Abstracts

Rationale: Some neurologists and psychotherapists emphasize the psychological etiology of psychogenic nonepileptic attacks (PNEA) in diagnosing and treating the disorder, whereas others do not. The impact of patient beliefs regarding PNEA and treatment is unknown. We conducted a prospective cohort study of patients with PNEA to examine the impact of patient views regarding PNEA on their treatment. Methods: Participants with video-electroencephalogram confirmed PNEA were evaluated for demographics and PNEA frequency in a semi-structured neuropsychiatric interview, and for quality of life using the Quality of Life in Epilepsy (QOLIE)-10 instrument. Following diagnosis but prior to the initiation of psychotherapy, participants completed a standardized questionnaire assessing their beliefs about PNEA and their treatment. Participants reported their beliefs about the psychological vs. physical etiology of their illness, their confidence in their doctors’ understanding of their condition, and their feelings of being dismissed or belittled on 5-point Likert-type scales. All participants were referred to psychotherapy. We called participants at 12-24 month follow-up and obtained follow-up data via structured interviews, including PNEA frequency and quality of life as assessed on the QOLIE-10. Our primary outcome was the association between participants’ belief in a psychological etiology of PNEA and improved PNEA frequency at follow-up. We conducted univariate screens followed by multivariate logistic or linear regression for each outcome of interest, including adherence with psychotherapy, improvement in PNEA frequency, and improvement in quality of life. Participants were considered adherent with psychotherapy if they attended at least 8 sessions within a 16-week period starting at the time of referral. PNEA frequency was considered improved if frequency decreased by at least 50% from baseline to follow-up. Results: One hundred seventy-two participants were evaluated and 148 (86%) provided follow-up data. Overall, 70% of participants experienced a 50% reduction in PNEA frequency at follow-up. The percentage of such responders ranged from 56% among participants who believed their illness to be entirely physical in etiology to 84% among participants who believed their illness to be entirely psychological in etiology (Table 1, Fisher’s exact test p=0.036). Belief that PNEA are caused by a primarily psychological rather than physical etiology predicts a 50% reduction in PNEA frequency at follow-up. This association holds in both a univariate screen and a multivariate logistic model (Table 2, odds ratio 1.39, p=0.023). Belief that PNEA is caused by a primarily psychological etiology is also associated with greater improvement in quality of life at follow-up (ß-coefficient -1.58, p=0.007). A participant’s perception that they have not been dismissed or belittled by clinicians is associated with better adherence with psychotherapy (odds ratio 0.68, p=0.020) and with greater improvement in quality of life at follow-up (ß-coefficient -1.35, p=0.038). Conclusions: Our study is limited in that it establishes an association but cannot establish a causal relationship between patient beliefs and treatment outcomes. Further, the results may not generalize beyond the single tertiary care center study site. Our study demonstrates that patients’ belief in the psychological rather than physical etiology of PNEA predicts better treatment outcomes. Patients’ perceptions that clinicians have dismissed or belittled them are associated with worse adherence with treatment and treatment outcomes. These findings may guide neurological evaluation and psychotherapeutic treatment of patients with PNEA. Funding: Veterans Administration Veterans Integrated Service Network 1 Career Development AwardSwebilius Grant