Title: Emerging treatment options for psychogenic non-epileptic seizures

Appraiser: Brett Fields

Date: 3/15/18

Clinical Question: Which treatment options are available for patients with psychogenic
pseudoseizures?

Search Strategy: PubMed database; text words ‘Psychogenic non-epileptic seizures AND
treatment’; selected most relevant study

Bottom Line: Even with the effectiveness of CBT, psychogenic non-epileptic seizures are
difficult to treat as they are multifascited without a clear biological cause.

Evidence Summary:
1. Pilot randomized clinical trial at 3 academic medical centers with mental health clinicians
trained to administer psychotherapy or psychopharmacology to outpatients with PNES.
2. Thirty-eight participants were randomized in a blocked schedule among the 3 sites
3. Treatment groups were Medication (flexible-dose sertraline hydrochloride) only,
cognitive behavioral therapy informed psychotherapy (CBT-ip) only, CBT-ip with
medication (sertraline), or treatment as usual.
4. Within-group analyses for each arm were performed on primary (seizure frequency) and
secondary outcomes from treatment-blinded raters using an intention-to-treat analysis.
5. The psychotherapy (CBT-ip) arm showed a 51.4% seizure reduction (P = .01) and
significant improvement from baseline in secondary measures including depression,
anxiety, quality of life, and global functioning (P < .001). The combined arm (CBT-ip
with sertraline) showed 59.3% seizure reduction (P = .008) and significant improvements
in some secondary measures, including global functioning (P = .007). The sertraline-only
arm did not show a reduction in seizures (P = .08). The treatment as usual group showed
no significant seizure reduction or improvement in secondary outcome measures (P 
= .19).

Comments:
1. This study followed n=38 subjects to completion over 3 academic medical centers. This
small sample size makes it difficult to extrapolate to the general population.
2. Pharmacological treatment options only included 1 SSRI (sertraline). Further studies
could assess the effectiveness of combining different SSRIs with CBT.
3. This study supports the use of manualized psychotherapy (CBT) for psychogenic non-
epileptic seizures and successful training of mental health clinicians in the treatment.
Future studies could assess larger-scale intervention dissemination.
4. Only a minority of patients became episode-free in either of the CBT arms, and the
durability of response beyond four months is not known.

Citation: Multicenter pilot treatment trial for psychogenic nonepileptic seizures: a randomized
clinical trial. LaFrance WC Jr, Baird GL, Barry JJ, Blum AS, Frank Webb A, Keitner GI, Machan
JT, Miller I, Szaflarski JP, NES Treatment Trial (NEST-T) Consortium. JAMA Psychiatry.
2014;71(9):997.