Evaluation of a new body-focused group therapy versus a guided self-help group program for adults with psychogenic non-epileptic seizures (PNES): a pilot randomized controlled feasibility study.

OBJECTIVE: Psychogenic non-epileptic seizures (PNES), a common phenomenon in neurological settings, are regarded as a paroxysmal type of functional neurological disorder (FND). In a substantial proportion, PNES are disabling with poor long-term outcomes and high economic costs. Despite the clinical and financial consequences of PNES, there is still a lack of controlled clinical trials on the treatment of this challenging disorder. The study aims to evaluate the feasibility and collect first evidence of the efficacy of a group based-intervention in PNES-patients. METHODS: A pilot randomized controlled feasibility study with a parallel-group design was performed in adult outpatients with PNES to evaluate a new body-focused group therapy (CORDIS) versus guided self-help groups. Self-assessment of dissociation (Dissociation Experience Scale-DES-20) and seizure severity (Liverpool Seizure Severity Scale-LSSS) were assessed two weeks before and two weeks after the treatment intervention and also six months after treatment as primary outcome parameters. RESULTS: A total of 53 patients were recruited from a specialized outpatient clinic, and out of those, 29 patients completed either the body-focused group therapy program (n = 15) or a guided self-help group (SHG) therapy (n = 14). When analyzing the ITT sample (n = 22 CORDIS group, n = 20 SHG), both groups showed an effect on seizure severity and level of dissociation. In the per protocol sample (n = 13 CORDIS group, n = 12 SHG), CORDIS was superior to the self-help group for reducing seizure severity 6 months after the treatment. SIGNIFICANCE: CORDIS is a newly developed body-focused group therapy program for adults with PNES. Further studies should include a multicentric design with a higher number of participants.

Executive Functions and Attention in Patients With Psychogenic Nonepileptic Seizures Compared With Healthy Controls: A Cross-Sectional Study.

OBJECTIVE: Psychogenic nonepileptic seizures (PNESs) are considered functional neurological symptoms and are highly prevalent in specialized epilepsy clinics. The underlying mechanisms of PNES are not fully understood. Recent findings point toward possible alterations in attention and executive functions. This study aimed to extend the current knowledge of attention and executive function in patients with PNES and to assess possible relationships between seizures and dissociation, childhood trauma, and cognitive function. METHODS: We recruited 40 patients with PNES and 40 sex-, age-, and education-matched healthy controls (HCs) in this study. Participants completed self-report questionnaires to assess early life stress (Childhood Trauma Questionnaire [CTQ]), dissociation (the German version of the Dissociative Experience Scale, or Fragebogen zu dissoziativen Symptomen), and depression (Patient Health Questionnaire-9). Executive functions and attention were assessed with the Trail Making Test (TMT), Digit Span, and Attention Network Task. RESULTS: Compared with HCs, patients with PNES reported significantly higher levels of childhood trauma, depression, and dissociation. Patients with PNES also had reduced performance indices for Digit Span Forward (d = 0.62), Digit Span Backward (d = 0.62), and TMT (d = 0.67) but not Attention Network Task. CTQ scores positively correlated with TMT and Digit Span Backward performance in patients with PNES. Adjusting for CTQ scores attenuated the observed group difference in TMT performance. Depression and dissociation did not explain the observed findings. CONCLUSIONS: These results contribute to the evidence of impaired executive functions in patients with PNES. Furthermore, childhood trauma scores, but not (trait) dissociation or depression scores, seem to drive group differences (HC versus patients with PNES).

Insecure and Unresolved/Disorganized Attachment in Patients With Psychogenic Nonepileptic Seizures.

BACKGROUND: Psychogenic nonepileptic seizures (PNES) are still poorly understood and difficult to treat. Attachment theory could add new aspects to the understanding of the multifactorial genesis and maintenance of PNES and the therapeutic needs of this patient group. OBJECTIVE: The aim of the present study is to systematically assess attachment in adult patients with PNES with a focus on the role of unresolved/disorganized attachment. METHODS: A cross-sectional design was chosen to compare patients with confirmed PNES (n = 44) and healthy controls (n = 44) matched for gender, age, and education. Attachment was assessed using the Adult Attachment Projective Picture System. Psychometric questionnaires included the Childhood Trauma Questionnaire; Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) axis II disorders, Patient Questionnaire; the Somatoform Dissociation Questionnaire; and the Patient Health Questionnaire. RESULTS: We found significantly less secure (P = 0.006) and more unresolved/disorganized (P = 0.041) attachment classifications in the PNES group. Among patients with PNES, 7% were classified secure and 43% were classified unresolved/disorganized. Patients with an unresolved attachment representation were significantly more likely to be screened positive for personality pathology in the Structured Clinical Interview for DSM-IV axis II disorders, Patient Questionnaire (P = 0.03) and to report more emotional abuse in the Childhood Trauma Questionnaire (P = 0.007) than patients with other attachment classifications. CONCLUSIONS: Our findings suggest that unresolved/disorganized attachment might be the predominant attachment style in patients with PNES and might be associated with more severe personality pathology. This could be of therapeutic relevance. The present study is the first to assess adult attachment in patients with PNES using a semi-structured interview in comparison to matched healthy controls.

[Pilot Data from the Evaluation of an Integrative Body Psychotherapy Program for Patients with Psychogenic Non-Epileptic Seizures]. / Pilotäre Zwischenergebnisse zur Evaluation eines störungsspezifischen, körperpsychotherapeutisch orientierten Gruppenbehandlungsprogramms für Menschen mit psychogenen Anfällen.

Psychogenic non-epileptic seizures (PNES) occur in the context of various diseases. Therefore, PNES patients represent a heterogeneous group with different causative disorders. The etiology is still poorly understood. Previous concepts assume an increased rate of trauma disorders in PNES, which has been proven several times by previous studies 1 2. The clinical picture is threatening, which means that those affected often receive intensive care measures without benefiting from them 3. PNES patients accumulate especially in epilepsy centers, since a diagnostic differentiation from epileptic seizures is possible at those specialized centers. Often, the transition from making the diagnosis in epilepsy centers to follow-up treatment in psychosomatic/psychiatric settings is difficult. A reason could be that patients and practitioners are often involved in somatic disease concepts, which might be caused by the threatening clinical picture of PNES 28. Due to this difficulties, a special outpatient clinic was set up at the Charité Berlin for people with dissociative seizures, which settles in the transition from neurology to psychosomatics and works as a cooperation project 27. Out of the ambulance, a group treatment program (CORDIS) was developed, which aims at a better care of PNES patients at the interface between neurology and psychosomatic medicine. This modularized 10-week treatment program will be presented in this article and is the subject of a currently ongoing randomized, controlled evaluation study. The pilot data from the ongoing RCT study presented here showed significant effects in the effectiveness of the program, in particular the primary and secondary outcome measures.

Ictal level of awareness in psychogenic nonepileptic seizures correlates with the experience of traumatic events in childhood: A cross sectional study.

There is a great amount of research regarding the particular ictal manifestations of psychogenic nonepileptic seizures (PNES) with a focus on the differences to epileptic seizures (Vogrig et al., 2019 [4]; Tyson et al., 2018 [5]; De Paola et al., 2016 [6]). Most of the research aims to define guidelines for diagnosing PNES in differentiation from epilepsy, because this differentiation is clinically relevant for clinical neurological settings. In contrast, very few studies aimed to gain insight about particular ictal manifestations of the different semiological appearances of PNES regarding distinctive psychological processes or prognostic outcomes (Brown, 2016 [7]; Pick et al., 2017 [8]; Brown, 2006 [9]; Cohen, 2013). One study revealed that a higher level of mental dissociation and cognitive impairment was associated with a higher level of traumatization in patients with PNES (Pick et al., 2017 [8]). We analyzed the seizure semiology with a focus on the level of awareness in 60 patients with PNES. Patients were divided into two groups: one with an impaired awareness during their seizures and the other one with preserved awareness during their seizures. We assessed the amount of adverse traumatic experience in childhood with the "Childhood Trauma Questionnaire (CTQ)". We found that patients with PNES with impaired awareness showed more childhood traumatic experiences in the CTQ, especially on the subscales of sexual and emotional abuse as well as physical neglect. Furthermore, patients with PNES with impaired awareness during seizures were significantly younger, more often female, showed a lower degree on education, and a higher amount of self-harm behavior compared with patients with PNES with preserved awareness during seizures. Our study presents clinical evidence for the potential significance of the level of awareness during PNES for the etiology of PNES. Our results point toward the existence of clinical subgroups of patients with PNES with distinctive etiological mechanisms and indicate that seizure semiology might help to differentiate those potential subgroups.