Data Inconclusive on Psychological Interventions for Pediatric Nonepileptic Seizures

Julia Gledhill, MD, MRCPsych

A recent systematic review on the effectiveness of psychological interventions for patients pediatric and adolescent patients with nonepileptic seizures (NES) had inconclusive results when determining the superior treatment approach. Investigators note that outcomes in this patient population were generally positive when using a range of these interventions, and information from the review may contribute to management guidelines. 

Following the development of inclusion criteria and removal of duplicates, investigators included 12 studies. The most frequent interventions for NES were psychoeducation and top-down psychotherapy, such as cognitive therapies, while newer studies included bottom-up approaches that were body-oriented. Multiple treatment approaches were included in 10 studies, while 2 had a single treatment modality. 

While the follow-up period varied from 1 week to 6 years, most patients in the included studies had positive results, in the form of either seizure cessation or reduction in seizure frequency. Psychoeducation was a key intervention in 9 studies, where patients were given an explanation of their diagnosis, followed by validation of symptoms, then psychological interventions. Helping patients regain control of symptoms, focusing on the mind/body approach, was another intervention used in bottom-up/body-oriented psychotherapy. 

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“The existing literature suggests that in view of the range of predisposing, precipitating, and perpetuating factors contributing to NES, on modality of treatment is unlikely to be effective for all patients,” wrote coauthor Julia Gledhill, MD, MRCPsych, consultant child psychiatrist, Honorary Senior Lecturer, Centre for Psychiatry, Imperial College London; and lead, Child and Adolescent Mental Health Research, Central and North West London NHS Foundation Trust, et al.

“Combining top-down and body-oriented (bottom-up) approaches may improve the effectiveness and understanding of psychological treatments, as evidenced by a study which combined CBT [cognitive behavioral therapy], group psychotherapy and biofeedback, which demonstrated a significant reduction in monthly seizure frequency at discharge, after an average treatment duration of just under 8 months,” Gledhill et al added. 

Of the evaluated studies, 1 was a randomized control trial; 1 had the primary goal of evaluating and intervention; 2 were prospective outcome studies; and the remaining 8 were retrospective analyses of clinical data, most often evaluating seizure frequency among these patients. All 12 studies had an assessment or treatment of a comorbidity. Other intervention tactics included collaboration between physical and mental health services, stopping antiepileptic medications following NES diagnosis, support for parents, and a liaison with school—all of which emphasize the need for individualized treatment plans. 

The study was limited due to the varying sample size, follow-up periods, and general characteristics among the included studies. As many studies also utilized self-reporting from patients and parents, there may be a disconnection in the correlation with functioning. Additionally, there was no separate analyses for outcome measures when subgroups were treated with different interventions, and the continuation of treatment after cessation of seizures also varied within and between studies. Noted was 1 study that did not have all participants accounted for at follow-up, a lack of accounting for total number of treatment sessions, and patients receiving various interventions, making individual analyses impossible.

“The multiple factors which contribute to NES as well as its high comorbidity may explain why few studies have attempted to evaluate single interventions, and the current evidence suggests that multifaceted individualized treatment approaches are likely to be most appropriate,” Gledhill et al wrote. “In line with the evidence, we would recommend collaborative working between neurology and child and adolescent psychiatry, psychoeducation, formulation-based psychotherapy incorporating body-oriented (bottom-up) and top-down approaches, family involvement, and liaison with school.”

REFERENCE

Velani H and Gledhill J. The effectiveness of psychological interventions for children and adolescents with non-epileptic seizures. Seizure–Eur J Epilep. Published online September 13, 2021. doi:10.1016/j.seizure.2021.09.006