Nonepileptic seizures

Abstract

The primary goal of treatment in nonepileptic seizures (NES) is to improve the patient's quality of life by terminating seizure production or reducing seizure frequency. Initial treatment consists of explaining the diagnosis and its psychological nature to patients without judging them or giving the NES excessive attention. Next, help patients identify stresses and refer them for mental health treatment. Neurologists should continue to see patients intermittently to wean anticonvulsants, and encourage compliance with mental health care. Psychiatric treatment of NES has the following three aims: 1) Help patients identify and eliminate contributing stresses. 2) Teach better coping mechanisms and increased expression of suppressed feelings that are being communicated somatically. 3) Diagnose and treat comorbid psychiatric conditions such as depression, anxiety, dissociation, or post-traumatic symptoms. The mainstay of psychiatric treatment for NES is some kind of individual or family psychotherapy or hypnosis. Selective serotonin reuptake inhibitor antidepressant medications (first-line drugs) or tricyclic antidepressants (second-line drugs) may be needed to treat comorbid depression, panic, or post-traumatic stress disorder (PTSD), but medications should nearly always be combined with psychotherapeutic approaches. Benzodiazepines should be used only with psychotherapy to teach better coping. Families or caregivers may need to learn behavior modification to minimize covert environmental rewards for NES. With proper diagnosis and treatment, about 45% of patients will become seizure-free, and another one third of patients will show reduced seizure frequency.

The Diagnostic Significance of Video‐EEG Monitoring Findings on Pseudoseizure Patients Differs Between Neurologists and Psychiatrists

“…This characteristic should make the diagnosis of psychogenic pseudoseizures with video‐EEG monitoring both relatively simple and readily acceptable. The certainty of a psychogenic basis for the events should then be clearly conveyed to the patient (7); this in and of itself is an initial step toward therapeutic success.…”

“…Psychogenic pseudoseizures result from various types of psychiatric disorders including dissociative disorders, affective disorders, personality disorders, and somatoform disorders (including conversion disorders) (6,7). It is reasonable, therefore, that after a diagnosis of pseudoseizures is documented in an epilepsy center, a psychiatric evaluation be requested.…”

The Treatment of Nonepileptic Seizures: Historical Perspectives and Future Directions

“…Rusch et al (32) found that matching specific psychotherapies to the patient's comorbid diagnoses produced greater seizure‐free rates, with 21 of 33 patients (63%) reaching event‐free status at the end of treatment. The pharmacologic references for NES treatment using intravenous barbiturates, tricyclic antidepressants, selective serotonin reuptake inhibitors, β‐blockers, analgesics, or benzodiazepines are anecdotal references in case reports, journal review articles, or book chapters (26,39,43, 45,46).…”

Etiology, diagnosis, and treatment of nonepileptic seizures

“…Other disorders are reviewed where stress and depression clearly cause generally accepted physical disease like intestinal disorders, cardiac disease, and diabetes. An analogy of a pressure cooker has been used, where emotions are built up, their expression is blocked, and this results in an internal explosion [47]. I review the setting in which we generally find people experiencing these difficulties (ie, histories of childhood dysfunction, depression, and stress).…”

“…In addition, this avoids a message of abandonment, and the patient can be monitored for the emergence of a mixed NES/ES syndrome. Bowman [47] has recommended a four-part approach involving the following:…”