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Psychological and behavioural treatments for adults with non-epileptic attack disorder

  1. Jayne Martlew1,*,
  2. Jennifer Pulman2,
  3. Anthony G Marson2

Editorial Group: Cochrane Epilepsy Group

Published Online: 11 FEB 2014

Assessed as up-to-date: 7 FEB 2014

DOI: 10.1002/14651858.CD006370.pub2


How to Cite

Martlew J, Pulman J, Marson AG. Psychological and behavioural treatments for adults with non-epileptic attack disorder. Cochrane Database of Systematic Reviews 2014, Issue 2. Art. No.: CD006370. DOI: 10.1002/14651858.CD006370.pub2.

Author Information

  1. 1

    The Walton Centre, Department of Neuropsychology, Liverpool, Mersyside, UK

  2. 2

    Institute of Translational Medicine, University of Liverpool, Department of Molecular and Clinical Pharmacology, Liverpool, Merseyside, UK

*Jayne Martlew, Department of Neuropsychology, The Walton Centre, Jubilee House, 10th Avenue, Fazakerley, Liverpool, Mersyside, L9 7AL, UK. Jayne.Martlew@thewaltoncentre.nhs.uk. jayneg1nxs@googlemail.com.

Publication History

  1. Publication Status: New search for studies and content updated (no change to conclusions)
  2. Published Online: 11 FEB 2014

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Characteristics of included studies [ordered by study ID]
Ataoglu 2003

MethodsRandomised controlled trial, single centre (Psychiatry Department in Turkey)
Treatment duration: 3 weeks of paradoxical therapy or 6 weeks of drug treatment


ParticipantsDiagnosis: pseudoseizures/conversion disorder using DSM-IV criteria
No information provided regarding previous seizures or comorbid conditions
30 patients were randomised
29 female, 1 male
Aged 16 to 35 years


InterventionsIntervention group: paradoxical intention (N = 15): inpatient treatment in psychiatric ward, 2 sessions a day for 3 weeks
Control group: diazepam (N = 15): outpatient treatment (5 to 15 mg/day). Appointments at 10, 20, 30 and 45 days


Outcomes1) Frequency of conversion attacks in past week noted for each patient with changes in these scores converted to percentages
2) Anxiety

Measurements taken at baseline and end of treatment


NotesPatients primarily female and low in education


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskComputer-generated method of randomisation used; adequate method

Allocation concealment (selection bias)Unclear riskNo details on allocation concealment

Blinding (performance bias and detection bias)
All outcomes
Low riskOutcome assessor was blinded to treatment conditions

Confounding variables (for non-randomised studies)
All outcomes
Low riskNA

Incomplete outcome data (attrition bias)
All outcomes
Low riskNo missing data

Selective reporting (reporting bias)Low riskOutcomes outlined in the methods section were measured, analysed and reported in the results

Other biasUnclear riskThe patients were mostly female and of low education

Barry 2008

MethodsBefore and after non-controlled study, single centre (US)

Treatment duration: 32 weeks


Participants12 patients with non-epileptic seizures enrolled in study, 7 received intended treatment (completed 75%) and 7 analysed

Mean age of 7 analysed: 45.4 years (30 to 60 years)
All 7 female


InterventionsPsychodynamic group therapy

5 patients also received individual cognitive behavioural therapy during the study and 1 saw a former therapist sporadically


Outcomes1) Depression

2) Symptoms

3) Seizure frequency

4) Quality of life

Measurements taken at baseline, 16 weeks into therapy and at 32 weeks on completion of therapy


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)High riskNon-randomised study therefore automatically at high risk of bias

Allocation concealment (selection bias)High riskNo methods for concealed allocation

Blinding (performance bias and detection bias)
All outcomes
High riskRated as 5 on 'Risk of bias' scale as no blinding techniques used in study

Confounding variables (for non-randomised studies)
All outcomes
High riskRated as 5 on 'Risk of bias' scale as several confounding variables from our prespecified list were apparent in the study and no methods were employed to deal with the variables (mixed aetiologies, extra individual therapy sessions, duration of treatment differed)

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskRated as 3 on 'Risk of bias' scale as it was clear there were missing data; only 7 participants completed 75% of the intended treatment (> 25% missing) therefore there is a possible influence on the outcome

Selective reporting (reporting bias)Low riskRated as 2 on 'Risk of bias' scale as outcomes were outlined in the methods and measured, analysed and reported in the results, however it was unclear which outcomes were primary and which were secondary. Also, there was no a priori protocol to compare these outcomes to the published report

Other biasHigh riskRated as 5 on 'Risk of bias' scale as 1 patient was tapering off diazepam during the study and 1 patient was being treated for hepatitis C

Goldstein 2004

MethodsBefore and after non-controlled study, single centre (UK)

Treatment duration: 12-24 weeks. Follow-up period: 6 months


Participants20 patients with dissociative seizures were enrolled in the study, 16 patients received the intended treatment and 16 were analysed

Mean age 34.9 years
14 females and 2 males


InterventionsIndividual cognitive behavioural sessions. 12 sessions, first session 2 hours, all other sessions 1 hour in duration, either weekly or fortnightly


Outcomes1) Seizure frequency

2) Work and social adjustment

3) Fear

4) Anxiety and depression

5) Employment

6) Health locus of control

7) Illness perception

Measurements taken at baseline, post-treatment and at follow-up


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)High riskNon-randomised study therefore automatically at high risk of bias.

Allocation concealment (selection bias)High riskNo methods of concealing allocation used.

Blinding (performance bias and detection bias)
All outcomes
High riskRated as 5 on RoB scale as no methods of blinding were used.

Confounding variables (for non-randomised studies)
All outcomes
High riskRated as 4 on RoB scale as patients had mixed aetiologies (abusive history) and no methods used to control for any of the pre-specified confounding variables.

Incomplete outcome data (attrition bias)
All outcomes
Low riskRated as 2 on RoB scale as there was a small amount of missing data which was incorporated into ITT analysis for two outcomes.

Selective reporting (reporting bias)Low riskRated as 2 on RoB scale as outcomes outlined in methods were measured, analysed and reported however there was no a priori protocol available to compare these outcomes.

Other biasLow riskRated as 1 on RoB scale as no other biases were identified.

Goldstein 2010

MethodsRandomised controlled trial, single centre (UK)

Treatment duration: 4 months. Follow-up period: 6 months


Participants66 patients with psychogenic non-epileptic seizures were randomised
50 female, 16 male

Mean age in intervention group 37.4 years, mean age in control group 35.9 years


InterventionsIntervention group: cognitive behavioural therapy and standard medical care for up to 12 weeks, 1-hour sessions

Control group: standard medical care only


Outcomes1) Monthly seizure frequency

2) Seizure freedom

3) Work and social adjustment

4) Anxiety and depression

5) Health service use and employment

Measurements taken at pretreatment, end of treatment and at 1, 3 and 6 months follow-up


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskUsed random number table to generate randomisation sequence; adequate method used

Allocation concealment (selection bias)Low riskSequentially numbered, sealed envelopes administered to patients; adequate method used

Blinding (performance bias and detection bias)
All outcomes
Unclear riskUnclear if outcome assessor blinded

Confounding variables (for non-randomised studies)
All outcomes
Low riskNA

Incomplete outcome data (attrition bias)
All outcomes
Low riskSmall amount of missing data, however ITT analysis employed; adequate method

Selective reporting (reporting bias)Low riskPrimary and secondary outcomes clearly outlined in the methods section; all measured, analysed and reported in the results section. No protocol with which to compare a priori outcomes

Other biasUnclear riskStandard medical care sessions varied according to the needs of the patients, number of CBT sessions varied

Kuyk 2008

MethodsBefore and after non-controlled study, single centre (The Netherlands)

Treatment duration: unclear. Follow-up period: 6 months


Participants29 patients with non-epileptic seizures were enrolled in the study, 26 completed the intended treatment and 22 were analysed

Mean age 30.6 years
77.3% female, 22.7% male


InterventionsPsychological treatment including individual psychotherapy, psychomotor and creative therapy, family therapy and group therapies


Outcomes1) Seizure frequency

2) Seizure duration

3) Number of AEDs taken

4) Symptoms

5) Depression

6) Anxiety

7) Coping behaviour

8) Quality of life

Measurements taken at the start of treatment, on discharge and at 6 months follow-up


Notes4 patients excluded due to occurrences of epileptic seizures; 3 excluded due to stopping prematurely


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)High riskNon-randomised study therefore automatically rated as high risk of bias.

Allocation concealment (selection bias)High riskNo methods of concealing allocation used.

Blinding (performance bias and detection bias)
All outcomes
High riskRated as 5 on RoB scale as no one was blinded in this study.

Confounding variables (for non-randomised studies)
All outcomes
High riskRated as 4 on RoB scale as mixed seizure patients were included in the study however excluded from the analysis altogether. The duration of treatment was unclear, reported average of 4.8 months. No methods used to account for any pre-specified confounding variables.

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskRated as 3 on RoB scale as there was missing data and no methods used in the analysis to account for it.

Selective reporting (reporting bias)Low riskRated as 2 on RoB scale as secondary outcomes were unclear and there was no protocol to compare a priori list of outcomes.

Other biasLow riskRated as 2 on RoB scale as group was self-selected, unsure how much this could affect outcomes.

LaFrance 2009

MethodsBefore and after, non-controlled study, single centre (US)

Baseline period: 2 weeks. Treatment duration: 12 weeks. Follow-up period: 12 months


Participants21 patients with psychogenic non-epileptic seizures (some with epileptic seizures also) enrolled in the study, 17 completed the intended treatment and 20 were analysed

Mean age 36.0 years
17 female, 4 male


Interventions12 sessions of cognitive behavioural therapy (1 hour per session)


Outcomes1) Seizure frequency

2) Depression

3) Anxiety

4) Symptoms

5) Impulsivity

6) Family functioning

7) Somatic symptoms

8) Global functioning

9) Disability

10) Psychosocial functioning

11) Coping techniques

12) Quality of life

Measurements taken at baseline, month 1 of treatment, final week of treatment and at 4, 8 and 12 months follow-up


Notes1 patient dropped out prior to receiving any treatment and was therefore excluded from the intention-to-treat analysis


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)High riskNon-randomised study therefore automatically rated as high risk of bias

Allocation concealment (selection bias)High riskNo methods used to conceal allocation

Blinding (performance bias and detection bias)
All outcomes
High riskRated as 5 on 'Risk of bias' scale as no methods of blinding were employed

Confounding variables (for non-randomised studies)
All outcomes
High riskRated as 5 on 'Risk of bias' scale as patients has mixed diagnoses and aetiologies and no adjustments were made in the analyses for any of the prespecified confounders

Incomplete outcome data (attrition bias)
All outcomes
Low riskRated as 2 on 'Risk of bias' scale as there were missing data and a modified ITT analysis was employed

Selective reporting (reporting bias)Low riskRated as 2 on 'Risk of bias' scale as outcomes outlined in the methods were measured, analysed and reported in the results, however there was no a priori protocol available with which to compare these outcomes

Other biasUnclear riskRated as 3 as there were insufficient details to judge other bias in this study

Moene 2002

MethodsRandomised controlled trial, 2 outpatient psychiatric departments (The Netherlands)
Treatment duration: hypnosis group 8 weeks, rehab group 12 weeks. Follow-up period: 8 months from before treatment started


Participants49 patients with conversion disorder (motor type) or somatisation disorder (with motor conversion symptoms) were enrolled at the start of the study, 45 received the intended treatment and 45 were analysed
34 female, 11 male
Mean age 36.8 years, ranging from 18 to 56 years


InterventionsIntervention group (N = 26) included an introductory session followed by 1 hour per week for 8 weeks of hypnosis. Also encouraged to practise self hypnosis for 0.5 hours per day with audiotape
Control group (N = 23) included 8 weeks of 1-hour sessions encouraging patients to talk about their experience and homework to write about sessions

Both groups consisted of inpatient treatment programme (group work, individual physiotherapy, exercise and bed rest)


Outcomes1) Motor conversion symptoms
2) Disability
3) Symptoms


Notes4 patients dropped out prior to completion of the treatment, 2 from the intervention group and 2 from the control group; ITT analysis not performed


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskBlock randomisation method used to generate randomisation sequence; adequate method

Allocation concealment (selection bias)Unclear riskAllocation concealment stated but methods not explained

Blinding (performance bias and detection bias)
All outcomes
Unclear riskUnclear description of blinding methods

Confounding variables (for non-randomised studies)
All outcomes
Low riskNA

Incomplete outcome data (attrition bias)
All outcomes
Low riskSmall amount of missing data, so although ITT not employed, outcomes unlikely to be affected

Selective reporting (reporting bias)Low riskClearly described outcomes in the methods section, measured, analysed and reported in the results. No protocol with which to enable comparison

Other biasHigh riskPatients were either inpatients or outpatients and all data were combined together in analysis

Moene 2003

MethodsRandomised controlled trial, 2 outpatient psychiatric clinics (The Netherlands)
Treatment duration: 3 months (follow-up at 6 months for treatment group)


Participants49 patients with a diagnosis of conversion disorder (motor type) or somatisation disorder (with motor conversion symptoms) were enrolled at the start of the study, 44 received the intended treatment and 44 were analysed
Mean age 36.6 years, range 18 to 61 years
75% female


InterventionsIntervention group (N = 24) 1-hour introductory session explaining rationale for using hypnosis followed by hypnosis sessions 1 hour per week for 10 weeks. Also encouraged to practise self hypnosis for ½ hour per day with audiotape
Control group (N = 25) waiting list for hypnosis


Outcomes1) Motor conversion symptoms
2) Disability
3) Symptoms


Notes5 patients dropped out prior to completion of the treatment, 4 from the intervention group and 1 from the control group


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskBlock randomisation method used to generate randomisation sequence; adequate method

Allocation concealment (selection bias)Unclear riskNo methods indicated in the text

Blinding (performance bias and detection bias)
All outcomes
Unclear riskUnclear description of blinding methods

Confounding variables (for non-randomised studies)
All outcomes
Low riskNA

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskEvidence of missing data, however unclear how outcome likely to be affected as ITT not employed

Selective reporting (reporting bias)Low riskAll outcomes outlined in the methods were measured, analysed and reported in the results section. No protocol available

Other biasUnclear riskInsufficient details to judge bias in this study

Prigatano 2002

MethodsBefore and after non-controlled study, single centre (US)

Treatment duration: 6 months


Participants15 patients with psychogenic non-epileptic seizures enrolled at the start of the study, 8 were treated first followed by 7 treated second. 13 patients received the intended treatment and 13 were analysed

Mean age 36.0 years, ranging from 20 to 48 years
All participants female


Interventions6-month psychotherapy programme delivered in 1.5-hour sessions over 24 weeks


Outcomes1) Seizure frequency

2) Knowledge of previous session

3) Cerebral functioning

4) Intelligence

5) Verbal learning and memory

6) Personality

Measures were reported following the first 12 sessions and following the last 12 sessions. Data reported are descriptive only


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)High riskNon-randomised study therefore automatically rated as high risk of bias

Allocation concealment (selection bias)High riskNo methods of allocation concealment used

Blinding (performance bias and detection bias)
All outcomes
High riskNo methods of blinding used

Confounding variables (for non-randomised studies)
All outcomes
High riskRated as 4 on 'Risk of bias' scale as one group had no exclusion criteria applied whilst other had a list of exclusion criteria and therefore no confounding variables were accounted for in one group. No methods for accounting for prespecified confounding variables in either groups within the analysis

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskRated as 3 on 'Risk of bias' scale as some data missing from study and not incorporated in the analysis

Selective reporting (reporting bias)Low riskRated as 2 on 'Risk of bias' scale as outcomes outlined in the methods were measured, analysed and reported in the results, however there was no a priori protocol available with which to compare these outcomes

Other biasHigh riskRated as 4 on 'Risk of bias' scale as both groups were handled very differently; one therapist took a planned vacation during the study

Ramani 1982

MethodsBefore and after non-controlled study, single centre (US)

Treatment duration: 4 to 9 weeks inpatient treatment. Follow-up period: 4 years


Participants9 patients with hysterical seizures and epileptic seizures enrolled in the study and 8 were analysed at follow-up

Mean age 31.6 years, ranging from 17 to 54 years
1 male and 8 female


InterventionsIndividualised psychotherapy

7 patients received behavioural therapy, 1 received behaviour modification therapy and 1 received short-term dynamic therapy


Outcomes1) Seizure frequency

2) Medications

3) Living conditions

4) Employment

5) Hospitalisation

6) Attitude towards self

7) Significant events

Measurements taken at baseline and at follow-up


Notes1 patient did not complete the follow-up questionnaire


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)High riskNon-randomised study therefore automatically rated as high risk of bias

Allocation concealment (selection bias)High riskNo methods of allocation concealment used

Blinding (performance bias and detection bias)
All outcomes
High riskNo methods of blinding used

Confounding variables (for non-randomised studies)
All outcomes
High riskRated as 5 on 'Risk of bias' scale as treatments were highly individualised, patients had mixed diagnoses and there was no indication of treatment lengths

Incomplete outcome data (attrition bias)
All outcomes
Low riskRated as 2 on 'Risk of bias' scale as there was a small amount of missing data which was unlikely to affect the outcomes

Selective reporting (reporting bias)Low riskRated as 2 on 'Risk of bias' scale as outcomes outlined in the methods were measured, analysed and reported in the results, however there was no a priori protocol available with which to compare these outcomes

Other biasHigh riskRated as 5 on 'Risk of bias' scale as in a sample size of 9, IQ ranged from 30 to 116 and 1 patient was described as "severely retarded"

Rusch 2001

MethodsBefore and after non-controlled study, single centre (US)

Treatment duration: unclear. Follow-up period: 6 and 12 months


Participants33 patients with non-epileptic events enrolled at the start of the study, 26 received the intended treatment and 26 were analysed

Mean age 33.8 years, ranging from 6 to 56 years
25 female and 8 male patients


InterventionsPatients were grouped according to clinical characteristics; patients received 6 separate forms of psychotherapy:
(1) Accurate identification of anxiety and panic symptoms; cognitive therapy with exposure (N = 6)
(2) Intensive psychotherapy (N = 6)
(3) Insight-orientated psychotherapy (N = 2)
(4) Cognitive behavioural therapy (N = 2)
(5) Exposure-based therapies (N = 7)
(6) Behavioural management strategies (N = 3)

Mean number of sessions (9.5) ranging from 2 to 30 sessions


Outcomes1) Seizure freedom

2) Seizure frequency

3) Seizure characteristics

4) Psychiatric history

Measurements reported at less than 12 months and more than 12 months


Notes7 patients terminated treatment early


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)High riskNon-randomised study therefore automatically rated as high risk of bias

Allocation concealment (selection bias)High riskNo methods of allocation concealment used

Blinding (performance bias and detection bias)
All outcomes
High riskNo methods of blinding used

Confounding variables (for non-randomised studies)
All outcomes
High riskRated as 4 on 'Risk of bias' scale as therapy was modified as it went on; 15 patients had both non-epileptic and epileptic seizures, mixed aetiologies

Incomplete outcome data (attrition bias)
All outcomes
Low riskRated a 2 on 'Risk of bias' scale as there was a small amount of missing data with no ITT analysis, unlikely to affect the outcomes

Selective reporting (reporting bias)Unclear riskRated as unclear on 'Risk of bias' scale as main outcome reported as significant, however no corresponding P value reported in the text

Other biasHigh riskRated as 4 on 'Risk of bias' scale as there is little information to determine any other risk of bias; sample size was small; very few patients in each group

Zaroff 2004

MethodsBefore and after non-controlled study, single centre (US)

Treatment period: 10 weeks


Participants10 patients with psychogenic non-epileptic seizures were enrolled at the start of the study, 7 completed the majority of the intended treatment and 7 were analysed

Mean age 35.7 years, ranging from 21 to 57 years
6 women and 4 men


InterventionsGroup psychotherapy

10 sessions for 1 hour per week carried out in 3 separate groups


Outcomes1) Seizure frequency

2) Curious experiences

3) Quality of life

4) Avoidance

5) Anger

6) Emotion

7) Task

Measurements were taken at baseline and post-treatment. Pre- and post-treatment scores were also compared to normative samples for each outcome


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)High riskNon-randomised study therefore automatically rated as high risk of bias

Allocation concealment (selection bias)High riskNo methods of allocation concealment used

Blinding (performance bias and detection bias)
All outcomes
High riskNo methods of blinding used

Confounding variables (for non-randomised studies)
All outcomes
High riskRated as 4 on 'Risk of bias' scale as patients had mixed aetiologies; no methods used to deal with prespecified list of variables

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskMissing data and no ITT analysis

Selective reporting (reporting bias)Low riskRated as 2 on 'Risk of bias' scale as outcomes outlined in the methods were measured, analysed and reported in the results, however there was no a priori protocol available with which to compare these outcomes

Other biasUnclear riskRated as 4 as there is little information to determine any other risk of bias and 3 patients were actually seizure-free at the start of treatment

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Allen 2006Somatisation patients; no differentiation between patients with NEAD or PNES

Betts 1992Retrospective study and case study data only

Bhatia 2005Not an intervention study; no before and after measures taken

Bleichhardt 2004Somatisation patients; no differentiation between patients with NEAD or PNES

Buchanan 1993Retrospective study; no intervention

Chinta 2008Not an intervention study

Elsas 2011Epilepsy patients; not NEAD or PNES patients

Flom 1999Not an intervention study; retrospective design

Ghosh 2007Retrospective study; no intervention

Gupta 2011Somatisation patients; no differentiation between patients with NEAD or PNES

Hiller 2003Not an intervention study; no PNES patient data

Hovorka 2007Not an intervention study; no before and after measures taken

Kashner 1995Somatisation patients; no differentiation between patients with NEAD or PNES

Katsamanis 2011Patients with medically unexplained physical symptoms; no differentiation between patients with NEAD or PNES

Khattak 2006Somatisation patients; no differentiation between patients with NEAD or PNES

Lidbeck 1997Somatisation patients; no differentiation between patients with NEAD or PNES

Lidbeck 2003Somatisation patients, no differentiation between patients with NEAD or PNES

Magallon 2008Protocol for study

Martin 2007Somatisation patients; no differentiation between patients with NEAD or PNES

Mayor 2010Follow-up data collected retrospectively

McDade 1992No before and after comparisons made

McLeod 1997Somatisation patients; no differentiation between patients with NEAD or PNES

Miller 1983Case study design

Mims 1994Not defined behavioural treatment; presents case study data

Nanke 2000Somatisation patients; no differentiation between patients with NEAD or PNES

Nanke 2003Somatisation patients; no differentiation between patients with NEAD or PNES

Posse 2004Somatisation patients; no differentiation between patients with NEAD or PNES

Schweickhardt 2007Somatisation patients; no differentiation between patients with NEAD or PNES

Share 1996Not an intervention study; letter to editor

Smith 1986Somatisation patients; no differentiation between patients with NEAD or PNES

Smith 2009Somatisation patients; no differentiation between patients with NEAD or PNES

Speckens 1996Somatisation patients; no differentiation between patients with NEAD or PNES

Timmer 2004Somatisation patients; no differentiation between patients with NEAD or PNES

Timmer 2006Somatisation patients; no differentiation between patients with NEAD or PNES

 
Characteristics of studies awaiting assessment [ordered by study ID]
La France

Methods Prospective, multi-centre, multi-arm, combined treatment pilot RCT. Data collected at baseline, week 2, week 8 and week 16

Participants38 PNES patients enrolled, 35 patients completed baseline measurements and were randomised

Interventions1) Medication (flexible-dose sertraline)
2) CBT only
3) CBT and medication combined
4) Standard medical care

OutcomesSeizure frequency

Psychosocial and function variables

NotesAwaiting publication

 
Summary of findings for the main comparison. RCT evidence for people with non-epileptic attacks

Behavioural treatments compared with control interventions for people with non-epileptic attack disorder

Patient or population: people with non-epileptic attack disorder

Settings: hospital

Intervention: behavioural treatments

Comparison: control intervention

OutcomesNo of participants
(studies)
Quality of the evidence
(GRADE)
Comments

Seizure frequency: > 50% seizure reduction66
(1)
⊕⊕⊕⊕
high
Only one study compared a behavioural treatment (CBT) to a control intervention (standard medical care). This study was a well-conducted RCT (no evidence of bias) and reported a significant decrease in seizures in the CBT intervention group compared to the standard medical care group. Study reports median monthly seizure frequency; no dichotomous data available to provide an overall effect estimate for the outcome of 50% seizure reduction.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.
RCT: randomised controlled trial

 
Summary of findings 2. Non-randomised evidence for people with non-epileptic attacks

Behavioural treatments for people with non-epileptic attack disorder

Patient or population: people with non-epileptic attack disorder

Settings: hospital

Intervention: behavioural treatments

OutcomesNo of participants
(studies)
Quality of the evidence
(GRADE)
Comments

Seizure frequency: > 50% reduction in seizures120
(6)
⊕⊝⊝⊝
very low
Providing an overall effect estimate from the non-randomised evidence for the effectiveness of behavioural interventions in people with NEAD is problematic due to the heterogenous nature of the studies. Studies investigated differing behavioural treatments and patients receiving a behavioural intervention were often receiving other forms of therapy simultaneously. Therefore we rated the quality of evidence provided by these studies as very low.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.
NEAD: non-epileptic attack disorder

 
Summary of findings 3. RCT evidence for people with conversion disorder

Behavioural interventions compared with control interventions for people with conversion disorder

Patient or population: people with conversion disorder

Settings: hospital

Intervention: behavioural interventions

Comparison: control interventions

OutcomesNo of participants
(studies)
Quality of the evidence
(GRADE)
Comments

Seizure frequency: > 50% reduction in seizures128
(3)
⊕⊕⊕⊝
moderate
Evidence for this outcome downgraded once for heterogeneity between studies due to differences in intervention investigated. On the whole we rated all three studies as low/unclear risk of bias due to lack of detailed methodology reported in the papers.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 
Summary of findings 4. Non-randomised evidence for people with conversion disorder

Behavioural interventions compared with control interventions for people with conversion disorder

Patient or population: people with conversion/dissociative/hysterical seizures

Settings: hospital

Intervention: behavioural interventions

Comparison: control interventions

OutcomesNo of participants
(studies)
Quality of the evidence
(GRADE)
Comments

Seizure frequency > 50% seizure reduction29
(2)
⊕⊕⊕⊝
low
The evidence for the effectiveness of behavioural interventions used for conversion disorder patients is low quality due to the inconsistency between study interventions and certain aspects of risk of bias

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.