposefully engage in values-based behavior which decreases automatized processes that lead to PNES |
Awareness of contexts and vulnerable states, values and behaviors | Seizure record, stress management (relaxation) techniques, crisis survival tools, behavior chain analysis, values identification exercises, mindfulness, emotion recognition logs, relapse prevention plan | ↓seizure frequency and intensity Improved QOL. |
| Brief psychodynamic interpersonal model for FND/PNES (Reuber et al, 2007; Howlet and Reuber, 2009; Mayor et al 2010) | 2-hour initial interview and 19 (50-minute) sessions | Adaptation of the brief interpersonal psychodynamic therapy model (Hobson, 1985). Symptoms are explained based on generated hypotheses based on an individualized formulation of predisposing, precipitating, perpetuating factors, and triggers. |
Unconscious interpersonal relationship patterns, emotional processing, psychological trauma. | Seizure/somatic symptom record, sensory grounding, relaxation techniques, life charts, sensory focusing, emotional freedom technique, EMDR, exposure (linking memories, emotions, symptoms), emotion diary. | ↓seizure frequency. Improvements in psychological distress, somatic symptoms and QOL. Reduced medical resource utilization |
| Short term psychodynamic psychotherapy for FMD (Hinson et al 2006; Kompolity et al, 2014) | 12 (1 hour)/3 months | Childhood experiences, family dynamics, and personality traits link to current life experiences and produce symptoms | Unconscious interpersonal relationship patterns, emotional processing/alexithymia | Insight into unconscious phenomena, working through underlying conflict. | Improvement in depression, anxiety, functioning and severity of functional movements (based on one study). |
| Psychoeducational Group for PNES (Zaroff et al, 2003) | 10 (1 hour) | By learning more about the diagnosis, patients gain more control over their symptoms. | Lack of health information and unfamiliarity with psychological tools | Handouts, relaxation techniques. | No improvement in seizure frequency. Improved posttraumatic, dissociative symptoms and coping strategies. |
| Psychoeducational group (Chen et al, 2014) | 3 (90 minutes) | By learning more about the diagnosis, patients gain more control over their symptoms. | Lack of health information and unfamiliarity with psychological tools | Seizure record, handouts, stress journal, distress tolerance techniques, support group | No improvement in seizure frequency. Improved work and social adjustment scores and reduced medical resource utilization. |
| Group psychotherapy for PNES (Barry et al, 2008) | 32 (90 minutes) | The need for functional symptoms is eliminated by making emotional distress conscious and verbalized. | Similar to other psychodynamic therapies, anger and assertive behavior | Self-hypnosis, coping strategies, assertiveness training, support group | ↓seizure frequency, improved depression, severity of psychological symptoms. |
| DBT skills group for PNES (Bullock et al, 2015) | 8–10 weeks (90 minutes) | Deficit in implicit-to-explicit processing of emotion generates symptoms. When patients learn emotion and behavior regulation skills, symptoms improve. | Distress intolerance, emotion dysregulation, and interpersonal difficulties | DBT diary cards, mindfulness training, skills training, seizure record. | ↓ seizure frequency |
| Body-centered psychotherapy (Kozlowska et al, 2018; Sawchuck et al, 2020) | Assessment + 2-week inpatient program or 1–3 sessions as part of larger program | Development of somatic awareness is necessary to then use neurophysiological regulation to reduce autonomic arousal and increase upregulate vagal function. | Interoception, proprioception and kinesthesis help develop somatic awareness. | Biofeedback, exercise program, body map. | ↓ seizure frequency, reintegration to school |
| Group CBT for FND (including PNES) (Conwill et al, 2014) | 4 for PNES, 5 for other FND (1 hour) | By understanding and changing cognitive and behavioral responses to symptoms, there is improved physical and emotional well-being | Knowledge about diagnosis, isolation, thoughts, feelings, physical sensations and actions related to symptoms. | Presentations, handouts, discussion of new behavioral strategies. | Improved emotional well-being. |
| PE for PNES + PTSD (Myers et al, 2017) | 12–15 (90 minutes) | Emotion Processing Theory: Avoidance maintains PTSD and functional symptoms and exposure provides corrective learning experiences; therefore, symptoms are no longer necessary. | Avoidance (thoughts and actions), emotional dysregulation, and distorted views of world and self | Seizure record, breathing retraining, workbook, in vivo and imaginal exposure, sensory grounding (if needed) | ↓seizure frequency, improved depression, PTSD symptoms, improved work adjustment |
| ReACT (Fobian et al, 2020) | 8 | Integrated Etiological Summary Model: FS result from catastrophic symptom expectations and/or classically conditioned responses | catastrophic symptom expectations, low sense of control over symptoms | Goal setting, identification of reinforcers and use of “punishers” | ↓seizure frequency |
| Group psychotherapy for PNES + epilepsy (Barros et al, 2018) | 8 | Mixes elements of CBT, PIT, MBT. Improved knowledge about illness and identification of thoughts and emotions and effective body monitoring lead to lower risk of symptoms. |
Lack of health information, distorted thoughts and emotions, body monitoring, identification of stressors and triggers. | Seizure log, relaxation training | ↓seizure frequency. Improved QOL, depression, anxiety, alexithymia. |
CBT-ip: cognitive behavioral therapy-informed psychotherapy; DBT: dialectical behavioral therapy; PIT: Psychodynamic interpersonal therapy; EMDR: eye movement desensitization and reprocessing; MBT: Mindfulness-based therapy; PE: prolonged exposure; QOL = Quality of life; ReACT: retraining and control therapy.