Psychogenic Nonepileptic Seizure Patients May Find Benefit With Flexible CBT

People with psychogenic nonepileptic seizures (PNES) who were treated with cognitive behavioral therapy over a longer period of time than expected had improved seizure control and psychiatric symptoms, retrospective data suggested.

Patients who took more than 3 months to attend at least seven of 12 sessions of cognitive behavioral therapy-informed psychotherapy (CBT-ip) showed improvement in seizure frequency, depression, and anxiety, reported Becky Tilahun, PhD, of the Cleveland Clinic in Ohio, during a presentation at the 2021 American Epilepsy Society annual meeting.

“Patients with psychogenic nonepileptic seizures need psychological treatment to control their symptoms,” Tilahun told MedPage Today. “However, these patients commonly drop out of counseling treatment and remain symptomatic and disabled. One of the reasons for poor adherence has been poor access to specialized counseling in local vicinities.”

The study aimed to test whether the patients who partially completed a 12-week treatment plan or attended weekly sessions infrequently benefitted from therapy.

“Although the 12-week CBT-ip treatment is known to be effective, using the treatment in a flexible schedule was not examined previously,” Tilahun noted. “We showed that patients who did not follow the treatment protocol strictly showed some improvement.”

“This is particularly significant because PNES patients often remain untreated,” she added. “We need to think out of the box to increase their access to care.”

PNES are seizure-like episodes without EEG abnormality, and are diagnosed as a functional neurologic symptom disorder in the DSM-5. An estimated 5% to 10% of outpatients in epilepsy clinics and 20% to 40% of inpatients in epilepsy monitoring units have PNES.

Cognitive behavioral therapy is a tested intervention for PNES. In 2014, a randomized clinical trial assessed the effectiveness of CBT-ip, and showed a 51.4% seizure reduction (P=0.01) and significant improvements in depression, anxiety, quality of life, and global functioning from baseline.

CBT-ip is delivered weekly over 12 sessions by a seizure counselor. For this analysis, Tilahun and colleagues obtained retrospective patient-reported outcomes (PRO) data from patients treated with CBT-ip from 2015 to 2020 at an outpatient tertiary care epilepsy center.

The researchers included 238 patients: 126 people attended 12 or more CBT-ip sessions, and 112 attended seven to 12 sessions. Only 64 people had pre- and post-treatment PRO data. Included patients had a mean age of 33 at PNES onset, and 73% were women.

Outcome variables including seizure frequency, depression, anxiety, and quality of life were assessed with self-reported outcome scores. The researchers controlled for demographic and other clinical and psychosocial confounders in their analysis.

They first compared pre-treatment scores with post-treatment scores at 3 months and found no significant change in seizure frequency, depression, anxiety, and quality-of-life outcomes.

However, when they compared pre- and post-treatment scores in patients who completed the treatment in >3 months, they saw improvements in primary and secondary outcomes. For seizure frequency, 10 patients had data for “seizures per day in the last 6 months” and half of them improved by 50% or more in the number of seizures per day. The researchers also found significant reductions in depression and anxiety scores, but not in quality of life.

“Our findings imply that we need to test a different intensity and dose of treatment of the CBT-ip for PNES patients who have logistical barriers to participating in the full program,” Tilahun said.

The observational and exploratory nature of the study limits its generalizability, the researchers noted. In addition, a large number of people without completed PRO data were not included in the study; it’s not known why they didn’t complete assessments.