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Functional seizures

Therapeutic modalities for the management of functional seizures

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There are a range of therapeutic interventions for the treatment of functional seizures, such as psychoeducation, symptom control methods (identification of symptom triggers), emotional regulation techniques, relaxation techniques, EMDR, identification of avoidance and safety behaviours, as well as identifying and working on maladaptive patterns of thinking, feeling and acting (LaFrance et al., 2013).

However, appropriate psychological therapies and interventions are still being developed. The most commonly used therapies are CBT, psychoanalysis and various psychoeducational therapies (Carlson and Nicholson, 2017). 

  • Appropriate communication of the diagnosis is a key therapeutic intervention. We describe to the patient in simple terms what seizures are, why and how they occur, and the difference between epileptic and functional seizures.

  • We use a motivational interviewing technique to encourage the patient to take control and to actively involve them in the treatment process.

  • A clinical/psychological/psychiatric assessment should be carried out to rule out any associated psychiatric disorders such as depression, anxiety, PTSD, etc. The assessment should include an assessment of symptoms, developmental history and an assessment of personality and psychosocial environment. If an associated disorder is diagnosed, plan appropriate treatment. Neuropsychological testing of emotional and cognitive domains may also potentially be performed. The overall psychiatric assessment should consist of a differential diagnosis, assessment of psychiatric comorbidity, psychopharmacological and psychological treatment, and acute risk assessment.

  • Explain to the patient the three types of factors that interact to cause, trigger and maintain functional seizures. The assessment of the factors should be individualised and made together with the patient and family members. Sometimes patients do not recall or minimise key events from the past. It is also important that a trusting therapeutic relationship is established. Update the factor model at the time of relapse.

  • Due to the complex nature of functional seizures, most patients will initially struggle to accept the diagnosis. They will be deprived of a neurological diagnosis (e.g. epilepsy) and suddenly a psychiatric/psychological one will be added. Although psychological treatment is currently the most effective and well-studied, do not force the patient, as the effectiveness of psychological treatment is strongly dependent on the patient's acceptance and understanding of the diagnosis.

  • CBT is the most common form of therapy for the treatment of functional seizures. Two models are used and have been scientifically studied.

    The first is the model of Goldstein and colleagues (2010), which addresses the cognitive, emotional, physiological and behavioural aspects of seizures.

    It is based on the escape-avoidance model of fear and assumes that functional seizures are a dissociative response to various cognitive, emotional and physiological stimuli in the environment. These are associated with traumatic events in the past (e.g. abuse) during which the patient experienced intense feelings of fear and anxiety.

    The treatment consists of 12 sessions, which include core CBT techniques and strategies. These are techniques relating to seizures, identifying and changing negative cognitions, attention redirection, relaxation techniques, grounding techniques and coping with avoidant behaviour. At the end of the sessions, the patient is given a homework assignment which includes a 'seizure diary'. Involvement of family members is also encouraged.

    There are five stages of treatment:

    • Involvement and clarification of KVT

    • Learning and applying attack control techniques

    • Reducing avoidance behaviour

    • Identifying and modifying cognitions and emotions associated with an attack

    • Plan and strategies to cope with relapses

    The second is the model of LaFrance et al. (2009), which is based on the Beckian approach and aims at taking control of functional attacks. It is based on the assumption that early life experiences contribute to the formation of negative core schemas, which are the basis for patients' cognitive distortions and somatic symptoms. It also consists of 12 sessions, including:

    • Assessment and contextualisation of the individual's environment

    • Identification of thoughts, feelings and situations

    • Training in communication, support-seeking and goal-setting skills

    • Psychoeducation on the central nervous system and medicines

    • Identification of the aura

    • Conducting a functional behaviour analysis

    • Identification of stressors, internal/external triggers

    • Promoting holistic health

    • Preparing for life after CBT

  • Psychodynamic therapies primarily focus on interpersonal relationships and aspects of emotional processing, which they link to unprocessed conflicts and (traumatic) childhood experiences.

    The goals of therapy are to identify and change inappropriate patterns in interpersonal relationships and to process emotions more effectively (express, explore and accept them).

    The shorter interpersonal psychodynamic therapy thus consists of a longer session aimed at developing the formulation (up to 90 minutes) and 19 shorter sessions of 50 minutes each, in which the following themes are addressed:

    • Beliefs about the disease

    • Symptom control

    • Emotional processing

    • Linking emotions to symptoms

    • Increasing autonomy and independence

    • Encouraging you to look after yourself

    • Processing trauma

  • Confirm the reality of the symptoms and name the condition

    "The good news is that you don't have epilepsy, but that doesn't mean your seizures aren't real and that you are simulating them. You have functional seizures that are triggered and maintained by different factors. I believe that seizures are frightening and that they are a major threat to your quality of life. "

  • Confirm that it is a common problem

    "Functional seizures are common. Don't worry - you're not 'crazy' and you don't have 'everything in your head'."

  • Try to explain the cause of the seizures

    "The causes of functional seizures are complex. There are certain risk factors, but we cannot identify the exact factor that led to the diagnosis. Identifying the factors that contribute to triggering seizures and the factors that maintain seizures will be more important in treatment. Trigger factors are often related to our coping strategies to deal with stress and emotions, while maintenance factors are related to, for example, worry or stress that the seizures will get worse, which can lead to a negative cycle of thinking that amplifies and perpetuates your seizures."

  • Explain the course of treatment

    "Antiepileptic drugs won't help treat seizures because you don't have epilepsy. Psychological therapy has been shown to be effective in helping you understand your diagnosis and identify the factors that trigger and maintain your seizures. Referral to a psychologist does not mean that the cause of your seizures is entirely psychological in nature, but it can help you to take control of them."

    • Baslet, G., Seshadri, A., Bermeo-Ovalle, A., Willment, K., in Myers, L. (2016). Psychogenic Non-epileptic Seizures: An Updated Primer. Psychosomatics, 57(1), 1-17. doi:10.1016/j.psym.2015.10.004.

    • Brown, R. J., and Reuber, M. (2016). Psychological and psychiatric aspects of psychogenic non-epileptic seizures (PNES): A systematic review. Clinical Psychology Review, 45, 157-182. doi:10.1016/j.cpr.2016.01.003

    • Howlett, S., and Reuber, M. (2009). An augmented model of brief psychodynamic interpersonal therapy for patients with nonepileptic seizures. Psychotherapy: Theory, Research, Practice, Training, 46(1), 125-138. doi:10.1037/a0015138

    • LaFrance, W. C., Miller, I. W., Ryan, C. E., Blum, A. S., Solomon, D. A., Kelley, J. E., and Keitner, G. I. (2009). Cognitive behavioral therapy for psychogenic nonepileptic seizures. Epilepsy & Behavior, 14(4), 591-596. doi:10.1016/j.yebeh.2009.02.016

    • LaFrance, W. C., Reuber, M., and Goldstein, L. H. (2013). Management of psychogenic nonepileptic seizures. Epilepsia, 54, 53-67. doi:10.1111/epi.12106