Markus Reuber

The pooled findings of the meta-analysis by Noble et al of five randomised controlled studies in which at least some elements of CBT were used to treat depression or anxiety in patients with epilepsy demonstrate that the chances of reliable improvement according …

Treatment strategies for focal epilepsy need to take account of the phase and severity of the seizure disorder, comorbidity, gender and age. Expert review and evaluation of major studies on the treatment of focal epilepsy. Complete seizure control is most often achieved with antiepileptic drug (AED) monotherapy. In the choice of AED, possible unfavourable endocrine, cognitive or psychiatric adverse effects and their interaction with the non-seizure manifestations of focal epilepsy have to be considered. In women teratogenic risks associated with AED may be relevant. If complete seizure control cannot be achieved with the first three steps of AED treatment, epilepsy surgery becomes the most likely treatment modality to provide complete seizure control. It is proposed that AED combination treatment should be limited to two or three agents to minimize the risk of side effects, especially negative effects on cognition. Recent developments in the treatment of focal epilepsy have made it easier to tailor AED therapy to patients' demographic and clinical profile.

Summary:  Purpose: To examine whether seizure remission is a comprehensive marker of outcome in psychogenic nonepileptic seizures (PNESs). Methods: A postal questionnaire was returned by 147 patients with PNESs a mean of 4.2 years after diagnosis (mean age at follow‐up, 38.1 years). The proportion of patients who were “unproductive” (receiving health‐related state benefits) at follow‐up was determined, with a comparison of markers of ongoing psychopathology (Global Severity Index, anxiety and depression scores of the Symptom Checklist 90, Somatization Index DSM of the SOMS‐2) in three outcome groups: group 1, continuing seizures; group 2, seizures stopped but patients “unproductive;” and group 3, seizures stopped, patients “productive.” Results: Of the patients, 71.4% continued to have seizures, and 28.6% had achieved seizure remission; 60.0% of patients with continuing seizures and 42.7% of patients in remission were “unproductive” (difference, NS). Ongoing psychopathology was related to the factor “group membership” with higher values in groups 2 and 3 than in group 1 (GSI, p < 0.001; anxiety, p = 0.01; depression, p = 0.02; Somatization Index DSM, p < 0.001). Across all patients and in the subgroup with PNESs and additional epilepsy, differences were significant only between groups 2 and 3, not between groups 1 and 2. In patients with PNESs alone, differences were significant only between groups 1 and 2. Conclusions: Seizure remission is not a comprehensive measure of good medical or psychosocial outcome in PNESs. Nearly half the patients who become seizure free remain unproductive. Many of these patients continue to report symptoms of psychopathology. Seizure control should not be the only focus of treatment in clinical practice or outcome observation in research studies.

Psychogenic nonepileptic seizures are relatively common, often disabling and costly to patients and society. Most authorities consider psychologic treatment as the therapeutic intervention of choice. This review is intended primarily for psychologists and therapists who treat patients with psychogenic nonepileptic seizures, and for neurologists who make the diagnosis and wish to find out more about psychologic treatment options. The first section describes the nature and etiology of psychogenic nonepileptic seizures. General questions regarding the psychologic treatment of patients with psychogenic nonepileptic seizures are addressed, before discussing specific therapeutic approaches. The final part summarizes the authors' views on optimal treatment and the direction of future research.

Objectives: To determine whether patients with psychogenic non-epileptic seizures (PNES) have evidence of maladaptive personality, and whether they have a single or several different typical pathological personality profiles. Methods: Patients were recruited from the department of epileptology, Bonn, Germany. In all, 85 patients with PNES and 63 with epilepsy completed a postal questionnaire including the dimensional assessment of personality pathology – basic questionnaire (DAPP-BQ). The DAPP-BQ was also completed by 100 healthy volunteers. The groups were compared and the PNES group was subjected to cluster analysis. Results: Patients with PNES had a greater degree of personality abnormality than clinical and non-clinical controls. There were several clusters of personality pathology. The profile of the largest cluster (n = 43) resembled that found in borderline personality disorder, that of the second largest (n = 37) was characterised by an overly controlled personality, that of the third (n = 4) was similar to the profile in avoidant personality disorder. Outcome differed between clusters. Conclusions: Maladaptive personality is common in patients with PNES. PNES are associated with several distinct profiles of pathological personality. This is relevant because outcome differed between profiles.