Treating psychogenic nonepileptic seizures: Easier said than done

Disorders such as psychogenic nonepileptic seizures (PNES) often strike our blind spots; patients can be misdiagnosed for years. Even though there are standard ways of classifying the patients, not everyone fits. Why do they occur? Some people express emotions physically. PNES (and their cousin disorders) are products of a number of factors. The first derives from the ways patients interact with those around them. This could be particularly (but not uniquely) important in people with inadequate coping skills or whose maladaptive behaviors have been reinforced. A second group of factors pertains to internal or internalized conflicts. These might be important for patients with affective disorders, panic attacks, anxiety, obsessivecompulsive disorders, conversion or somatization disorders, posttraumatic stress disorders, or sexual or physical abuse. For personal reasons, some patients may misinterpret normal physiological phenomena. Another group includes patients who have psychoses or are schizophrenic. Still another includes those with what used to be called personality disorders, with problems including borderline personality, malingering, or factitious disorder. In practice, these groupings are not distinct from one another: how you organize and perceive yourself and your experiences, and how flexible, pleasant, and open you are in your interactions derive from what you are, both inside and out. Patients with PNES are not always distinctly different from the rest of us. Formal psychiatric disorders may not be present. Patients’ personalities can be variants, even if extreme variants, of normal. When this occurs, patients’ similarities to ourselves may make empathic diagnosis and treatment more difficult. How should we treat? First, explain the diagnosis to the patient courteously and tactfully. The manner for describing PNES should be no different from describing epilepsy, or lupus. If the diagnosis is uncertain, say so. Consider with the patient why the episodes might be occurring. Sometimes that is enough; symptoms stop. More often patients need more treatment, but studies have shown that treatment is often unsuccessful, especially in patients with psychiatric diagnoses. Previous studies have utilized psychological testing to characterize patients with PNES. In this issue, Reuber and colleagues report that measurements of personality correlated with the success that PNES patients had in controlling their episodes. Somatization and dissociation linked with poorer outcome. Less than a third became seizure free; however, as the authors note, treatment was not evaluated systematically. It occurred after patients returned home, and not at their tertiary referral center. It is not clear what treatment patients did receive, if any. These are difficult patients and are best treated by therapists experienced with both epilepsy and PNES. This problem is not unique to epilepsy: symptoms and signs of emotional origin occur in every specialty and every subspecialty. Health care expenditures of patients with such disorders are nine times higher than those of others. The symptoms, and the patients themselves, can arouse our deepest emotions, and not always our best ones. We often do not treat these people well and sometimes do not like them. Nonetheless, many can be treated successfully by expert hands able to tailor treatment to the personality, functional capabilities, and life experiences of the individual patient. The challenge is to determine how best to do this, and for whom.