Outcome of CBT-based multimodal psychotherapy in patients with psychogenic nonepileptic seizures: A prospective naturalistic study.

PURPOSE: Psychotherapy is recommended in patients with psychogenic nonepileptic seizures (PNES). To date, however, a limited number of studies have attempted to assess the long-term effectiveness of psychotherapy in patients with PNES. Here, we report the short and six-month follow-up seizure and psychopathological outcomes in patients with PNES who have undergone a combination of cognitive-behavioral individual and group therapy. METHODS: In this prospective, naturalistic study, 80 patients with PNES underwent cognitive behavioral psychotherapy in an inpatient setting (mean duration: 64.5 days) and were evaluated prior to treatment (T1) and at its end (T2). Six months after treatment, 55 patients participated in the follow-up assessment (T3). Psychopathology questionnaires and PNES ratings were used at T1, T2, and T3 to determine outcomes. RESULTS: At T2, 23% of the patients were free from PNES for ≥2 weeks. At T3, 21.8% were seizure-free for ≥1 month and 10.9% for ≥3 months. Only two patients who were free from PNES at T2 remained free from PNES until T3. Ten further patients achieved seizure freedom during the follow-up period and were free from seizures for ≥1 month at T3. Nevertheless, a subjective improvement of the seizure situation was reported by 74.1% of the patients. Patients' psychopathology scores decreased from T1 to T2 and remained stable after discharge (except for a slight increase of depression score from T2 to T3). Those patients who were PNES-free at T3 had less severe psychopathology, experienced less traumatic events, and PNES were prolonged prior to treatment than those who did not become seizure-free. SIGNIFICANCE: Inpatient psychotherapy led to PNES freedom in a minority of patients. Pretreatment psychopathology was the key factor affecting six-month follow-up seizure outcomes. Expectations should be formed in accordance with these perspectives, i.e., seizure freedom is difficult to achieve in many patients, but psychotherapy may be useful to treat underlying psychopathology. As our results stem from a specific patient sample (i.e., patients with chronic and refractory PNES) treated in a very specific setting, the generalizability of our findings is limited.

Psychiatric disorders and trauma history in patients with pure PNES and patients with PNES and coexisting epilepsy.

Several studies found high prevalence rates of psychiatric disorders in patients with pure psychogenic nonepileptic seizures (PNES). Traumatic experiences were also reported to be elevated in patients with PNES and were discussed as a crucial risk factor for the development of PNES. Much less is known about psychiatric comorbidities and specifically, about trauma history in patients with PNES and coexisting epilepsy. Here, we aimed at directly comparing psychiatric disorders and traumatic life experiences in patients with pure PNES and in patients with PNES and coexisting epilepsy. We assessed the presence of current axes I and II disorders in 109 patients with either pure PNES (n = 67) or with PNES + epilepsy (n = 42) by using structured clinical interviews. We also compared the trauma histories by using the posttraumatic diagnostic scale (PDS) as an interview and the extent of physical, sexual, and emotional childhood maltreatment measured with the Childhood Trauma Questionnaire (CTQ). Patients of both groups had very high rates of psychiatric disorders: 79.1% of the patients with pure PNES and 76.2% of the patients with PNES + epilepsy had at least one psychiatric disorder. The frequencies of psychiatric disorders did not differ between groups. However, there was a trend towards higher rates of posttraumatic stress disorder (PTSD) in patients with PNES (32.9%) compared with patients with PNES + epilepsy (16.7%). In both groups, the proportion of patients who recalled traumatic events in the PDS was high (72.6% in the patients with pure PNES, 64.3% in the patients with PNES + epilepsy) and did not differ significantly between groups. The age at first traumatization, the types of trauma events experienced, the number of patients with single traumatization, and those with repeated traumatic experiences also did not differ between groups. We found high frequencies of childhood maltreatment in both groups. Our findings show that patients with PNES and patients with PNES and coexisting epilepsy could neither be differentiated by the amount of psychiatric additional disorders nor by the nature and extent of trauma and maltreatment experiences. Our results suggest that patients with PNES + epilepsy rather resemble patients with pure PNES than patients with epilepsy in respect to psychopathological characteristics and adverse life experiences. Trauma and maltreatment history are therefore assumed to be predisposing factors to PNES in both patients with pure PNES and patients with PNES and coexisting epilepsy.

Efficacy and safety of pregabalin in refractory focal epilepsy with and without comorbid anxiety disorders - results of an open-label, parallel group, investigator-initiated, proof-of-concept study.

Anxiety disorders are prevalent in people with epilepsy and severely influence daily living and quality of life. Pregabalin (PGB) is licensed in Germany for the add on-treatment of focal epilepsy and for generalized anxiety disorder in adults. To our knowledge, PGB has not been studied before in patients with epilepsy and comorbid anxiety disorder. We included 41 adult patients with focal epilepsy in a monocentric, noncontrolled open-label study adding up to 600 mg of PGB to an antiepileptic baseline medication. Patients were allocated to two groups: patients with epilepsy plus anxiety disorder (EAG) and patients with epilepsy only (EOG). Endpoints were responder rate, seizure frequency, adverse events, and anxiety symptoms. The responder rate in the EAG was higher compared to that in the EOG (per protocol population: 9 [75.0%] vs. 2 [12.5%], p=0.001). Improvements in several psychological scales were found.

Prevalence of anxiety disorders in patients with refractory focal epilepsy--a prospective clinic based survey.

Comorbid anxiety disorders severely affect daily living and quality of life in patients with epilepsy. We evaluated 97 consecutive outpatients (41.2% male, mean age=42.3+/-13.2 years, mean epilepsy duration=26.9+/-14.2 years) with refractory focal epilepsy using the German version of the anxiety section of the Structured Clinical Interview for DSM-IV Axis I disorders (SCID-I). Nineteen patients (19.6%) were diagnosed with an anxiety disorder (social phobia, 7.2%; specific phobia, 6.2%; panic disorder, 5.1%; generalized anxiety disorder, 3.1%; anxiety disorder not further specified, 2.1%; obsessive-compulsive disorder, 1.0%; posttraumatic stress disorder, 1.0%). Four-week prevalence rates reported elsewhere for the general population in Germany are 1.24% for social phobia, 4.8% for specific phobia, 1.1% for panic disorder, 1.2% for generalized anxiety disorder, 1.3% for anxiety disorder not further specified, and 0.4% for obsessive-compulsive disorder. A trend for people with shorter epilepsy duration (P=0.084) and younger age (P=0.078) being more likely to have a diagnosis of anxiety disorder was revealed. No gender differences were found; however, this may be due to the small sample size. In conclusion, anxiety disorders are frequent in patients with refractory focal epilepsy, and clinicians should carefully examine their patients with this important comorbidity in mind.