Abstracts

Rationale: Thirty percent of patients referred to the University of Colorado Epilepsy Monitoring Unit (EMU) have psychogenic nonepileptic seizures (PNES).This number is consistent with that found in other centers throughout the country. There are few consistently successful modalities of treatment for this large and heterogeneous population. Complicating treatment are high dropout rates, as well as a tendency for PNES symptoms to initially get worse when psychological triggers are uncovered. The field is in need of an approach to patients with PNES addressing their complex needs of these patients.Methods: Our epilepsy group actively encouraged psychiatric referral for 9 outpatients with PNES confirmed in our EMU, and 5 patients in whom PNES was clinically suspected, for outpatient evaluation and treatment over a 6 month period. Individualized treatment included standard psychiatric interview with medication evaluation and psychodynamic assessment, family assessment, stabilization and reduction of benzodiazepine use, panic skills, psychodynamic therapy varying from supportive to expressive, and focused family sessions when possible.Results: All 14 of the patients arrived for their first session; of those, 13 remained in treatment to the accomplishment of at least one goal. Of these 14, 11 had been prescribed benzodiazepines as needed and had symptoms of mild withdrawal anxiety; all patients had a history of repetitive trauma; 11 of 14 described invalidation of trauma and lack of appropriate supports at time of occurrence; all had global assessment of functioning (GAF) scores meeting or exceeding Global Assessment of Relational Functioning (GARF) scores; GARF scores improved by 10 to 40 points when families participated in treatment; all had significant depression or anxiety, and 10 of 14 qualified for a diagnosis of PTSD (the remaining 4 were subsyndromal). Eleve of these 14 could not consistently identify depression or anxiety as symptoms at first. During psychiatric treatment, several patients worked with their PCPs to diagnose significant medical illness in need of treatment. Urgent contacts with University providers decreased for all; stressors precipitated new contacts for 2 of 14, and in both cases self-directed pharmacologic changes also played a role. Two of 14 patients experienced a brief increase in PNES initially. Ten of 14 had decreased frequency of PNES by the end of our tabulations, including those with initial increases. Conclusions: An individualized, multi-modal approach which includes encouragement from epileptologists, medication review, psychodynamic and family assessment and engagement as tolerated, and education in panic skills, is thought to be a viable and helpful combination in addressing PNES patients. Improvement of individual function within a family or surrogate family system is thought to generalize to improved function within the healthcare system, facilitate slow recovery from trauma, and eventually reduce PNES symptoms. Further structured clinical research is indicated.