Using Tailored Cognitive Behavioral Therapy to Address Psychogenic Nonepileptic Seizures

Becky Tilahun, PhD

In December 2021, at the American Epilepsy Society (AES) Annual Meeting, the results from a retrospective study were presented that suggested significant improvements in seizure frequency, anxiety, and depression in patients with psychogenic nonepileptic seizures (PNES) when they were treated with Cognitive Behavioral Therapy-informed psychotherapy (CBTip) for more than a 12-week period.

These results of the 2-part analysis were presented by Becky Tilahun, PhD, clinical psychologist, Cleveland Clinic, and included 160 patients who were treated with at least 7 sessions of CBTip. The first analysis looked at changes in outcomes in pretreatment and 90-day patient-reported outcome (PRO) scores, while the second analysis looked at those in a flexible treatment schedule by comparing pretreatment scores with 90-day to 1-year post initial visit scores.

To inquire further about these data, how the assessment was conducted, and what the clinical community should know, NeurologyLive® spoke with Tilahun about the findings.

NeurologyLive®: Can you first detail your results? Which takeaways are the most important?

Beck Tilahun, PhD: Our work was with PNES patients who were enrolled in a CBTip program. This is a manualized counseling program that was previously tested with a controlled clinical trial and was found effective for seizure control for a mood as well as for improving the quality of life of these patients.

PNES patients have psychogenic seizures—a type of seizure that is triggered by stress and trauma. What we found was that patients in our population were also able to benefit from this program but in a flexible type of protocol. The existing protocol was a 12-session program, where patients were seen weekly, and then they were tested at the end of the treatment to see if that counseling helped. In our approach, patients were not able to do that. In some cases, some lived a little bit farther away, some have different barriers in terms of coming to us in a weekly type of protocol. We're in the weekly program, but some came to us every other week, and some came once a month because they live quite far from the clinics and needed to actually stay in a hotel for a week. So, people did a flexible type of engagement in participation in this program, and we saw that these patients also benefited from the flexible type of approach. We are encouraged that we're seeing this even though we did not do a controlled clinical trial.

What it is showing us is that when our patients can't do what we offer—the 12-week type of intervention—we have to be flexible with them. Especially with PNES patients, who tend to be heterogeneous, meaning they are different from one another in terms of what causes their symptoms. They have the same symptoms—psychogenic seizures—but they don't have the same cause and the risk factors are very different from person to person. So based on the intensity, their individual circumstances, and their logistical barriers, we may be able to be flexible with them in terms of the type of program that we offer them. We need to continue to test different ways of delivering care for our patients.

How did you specifically tailor your program?

One of the things that is really good about this type of intervention, is that CBTip is actually a type of CBT that's specifically designed for nonepileptic seizure patients. We know that many patients if there was PNES or other similar functional symptoms, are known not to be very adherent. They tend to drop out of treatment early when it's more like a general CBT. Whereas this specific type of intervention addresses seizure triggers, and addresses pre-seizure aura, so it's really tailored to the type of symptoms that they have and the type of struggles that they have. That's the reason why I think this is this approach is very effective, even when we're flexible. When we're not following the formal robust protocol, we saw these benefits because it's kind of specific to the type of symptom. I think CBT, or cognitive behavioral therapy, is effective for this type of neurological or functional neurological condition. But we also need to be more look at it more closely to see what we need to add specifically to tailor our intervention to the specific needs of our patients.

Are there ways to continue to expand the use of this type of therapy?

We're going to do more clinical trials to see if patients who are seen just a few times, maybe less than 12 times as the protocol shows, to see if that would help. The other approach we're going to take is to see if we can deliver counseling virtually because these patients can’t come in-person—that's why we need to be flexible—but when we deliver it virtually, from their homes, would they be more compliant? Would they be more adherent? Can we see better outcomes, better improvements? So that's one of the things we are working on.

We're actually doing research with that as well, to see if we can do virtual care to help patients access these counseling programs remotely because one of the struggles PNES patients have is most don't have PNES-trained specialists in their local vicinities. There is a scarcity of providers for functional neurological disorders. One of the things you're going need to do is try different approaches and do more research to make these interventions more approachable, more accessible for patients, as opposed to just saying, “Well, you can't come in, we have 1 type of approach and there is no option for you.”

Transcript edited for clarity. For more coverage of AES 2021, click here.

REFERENCE
Tilahun B, Thompson N, Sankary L, Laryea F, Trunick C. Outcomes in the treatment of psychogenic non-epileptic seizures (PNES) with CBTip: improvement in seizure frequency, mood, and quality of life. Presented at AES Annual Meeting; December 3-7, 2021. Abstract 3.256