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Three Part Question

In [adults with non epileptic attack disorder], do [behavioural treatments] affect the [frequency of seizures]?

Clinical Scenario

A twenty four year old woman attended clinic after a routine referral from her GP. She had become ill at home and presented to the GP the following day with partner. Her partner was a witness to what had happened and explained how she had said she had felt dizzy and then all of a sudden fell to the floor, with all four limbs shaking, which lasted for around fifteen minutes. There was no tongue biting and no incontinence. As soon as the shaking ceased she sat up and was able to hold a conversation. She was orientated in time and place and didn't seem to be confused, however she was fairly drowsy. In clinic she was given a diagnosis of non epileptic attack disorder. Her partner was wondering whether there was any evidence to support behavioural treatments as a means to reducing seizure frequency.

Search Strategy

Cochrane library
PubMed
Ovid Online
Cochrane Library “non epileptic attack disorder”, 12 hits, 1 review of behavioural treatments for non epileptic attack disorder
PubMed “non epileptic attack disorder” and “behavioural treatments” limits human, adult age 19+, English, 0 hits.
PubMed “non epileptic attack disorder” limits human, adult age 19+, English, after 1996,11 hits. 0 Randomised clinical trials, 1 clinical trial
PubMed “dissociative seizures” and “treatment”, limits human, adult age 19+, English, after 1996, 2 hits, 1 relevant clinical trial
PubMed “pseudoseizures” and “treatment”, limits human, adult age 19+, English after 1996, 35 hits, no new relevant papers found.
Ovid online 1996 to 2009 “non epileptic attack disorder” 15 hits, 1 cochrane review of behavioural treatments for non epileptic attack disorder

Search Outcome

PubMed search yielded one relevant clinical trial, which was included in the cochrane review.
Cochrane Library search found a review of behavioural treatments for non epileptic attack disorder which also came up in the Ovid search.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Brooks, Baker et al (Cochrane Review) 2007	Patients with a diagnosis of Non Epileptic Attack Disorder.	3 small randomised controlled trials, met the inclusion criteria, two looking at hypnosis and the other paradoxical injunction therapy	There have been many studies conducted in order to investigate the cause of non epileptic seizures however in terms of treatment for these attacks, the literature is limited.	Due to the limitations of the studies found, and the small number of studies available, no reliable evidence has been found in favour of behavioural treatments.	Small number of studies, many discounted as they were retrospective and not randomised controlled trials.
Goldstein L, Deale A et al 2004	20 patients with a diagnosis of dissociative seizures.	Open prospective trial	Patients were offered 12 sessions of cognitive behavioural therapy. Following the CBT outcomes measured include, dissociative seizure frequency, psychosocial functioning, employment status and general mood. Patients were assessed before, during and six months after treatment.	Following treatment with cognitive behavioural therapy, there was a significant decrease in the frequency of seizures as well as an increase in self rated mood and emploment rate.	Only 16 out of the 20 patients completed the course of treatment, small patient group, not a randomised controlled trial and therefore did not meet the inclusion criteria for the cochrane review.
Riaz H, Comish S et al 1998	91 patients in an inpatient setting, 25 of them had a diagnosis of NEAD	Retrospective study	20% of patients had seen a psychiatrist, 40% seen in epilepsy clinics and 40% had had no follow up.	27% of patients were seizure free, 40% had a reduction in seizure frequency by over 50% and 13% had an increase in seizure frequency.	Not included in Cochrane as not a randomised controlled trial. It doesn’t indicate if the group that were seizure free had an intervention therefore the evidence is unreliable. The study does not show whether the group that were seizure free had seen a psychiatrist, gone to epilepsy clinic or seen no one.
Moene et al 2002 2002	45 patients with conversion disorder, 24 were in an experimental group, 21 in a control group	Randomised controlled trial, double blinded	Both patient group followed a programme with sport, psychotherapy, social therapy and physio. The experimental group also had hypnosis. The video rating scale for motor conversion symptoms was measured and the groups followed up after 8 months.	There were no results specific to non epileptic seizures. The authors came to the conclusion that there was no reliable evidence for use of hypnosis in the treatment of non epileptic seizures.	There was no detail provided regarding seizure frequency or change in frequency, nor was severity considered. The assessors were also blind as to the method of treatment allocation.
Moene et al 2003	44 patients with conversion disorder, 20 were in experimental group and 24 in a control group	Randomised controlled trial	The treatment group were given hypnosis and the control group were not. The video rating scale for motor conversion was measured as an outcome and the groups were followed up after 6 months.	It was reported that there was a significant treatment results for a conversion disorder	Assessors were blind to treatment allocation, patients were block randomised into a group, no data regarding seizure frequency or change in frequency. Rendering the results to be unreliable evidence.
Ataoglu A, Ozcetin A et al. 2003	30 patients, 15 in an experimental group and 15 in a control group	Randomised controlled trial	The treatment group were given two session each day of paradoxical intention treatment for three weeks, where they were encouraged to imagine situations provoking anxiety. They were followed up three weeks after discharge and there Hamilton rating scale for anxiety score was measured.	No specific seizure frequency or severity results were documented as the study was concerned with an anxiety level. Neither group had any significant change in anxiety score after treatment compared to their score before treatment.	The two groups received interventions in different settings, the assessor was blind as to the treatment, randomisation was done by computer.

Comment(s)

A recent 2007 cochrane review has found that there is no reliable evidence for behavioural therapy in terms of treating non epileptic attack disorder. Studies reviewed include three randomised controlled trials, two looking at the effect of hypnosis (Moene et al) and one looking at the effect of paradoxical injunction therapy, which is a form of treatment through which the patient is placed in a double bind promoting behavioural change whether or not they are compliant, as they then have two equally unsatisfying choices (Ataoglu et al). These are examples of treatments which have been tried and tested for patients with NEAD (Brooks, Baker et al). The other studies were excluded because they were not randomised controlled trials. They were either retrospective or there was no evidence that they were relevant to patients with non epileptic seizures. Riaz et al, a retrospective study concluded that 27% of patients involved had become seizure free, however it did confirm the type of intervention they had received whether it was no treatment, whether they were seen in epilepsy clinic or if they were seen by a psychiatrist. It was thus excluded because the evidence found was unreliable. Goldstein et al, an open prospective study came to the conclusion that a course of cognitive behavioural therapy can lead to a decrease in seizure frequency and an increase in empolyment rate and improved mood. These findings are promising, however because there was no control group involved, the study did not meet the cochrane inclusion criteria. With regards to non epileptic attack disorder, the current literature is focused towards patient’s reaction upon diagnosis and the nomenclature of the attacks, with very few trials conducted in order to investigate different treatment modalities.

Clinical Bottom Line

The recent 2007 Cochrane review found no reliable evidence for behavioural treatment for non epileptic attack disorder, and suggested that more research should be conducted in this field, in the form of prospective, randomised controlled trials.

References

1. Brooks J, Baker G et al Behavioural treatments for non epileptic attack disorder. Cochrane Database of Systematic Reviews 2007, Issue 1
2. Goldstein L, Deale A et al An evaluation of cognitive behavioural therapy as a treatment for dissociative seizures: a pilot study. Cognitive Behavioural Neurology 2004 March 17(1):41-9
3. Riaz H, Comish S et al Non epileptic attack disorder and clinical outcome: a pilot study. Science 1998;7(5):365-368.
4. Moene F, Spinhoven P et al A randomised controlled clinical trial on the additional effect of hypnosis in a comprehensive treatment programme for in-patients with conversion disorder of the motor type. Psychotherapy and Psychosomatics 2002;71(2):66-76.
5. Moene F, Spinhoven et al A randomised controlled clinical trial of a hypnosis-based treatment for patients with conversion disorder, motor type. International Journal of Clinical and Experimental Hypnosis 2003;51:29-80.
6. Ataoglu A, Ozcetin A et al. Paradoxical therapy in conversion reaction Journal of Korean Medicine 2003;18:581-584