Treatment of Psychogenic Non-Epileptic Seizures

Psychogenic Non-Epileptic Seizures (PNES), also known as dissociative or functional seizures or Functional Non-Epileptic Attacks (FNEA), are episodes of sensory or involuntary motor symptoms that can be difficult to distinguish from epileptic attacks. A substantial part of all patients under investigation for seizures are thought to have PNES, and anti-epileptic drugs do not alleviate symptoms for these patients. Although the cause of PNES is largely unknown, psychological factors are thought to contribute.

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SBU Enquiry Service

Consists of structured literature searches to highlight studies that can address questions received by the SBU Enquiry Service from Swedish healthcare or social service providers. We assess the risk of bias in systematic reviews and when needed also quality and transferability of results in health economic studies. Relevant references are compiled by an SBU staff member, in consultation with an external expert when needed.

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Published: Report no: ut202203 Registration no: SBU 2021/624

Question

What systematic reviews or scientific studies are there on treatment of Psycogenic Non-epileptic Seizures?

Identified literature

One systematic review with low risk of bias [1] and twelve primary studies were identified [2-13]. The primary studies were not assessed for risk of bias.

Table 1. Systematic reviews with low/medium risk of bias
Included studies Population/Intervention Outcome and Results
Martlew et al, 2014 [1]
Psychological and behavioural treatments for adults with nonepileptic attack disorder (Review)
Included studies:
  • 4 RCTs
  • 8 before and after non-controlled studies
 Population: Adults with any type of non-organic, non-epileptic seizures, with or without learning disabilities (n=343).

Intervention: Behavioural or psychological interventions.

Interventions in included studies: cognitive behavioural therapy (n=3), hypnotherapy (n=2), paradoxical intention therapy (n=1), psychotherapy (n=5), mixed interventions (n=1).		 Cognitive behavioural therapy vs standard medical care:

1 RCT (n=66)

Significant decrease in seizures in the CBT intervention group compared to the standard medical care group.

Cognitive behavioural therapy, before and after measurement:

1 RCT (n=66), 2 non-controlled studies (n=37)

All three studies reported significant seizure reduction post-treatment compared to pre-treatment.

Psychotherapy, before and after measurement:

5 non-controlled studies (n=53)

In three of the five studies the majority of participants experienced a decrease in seizure frequency at the end of the treatment.

Mixed intervention, before and after measurement:
1 non-controlled study

The majority of participants were event-free at the end of the treatment.
Authors' conclusion: “There is little reliable evidence to support the use of any treatment, including CBT, in the treatment of non-epileptic seizures. Further randomised controlled trials of CBT and other interventions are needed.”

 

Table 2. Primary studies
Publication Study type Population Treatment
Senf-Beckenbach et al
2022 [10]		 Pilot RCT Adult outpatients with PNES Body-focused group therapy
Goldstein et al
2021 [6]
Studien är även publicerad i Lancet 2020		 RCT (HTA) Adults with dissociative seizures CBT
Stager et al
2021 [11]		 RCT (follow up) Children with PNES Retraining and Control Therapy (ReACT)
Fobian et al 2020 [5] RCT Children with PNES Retraining and Control Therapy (ReACT)
Tolchin et al
2019 [13]		 RCT Adults with PNES Motivational interviewing
Baird et al
2017 [2]		 Pilot RCT Adults with PNES CBT informed psychotherapy with or without sertraline or sertraline alone
Hill et al
2017 [7]		 Retrospective observational cohort Adults with PNES Standardized follow-up
Drane et al 2016 [4] RCT Adults with PNES Structured feedback
Hubschmid et al
2015 [8]		 RCT Adults with conversion disorder with motor or NEA symptoms Interdisciplinary psychotherapeutic intervention
Chen et al
2014 [3]		 RCT Adults with PNES Group psychoeducation
LaFrance et al
2014 [9]		 Pilot RCT Adults with PNES CBT informed psychotherapy with or without sertraline or sertraline alone
Thompson et al2012 [12] Pilot RCT Adults with PNES Brief educational intervention

References

  1. Martlew J, Pulman J, Marson AG. Psychological and behavioural treatments for adults with non-epileptic attack disorder. Cochrane Database Syst Rev. 2014(2):CD006370. Available from: https://doi.org/10.1002/14651858.CD006370.pub2.
  2. Baird GL, Harlow LL, Machan JT, LaFrance WC, Jr. Cluster reduction in patients in a pilot treatment trial for psychogenic nonepileptic seizures. Epilepsy Behav. 2017;73:273-9. Available from: https://doi.org/10.1016/j.yebeh.2017.04.015.
  3. Chen DK, Maheshwari A, Franks R, Trolley GC, Robinson JS, Hrachovy RA. Brief group psychoeducation for psychogenic nonepileptic seizures: a neurologist-initiated program in an epilepsy center. Epilepsia. 2014;55(1):156-66. Available from: https://doi.org/10.1111/epi.12481.
  4. Drane DL, LaRoche SM, Ganesh GA, Teagarden D, Loring DW. A standardized diagnostic approach and ongoing feedback improves outcome in psychogenic nonepileptic seizures. Epilepsy Behav. 2016;54:34-9. Available from: https://doi.org/10.1016/j.yebeh.2015.10.026.
  5. Fobian AD, Long DM, Szaflarski JP. Retraining and control therapy for pediatric psychogenic non-epileptic seizures. Ann Clin Transl Neurol. 2020;7(8):1410-9. Available from: https://doi.org/10.1002/acn3.51138.
  6. Goldstein LH, Robinson EJ, Pilecka I, Perdue I, Mosweu I, Read J, et al. Cognitive-behavioural therapy compared with standardised medical care for adults with dissociative non-epileptic seizures: the CODES RCT. Health Technol Assess. 2021;25(43):1-144. Available from: https://doi.org/10.3310/hta25430.
  7. Hill CE, Schwartz H, Dahodwala N, Litt B, Davis KA. Postdiagnosis neurological care for patients with psychogenic nonepileptic spells (PNES). Epilepsy Behav. 2017;74:64-8. Available from: https://doi.org/10.1016/j.yebeh.2017.06.029.
  8. Hubschmid M, Aybek S, Maccaferri GE, Chocron O, Gholamrezaee MM, Rossetti AO, et al. Efficacy of brief interdisciplinary psychotherapeutic intervention for motor conversion disorder and nonepileptic attacks. Gen Hosp Psychiatry. 2015;37(5):448-55. Available from: https://doi.org/10.1016/j.genhosppsych.2015.05.007.
  9. LaFrance WC, Jr., Baird GL, Barry JJ, Blum AS, Frank Webb A, Keitner GI, et al. Multicenter pilot treatment trial for psychogenic nonepileptic seizures: a randomized clinical trial. JAMA Psychiatry. 2014;71(9):997-1005. Available from: https://doi.org/10.1001/jamapsychiatry.2014.817.
  10. Senf-Beckenbach P, Hoheisel M, Devine J, Frank A, Obermann L, Rose M, et al. Evaluation of a new body-focused group therapy versus a guided self-help group program for adults with psychogenic non-epileptic seizures (PNES): a pilot randomized controlled feasibility study. J Neurol. 2022;269(1):427-36. Available from: https://doi.org/10.1007/s00415-021-10652-0.
  11. Stager L, Szaflarski JP, Fobian AD. One-year follow-up of treatment outcomes and patient opinions of Retraining and Control Therapy (ReACT) for pediatric functional seizures. Epilepsy Behav Rep. 2021;16:100503. Available from: https://doi.org/10.1016/j.ebr.2021.100503.
  12. Thompson N, Connelly L, Peltzer J, Nowack WJ, Hamera E, Hunter EE. Psychogenic nonepileptic seizures: a pilot study of a brief educational intervention. Perspect Psychiatr Care. 2013;49(2):78-83. Available from: https://doi.org/10.1111/j.1744-6163.2012.00353.x.
  13. Tolchin B, Baslet G, Suzuki J, Martino S, Blumenfeld H, Hirsch LJ, et al. Randomized controlled trial of motivational interviewing for psychogenic nonepileptic seizures. Epilepsia. 2019;60(5):986-95. Available from: https://doi.org/10.1111/epi.14728.

Literature searc

Medline via OvidSP 11 January 2022
Title: Treatment for Psychogenic non-epileptic seizures
The final search result, usually found at the end of the documentation, forms the list of abstracts.

.ab. = Abstract; .ab,ti. = Abstract or title; .af. = All fields; Exp = Term from the Medline controlled vocabulary, including terms found below this term in the MeSH hierarchy; .sh. = Term from the Medline controlled vocabulary; .ti. = Title; / = Term from the Medline controlled vocabulary, but does not include terms found below this term in the MeSH hierarchy; * = Focus (if found in front of a MeSH-term); * or $ = Truncation (if found at the end of a free text term); .mp = Text, heading word, subject area node, title; “ “ = Citation Marks; searches for an exact phrase; ADJn = Positional operator that lets you retrieve records that contain your terms (in any order) within a specified number (n) of words of each other.
Search terms Items found
Population: Psychogenic non-epileptic seizures
1. Psychogenic Nonepileptic Seizures/ 4
2. ((psychogenic or dissoc* or nonorganic or non-organic) adj3 (episod* or seizure* or attack* or event* or convulsion*)).ab,kf,ti. 2 612
3. (functional adj3 (episod* or seizure* or attack* or convulsion*)).ab,kf,ti. 803
4. (pseudoseizure* or pseudo-seizure* or nonepileptic* or non-epileptic*).ab,kf,ti. 4 257
5. 1 OR 2 OR 3 OR 4 6 057
Intervention: Treatment
6. exp psychotherapy/ or (therap* or treatment* or psychotherap* or CBT or management or care).ab,kf,ti.
Study types: Systematic reviews
7. (Systematic Review or Meta-Analysis).pt. or Cochrane Database Syst Rev.ja. or ((systematic adj3 review) or "meta analys*" or metaanalys*).ti,ab.
Limits: XX
8. From 2013
Combined sets
9. 5 AND 7 98
10. 5 AND 6 AND 8 1 037
Final result
11. Systematic reviews on Psychogenic non-epileptic seizures 98
12. Psychogenic non-epileptic seizures treatment studies from 2013 - 1 037

 

CINAHL via EBSCO 11 January 2022
Title: Treatment of Psychogenic non-epileptic seizures
The final search result, usually found at the end of the documentation, forms the list of abstracts.
AB = Abstract; AU = Author; DE = Term from the thesaurus; MH= Exact Subject Heading from CINAHL Subject Headings; MM = Major Concept; TI = Title; TX = All Text. Performs a keyword search of all the database's searchable fields; ZC = Methodology Index; * = Truncation; “ “ = Citation Marks; searches for an exact phrase; N = Near Operator (N) finds the words if they are a maximum of x words apart from one another, regardless of the order in which they appear.; W = Within Operator (W) finds the words if they are within x words of one another, in the order in which you entered them.
Search terms Items found
Population: Psychogenic non-epileptic seizures
1. TI ( ((psychogenic OR dissoc* OR nonorganic OR non-organic) N3 (episod* OR seizure* OR attack* OR event* OR convulsion*)) ) OR SU ( ((psychogenic OR dissoc* OR nonorganic OR non-organic) N3 (episod* OR seizure* OR attack* OR event* OR convulsion*))) OR AB ( ((psychogenic OR dissoc* OR nonorganic OR non-organic) N3 (episod* OR seizure* OR attack* OR event* OR convulsion*)) ) 566
2. TI ( functional N3 (episod* OR seizure* or attack* OR convulsion*) ) OR SU ( functional N3 (episod* OR seizure* or attack* OR convulsion*) ) OR AB ( functional N3 (episod* OR seizure* or attack* OR convulsion*) ) 267
3. TI ( pseudoseizure* OR pseudo-seizure* OR non-epileptic* OR nonepileptic* ) OR SU ( pseudoseizure* OR pseudo-seizure* OR non-epileptic* OR nonepileptic* ) OR AB ( pseudoseizure* OR pseudo-seizure* OR non-epileptic* OR nonepileptic* ) 811
4. 1 OR 2 OR 3 1 233
Intervention: Treatment
5. TI ( therap* OR treatment* OR psychotherap* OR CBT OR management OR care ) OR SU ( therap* OR treatment* OR psychotherap* OR CBT OR management OR care ) OR AB ( therap* OR treatment* OR psychotherap* OR CBT OR management OR care )  
Study types: Systematic reviews
6. TI ( (systematic N3 review) OR "meta analys*" OR metaanalys* ) OR AB ( (systematic N3 review) OR "meta analys*" OR metaanalys* ) OR PT ( (systematic N3 review) OR "meta analys*" OR metaanalys* )  
Limits: XX
7. From 2013  
8. Limit to academic journals  
Combined sets:
8. 4 AND 6 31
9. 4 AND 5 644
10. 10 AND 7 AND 8 483
Final result
11. Systematic reviews on Psychogenic non-epileptic seizures 31
12. Psychogenic non-epileptic seizures treatment studies from 2013 - 483

 

 

Multi-database searching: PsycINFO, Psychology and behavioral sciences collection via EBSCO 11 January 2022 Title: Treatment of psychogenic non-epileptic seizures
The final search result, usually found at the end of the documentation, forms the list of abstracts.

AB = Abstract; AU = Author; DE = Term from the thesaurus; MH= Exact Subject Heading from CINAHL Subject Headings; MM = Major Concept; TI = Title; TX = All Text. Performs a keyword search of all the database's searchable fields; ZC = Methodology Index; * = Truncation; “ “ = Citation Marks; searches for an exact phrase; N = Near Operator (N) finds the words if they are a maximum of x words apart from one another, regardless of the order in which they appear.; W = Within Operator (W) finds the words if they are within x words of one another, in the order in which you entered them.
Search terms Items found
Population: Psychogenic non-epileptic seizures
1. TI ( ((psychogenic OR dissoc* OR nonorganic OR non-organic) N3 (episod* OR seizure* OR attack* OR event* OR convulsion*)) ) OR SU ( ((psychogenic OR dissoc* OR nonorganic OR non-organic) N3 (episod* OR seizure* OR attack* OR event* OR convulsion*))) OR AB ( ((psychogenic OR dissoc* OR nonorganic OR non-organic) N3 (episod* OR seizure* OR attack* OR event* OR convulsion*)) ) 2 054
2. TI ( functional N3 (episod* OR seizure* or attack* OR convulsion*) ) OR SU ( functional N3 (episod* OR seizure* or attack* OR convulsion*) ) OR AB ( functional N3 (episod* OR seizure* or attack* OR convulsion*) ) 739
3. TI ( pseudoseizure* OR pseudo-seizure* OR non-epileptic* OR nonepileptic* ) OR SU ( pseudoseizure* OR pseudo-seizure* OR non-epileptic* OR nonepileptic* ) OR AB ( pseudoseizure* OR pseudo-seizure* OR non-epileptic* OR nonepileptic* ) 2 561
4. 1 OR 2 OR 3 4 101
Intervention: Treatment
5. TI ( therap* OR treatment* OR psychotherap* OR CBT OR management OR care ) OR SU ( therap* OR treatment* OR psychotherap* OR CBT OR management OR care ) OR AB ( therap* OR treatment* OR psychotherap* OR CBT OR management OR care )
Study types: Systematic reviews
6. TI ( (systematic N3 review) OR "meta analys*" OR metaanalys* ) OR AB ( (systematic N3 review) OR "meta analys*" OR metaanalys* ) OR PT ( (systematic N3 review) OR "meta analys*" OR metaanalys* )
Limits: XX
7. From 2013 -
8. Limit to academic journals
Combined sets:
9. 4 AND 6 68
10. 4 AND 5 1 746
11. 10 AND 7 AND 8 903
Final result
12. Systematic reviews on Psychogenic non-epileptic seizures 68
13. Psychogenic non-epileptic seizures treatment studies from 2013 - 903

 

Scopus via Elsevier 11 January 2022
Title: Treatment of psychogenic non-epileptic seizures
The final search result, usually found at the end of the documentation, forms the list of abstracts.

TITLE-ABS-KEY = Title or abstract or keywords; ALL = All fields; PRE/n = "precedes by". The first term in the search must precede the second by a specified number of terms (n).; W/n = "Within". The terms in the search must be within a specified number of terms (n) in any order.; * = Truncation; “ “ = Citation Marks; searches for an exact phrase; LIMIT-TO (SRCTYPE, "j" = Limit to source type journal; LIMIT-TO (DOCTYPE, "ar" = Limit to document type article; LIMIT-TO (DOCTYPE, "re" = Limit to document type review
Search terms Items found
Population: Psychogenic non-epileptic seizures
1. TITLE-ABS-KEY ( ( ( psychogenic OR dissoc* OR nonorganic OR non-organic ) W/2 ( episod* OR seizure* OR attack* OR event* OR convulsion* ) ) ) 3 679
2. TITLE-ABS-KEY ( ( functional W/2 ( episod* OR seizure* OR attack* OR convulsion* ) ) ) 1 066
3. TITLE-ABS-KEY ( ( pseudoseizure* OR pseudo-seizure* OR non-epileptic* OR nonepileptic* ) ) 5 544
4. 1 OR 2 OR 3 8 081
Intervention: Treatment
5. TITLE-ABS-KEY ( ( therap* OR treatment* OR psychotherap* OR cbt OR management OR care ) )
Study types: Systematic reviews
6. TITLE-ABS-KEY ( ( systematic W/2 review ) OR "meta analys*" OR metaanalys* ) OR ( SRCTITLE ( cochrane ) AND DOCTYPE ( re ) )
Limits:
7. From 2013 -
8. Document type: Journal article
Combined sets
9. 4 AND 6 156
10. 4 AND 5 3 505
11. 10 AND 7 AND 8 1 423
Final result
12. Systematic reviews on Psychogenic non-epileptic seizures 156
13. Psychogenic non-epileptic seizures treatment studies from 2013 - 1 423
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