What professionals should be involved in treatment?

Neurologists usually have little interest in continuing to care for patients in whom NESs are diagnosed, considering most of these patients not to have neurologic disease. Further, many psychiatrists are reluctant to care for patients with somatoform disorders. This reluctance is a problem for these patients, who suffer from significant disability. The psychiatrist should cooperate closely with the referring neurologist. The patient thus gains by receiving continuing support on the medical side while exploring the root causes of the psychiatric disability.

Probably the best approach to treatment for most patients is offered by a multidisciplinary team composed of specialists in the fields of

  • neurology
  • psychiatry
  • psychology
  • social work

Such a group addresses the multidimensional nature of NESs. Besides diagnosing and managing the underlying psychiatric condition, the treatment can also address problems of psychosocial functioning, occupational issues, and family interactions. Coordination of efforts in these several spheres is key to the team approach. The goal is to restore the patient to normal functioning in the shortest possible time.

Types of programs

The patient can be treated as either an inpatient or an outpatient. The goals for both approaches are the same and in the long run they probably produce similar outcomes.

Inpatient programs are usually associated with epilepsy centers. Two excellent ones are located in Minneapolis and St. Paul, Minnesota. On discharge, the patient is referred to a local psychiatrist, who carries out longer-term intervention. The major advantage to the inpatient approach is the intensity and focus that is possible at the onset of treatment. A major disadvantage is the cost associated with hospitalization.

The outpatient approach is less intense but cost-effective. The outpatient approach combines regular team meetings with ongoing therapy. The principal therapist may be the psychiatrist, psychologist, or social worker, depending on the nature and extent of the patient's particular problem.

Each patient with NESs requires an individualized treatment program. Those with significant depression may be treated with antidepressants along with ongoing psychotherapy. Patients with panic disorder may receive appropriate pharmacotherapy with an agent such as desipramine. Some will require only short-term psychotherapy.

For patients with somatoform disorder, supportive treatment and encouragement can aid overall functioning and stop "doctor shopping" for multiple somatic complaints. NESs are likely to continue in this group, however.

Prognosis

The prognosis for patients with NESs is variable. Even without specific treatment, NESs tend to decline over time. A 1-year follow-up study of 80 patients in whom NESs were diagnosed during EEG-video monitoring revealed that 59% had become seizure-free in the interval, and an additional 20% reported a decline in event frequency. Other studies have found that even with specific intervention, fewer than 50% become seizure-free, and some who become seizure-free develop other (substitution) conversion symptoms.

The literature is sparse with respect to the effectiveness of psychotherapy, but some improvement occurs in up to 60% of patients. Success rates appear to depend on the severity and duration of the psychiatric illness. Those with NESs of relatively short duration, perhaps related to an intercurrent situation such as an acute loss, have a favorable prognosis. Short-term psychotherapy may be highly effective in these cases.

On the other hand, prolonged duration of NESs associated with severe psychopathology may be refractory to treatment. In these cases, supportive treatment may be all that can be offered.

An optimistic attitude on the part of the caregivers is important and indeed justified. This attitude should be conveyed to the patient at the outset and continually reinforced.

Adapted from: Rowan AJ. Diagnosis and management of nonepileptic seizures. In: Schachter SC, Schomer DL, eds. The comprehensive evaluation and treatment of epilepsy. San Diego, CA: Academic Press; 1997. p. 173-184. With permission from Elsevier (www.elsevier.com).

Authored By: 
Orrin Devinsky
MD
I<
Authored Date: 
02/2004