Abstracts

Rationale: Rationale: Among patients with psychogenic nonepileptic seizures (PNES), individual cognitive behavioral therapy (CBT) based approaches have shown clinically meaningful results in two pilot randomized controlled trials (Goldstein et al., Neurology, 2010; LaFrance et al., JAMA Psychiatry, 2014). Compared to individual therapies, group treatments have the potential advantages of peer support, group synergy, and cost effectiveness. One small sample size cognitive behavioral based group therapy study (Conwill et al., Epilepsy Behav, 2014), which included patients experiencing conversion symptoms with or without PNES, has shown significant improvements in emotional domains of quality of life (but did not describe seizure outcomes). To build on these results, we pursued a pilot prospective, multi-center study investigating whether an evidenced-supported individual CBT based approach (LaFrance et al., JAMA Psychiatry, 2014) may be feasible and effective when applied in the group setting. Methods: Methods: Our subject pool consisted of patient referrals for group treatment, from 3/2016 to 10/2018, who have had previous video-EEG confirmed PNES. In total, we prospectively enrolled a total of 25 patients who met inclusion/exclusion criteria. Twenty patients completed the entire treatment protocol, including 8 subjects from Houston VA (across 3 groups), 10 subjects from SF VA (across 3 groups), and 2 subjects from Durham VA (1 group). Among the 5 patients who dropped out, 2 patients completed > 50% of sessions, yielding an adherence rate of 88%. The group CBT consisted of 12 weekly, 1.5 hour sessions, with 2-4 patients per group. Should a patient missed a group session, make-up individual sessions were pursued. For outcome measures, patients maintained a weekly standardized seizure log throughout duration of treatment (primary outcome). They also completed a battery of validated neuropsychiatric instruments at start of treatment and then completed the same instruments at midpoint as well as end of treatments (secondary outcomes). Evaluations of the patient’s psychiatric morbidities were completed via formal psychiatric assessments based on Mini International Neuropsychiatric Interview (MINI, version 7.0.0) and Structured Clinical Interview for DSM-IV Axis II (SCID-II). Refer to Table 1 for summary of patients’ demographics and psychiatric morbidities. Results: Results: For primary outcome, a generalized linear mixed model examining seizure counts across time yielded a significant rate of seizure reduction (Slope = -0.11, P = 0.001). Compared to the start of treatment, our patients reported a 55.7% reduction in seizure counts by the end of treatment (post-treatment/start-of-treatment seizure ratio = 0.44, with 95% CI [0.12 to 0.77]). Linear trend estimates on secondary outcomes spanning the three assessment periods showed statistically significant (P < 0.05) and clinically relevant (moderate or greater effect sizes) improvement on all three global measures of psychological distress on the Symptom Checklist-90-Revised, and two subscales of the Family Assessment Device (effective response and general functioning). Refer to Table 2 for summary of secondary outcome measures. Conclusions: Conclusion: Cognitive behavioral based group treatment is both feasible and potentially effective. Treatment feasibility is supported by independent execution across three VA centers with robust adherence rate. Potential efficacy is evidenced by similar primary and second outcomes of this group approach, when compared to the outcomes from a pilot randomized control trial of individual therapy based on same manualized CBT-informed protocol (LaFrance et al., JAMA Psychiatry, 2014). Funding: No funding