- Email: [email protected]
Mindfulness-based therapy for psychogenic nonepileptic seizures
YEBEH-106534; No of Pages 7 Epilepsy & Behavior xxx (xxxx) xxx
Contents lists available at ScienceDirect
Epilepsy & Behavior journal homepage: www.elsevier.com/locate/yebeh
Mindfulness-based therapy for psychogenic nonepileptic seizures Gaston Baslet a,⁎, Alexa Ehlert b, Megan Oser a, Barbara A. Dworetzky c a b c
Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA 02115, USA Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115, USA Department of Neurology, Brigham and Women’s Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA 02115, USA
a r t i c l e
i n f o
Article history: Received 25 July 2019 Revised 28 August 2019 Accepted 30 August 2019 Available online xxxx Keywords: Psychogenic nonepileptic seizures Functional neurological disorder Trial Mindfulness Psychotherapy
a b s t r a c t Background: Mindfulness-based therapies (MBTs) are effective in many neuropsychiatric disorders, and represent a potential therapeutic strategy for psychogenic nonepileptic seizures (PNES). Objective: The objective of this study was to investigate the clinical effect of a manualized 12-session MBT for PNES in an uncontrolled trial. We hypothesized reductions in PNES frequency, intensity, and duration, and improvements in quality of life and psychiatric symptom severity at treatment completion. Methods: Between August 2014 and February 2018, 49 patients with documented PNES (with video electroencephalography [EEG]) were recruited at Brigham and Women's Hospital to participate in the MBT for PNES treatment study. Baseline demographic and clinical information and self-rating scales were obtained during the diagnostic evaluation (T0). Baseline PNES frequency, intensity, and duration were collected at the first followup postdiagnosis (T1). Frequency was obtained at each subsequent MBT session and analyzed over time with median regression analysis. Outcomes for other measures were collected at the last MBT session (T3), and compared to baseline measures using linear mixed models. Results: Twenty-six patients completed the 12-session MBT program and were included in the analysis. Median PNES frequency decreased by 0.12 events/week on average with each successive MBT session (p = 0.002). At session 12, 70% of participants endorsed a reduction in PNES frequency of at least 50%. Freedom from PNES was reported by 50% of participants by treatment conclusion. Seventy percent reported a 50% reduction in frequency from baseline and 50% reported remission at session 12. By treatment end, PNES intensity decreased (p = 0.012) and quality of life improved (p = 0.002). Event duration and psychiatric symptom severity were lower after treatment, but reductions were not statistically significant. Conclusions: Completion of a manualized 12-session MBT for PNES provides improvement in PNES frequency, intensity, and quality of life. The high dropout rate is consistent with adherence studies in PNES. Possible reasons for dropout are discussed. Randomized controlled trials and longer-term outcomes are needed to demonstrate the efficacy of MBT in PNES. © 2019 Elsevier Inc. All rights reserved.
1. Introduction Despite advances in the understanding of functional neurological disorders, evidence-based treatments for psychogenic nonepileptic seizures (PNES) remain limited. Cognitive-behavioral therapy (CBT) is the most rigorously studied treatment modality with evidence of efficacy for PNES [1,2]. Results from the first large-scale multicenter randomized controlled trial for PNES using CBT as the active intervention will be reported shortly [3]. Other treatment modalities examined in PNES include, but are not restricted to, paradoxical intention,
⁎ Corresponding author at: Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA 02115, USA. E-mail addresses: [email protected] (G. Baslet), [email protected] (A. Ehlert), [email protected] (M. Oser), [email protected] (B.A. Dworetzky).
psychoeducational interventions, individual and group psychodynamic psychotherapies and psychopharmacological treatments [4–8]. Mindfulness-based therapy (MBT) refers globally to psychotherapeutic modalities where the primary intervention is rooted in the practice of mindfulness. Within the realm of MBTs, mindfulness is commonly defined as “paying attention in a particular way: on purpose, in the present moment and non-judgmentally” [9]. Dialectical behavioral therapy, mindfulness-based stress reduction, acceptance and commitment therapy, and mindfulness-based cognitive therapy are examples of specific evidence-based psychotherapeutic approaches that have mindfulness as a core principle but differ in the way that such principle is technically applied and delivered [9–12]. A number of psychiatric diagnoses with underlying affective dysregulation and difficulty controlling behaviors, such as borderline personality disorder and substance use disorders, are effectively treated with different types of MBT [13,14]. Difficulties in emotion recognition,
https://doi.org/10.1016/j.yebeh.2019.106534 1525-5050/© 2019 Elsevier Inc. All rights reserved.
Please cite this article as: G. Baslet, A. Ehlert, M. Oser, et al., Mindfulness-based therapy for psychogenic nonepileptic seizures, Epilepsy & Behavior, https://doi.org/10.1016/j.yebeh.2019.106534
2
G. Baslet et al. / Epilepsy & Behavior xxx (xxxx) xxx
psychopathology that could impact participation in treatment (specifically, active psychotic or manic symptoms, active substance use, or recent suicidal behavior that were deemed to interfere with treatment participation and/or required prioritized clinical attention). Comorbid epilepsy was allowed as long as the nature of the episodes (psychogenic versus epileptic) was accurately identified by patients. If patients attended the first postdiagnosis appointment, met clinical eligibility criteria, and accepted to participate in the study, they were enrolled. Please refer to the study flowchart (Fig. 1) for a timeline of the participant selection process. All subjects provided consent for participation. There was no control intervention. The study was approved by the hospital's Institutional Review Board.
acceptance, and management are well-documented psychological vulnerabilities in PNES [15,16], and therefore, MBT approaches deserve exploration in this population. There is preliminary evidence of MBT clinical benefits in PNES. Bullock et al. demonstrated that participation in a dialectical behavioral therapy skills training group (DBT-ST) reduced symptoms in PNES [17]. One of the authors (GB) developed a psychotherapy treatment protocol that consists of 12 sessions and incorporates elements from different MBT approaches. A case series using an earlier version of this MBT manual showed symptomatic improvement in 6 patients with PNES [18]. We aimed to determine the clinical effect of a manualized 12-session MBT program for PNES in a prospective uncontrolled trial. We hypothesized significant reductions in episode (seizure) frequency, intensity, and duration, and improvements in quality of life and psychiatric symptom severity at treatment completion.
2.2. Outcome measures Weekly frequency of PNES was the primary outcome measure. Secondary outcome measures included PNES average duration, PNES intensity, quality of life, and measures of psychopathology severity. Data were collected at specific time points: T0 (assessment at the time of diagnosis either in the epilepsy monitoring unit or first outpatient encounter); T1 (first postdiagnosis follow-up), T2 (treatment midpoint, which coincided with session 6 (S6) of the MBT protocol), T3 (end of treatment, which coincided with session 12 (S12) of the MBT protocol). Data collected at each time point included the following: baseline demographic and clinical information at T0; PNES weekly frequency at T1 and at each subsequent MBT session (S1–S12); PNES intensity, duration, and quality of life at T1, T2, and T3; and measures of psychopathology severity at T0 and T3. Baseline demographic and clinical data were obtained through a semistructured neuropsychiatric interview conducted by the same United Council for Neurological Subspecialties-
2. Materials and methods 2.1. Participants Patients with documented PNES (via video electroencephalography [EEG]) were screened and consented for participation in a larger prospective longitudinal study between August 2014 and February 2018 at Brigham and Women's Hospital. Only patients that attended the first postdiagnosis follow-up appointment and met clinical eligibility criteria were offered to participate in the 12-session MBT study. Clinical eligibility criteria included the following: 1) clinically-established intellectual capability to understand the material (based on the patient's observed vocabulary and education history); 2) no active
Video EEG confirmed PNES patients who consented for prospective longitudinal naturalistic study (T0) (n=144) Did not attend first post- diagnosis follow-up (n=22) Attended first post-diagnosis follow-up (T1) (n=122)
Did not meet clinical eligibility criteria (n=15) Active substance use (n=7) Active mania/hypomania or psychosis (n=7) Active psychosis and substance use (n=1)
Declined to participate in MBT study (n=58) Preferred treatment with established therapist or referral to therapist locally (n=42) No specified reason for decline (n=16)
Enrolled in MBT study (n=49)
Did not complete MBT protocol (n=23) Did not attend any session (n=2) Attended at least one session, with last session being: S1 (n=7), S2 (n=2), S3 (n=4), S4 (n=3), S5 (n=1), S8 (n=1), S9 (n=2), S11 (n=1)
Completed MBT protocol (n=26) Fig. 1. Study flowchart.
Please cite this article as: G. Baslet, A. Ehlert, M. Oser, et al., Mindfulness-based therapy for psychogenic nonepileptic seizures, Epilepsy & Behavior, https://doi.org/10.1016/j.yebeh.2019.106534
G. Baslet et al. / Epilepsy & Behavior xxx (xxxx) xxx
certified neuropsychiatrist (GB). Frequency of PNES was obtained from a weekly patient-completed episode log. Duration of PNES was averaged from self-report of episode duration in patient weekly episode log. Intensity of PNES was self-rated in a 0-to-10 Likert scale (with 0 representing “PNES are not intense or bothersome at all” and 10 representing “PNES are at their highest intensity or severity”). Measures of psychopathology severity were obtained via the following standardized instruments. The Beck Depression Inventory-II (BDI-II) is a 21-item self-report scale that measures depressive symptoms over the preceding 2 weeks and was developed to assess Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) depressive symptoms. Severity is determined based on the total score: minimal or no depression (0–13), mild (14–19), moderate (20–28), and severe (29–63) [19]. The Depression, Anxiety, and Stress Symptoms scale (DASS) is a 42item self-report questionnaire that measures depression (DASS-D), anxiety (DASS-A), and stress (DASS-S) levels over the preceding week. We only scored the 14 items specific for the anxiety subscale (DASSA). Severity for the DASS-A is based on the following total subscale score: normal (0–7), mild (8–9), moderate (10–14), severe (15–19), and extremely severe (20–42). The DASS-A has been shown to correlate highly with the Beck anxiety inventory (r = 0.81) [20]. The Patient Health Questionnaire 15 (PHQ-15) is a 15-item selfrated instrument that assesses the level of distress caused by different somatic symptoms over the preceding 4 weeks; severity is rated as 0 (“not at all bothered”), 1 (“bothered a little”), or 2 (“bothered a lot”). Severity is determined based on the total score: no or minimal severity (0– 4), low severity (5–9), medium severity (10–14), and high severity (15– 30) [21]. The Dissociative Experiences Scale (DES) is a 28-item self-report questionnaire designed to assess the current degree of dissociative experiences using an 11-point multiplechoice response format that ranges from 0% to 100%. Higher scores indicate likelihood of a dissociative disorder [22]. Scores about 30 are considered indicative of a significant level of dissociation [23]. Quality of life was measured with the Quality of Life in Epilepsy-10 (QOLIE-10), a 10-item Likert-type scale measuring a range of health concepts related to living with epilepsy. This includes emotional wellbeing, seizure worry, medication effects, cognitive functioning, social functioning, energy/fatigue, and overall quality of life. Lower scores indicate better quality of life [24]. For our study, subjects were specifically instructed to rate their quality of life as affected by PNES, not epilepsy. 2.3. Treatment intervention The MBT sessions were scheduled weekly and conducted in person by licensed independent clinical social workers (they had completed
Table 1 Mindfulness-based therapy for PNES: content of the 12-session program. MODULE I: UNDERSTANDING YOUR DISEASE AND YOUR TREATMENT Session 1: Understanding Your Illness Session 2: Identifying the function of the symptom. Session 3: Identifying values. MODULE II: STRESS MANAGEMENT STRATEGIES Session 4: Understanding the stress cycle Session 5: Mastering a stress management skill MODULE III: MINDFULNESS Session 6: Introduction to mindfulness Session 7: Incorporating mindfulness into everyday life MODULE IV: EMOTION MANAGEMENT Session 8: Emotion Recognition Session 9: Emotion Acceptance Session 10: Regulation of emotion-driven behavior MODULE V: REWORKING COGNITIONS & RELAPSE PREVENTION Session 11: Reworking cognitions Session 12: Relapse Prevention
3
sufficient training to practice without supervision). Content of the MBT protocol was divided in 5 modules and 12 sessions as outlined in Table 1. All therapists included in this study were versed in mindfulness-based psychotherapy principles and had to first complete all 12 sessions with one patient (not included in the study) and undergo weekly supervision to be considered therapists in this study. While conducting the treatment of study participants, therapists followed specific guidelines, including didactic content and in-session practices, and completed a checklist for each session to ensure consistency. Fidelity to the MBT protocol was further determined through weekly supervision to review adherence to session guidelines. Given the nature of psychotherapy, the following deviations from the specified treatment were allowed: up to 3 extra sessions to catch up with material or to address crises, up to 3 missed sessions, and up to 30 days between appointments. The MBT program was discontinued for patients who required further deviation from the protocol. 2.4. Statistical analysis Statistical analysis was conducted using SAS version 9.4 (Cary, NC). Median regression analysis (PROC QUANTREG) was used to determine decrease in PNES weekly frequency at each subsequent MBT session. Linear mixed-effect models (PROC MIXED) were used to determine decreases between time points for all other secondary outcome measures (PNES intensity, PNES duration, quality-of-life measure and measures of psychopathology severity). 3. Results 3.1. Participants One hundred and forty-four patients with documented videoEEG diagnosis of PNES were consecutively assessed for recruitment. Thirty-seven did not meet eligibility criteria (22 for not attending the first postdiagnosis follow-up appointment and 15 for not meeting the clinical inclusion criteria despite attendance to the appointment). Of the eligible patients, 58 declined to participate in the MBT study: of these 58 patients, 16 stated no reason for refusing treatment. The remaining 42 eligible patients that declined participation in treatment had an established therapist and/or could not come to our center for treatment because of limited geographical or transportation limitation. If the latter was the case, patients accepted a referral to a local therapist. The remaining 49 patients were enrolled in the MBT study: 2 enrolled subjects did not attend any session; 21 attended at least one session, and 26 completed the 12 sessions of the treatment. Fig. 1 presents the study flowchart and details the last attended session for the noncompleters. Data and analyses are presented on the 26 patients who completed the 12 sessions of the MBT program. Demographic and clinical characteristics of the 26 patients that completed the MBT study protocol and the 23 enrolled subjects who did not complete the study are summarized in Table 2. Compared with participants that completed the study, the group of enrolled subjects who did not complete the treatment were younger at the time of the evaluation, tended to belong to ethnic minorities, and had less years of education. The only clinical difference between the two groups was a more frequent history of depression in the group of completers; however, baseline BDI-II scores (indicative of current mood state) were not different between groups. 3.2. Treatment fidelity and allowed treatment deviations Therapists attended weekly supervision while providing treatment to participants. Review of the manual checklists, notes and discussions determined that therapists complied with the elements to be covered in each session. In terms of treatment deviations, 50% (n = 13) of the
Please cite this article as: G. Baslet, A. Ehlert, M. Oser, et al., Mindfulness-based therapy for psychogenic nonepileptic seizures, Epilepsy & Behavior, https://doi.org/10.1016/j.yebeh.2019.106534
4
G. Baslet et al. / Epilepsy & Behavior xxx (xxxx) xxx
Table 2 Baseline demographic and clinical characteristics of enrolled subjects completing the MBT protocol vs enrolled subjects not completing the MBT protocol. Completers (n = 26) Demographic variable Age at evaluation, mean⁎ Ethnicity, n⁎ White Black Hispanic Other Gender (female), n Years of education, mean⁎ Marital status, n Never married Married Separated/divorced Widow Employment status, n Employed Unemployed Disabled Student Retired Psychiatric Variable Psychiatric history, n (current or past symptoms) Depressive disorders⁎ Anxiety disorders PTSD Mania/hypomania Psychosis Substance use disorders Eating disorders Impulsivity Other somatic symptoms (except pain/ headache) Other dissociative symptoms Past inpatient admission Past psychiatric treatment Past suicide attempt Trauma, n Physical abuse Sexual abuse Emotional/verbal abuse Abuse during childhood Any trauma Self-report measures, mean BDI-II DASS (anxiety) DES PHQ-15 PNES or Neurological Variable Age at onset of PNES, mean Delay in diagnosis (months), mean Documented epilepsy, n Stressor at onset of PNES, n Identified triggers for events, n Neurological history, n Traumatic brain injury Headaches Pain Family history of seizures Primary captured semiology, n Primary motor Primary unresponsiveness Other (sensory, speech)
Noncompleters (n = 23)
n (%) or mean (SD) 46.4 (16.2) 34.4 (9.9) 22 (84.6) 3 (11.5) 1 (3.8) 0 (0) 23 (88.5) 15.3 (3.2)
11 (47.8) 4 (17.4) 7 (30.4) 1 (4.3) 19 (82.6) 13.5 (2.0)
8 (30.8) 14 (53.8) 3 (11.5) 1 (3.8)
12 (52.2) 10 (43.5) 0 (0) 1 (4.3)
8 (27.7) 7 (26.9) 6 (23.1) 3 (11.5) 2 (7.7)
4 (17.3) 5 (21.7) 9 (39.1) 5 (21.7) 0 (0) n (%) or mean (SD)
21 (80.8) 23 (88.5) 14 (53.8) 1 (3.8) 4 (15.4) 6 (23.1) 3 (11.5) 8 (30.8) 9 (34.6)
12 (52.2) 20 (87.0) 12 (52.2) 3 (13.0) 3 (13.0) 3 (13.0) 5 (21.7) 5 (21.7) 14 (60)
4 (15.4) 9 (34.6) 23 (88.5) 6 (23.1)
4 (17.4) 5 (21.7) 17 (73.9) 6 (26.1)
5 (19.2) 11 (42.3) 13 (50) 8 (30.8) 16 (61.5)
7 (30.4) 11 (47.8) 8 (34.8) 8 (34.8) 13 (56.5)
13.8 (9.3) 9.4 (6.3) 30.2 (25.1) 11.4 (4.3)
17.56 (13.6) 12.33 (11.6) 42.25 (46.9) 13.48 (4.8)
n (%) or mean (SD) 39.4 (18.2) 31.2 (10.9) 75.3 (157.6) 33.6 (67.3) 3 (11.5) 0 (0) 22 (84.6) 16 (69.5) 19 (73.1) 19 (82.6) 16 (61.5) 18 (69.2) 16 (61.5) 6 (23.1)
10 (43.5) 15 (65.2) 12 (52.2) 8 (36.4)
12 (46.6) 12 (46.6) 2 (7.7)
13 (56.5) 9 (39.1) 1 (4.3)
BDI-II: Beck Depression Inventory-II; DASS Anxiety: Depression, Anxiety and Stress Scale, Anxiety Subscale; DES: Dissociative Experiences Scale; PHQ-15: Patient Health Questionnaire – 15. ⁎ p b 0.05.
completers required at least one additional session (7 required one additional session, 5 required two additional sessions, and only one patient required 3 additional sessions). The average time between
sessions was 10.15 days (SD = 2.23). No subjects were excluded from the study for requiring more than 3 additional sessions or for taking more than 30 days between completed sessions. 3.3. Primary outcome measure (PNES weekly frequency) Median PNES weekly frequencies at baseline (at postdiagnosis appointment) and at each subsequent MBT session are presented in Fig. 2 and Table 3. The quantile median regression analysis demonstrated that median PNES frequency decreased by 0.12 episodes per week (95%CI 0.2–0.04) for every successive session (p = 0.002). Fifty percent of patients (n = 13) reported no PNES at the last session (from the previous session), and 23% (n = 6) reported sustained cessation of PNES during the last 4 weeks of treatment. Three subjects had reported no episodes during their baseline T1 measurement; of the remaining 23 completers, 70% (n = 16) had a 50% reduction in PNES weekly frequency at the last session and 52% (n = 12) had 50% reduction based on reports from the last 4 weeks of treatment. 3.4. Secondary outcome measures Median PNES duration at the postdiagnosis appointment was 4.5 min. At the last session, median PNES duration was reduced to 2.5 min, which did not achieve statistical significance (p = 0.10). At the last session, median PNES duration was reduced to 2.5 min, which did not achieve statistical significance (p = 0.10) (Table 4). Mean PNES intensity at the postdiagnosis appointment was 5.56 (SD 2.14). At the last session, mean PNES intensity was significantly reduced to 3.74 (SD 2.65) (p = 0.012) (Table 4). Quality of life improved (lower scores on QOLIE-10) from the postdiagnosis appointment to the last session (p = 0.002) (Table 4). None of the reductions observed in the four psychopathology measures (BDI-II, DASS anxiety subscale, DES, and PHQ-15) by the end of the treatment achieved statistical significance (Table 5). 3.5. Dropout participants Fig. 1 shows that 23 patients did not complete the MBT protocol. Two of them failed to attend the first appointment. Seven of them only attended one session, and thirteen of them dropped before session 4. Patients were still scheduled to follow with the treatment team every two months, but only 10 attended the scheduled bimonthly follow-up appointments. Data are therefore limited in terms of reasons for dropout. Qualitative inquiry about reasons for lack of completion of the treatment revealed that difficulty coming to appointments was a very common answer. 4. Discussion Our manualized 12-session MBT protocol is the first mindfulnessbased psychotherapy intervention tailored for patients with PNES. Improvements could be observed in participants after completion of the treatment. These improvements included reductions in episode frequency and episode intensity and increases in quality of life. This finding indicates that mindfulness-based approaches may represent an additional type of psychotherapy intervention available for patients with PNES. This benefit is hypothetically derived from skills learned throughout treatment, particularly the application of mindfulness principles on emotion and cognitive processes. Patients with PNES usually either feel overwhelmed by their emotions and/or have become quite distant from them, as an adaptive strategy or defense mechanism [15,16]. Therefore, increasing awareness of emotional states and developing effective strategies to respond to them can lead to symptomatic improvement. Additionally, many functional disorders are reinforced by cognitive processes, such as increased attention on body symptoms and symptom misattribution [25,26]. Cognitive processes, such as symptom
Please cite this article as: G. Baslet, A. Ehlert, M. Oser, et al., Mindfulness-based therapy for psychogenic nonepileptic seizures, Epilepsy & Behavior, https://doi.org/10.1016/j.yebeh.2019.106534
G. Baslet et al. / Epilepsy & Behavior xxx (xxxx) xxx
5
Fig. 2. Change in PNES weekly frequency with each successive session from the MBT protocol using median regression analysis (PROC QUANTREG). Median PNES weekly frequency decreases by 0.12 episodes/week (95%CI 0.2–0.04) for every successive session (p = 0.002).
misattribution, are amenable to mindfulness strategies through cognitive defusion, a mechanism that leads to symptomatic improvement in psychological distress [27]. The benefit of our MBT protocol for PNES on episode duration and on measures of psychopathology severity did not reach statistical significance. One possible explanation for the lack of significant benefit on measures of depression, anxiety, somatization, and dissociation is that the degree of severity at baseline did not seem too elevated in our small-size sample. For instance, the baseline mean scores for BDI-II and DASS-A in our sample fall within the minimal or mild severity range [19,20], and the baseline mean score for PHQ-15 is in the lower end of the medium severity range [21]. The baseline mean DES score is barely about the cutoff of 30, although this is consistent with previous DES scores in samples of patients with PNES [23,28]. It is possible that an
Table 3 Changes in PNES frequency at each successive MBT session. Time
Median frequency (25–75%ile)
T1 S1 S2 S3 S4 S5 S6 S7 S8 S9 S10 S11 S12
1.75 (0.3–5) 1.25 (0–2.5) 1.93 (1–3.5) 1.63 (0–5) 0.83 (0–3.5) 1 (0–4.2) 2 (0–4.2) 1.28 (0–4) 0 (0–2.5) 0.29 (0–2) 0.54 (0–2.8) 1.12 (0–4.5) 0.17 (0–2.8)
T1: Baseline measurement of PNES weekly frequency; S1– 12: each successive session from the MBT program.
adequately powered study could have detected a statistically significant reduction in psychopathology measures and episode duration. Reduction in episode frequency is the most broadly accepted primary outcome measure to establish efficacy of a treatment modality in PNES [29]. During a psychotherapeutic process, there are a number of topics that may be discussed and behavioral changes that may occur that are not captured in a numerical value such as episode frequency. Therefore, qualitative data, in addition to quantitative measures, may reveal clinically meaningful information about individual dynamics that can strengthen the benefit of a treatment intervention. For example, one of our patients who had improvement in episode frequency by treatment completion, also learned to identify interpersonal dynamics with his family as triggers for his episodes. At the conclusion of treatment, he had gained understanding about these interactions and developed new skills that helped him make more effective decisions and had a positive impact on his living arrangement and relationships. In other cases, symptoms may temporarily worsen as patients go through a process of behavioral exploration and change. The most significant limitations in this study include a convenience sample bias, small sample size, and lack of a controlled intervention. Patients were offered to participate in this treatment if they were able to attend the 12 sessions in person and if they either did not have an established psychotherapist in the community or, in that case they did, the psychotherapist either agreed to keep his/her interventions at a supportive level or took a break from working with the patient during the time of their participation in the MBT program. Remote-access participation in psychotherapy (through platforms such as telehealth or web-based programs) is becoming increasingly available [30], and it is possible that MBT would have been as effective if those patients unable to attend because of geographic access had completed the treatment remotely. Although the frequency and nature of therapy supervision provided an assessment of treatment fidelity, certain elements such as therapists' interaction skills during sessions was not evaluated beyond the
Please cite this article as: G. Baslet, A. Ehlert, M. Oser, et al., Mindfulness-based therapy for psychogenic nonepileptic seizures, Epilepsy & Behavior, https://doi.org/10.1016/j.yebeh.2019.106534
6
G. Baslet et al. / Epilepsy & Behavior xxx (xxxx) xxx
Table 4 Changes in PNES intensity and duration and in quality of life (end of treatment compared to baseline measures).
PNES intensity QOLIE-10
PNES duration (min)
T1 mean (SD)
T2 mean (SD)
T3 mean (SD)
5.56 (2.14) 2.59 (0.73)
3.92 (2.69)⁎ 2.40 (0.76)
3.74 (2.65)# 2.14 (0.77)⁎
T1 median (25–75%ile)
T2 median (25–75%ile)
T3 median (25–75%ile)
4.5 (1–10)
4 (1–6)
2.5 (0.75–7.5)
Statistical significant reductions from baseline scores are indicated with * for p b 0.01 and # for p b 0.05. QOLIE-10: Quality of Life in Epilepsy-10.
therapists' reports. Fidelity evaluation with video-recorded sessions would ensure that such elements are carefully evaluated throughout the course of treatment. The current analysis only shows results at the time of completion of the psychotherapy treatment. Ideal effective therapies for PNES will provide sustained symptomatic and functional benefit after completion of the treatment. The goal of this study was to evaluate the initial benefit of the intervention. Long-term data will be necessary to evaluate if benefits are sustained. This MBT protocol for PNES had a treatment completion rate of 55%, which is low but consistent with other prospective naturalistic adherence studies in PNES [31]. Even in the setting of a randomized controlled trial in PNES, with resources available for closer follow-up, completion rates in a previous trial were reported at around two-thirds of the initial participants [1]. Adherence to treatment is an important challenge in the management of patients with PNES, and it is possible that specific therapeutic components need to be implemented in those patients at higher risk of not engaging in treatment. For example, motivational interviewing has demonstrated to be an effective strategy to improve treatment adherence in several complex disorders, and recently in PNES as well. [32]. Given that our qualitative inquiry revealed lack of access as a common reason for dropping out of treatment, it is possible that many participants had the initial intention to participate in the MBT program, but as they noted the required logistical effort to complete treatment, they did not pursue it any longer. Other possible reasons for dropout are lack of perceived immediate resolution of symptoms (despite our explanation of treatment as a process) and/or psychological barriers. Yet, another possibility is that patients already experienced some benefit with the very initial sessions, and they felt treatment was no longer required. Interestingly, enrolled subjects not completing treatment were younger, less educated and proportionally more likely to belong to an ethnic minority. These demographic findings in noncompleters are consistent with the literature on adherence with mental health treatment and in general [33,34]. Most of the patients not completing the MBT program attended 4 or fewer sessions, and they did not provide follow-up data. Therefore, this lack of data limits our ability to determine benefit (or lack thereof) in those patients who had limited exposure to the treatment protocol. Mindfulness-based psychotherapy can now be considered among the psychotherapies that can lead to a reduction in episode frequency and intensity and improvement quality of life in patients with PNES. Randomized controlled trials with adequately powered samples, easily
Table 5 Changes in psychopathology measures (end of treatment compared to baseline). Scale
T0 mean (SD)
T3 mean (SD)
BDI-II DASS (anxiety) DES PHQ-15
13.8 (9.3) 9.4 (6.3) 30.2 (25.1) 11.4 (4.3)
12.12 (11.9) 8.96 (9.8) 29.41 (31.8) 10.40 (6.0)
None of the reductions had p b 0.05. BDI-II: Beck Depression Inventory-II; DASS Anxiety: Depression, Anxiety and Stress Scale, Anxiety Subscale; DES: Dissociative Experiences Scale; PHQ-15: Patient Health Questionnaire – 15.
accessible methods of delivery and longer-term follow-up are necessary to help position MBT as an effective treatment modality for PNES.
Declaration of competing interest The authors report no competing interest. Acknowledgments We would like to acknowledge the following licensed independent clinical social workers who provided the psychotherapy treatment according to the treatment manual: Gabe Gruner, Timothy Larose, Margaret Latawiec, Laura Morrissey, Robert Ridlon. Funding This work was partially supported by the A.J. Trustey Epilepsy Research Fund. References [1] Goldstein LH, Chalder T, Chigwedere C, Khondoker MR, Moriarty J, Toone BK, et al. Cognitive-behavioral therapy for psychogenic nonepileptic seizures: a pilot RCT. Neurology. 2010;74:1986–94. https://doi.org/10.1212/WNL.0b013e3181e39658. [2] LaFrance WCJ, Baird GL, Barry JJ, Blum AS, Frank Webb A, Keitner GI, et al. Multicenter pilot treatment trial for psychogenic nonepileptic seizures: a randomized clinical trial. JAMA Psychiat. 2014;71:997–1005. https://doi.org/10.1001/jamapsychiatry. 2014.817. [3] Goldstein LH, Mellers JDC, Landau S, Stone J, Carson A, Medford N, et al. COgnitive behavioural therapy vs standardised medical care for adults with Dissociative nonEpileptic Seizures (CODES): a multicentre randomised controlled trial protocol. BMC Neurol. 2015;15:98. https://doi.org/10.1186/s12883-015-0350-0. [4] Barry JJ, Wittenberg D, Bullock KD, Michaels JB, Classen CC, Fisher RS. Group therapy for patients with psychogenic nonepileptic seizures: a pilot study. Epilepsy Behav. 2008;13:624–9. https://doi.org/10.1016/j.yebeh.2008.06.013. [5] Ataoglu A, Ozcetin A, Icmeli C, Ozbulut O. Paradoxical therapy in conversion reaction. J Korean Med Sci. 2003;18:581–4. https://doi.org/10.3346/jkms.2003.18.4.581. [6] Chen DK, Maheshwari A, Franks R, Trolley GC, Robinson JS, Hrachovy RA. Brief group psychoeducation for psychogenic nonepileptic seizures: a neurologist-initiated program in an epilepsy center. Epilepsia. 2014;55:156–66. https://doi.org/10.1111/epi. 12481. [7] Mayor R, Howlett S, Grunewald R, Reuber M. Long-term outcome of brief augmented psychodynamic interpersonal therapy for psychogenic nonepileptic seizures: seizure control and health care utilization. Epilepsia. 2010;51:1169–76. https://doi.org/10.1111/j.1528-1167.2010.02656.x. [8] LaFrance WCJ, Keitner GI, Papandonatos GD, Blum AS, Machan JT, Ryan CE, et al. Pilot pharmacologic randomized controlled trial for psychogenic nonepileptic seizures. Neurology. 2010;75:1166–73. https://doi.org/10.1212/WNL.0b013e3181f4d5a9. [9] Kabat-Zinn J. Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness. New York, NY: Delacorte; 1990. [10] Linehan M. Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press; 1993. [11] Hayes SC, Strosahl K, Wilson KG. Acceptance and commitment therapy: an experiential approach to behavior change. Paperback ed New York, NY: Guilford Press; 2003. [12] Segal ZV, Williams JMG, Teasdale JD. Mindfulness-based cognitive therapy for depression: a new approach to preventing relapse. New York: Guilford Press; 2002. [13] Lee EB, An W, Levin ME, Twohig MP. An initial meta-analysis of acceptance and commitment therapy for treating substance use disorders. Drug Alcohol Depend. 2015; 155:1–7. https://doi.org/10.1016/j.drugalcdep.2015.08.004. [14] Soler J, Pascual JC, Tiana T, Cebria A, Barrachina J, Campins MJ, et al. Dialectical behaviour therapy skills training compared to standard group therapy in borderline personality disorder: a 3-month randomised controlled clinical trial. Behav Res Ther. 2009;47:353–8. https://doi.org/10.1016/j.brat.2009.01.013.
Please cite this article as: G. Baslet, A. Ehlert, M. Oser, et al., Mindfulness-based therapy for psychogenic nonepileptic seizures, Epilepsy & Behavior, https://doi.org/10.1016/j.yebeh.2019.106534
G. Baslet et al. / Epilepsy & Behavior xxx (xxxx) xxx [15] Williams IA, Levita L, Reuber M. Emotion dysregulation in patients with psychogenic nonepileptic seizures: a systematic review based on the extended process model. Epilepsy Behav. 2018;86:37–48. https://doi.org/10.1016/j.yebeh.2018.06.049. [16] Uliaszek AA, Prensky E, Baslet G. Emotion regulation profiles in psychogenic non-epileptic seizures. Epilepsy Behav. 2012;23:364–9. https://doi.org/10.1016/j.yebeh. 2012.01.009. [17] Bullock KD, Mirza N, Forte C, Trockel M. Group dialectical-behavior therapy skills training for conversion disorder with seizures. J Neuropsychiatry Clin Neurosci. 2015;27:240–3. https://doi.org/10.1176/appi.neuropsych.13120359. [18] Baslet G, Dworetzky B, Perez DL, Oser M. Treatment of psychogenic nonepileptic seizures: updated review and findings from a mindfulness-based intervention case series. Clin EEG Neurosci. 2015;46:54–64. https://doi.org/10.1177/1550059414557025. [19] Beck AT, Steer RA, Brown GK. BDI-II, Beck depression inventory: manual. 2nd ed.. San Antonio, Tex.: Boston: Psychological Corp.; Harcourt Brace; 1996. [20] Lovibond PF, Lovibond SH. The structure of negative emotional states: comparison of the depression anxiety stress scales (DASS) with the Beck depression and anxiety inventories. Behav Res Ther. 1995;33:335–43. [21] Kroenke K, Spitzer RL, Williams JBW. The PHQ-15: validity of a new measure for evaluating the severity of somatic symptoms. Psychosom Med. 2002;64:258–66. [22] Vanijzendoorn M, Schuengel C. The measurement of dissociation in normal and clinical populations: meta-analytic validation of the Dissociative Experiences Scale (DES). Clin Psychol Rev. 1996;16:365–82. https://doi.org/10.1016/0272-7358(96)00006-2. [23] Goldstein LH, Mellers JD. Ictal symptoms of anxiety, avoidance behaviour, and dissociation in patients with dissociative seizures. J Neurol Neurosurg Psychiatry. 2006; 77:616–21. https://doi.org/10.1136/jnnp.2005.066878. [24] Cramer JA, Perrine K, Devinsky O, Meador K. A brief questionnaire to screen for quality of life in epilepsy: the QOLIE-10. Epilepsia. 1996;37:577–82. [25] Nielsen G, Ricciardi L, Demartini B, Hunter R, Joyce E, Edwards MJ. Outcomes of a 5day physiotherapy programme for functional (psychogenic) motor disorders. J Neurol. 2015;262:674–81. https://doi.org/10.1007/s00415-014-7631-1.
7
[26] Edwards MJ, Adams RA, Brown H, Parees I, Friston KJ. A Bayesian account of “hysteria”. Brain. 2012;135:3495–512. https://doi.org/10.1093/brain/aws129. [27] Larsson A, Hooper N, Osborne LA, Bennett P, McHugh L. Using brief cognitive restructuring and cognitive defusion techniques to cope with negative thoughts. Behav Modif. 2016;40:452–82. https://doi.org/10.1177/0145445515621488. [28] Cohen ML, Testa SM, Pritchard JM, Zhu J, Hopp JL. Overlap between dissociation and other psychological characteristics in patients with psychogenic nonepileptic seizures. Epilepsy Behav. 2014;34:47–9. https://doi.org/10.1016/j. yebeh.2014.03.001. [29] LaFrance WCJ, Alper K, Babcock D, Barry JJ, Benbadis S, Caplan R, et al. Nonepileptic seizures treatment workshop summary. Epilepsy Behav. 2006;8:451–61. https://doi. org/10.1016/j.yebeh.2006.02.004. [30] Fletcher TL, Hogan JB, Keegan F, Davis ML, Wassef M, Day S, et al. Recent advances in delivering mental health treatment via video to home. Curr Psychiatry Rep. 2018;20: 56. https://doi.org/10.1007/s11920-018-0922-y. [31] Tolchin B, Dworetzky BA, Martino S, Blumenfeld H, Hirsch LJ, Baslet G. Adherence with psychotherapy and treatment outcomes for psychogenic nonepileptic seizures. Neurology. 2019;92:e675–9. https://doi.org/10.1212/WNL.0000000000006848. [32] Tolchin B, Baslet G, Suzuki J, Martino S, Blumenfeld H, Hirsch LJ, et al. Randomized controlled trial of motivational interviewing for psychogenic nonepileptic seizures. Epilepsia. 2019;60:986–95. https://doi.org/10.1111/epi.14728. [33] Olfson M, Mojtabai R, Sampson NA, Hwang I, Druss B, Wang PS, et al. Dropout from outpatient mental health care in the United States. Psychiatr Serv. 2009;60:898–907. https://doi.org/10.1176/ps.2009.60.7.898. [34] Mathes T, Jaschinski T, Pieper D. Adherence influencing factors — a systematic review of systematic reviews. Arch Public Health. 2014;72:37. https://doi.org/10. 1186/2049-3258-72-37.
Please cite this article as: G. Baslet, A. Ehlert, M. Oser, et al., Mindfulness-based therapy for psychogenic nonepileptic seizures, Epilepsy & Behavior, https://doi.org/10.1016/j.yebeh.2019.106534
Contents lists available at ScienceDirect
Epilepsy & Behavior journal homepage: www.elsevier.com/locate/yebeh
Mindfulness-based therapy for psychogenic nonepileptic seizures Gaston Baslet a,⁎, Alexa Ehlert b, Megan Oser a, Barbara A. Dworetzky c a b c
Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA 02115, USA Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115, USA Department of Neurology, Brigham and Women’s Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA 02115, USA
a r t i c l e
i n f o
Article history: Received 25 July 2019 Revised 28 August 2019 Accepted 30 August 2019 Available online xxxx Keywords: Psychogenic nonepileptic seizures Functional neurological disorder Trial Mindfulness Psychotherapy
a b s t r a c t Background: Mindfulness-based therapies (MBTs) are effective in many neuropsychiatric disorders, and represent a potential therapeutic strategy for psychogenic nonepileptic seizures (PNES). Objective: The objective of this study was to investigate the clinical effect of a manualized 12-session MBT for PNES in an uncontrolled trial. We hypothesized reductions in PNES frequency, intensity, and duration, and improvements in quality of life and psychiatric symptom severity at treatment completion. Methods: Between August 2014 and February 2018, 49 patients with documented PNES (with video electroencephalography [EEG]) were recruited at Brigham and Women's Hospital to participate in the MBT for PNES treatment study. Baseline demographic and clinical information and self-rating scales were obtained during the diagnostic evaluation (T0). Baseline PNES frequency, intensity, and duration were collected at the first followup postdiagnosis (T1). Frequency was obtained at each subsequent MBT session and analyzed over time with median regression analysis. Outcomes for other measures were collected at the last MBT session (T3), and compared to baseline measures using linear mixed models. Results: Twenty-six patients completed the 12-session MBT program and were included in the analysis. Median PNES frequency decreased by 0.12 events/week on average with each successive MBT session (p = 0.002). At session 12, 70% of participants endorsed a reduction in PNES frequency of at least 50%. Freedom from PNES was reported by 50% of participants by treatment conclusion. Seventy percent reported a 50% reduction in frequency from baseline and 50% reported remission at session 12. By treatment end, PNES intensity decreased (p = 0.012) and quality of life improved (p = 0.002). Event duration and psychiatric symptom severity were lower after treatment, but reductions were not statistically significant. Conclusions: Completion of a manualized 12-session MBT for PNES provides improvement in PNES frequency, intensity, and quality of life. The high dropout rate is consistent with adherence studies in PNES. Possible reasons for dropout are discussed. Randomized controlled trials and longer-term outcomes are needed to demonstrate the efficacy of MBT in PNES. © 2019 Elsevier Inc. All rights reserved.
1. Introduction Despite advances in the understanding of functional neurological disorders, evidence-based treatments for psychogenic nonepileptic seizures (PNES) remain limited. Cognitive-behavioral therapy (CBT) is the most rigorously studied treatment modality with evidence of efficacy for PNES [1,2]. Results from the first large-scale multicenter randomized controlled trial for PNES using CBT as the active intervention will be reported shortly [3]. Other treatment modalities examined in PNES include, but are not restricted to, paradoxical intention,
⁎ Corresponding author at: Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA 02115, USA. E-mail addresses: [email protected] (G. Baslet), [email protected] (A. Ehlert), [email protected] (M. Oser), [email protected] (B.A. Dworetzky).
psychoeducational interventions, individual and group psychodynamic psychotherapies and psychopharmacological treatments [4–8]. Mindfulness-based therapy (MBT) refers globally to psychotherapeutic modalities where the primary intervention is rooted in the practice of mindfulness. Within the realm of MBTs, mindfulness is commonly defined as “paying attention in a particular way: on purpose, in the present moment and non-judgmentally” [9]. Dialectical behavioral therapy, mindfulness-based stress reduction, acceptance and commitment therapy, and mindfulness-based cognitive therapy are examples of specific evidence-based psychotherapeutic approaches that have mindfulness as a core principle but differ in the way that such principle is technically applied and delivered [9–12]. A number of psychiatric diagnoses with underlying affective dysregulation and difficulty controlling behaviors, such as borderline personality disorder and substance use disorders, are effectively treated with different types of MBT [13,14]. Difficulties in emotion recognition,
https://doi.org/10.1016/j.yebeh.2019.106534 1525-5050/© 2019 Elsevier Inc. All rights reserved.
Please cite this article as: G. Baslet, A. Ehlert, M. Oser, et al., Mindfulness-based therapy for psychogenic nonepileptic seizures, Epilepsy & Behavior, https://doi.org/10.1016/j.yebeh.2019.106534
2
G. Baslet et al. / Epilepsy & Behavior xxx (xxxx) xxx
psychopathology that could impact participation in treatment (specifically, active psychotic or manic symptoms, active substance use, or recent suicidal behavior that were deemed to interfere with treatment participation and/or required prioritized clinical attention). Comorbid epilepsy was allowed as long as the nature of the episodes (psychogenic versus epileptic) was accurately identified by patients. If patients attended the first postdiagnosis appointment, met clinical eligibility criteria, and accepted to participate in the study, they were enrolled. Please refer to the study flowchart (Fig. 1) for a timeline of the participant selection process. All subjects provided consent for participation. There was no control intervention. The study was approved by the hospital's Institutional Review Board.
acceptance, and management are well-documented psychological vulnerabilities in PNES [15,16], and therefore, MBT approaches deserve exploration in this population. There is preliminary evidence of MBT clinical benefits in PNES. Bullock et al. demonstrated that participation in a dialectical behavioral therapy skills training group (DBT-ST) reduced symptoms in PNES [17]. One of the authors (GB) developed a psychotherapy treatment protocol that consists of 12 sessions and incorporates elements from different MBT approaches. A case series using an earlier version of this MBT manual showed symptomatic improvement in 6 patients with PNES [18]. We aimed to determine the clinical effect of a manualized 12-session MBT program for PNES in a prospective uncontrolled trial. We hypothesized significant reductions in episode (seizure) frequency, intensity, and duration, and improvements in quality of life and psychiatric symptom severity at treatment completion.
2.2. Outcome measures Weekly frequency of PNES was the primary outcome measure. Secondary outcome measures included PNES average duration, PNES intensity, quality of life, and measures of psychopathology severity. Data were collected at specific time points: T0 (assessment at the time of diagnosis either in the epilepsy monitoring unit or first outpatient encounter); T1 (first postdiagnosis follow-up), T2 (treatment midpoint, which coincided with session 6 (S6) of the MBT protocol), T3 (end of treatment, which coincided with session 12 (S12) of the MBT protocol). Data collected at each time point included the following: baseline demographic and clinical information at T0; PNES weekly frequency at T1 and at each subsequent MBT session (S1–S12); PNES intensity, duration, and quality of life at T1, T2, and T3; and measures of psychopathology severity at T0 and T3. Baseline demographic and clinical data were obtained through a semistructured neuropsychiatric interview conducted by the same United Council for Neurological Subspecialties-
2. Materials and methods 2.1. Participants Patients with documented PNES (via video electroencephalography [EEG]) were screened and consented for participation in a larger prospective longitudinal study between August 2014 and February 2018 at Brigham and Women's Hospital. Only patients that attended the first postdiagnosis follow-up appointment and met clinical eligibility criteria were offered to participate in the 12-session MBT study. Clinical eligibility criteria included the following: 1) clinically-established intellectual capability to understand the material (based on the patient's observed vocabulary and education history); 2) no active
Video EEG confirmed PNES patients who consented for prospective longitudinal naturalistic study (T0) (n=144) Did not attend first post- diagnosis follow-up (n=22) Attended first post-diagnosis follow-up (T1) (n=122)
Did not meet clinical eligibility criteria (n=15) Active substance use (n=7) Active mania/hypomania or psychosis (n=7) Active psychosis and substance use (n=1)
Declined to participate in MBT study (n=58) Preferred treatment with established therapist or referral to therapist locally (n=42) No specified reason for decline (n=16)
Enrolled in MBT study (n=49)
Did not complete MBT protocol (n=23) Did not attend any session (n=2) Attended at least one session, with last session being: S1 (n=7), S2 (n=2), S3 (n=4), S4 (n=3), S5 (n=1), S8 (n=1), S9 (n=2), S11 (n=1)
Completed MBT protocol (n=26) Fig. 1. Study flowchart.
Please cite this article as: G. Baslet, A. Ehlert, M. Oser, et al., Mindfulness-based therapy for psychogenic nonepileptic seizures, Epilepsy & Behavior, https://doi.org/10.1016/j.yebeh.2019.106534
G. Baslet et al. / Epilepsy & Behavior xxx (xxxx) xxx
certified neuropsychiatrist (GB). Frequency of PNES was obtained from a weekly patient-completed episode log. Duration of PNES was averaged from self-report of episode duration in patient weekly episode log. Intensity of PNES was self-rated in a 0-to-10 Likert scale (with 0 representing “PNES are not intense or bothersome at all” and 10 representing “PNES are at their highest intensity or severity”). Measures of psychopathology severity were obtained via the following standardized instruments. The Beck Depression Inventory-II (BDI-II) is a 21-item self-report scale that measures depressive symptoms over the preceding 2 weeks and was developed to assess Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) depressive symptoms. Severity is determined based on the total score: minimal or no depression (0–13), mild (14–19), moderate (20–28), and severe (29–63) [19]. The Depression, Anxiety, and Stress Symptoms scale (DASS) is a 42item self-report questionnaire that measures depression (DASS-D), anxiety (DASS-A), and stress (DASS-S) levels over the preceding week. We only scored the 14 items specific for the anxiety subscale (DASSA). Severity for the DASS-A is based on the following total subscale score: normal (0–7), mild (8–9), moderate (10–14), severe (15–19), and extremely severe (20–42). The DASS-A has been shown to correlate highly with the Beck anxiety inventory (r = 0.81) [20]. The Patient Health Questionnaire 15 (PHQ-15) is a 15-item selfrated instrument that assesses the level of distress caused by different somatic symptoms over the preceding 4 weeks; severity is rated as 0 (“not at all bothered”), 1 (“bothered a little”), or 2 (“bothered a lot”). Severity is determined based on the total score: no or minimal severity (0– 4), low severity (5–9), medium severity (10–14), and high severity (15– 30) [21]. The Dissociative Experiences Scale (DES) is a 28-item self-report questionnaire designed to assess the current degree of dissociative experiences using an 11-point multiplechoice response format that ranges from 0% to 100%. Higher scores indicate likelihood of a dissociative disorder [22]. Scores about 30 are considered indicative of a significant level of dissociation [23]. Quality of life was measured with the Quality of Life in Epilepsy-10 (QOLIE-10), a 10-item Likert-type scale measuring a range of health concepts related to living with epilepsy. This includes emotional wellbeing, seizure worry, medication effects, cognitive functioning, social functioning, energy/fatigue, and overall quality of life. Lower scores indicate better quality of life [24]. For our study, subjects were specifically instructed to rate their quality of life as affected by PNES, not epilepsy. 2.3. Treatment intervention The MBT sessions were scheduled weekly and conducted in person by licensed independent clinical social workers (they had completed
Table 1 Mindfulness-based therapy for PNES: content of the 12-session program. MODULE I: UNDERSTANDING YOUR DISEASE AND YOUR TREATMENT Session 1: Understanding Your Illness Session 2: Identifying the function of the symptom. Session 3: Identifying values. MODULE II: STRESS MANAGEMENT STRATEGIES Session 4: Understanding the stress cycle Session 5: Mastering a stress management skill MODULE III: MINDFULNESS Session 6: Introduction to mindfulness Session 7: Incorporating mindfulness into everyday life MODULE IV: EMOTION MANAGEMENT Session 8: Emotion Recognition Session 9: Emotion Acceptance Session 10: Regulation of emotion-driven behavior MODULE V: REWORKING COGNITIONS & RELAPSE PREVENTION Session 11: Reworking cognitions Session 12: Relapse Prevention
3
sufficient training to practice without supervision). Content of the MBT protocol was divided in 5 modules and 12 sessions as outlined in Table 1. All therapists included in this study were versed in mindfulness-based psychotherapy principles and had to first complete all 12 sessions with one patient (not included in the study) and undergo weekly supervision to be considered therapists in this study. While conducting the treatment of study participants, therapists followed specific guidelines, including didactic content and in-session practices, and completed a checklist for each session to ensure consistency. Fidelity to the MBT protocol was further determined through weekly supervision to review adherence to session guidelines. Given the nature of psychotherapy, the following deviations from the specified treatment were allowed: up to 3 extra sessions to catch up with material or to address crises, up to 3 missed sessions, and up to 30 days between appointments. The MBT program was discontinued for patients who required further deviation from the protocol. 2.4. Statistical analysis Statistical analysis was conducted using SAS version 9.4 (Cary, NC). Median regression analysis (PROC QUANTREG) was used to determine decrease in PNES weekly frequency at each subsequent MBT session. Linear mixed-effect models (PROC MIXED) were used to determine decreases between time points for all other secondary outcome measures (PNES intensity, PNES duration, quality-of-life measure and measures of psychopathology severity). 3. Results 3.1. Participants One hundred and forty-four patients with documented videoEEG diagnosis of PNES were consecutively assessed for recruitment. Thirty-seven did not meet eligibility criteria (22 for not attending the first postdiagnosis follow-up appointment and 15 for not meeting the clinical inclusion criteria despite attendance to the appointment). Of the eligible patients, 58 declined to participate in the MBT study: of these 58 patients, 16 stated no reason for refusing treatment. The remaining 42 eligible patients that declined participation in treatment had an established therapist and/or could not come to our center for treatment because of limited geographical or transportation limitation. If the latter was the case, patients accepted a referral to a local therapist. The remaining 49 patients were enrolled in the MBT study: 2 enrolled subjects did not attend any session; 21 attended at least one session, and 26 completed the 12 sessions of the treatment. Fig. 1 presents the study flowchart and details the last attended session for the noncompleters. Data and analyses are presented on the 26 patients who completed the 12 sessions of the MBT program. Demographic and clinical characteristics of the 26 patients that completed the MBT study protocol and the 23 enrolled subjects who did not complete the study are summarized in Table 2. Compared with participants that completed the study, the group of enrolled subjects who did not complete the treatment were younger at the time of the evaluation, tended to belong to ethnic minorities, and had less years of education. The only clinical difference between the two groups was a more frequent history of depression in the group of completers; however, baseline BDI-II scores (indicative of current mood state) were not different between groups. 3.2. Treatment fidelity and allowed treatment deviations Therapists attended weekly supervision while providing treatment to participants. Review of the manual checklists, notes and discussions determined that therapists complied with the elements to be covered in each session. In terms of treatment deviations, 50% (n = 13) of the
Please cite this article as: G. Baslet, A. Ehlert, M. Oser, et al., Mindfulness-based therapy for psychogenic nonepileptic seizures, Epilepsy & Behavior, https://doi.org/10.1016/j.yebeh.2019.106534
4
G. Baslet et al. / Epilepsy & Behavior xxx (xxxx) xxx
Table 2 Baseline demographic and clinical characteristics of enrolled subjects completing the MBT protocol vs enrolled subjects not completing the MBT protocol. Completers (n = 26) Demographic variable Age at evaluation, mean⁎ Ethnicity, n⁎ White Black Hispanic Other Gender (female), n Years of education, mean⁎ Marital status, n Never married Married Separated/divorced Widow Employment status, n Employed Unemployed Disabled Student Retired Psychiatric Variable Psychiatric history, n (current or past symptoms) Depressive disorders⁎ Anxiety disorders PTSD Mania/hypomania Psychosis Substance use disorders Eating disorders Impulsivity Other somatic symptoms (except pain/ headache) Other dissociative symptoms Past inpatient admission Past psychiatric treatment Past suicide attempt Trauma, n Physical abuse Sexual abuse Emotional/verbal abuse Abuse during childhood Any trauma Self-report measures, mean BDI-II DASS (anxiety) DES PHQ-15 PNES or Neurological Variable Age at onset of PNES, mean Delay in diagnosis (months), mean Documented epilepsy, n Stressor at onset of PNES, n Identified triggers for events, n Neurological history, n Traumatic brain injury Headaches Pain Family history of seizures Primary captured semiology, n Primary motor Primary unresponsiveness Other (sensory, speech)
Noncompleters (n = 23)
n (%) or mean (SD) 46.4 (16.2) 34.4 (9.9) 22 (84.6) 3 (11.5) 1 (3.8) 0 (0) 23 (88.5) 15.3 (3.2)
11 (47.8) 4 (17.4) 7 (30.4) 1 (4.3) 19 (82.6) 13.5 (2.0)
8 (30.8) 14 (53.8) 3 (11.5) 1 (3.8)
12 (52.2) 10 (43.5) 0 (0) 1 (4.3)
8 (27.7) 7 (26.9) 6 (23.1) 3 (11.5) 2 (7.7)
4 (17.3) 5 (21.7) 9 (39.1) 5 (21.7) 0 (0) n (%) or mean (SD)
21 (80.8) 23 (88.5) 14 (53.8) 1 (3.8) 4 (15.4) 6 (23.1) 3 (11.5) 8 (30.8) 9 (34.6)
12 (52.2) 20 (87.0) 12 (52.2) 3 (13.0) 3 (13.0) 3 (13.0) 5 (21.7) 5 (21.7) 14 (60)
4 (15.4) 9 (34.6) 23 (88.5) 6 (23.1)
4 (17.4) 5 (21.7) 17 (73.9) 6 (26.1)
5 (19.2) 11 (42.3) 13 (50) 8 (30.8) 16 (61.5)
7 (30.4) 11 (47.8) 8 (34.8) 8 (34.8) 13 (56.5)
13.8 (9.3) 9.4 (6.3) 30.2 (25.1) 11.4 (4.3)
17.56 (13.6) 12.33 (11.6) 42.25 (46.9) 13.48 (4.8)
n (%) or mean (SD) 39.4 (18.2) 31.2 (10.9) 75.3 (157.6) 33.6 (67.3) 3 (11.5) 0 (0) 22 (84.6) 16 (69.5) 19 (73.1) 19 (82.6) 16 (61.5) 18 (69.2) 16 (61.5) 6 (23.1)
10 (43.5) 15 (65.2) 12 (52.2) 8 (36.4)
12 (46.6) 12 (46.6) 2 (7.7)
13 (56.5) 9 (39.1) 1 (4.3)
BDI-II: Beck Depression Inventory-II; DASS Anxiety: Depression, Anxiety and Stress Scale, Anxiety Subscale; DES: Dissociative Experiences Scale; PHQ-15: Patient Health Questionnaire – 15. ⁎ p b 0.05.
completers required at least one additional session (7 required one additional session, 5 required two additional sessions, and only one patient required 3 additional sessions). The average time between
sessions was 10.15 days (SD = 2.23). No subjects were excluded from the study for requiring more than 3 additional sessions or for taking more than 30 days between completed sessions. 3.3. Primary outcome measure (PNES weekly frequency) Median PNES weekly frequencies at baseline (at postdiagnosis appointment) and at each subsequent MBT session are presented in Fig. 2 and Table 3. The quantile median regression analysis demonstrated that median PNES frequency decreased by 0.12 episodes per week (95%CI 0.2–0.04) for every successive session (p = 0.002). Fifty percent of patients (n = 13) reported no PNES at the last session (from the previous session), and 23% (n = 6) reported sustained cessation of PNES during the last 4 weeks of treatment. Three subjects had reported no episodes during their baseline T1 measurement; of the remaining 23 completers, 70% (n = 16) had a 50% reduction in PNES weekly frequency at the last session and 52% (n = 12) had 50% reduction based on reports from the last 4 weeks of treatment. 3.4. Secondary outcome measures Median PNES duration at the postdiagnosis appointment was 4.5 min. At the last session, median PNES duration was reduced to 2.5 min, which did not achieve statistical significance (p = 0.10). At the last session, median PNES duration was reduced to 2.5 min, which did not achieve statistical significance (p = 0.10) (Table 4). Mean PNES intensity at the postdiagnosis appointment was 5.56 (SD 2.14). At the last session, mean PNES intensity was significantly reduced to 3.74 (SD 2.65) (p = 0.012) (Table 4). Quality of life improved (lower scores on QOLIE-10) from the postdiagnosis appointment to the last session (p = 0.002) (Table 4). None of the reductions observed in the four psychopathology measures (BDI-II, DASS anxiety subscale, DES, and PHQ-15) by the end of the treatment achieved statistical significance (Table 5). 3.5. Dropout participants Fig. 1 shows that 23 patients did not complete the MBT protocol. Two of them failed to attend the first appointment. Seven of them only attended one session, and thirteen of them dropped before session 4. Patients were still scheduled to follow with the treatment team every two months, but only 10 attended the scheduled bimonthly follow-up appointments. Data are therefore limited in terms of reasons for dropout. Qualitative inquiry about reasons for lack of completion of the treatment revealed that difficulty coming to appointments was a very common answer. 4. Discussion Our manualized 12-session MBT protocol is the first mindfulnessbased psychotherapy intervention tailored for patients with PNES. Improvements could be observed in participants after completion of the treatment. These improvements included reductions in episode frequency and episode intensity and increases in quality of life. This finding indicates that mindfulness-based approaches may represent an additional type of psychotherapy intervention available for patients with PNES. This benefit is hypothetically derived from skills learned throughout treatment, particularly the application of mindfulness principles on emotion and cognitive processes. Patients with PNES usually either feel overwhelmed by their emotions and/or have become quite distant from them, as an adaptive strategy or defense mechanism [15,16]. Therefore, increasing awareness of emotional states and developing effective strategies to respond to them can lead to symptomatic improvement. Additionally, many functional disorders are reinforced by cognitive processes, such as increased attention on body symptoms and symptom misattribution [25,26]. Cognitive processes, such as symptom
Please cite this article as: G. Baslet, A. Ehlert, M. Oser, et al., Mindfulness-based therapy for psychogenic nonepileptic seizures, Epilepsy & Behavior, https://doi.org/10.1016/j.yebeh.2019.106534
G. Baslet et al. / Epilepsy & Behavior xxx (xxxx) xxx
5
Fig. 2. Change in PNES weekly frequency with each successive session from the MBT protocol using median regression analysis (PROC QUANTREG). Median PNES weekly frequency decreases by 0.12 episodes/week (95%CI 0.2–0.04) for every successive session (p = 0.002).
misattribution, are amenable to mindfulness strategies through cognitive defusion, a mechanism that leads to symptomatic improvement in psychological distress [27]. The benefit of our MBT protocol for PNES on episode duration and on measures of psychopathology severity did not reach statistical significance. One possible explanation for the lack of significant benefit on measures of depression, anxiety, somatization, and dissociation is that the degree of severity at baseline did not seem too elevated in our small-size sample. For instance, the baseline mean scores for BDI-II and DASS-A in our sample fall within the minimal or mild severity range [19,20], and the baseline mean score for PHQ-15 is in the lower end of the medium severity range [21]. The baseline mean DES score is barely about the cutoff of 30, although this is consistent with previous DES scores in samples of patients with PNES [23,28]. It is possible that an
Table 3 Changes in PNES frequency at each successive MBT session. Time
Median frequency (25–75%ile)
T1 S1 S2 S3 S4 S5 S6 S7 S8 S9 S10 S11 S12
1.75 (0.3–5) 1.25 (0–2.5) 1.93 (1–3.5) 1.63 (0–5) 0.83 (0–3.5) 1 (0–4.2) 2 (0–4.2) 1.28 (0–4) 0 (0–2.5) 0.29 (0–2) 0.54 (0–2.8) 1.12 (0–4.5) 0.17 (0–2.8)
T1: Baseline measurement of PNES weekly frequency; S1– 12: each successive session from the MBT program.
adequately powered study could have detected a statistically significant reduction in psychopathology measures and episode duration. Reduction in episode frequency is the most broadly accepted primary outcome measure to establish efficacy of a treatment modality in PNES [29]. During a psychotherapeutic process, there are a number of topics that may be discussed and behavioral changes that may occur that are not captured in a numerical value such as episode frequency. Therefore, qualitative data, in addition to quantitative measures, may reveal clinically meaningful information about individual dynamics that can strengthen the benefit of a treatment intervention. For example, one of our patients who had improvement in episode frequency by treatment completion, also learned to identify interpersonal dynamics with his family as triggers for his episodes. At the conclusion of treatment, he had gained understanding about these interactions and developed new skills that helped him make more effective decisions and had a positive impact on his living arrangement and relationships. In other cases, symptoms may temporarily worsen as patients go through a process of behavioral exploration and change. The most significant limitations in this study include a convenience sample bias, small sample size, and lack of a controlled intervention. Patients were offered to participate in this treatment if they were able to attend the 12 sessions in person and if they either did not have an established psychotherapist in the community or, in that case they did, the psychotherapist either agreed to keep his/her interventions at a supportive level or took a break from working with the patient during the time of their participation in the MBT program. Remote-access participation in psychotherapy (through platforms such as telehealth or web-based programs) is becoming increasingly available [30], and it is possible that MBT would have been as effective if those patients unable to attend because of geographic access had completed the treatment remotely. Although the frequency and nature of therapy supervision provided an assessment of treatment fidelity, certain elements such as therapists' interaction skills during sessions was not evaluated beyond the
Please cite this article as: G. Baslet, A. Ehlert, M. Oser, et al., Mindfulness-based therapy for psychogenic nonepileptic seizures, Epilepsy & Behavior, https://doi.org/10.1016/j.yebeh.2019.106534
6
G. Baslet et al. / Epilepsy & Behavior xxx (xxxx) xxx
Table 4 Changes in PNES intensity and duration and in quality of life (end of treatment compared to baseline measures).
PNES intensity QOLIE-10
PNES duration (min)
T1 mean (SD)
T2 mean (SD)
T3 mean (SD)
5.56 (2.14) 2.59 (0.73)
3.92 (2.69)⁎ 2.40 (0.76)
3.74 (2.65)# 2.14 (0.77)⁎
T1 median (25–75%ile)
T2 median (25–75%ile)
T3 median (25–75%ile)
4.5 (1–10)
4 (1–6)
2.5 (0.75–7.5)
Statistical significant reductions from baseline scores are indicated with * for p b 0.01 and # for p b 0.05. QOLIE-10: Quality of Life in Epilepsy-10.
therapists' reports. Fidelity evaluation with video-recorded sessions would ensure that such elements are carefully evaluated throughout the course of treatment. The current analysis only shows results at the time of completion of the psychotherapy treatment. Ideal effective therapies for PNES will provide sustained symptomatic and functional benefit after completion of the treatment. The goal of this study was to evaluate the initial benefit of the intervention. Long-term data will be necessary to evaluate if benefits are sustained. This MBT protocol for PNES had a treatment completion rate of 55%, which is low but consistent with other prospective naturalistic adherence studies in PNES [31]. Even in the setting of a randomized controlled trial in PNES, with resources available for closer follow-up, completion rates in a previous trial were reported at around two-thirds of the initial participants [1]. Adherence to treatment is an important challenge in the management of patients with PNES, and it is possible that specific therapeutic components need to be implemented in those patients at higher risk of not engaging in treatment. For example, motivational interviewing has demonstrated to be an effective strategy to improve treatment adherence in several complex disorders, and recently in PNES as well. [32]. Given that our qualitative inquiry revealed lack of access as a common reason for dropping out of treatment, it is possible that many participants had the initial intention to participate in the MBT program, but as they noted the required logistical effort to complete treatment, they did not pursue it any longer. Other possible reasons for dropout are lack of perceived immediate resolution of symptoms (despite our explanation of treatment as a process) and/or psychological barriers. Yet, another possibility is that patients already experienced some benefit with the very initial sessions, and they felt treatment was no longer required. Interestingly, enrolled subjects not completing treatment were younger, less educated and proportionally more likely to belong to an ethnic minority. These demographic findings in noncompleters are consistent with the literature on adherence with mental health treatment and in general [33,34]. Most of the patients not completing the MBT program attended 4 or fewer sessions, and they did not provide follow-up data. Therefore, this lack of data limits our ability to determine benefit (or lack thereof) in those patients who had limited exposure to the treatment protocol. Mindfulness-based psychotherapy can now be considered among the psychotherapies that can lead to a reduction in episode frequency and intensity and improvement quality of life in patients with PNES. Randomized controlled trials with adequately powered samples, easily
Table 5 Changes in psychopathology measures (end of treatment compared to baseline). Scale
T0 mean (SD)
T3 mean (SD)
BDI-II DASS (anxiety) DES PHQ-15
13.8 (9.3) 9.4 (6.3) 30.2 (25.1) 11.4 (4.3)
12.12 (11.9) 8.96 (9.8) 29.41 (31.8) 10.40 (6.0)
None of the reductions had p b 0.05. BDI-II: Beck Depression Inventory-II; DASS Anxiety: Depression, Anxiety and Stress Scale, Anxiety Subscale; DES: Dissociative Experiences Scale; PHQ-15: Patient Health Questionnaire – 15.
accessible methods of delivery and longer-term follow-up are necessary to help position MBT as an effective treatment modality for PNES.
Declaration of competing interest The authors report no competing interest. Acknowledgments We would like to acknowledge the following licensed independent clinical social workers who provided the psychotherapy treatment according to the treatment manual: Gabe Gruner, Timothy Larose, Margaret Latawiec, Laura Morrissey, Robert Ridlon. Funding This work was partially supported by the A.J. Trustey Epilepsy Research Fund. References [1] Goldstein LH, Chalder T, Chigwedere C, Khondoker MR, Moriarty J, Toone BK, et al. Cognitive-behavioral therapy for psychogenic nonepileptic seizures: a pilot RCT. Neurology. 2010;74:1986–94. https://doi.org/10.1212/WNL.0b013e3181e39658. [2] LaFrance WCJ, Baird GL, Barry JJ, Blum AS, Frank Webb A, Keitner GI, et al. Multicenter pilot treatment trial for psychogenic nonepileptic seizures: a randomized clinical trial. JAMA Psychiat. 2014;71:997–1005. https://doi.org/10.1001/jamapsychiatry. 2014.817. [3] Goldstein LH, Mellers JDC, Landau S, Stone J, Carson A, Medford N, et al. COgnitive behavioural therapy vs standardised medical care for adults with Dissociative nonEpileptic Seizures (CODES): a multicentre randomised controlled trial protocol. BMC Neurol. 2015;15:98. https://doi.org/10.1186/s12883-015-0350-0. [4] Barry JJ, Wittenberg D, Bullock KD, Michaels JB, Classen CC, Fisher RS. Group therapy for patients with psychogenic nonepileptic seizures: a pilot study. Epilepsy Behav. 2008;13:624–9. https://doi.org/10.1016/j.yebeh.2008.06.013. [5] Ataoglu A, Ozcetin A, Icmeli C, Ozbulut O. Paradoxical therapy in conversion reaction. J Korean Med Sci. 2003;18:581–4. https://doi.org/10.3346/jkms.2003.18.4.581. [6] Chen DK, Maheshwari A, Franks R, Trolley GC, Robinson JS, Hrachovy RA. Brief group psychoeducation for psychogenic nonepileptic seizures: a neurologist-initiated program in an epilepsy center. Epilepsia. 2014;55:156–66. https://doi.org/10.1111/epi. 12481. [7] Mayor R, Howlett S, Grunewald R, Reuber M. Long-term outcome of brief augmented psychodynamic interpersonal therapy for psychogenic nonepileptic seizures: seizure control and health care utilization. Epilepsia. 2010;51:1169–76. https://doi.org/10.1111/j.1528-1167.2010.02656.x. [8] LaFrance WCJ, Keitner GI, Papandonatos GD, Blum AS, Machan JT, Ryan CE, et al. Pilot pharmacologic randomized controlled trial for psychogenic nonepileptic seizures. Neurology. 2010;75:1166–73. https://doi.org/10.1212/WNL.0b013e3181f4d5a9. [9] Kabat-Zinn J. Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness. New York, NY: Delacorte; 1990. [10] Linehan M. Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press; 1993. [11] Hayes SC, Strosahl K, Wilson KG. Acceptance and commitment therapy: an experiential approach to behavior change. Paperback ed New York, NY: Guilford Press; 2003. [12] Segal ZV, Williams JMG, Teasdale JD. Mindfulness-based cognitive therapy for depression: a new approach to preventing relapse. New York: Guilford Press; 2002. [13] Lee EB, An W, Levin ME, Twohig MP. An initial meta-analysis of acceptance and commitment therapy for treating substance use disorders. Drug Alcohol Depend. 2015; 155:1–7. https://doi.org/10.1016/j.drugalcdep.2015.08.004. [14] Soler J, Pascual JC, Tiana T, Cebria A, Barrachina J, Campins MJ, et al. Dialectical behaviour therapy skills training compared to standard group therapy in borderline personality disorder: a 3-month randomised controlled clinical trial. Behav Res Ther. 2009;47:353–8. https://doi.org/10.1016/j.brat.2009.01.013.
Please cite this article as: G. Baslet, A. Ehlert, M. Oser, et al., Mindfulness-based therapy for psychogenic nonepileptic seizures, Epilepsy & Behavior, https://doi.org/10.1016/j.yebeh.2019.106534
G. Baslet et al. / Epilepsy & Behavior xxx (xxxx) xxx [15] Williams IA, Levita L, Reuber M. Emotion dysregulation in patients with psychogenic nonepileptic seizures: a systematic review based on the extended process model. Epilepsy Behav. 2018;86:37–48. https://doi.org/10.1016/j.yebeh.2018.06.049. [16] Uliaszek AA, Prensky E, Baslet G. Emotion regulation profiles in psychogenic non-epileptic seizures. Epilepsy Behav. 2012;23:364–9. https://doi.org/10.1016/j.yebeh. 2012.01.009. [17] Bullock KD, Mirza N, Forte C, Trockel M. Group dialectical-behavior therapy skills training for conversion disorder with seizures. J Neuropsychiatry Clin Neurosci. 2015;27:240–3. https://doi.org/10.1176/appi.neuropsych.13120359. [18] Baslet G, Dworetzky B, Perez DL, Oser M. Treatment of psychogenic nonepileptic seizures: updated review and findings from a mindfulness-based intervention case series. Clin EEG Neurosci. 2015;46:54–64. https://doi.org/10.1177/1550059414557025. [19] Beck AT, Steer RA, Brown GK. BDI-II, Beck depression inventory: manual. 2nd ed.. San Antonio, Tex.: Boston: Psychological Corp.; Harcourt Brace; 1996. [20] Lovibond PF, Lovibond SH. The structure of negative emotional states: comparison of the depression anxiety stress scales (DASS) with the Beck depression and anxiety inventories. Behav Res Ther. 1995;33:335–43. [21] Kroenke K, Spitzer RL, Williams JBW. The PHQ-15: validity of a new measure for evaluating the severity of somatic symptoms. Psychosom Med. 2002;64:258–66. [22] Vanijzendoorn M, Schuengel C. The measurement of dissociation in normal and clinical populations: meta-analytic validation of the Dissociative Experiences Scale (DES). Clin Psychol Rev. 1996;16:365–82. https://doi.org/10.1016/0272-7358(96)00006-2. [23] Goldstein LH, Mellers JD. Ictal symptoms of anxiety, avoidance behaviour, and dissociation in patients with dissociative seizures. J Neurol Neurosurg Psychiatry. 2006; 77:616–21. https://doi.org/10.1136/jnnp.2005.066878. [24] Cramer JA, Perrine K, Devinsky O, Meador K. A brief questionnaire to screen for quality of life in epilepsy: the QOLIE-10. Epilepsia. 1996;37:577–82. [25] Nielsen G, Ricciardi L, Demartini B, Hunter R, Joyce E, Edwards MJ. Outcomes of a 5day physiotherapy programme for functional (psychogenic) motor disorders. J Neurol. 2015;262:674–81. https://doi.org/10.1007/s00415-014-7631-1.
7
[26] Edwards MJ, Adams RA, Brown H, Parees I, Friston KJ. A Bayesian account of “hysteria”. Brain. 2012;135:3495–512. https://doi.org/10.1093/brain/aws129. [27] Larsson A, Hooper N, Osborne LA, Bennett P, McHugh L. Using brief cognitive restructuring and cognitive defusion techniques to cope with negative thoughts. Behav Modif. 2016;40:452–82. https://doi.org/10.1177/0145445515621488. [28] Cohen ML, Testa SM, Pritchard JM, Zhu J, Hopp JL. Overlap between dissociation and other psychological characteristics in patients with psychogenic nonepileptic seizures. Epilepsy Behav. 2014;34:47–9. https://doi.org/10.1016/j. yebeh.2014.03.001. [29] LaFrance WCJ, Alper K, Babcock D, Barry JJ, Benbadis S, Caplan R, et al. Nonepileptic seizures treatment workshop summary. Epilepsy Behav. 2006;8:451–61. https://doi. org/10.1016/j.yebeh.2006.02.004. [30] Fletcher TL, Hogan JB, Keegan F, Davis ML, Wassef M, Day S, et al. Recent advances in delivering mental health treatment via video to home. Curr Psychiatry Rep. 2018;20: 56. https://doi.org/10.1007/s11920-018-0922-y. [31] Tolchin B, Dworetzky BA, Martino S, Blumenfeld H, Hirsch LJ, Baslet G. Adherence with psychotherapy and treatment outcomes for psychogenic nonepileptic seizures. Neurology. 2019;92:e675–9. https://doi.org/10.1212/WNL.0000000000006848. [32] Tolchin B, Baslet G, Suzuki J, Martino S, Blumenfeld H, Hirsch LJ, et al. Randomized controlled trial of motivational interviewing for psychogenic nonepileptic seizures. Epilepsia. 2019;60:986–95. https://doi.org/10.1111/epi.14728. [33] Olfson M, Mojtabai R, Sampson NA, Hwang I, Druss B, Wang PS, et al. Dropout from outpatient mental health care in the United States. Psychiatr Serv. 2009;60:898–907. https://doi.org/10.1176/ps.2009.60.7.898. [34] Mathes T, Jaschinski T, Pieper D. Adherence influencing factors — a systematic review of systematic reviews. Arch Public Health. 2014;72:37. https://doi.org/10. 1186/2049-3258-72-37.
Please cite this article as: G. Baslet, A. Ehlert, M. Oser, et al., Mindfulness-based therapy for psychogenic nonepileptic seizures, Epilepsy & Behavior, https://doi.org/10.1016/j.yebeh.2019.106534