First comprehensive look at treatment practices for nonepileptic seizures

A new nationwide clinician survey provides the first comprehensive look at what is community care or 'treatment as usual' for nonepileptic seizures (NES), laying the groundwork for clinical trials aimed at identifying effective treatments for this neuropsychiatric disorder.

There is currently no standard treatment for NES, a disorder that resembles an epileptic seizure but is not caused by abnormal activity in the brain. Findings of the survey are published in the April issue of Epilepsy & Behavior.

“Typically, neurologists are the first to encounter, diagnose and provide initial treatment for patients with NES, sometimes referring them for psychiatric treatment. But too often, patients with this disorder are lost between the practice divide of neurology and psychiatry,” says lead author W. Curt LaFrance, Jr., M.D., M.P.H., director of neuropsychiatry and behavioral neurology at Rhode Island Hospital.

“By helping to define ‘treatment as usual,’ our survey better equips researchers to design much-needed clinical trials to evaluate treatments for noneplipetic seizures, which we hope will someday bridge this divide and improve the quality of life of patients suffering from this disorder,” adds LaFrance, who’s also an assistant professor of psychiatry and neurology (research) at The Warren Alpert Medical School of Brown University.

Defined as involuntary episodes of sensation, movement, or behavior that may mimic epileptic seizures, NES are classified into two major groups: physiologic and psychogenic. Physiologic NES are triggered by a number of conditions, such as cardiac arrhythmia, sudden drops in blood pressure, sleep disorders, and hypoglycemia. A psychogenic NES appears to be caused by emotional trauma or excessive stress. According to estimates, of the three million people diagnosed with epilepsy in the U.S., between five and 20 percent of patients with seizures actually may have either NES alone or a combination of epileptic and nonepileptic seizures. NES is by far the most frequent nonepileptic condition seen in epilepsy centers.

More than 300 respondents across the United States completed the survey, including epileptologists, neurologists, neuropsychiatrists, and nurses. Approximately 80 percent of respondents said they believe psychotherapy is one of the most effective treatments for NES, followed by education and psychopharmacology. Nearly half prescribed psychotropic medications if patients were diagnosed with additional disorders, such as depression, and three-quarters reported tapering the amount of antiepileptic drugs that they prescribed.

Almost all respondents reported discussing the diagnosis of NES with their patients. Nearly 70 percent of neurologists continued to follow the patient after NES diagnosis. Treatment referrals were most commonly made to psychiatrists and psychologists, with 16 percent recommending psychiatric inpatient admission. “The study findings also underscores the importance of neurologists and psychiatrists working together to care for these patients,” adds LaFrance.

Barriers to treatment adherence were also identified, including insurance limitations, lack of reimbursement and lack of practitioners experienced with NES treatment.

They survey was administered in response to a recent NES Treatment Workshop sponsored by the National Institute of Neurological Disorders and Stroke, National Institute of Mental Health and the American Epilepsy Society.