Psychogenic Non-Epileptic Seizures

Psychogenic non-epileptic seizures, also known as PNES, are common events with physicians providing primary care and emergency medicine, pediatricians, as well as neurologists. The continued variability in the evaluation, diagnosis, and treatment of seizures has raised much interest. Therefore, the process of current work writing was negatively influenced by the lack of proper knowledge and understanding of psychogenic non-epileptic seizures. There is a lack of data regarding the disorder to show cumulative long-term outcomes generated by the paradigms that are utilized in treatment. The result of it reveals a situation characterized by costly health care services to the affected patients, high rates of both morbidity and iatrogenic injuries. The article seeks to address the history, prevalence, treatment, and prognosis of psychogenic non-epileptic seizures.

History, Prevalence, Treatment, and Prognosis of Psychogenic Non-Epileptic Seizures

PNESs have been described as paroxysmal behavioral variations, which resemble what is observed in case of seizures resulting from epilepsy. It occurs when the electrophysiological brain correlates are absent (Tremble & Schmitz, 2002). The disease can be described by such symptoms as changes in one’s behavioral, sensory, emotional, cognitive, as well as motor functioning. In most cases, the resulting condition is normally mistaken to be epilepsy. In addition, the condition is considered as an indication that one is suffering from psychological stressing factors irrespective of the fact that it does not include movements (Devinsky & Westbrook, 2001).

The paper considers the procedures provided by DSM-5 (Diagnostic and Statistical Manual of Mental Disorders). DSM-5 has three broad components, which include the diagnostic classification, the descriptive text, and the diagnostic criteria sets. DSM-5 will especially be applicable in the diagnosis and the prevalence sections of the work. For instance, under diagnostic classification, the involved professionals are expected to select such disorders that are best reflected in the observed symptoms and signs. According to DSM-5, health professionals involved in the process are also provided with symptoms and conditions that they must observe in their patients to conclude the presence of the disorder. The work applies the criterion in discussing the history, prevalence, prognosis, diagnosis, and treatment of PNES disorder.

History

Regarding its resemblance with epileptic seizures, non-epileptic seizures have presented neurologists, as well as a psychiatrist with a neuropsychiatric syndrome long time ago. Just like the epileptic seizures, PNES has also been known to present itself with behavior-related variation occurring suddenly, involuntarily and within a limited span of time. However, over time, studies have shown that unlike epileptic seizures, PNES does not originate from epileptogenic pathology. In addition, it never shows an epileptiform or electrographic pattern (Devinsky & LaFrace, 2004).

The study on PNES and other non-epileptic seizures gained significance with the unification of psychiatry and neurology to support the understanding of the brain/mind. It led to more understanding of paroxysmal disorders in both disciplines. That period, known as that of the brain, resulted in great advancements in therapy with regards to the disorders. Being among the non-epileptic seizures, PNES still was considered neither as a part of psychiatry nor neurology. For some specific period of time, not much was done with respect to its treatment. Today, the phenomenon of PNES has become more widespread and better outlined in medical-related kinds of literature. The peak of knowledge development regarding PNES came during the onset of the 1980s following the expanding usage of VEEG, which has remained important in the diagnosing of disorder (Ferri, 2012).

However, even with all the highlighted advancements in diagnosing PNES, there has never been a standard agreed on an approach to effectively treat the disorder. It calls for more studies on its treatment. The case is different from other related disorders like epilepsy, anxiety, stroke, as well as mood disorders, which have experienced important advancements in their treatment. According to Devinsky & LaFrace (2004), it has been contributed by the fact that no discipline has claimed the relation of PNES to them. However, it is largely accepted that the disorder can be best understood by neurologists who are experts in clinical neurophysiology. The professionals are able to monitor the symptoms over a long period of time or use VEEG in the diagnosis. The disorders can then be treated by psychologists and psychiatrist who are familiar with the conflicts and constructs accompanying the disorders due to their long term influence on the patients.

It is the “borderland diagnosis” that has led to most patients being misdiagnosed and receiving wrong drugs, which are normally meant for epileptic patients. Even in the situations where the disorder has been diagnosed correctly, a big percentage of the PNES patients are referred to those providing mental health services or to epileptic centers. There are cases where psychologists have preferred different treatment approaches compared to the ones proposed by the psychiatrists, making the patients choose between the two options. The final effect has a great impact on the overall functioning and outcome of the patients since it also affects their perception and understanding of the condition (Devinsky & LaFrace, 2004).

Even with all the challenges, one of the aspects that have experienced great improvement is the way in which the disease is diagnosed. The improvement has been witnessed over the last three decades. The most important one came when the simultaneous video-EEG was introduced to help in monitoring the patients. It provided a solution to the initially rampant iatrogenic hazards like the side effects, which were witnessed at any time the patients were given AED wrongfully. It also decreased the number of cases of failures in recognizing pseudo status epilepticus, which potentially led to intubation. It means that due to failures in recognizing the psychological nature of the seizures, there was an essential delay in delivery of appropriate treatment. Moreover, there was also a great number of patients who had been diagnosed with epilepsy, becoming hostile with the changing of diagnosis to PNES. It was caused by the fact that epilepsy, which the patients had been made to believe they were suffering from for a long time, was characterized with much stigma (Green & Muskin, 2013).

According to a study done by Durrant et al. (2011), the incidence of PNES can be estimated as 1.4 individuals for every 100,000 people annually. The finding is nearly the same to the one conducted by Bodde, et al. (2009) that estimated the cases of PNES to be approximately 1.5 persons for every 100, 000 people annually, which they estimated to be nearly four percent of all the cases of epilepsy. However, the researchers stated that according to the reports at the centers where epileptic people are taken care of, it was evident that of all patients who came to such centers to undergo refractory epilepsy diagnosis, twenty-five to thirty percent were diagnosed with PNES. The other finding showed that between five to forty percent of the patients who had been diagnosed with PNES either had experienced epileptic seizures in the past or had a concomitant diagnosis of epilepsy.

In addition, it indicated that of such population, twenty percent are taken to centers to provide tertiary care as to epileptic patients. It is caused by the fact that the same condition is witnessed among people with refractory seizures, making it vital in the context. People suffering from the disease, in most cases, receive misdiagnosis and are told that they are epileptic leading to wrong treatment with drugs meant for such group of patients. It may occur for several years leading to unwarranted side effects of the antiepileptic drugs. In other cases, some PNES patients have been put through invasive procedures based on the wrong assumption that the observed seizure is a symptom of the treatment-refractory epileptic disorder (Theodore, et al. 2015).

Just like in the case of other aspects of the disorder, population-based data regarding incidence or prevalence of the disorder among the pediatric population is not readily available. The disorder’s prevalence seems to be high among adults compared to the case with children. The prevalence increases with age from children through adolescents to adults. Such finding is also supported by a study by Smith (2014), which showed that the outcome in the patients is poorer in adults compared to what is experienced in children and adolescents. The researcher noted that it could be explained by the fact that the stressors’ psychopathology is not similar to the one experienced by adult patients. Equally, the duration for which the affected young children and youths have suffered the symptoms of the disorder is shorter. For children and adolescents, the disorder may show itself through family discords, as well as their refusal to go to school. In addition, they may experience serious disorders and continuous physical, as well as sexual abuse. The factors need thorough investigation whenever they are witnessed.

There is no much data with such respect, since nearly all studies that have ever been publicized on the disorder’s prevalence in the pediatric population have been lacking a thorough description of the intervention, representative samples, while also involving retrospective data analysis. Generally, it is agreeable that the low prevalence among children can further be reduced due to ensuring that people who are suspected to have the disorder are diagnosed as early as it can be done. The outcome of the diagnosis must then be communicated to the child and his/her family in a clear manner. Equally, there may also be the need to monitor such children. Such monitoring programs should integrate knowledge from various relevant disciplines. It also has to be comprehensive and based on an individual patient to ensure that it is relevant and more effective (Smith, 2014).

Another study by Benbadis, et al. (2014) showed that there is a high occurrence of the disorder among people whose relatives have conversion disorder. It occurs due to the possibility of system modeling from the family members who are already affected by the disorder. It means that there is a need for family history to be checked thoroughly. However, there are cases where monozygotic twins have shown an increased risk, while the level of risk among dizygotic twins remains normal. In addition, increased conversion risk is also experienced in cases of non-genetic familial factors like childhood incestuous sexual abuse. It must also be acknowledged that the conversion disorder remains as the only communication mechanism for both adolescents and children.

The data on the prevalence of PNES is also affected by misdiagnosis. Benbadis, et al. (2015) noted that there are numerous cases in which people with the disorder are misdiagnosed with epilepsy. It has been identified as the leading non-epileptic condition normally witnessed in centers meant for people with epilepsy. Though studies have shown that people who come to such centers form between 20 to 30 percent of the total number of patients. Moreover, between 50 to 70 percent are normally not diagnosed with seizure, while nearly 15 percent are found to be epileptic (Benbadis, et al. 2015). Just like conversion disorders, studies have shown that in most cases PNES begins in young adulthood and is more frequent in women compared to men. The disorder can equally occur among older people.

Finally, for accuracy in the data on the prevalence of the order, caution must be taken during the diagnosis of the disorder. It is most necessary as the disease begins showing symptoms in either old age or childhood. The two age groups have most people expressing non-epileptic physiologic events. For instance, parasomnias will be observed among most children. Other PNES disorder related symptoms common at this age include shuddering attacks and breath-holding spells (Benbadis et al. 2015).

Diagnosis

Being a psychiatric/conversion disorder, PNES can be categorized as a somatic symptom disorder in accordance with DSM-5. That is, neurological symptoms established following proper neurological assessment may be categorized under fictitious or conversion disorders. Another category that is appropriate in this case is malingering. Specifically, DSM-5 provides a number of criteria for conversion disorder. First, it should have at least a symptom associated with altered voluntary sensory or motor function. In this case, the findings must clinically prove that there is no compatibility between the established medical conditions and the symptom. Second, the symptom has to be that which cannot get its best explanation if another mental or medical disorder is to be used. Thirdly, the symptom should cause impairment or distress with clinical significance in one’s social, occupational life or other vital functioning aspects of life. It should also be able to cause the need for medical evaluation (Benbadis, et al. 2015).

DSM-5 categorizes PNES in the “with attacks or seizures” subtype of symptom. In this case, malingering or fictitious disorder have the implication that the individual is trying to fake the observed symptoms to deceive the physician. However, while malingering involves the patient giving a rational reason, factitious disorder involves faking symptoms for a pathological need to perform the role of a sick person. While malingering is never categorized under mental illnesses, fictitious disorders are. It means that malingering cannot be considered as a criterion for diagnosis (Benbadis, et al. 2015).

However, it is widely observed that most of the individuals who are diagnosed with PNES do have conversion disorder and neither fictitious nor malingering disorders. It reveals the limitations of the DSM-5 criteria of classifying such disorders. For instance, it shows that irrespective of the portrayed simplicity in the use, theoretically, a physician is not able to know when it is being faked by a patient for other reasons. There are circumstances where it can only be known that a patient is intentionally faking the symptoms by catching them during the faking act. It may involve seeing a person inflicting pain on himself/herself, taking un-prescribed medicines or using some eye drops to ensure that the patients show signs of living. In some cases, it is possible for malingering to be underdiagnosed, since the process of diagnosing may become an accusation (Benbadis, et al. 2015).

It is, therefore, evident that differential diagnosis forms one of the most vital processes in the treatment of the disease. It must not be done with a focus on removing the possibility of one suffering from epilepsy. Using such an approach can only lead to negative results as PNES subsequently fails to be a disease. There is a need for a positive diagnosis to allow for the evaluation of all the underlying psychological mechanisms necessary for the treatment of patients. Therefore, neurologists have a better possibility to realize the accurate results, especially those who are experts in clinical neurophysiology and are well-acknowledged of the required data for VEEG, as well as long-term monitoring (Louis & Ficker & O’Brian, 2015). On the other hand, the best professionals to initiate treatments are psychologists with experience in handling psychologically related conflicts and constructs (Bodde, et al. 2009).

Prognosis

The concept is mainly concerned with the probability of a patient recovering from the disorder by looking at its course, as well as the outcome. Generally, the outcome of PNES in adults is questionable, since the disorder negatively impacts the patient’s quality of life. Studies have shown that over 50 percent of the patients who have suffered from the disorder for at least 10 years have had to continuously experience seizures. Due to such fact, they have to be dependent on social security-related benefits offered by various countries (Summergrad & Cathol, 2014).

However, with education, it is possible to improve the outcomes of the disorder. However, it can be reached when the disorder is diagnosed at an early stage. It is possible since the psychiatrists and psychologists can monitor non-dramatic features, the low dissociation scores, fewer complaints with respect to additional somatoform, as well as the scores on the dimensions considered to be of high-order personalities, which have to below. The latter may include compulsivity, inhibition, as well as emotional dysregulation.

Studies have shown that those patients who have catatonic or limb type of disease may have a better prognosis compared to the patients experiencing the thrashing or convulsive type of disorder. However, the most important factor is the duration of the illness experienced by the patients. Studies have shown that the patients who have been treated for epilepsy have experienced worse prognosis. In fact, the situation worsens with the duration for which one has been subjected to the treatment of epilepsy. Therefore, it is important for one to undergo a definite diagnosis during the initial course of PNES. It has been a challenge in many cases prolonging the average delay in the way PNES is being diagnosed. There is a need for developing measures to improve the suspicion index for the symptoms of the disease. Finally, to help reduce the related subsequent cost of health, there is a need to ensure that PNES is accurately diagnosed.

Studies have also revealed that with the disease, better outcomes are realized with adolescents and children compared to the cases with adult patients. It is based on the period during which one has been ill, as well as the fact that the stressors affecting adults vary from those affecting pediatric patients. Some of the factors can include refusing by a child to attend school or misunderstandings within the family.

A study by Wyllie, et al. (2006) also revealed the same data. It showed that the outcome is more negative among adults than it is among the young people. Regarding the study by Bodde, at al. (2009), it also showed that among people who live with the symptoms of the disorder for a decade, at least 50 percent will continue experiencing a seizure. The authors reiterated that such a group of patients has to rely on the benefits given through social security. The study also revealed the relationship between treatment outcome and the patient’s level of education. It showed that patients with greater educational attainment experience greater outcome. The same situation was with patients of younger age at onset and diagnosis, as well as with those who experienced attacks but with less negative features. It was similar with people whose additional somatoform complaints were relatively few, people whose dissociate scores were relatively low, as well as those who scored low on dimensions of higher-order personality characterized by emotional dysregulation and compulsivity. It also revealed that the thrashing or the convulsive type may have poor prognosis than the catatonic or the limp type. Overall, all the patients diagnosed with PNES may have their quality of life severely affected.

In summary, it is clear that the most significant fact when dealing with a prognosis of the disorder is the period for which one has been ill. In addition, the study showed that prognosis worsened in situations when individuals with PNES received treatment for epilepsy. It is, therefore, recommended to obtain a definite diagnosis of the disorder early enough. Unfortunately, studies have shown that such delays are common phenomena in everyday practices, as far as PNES diagnosis is concerned. It is an indication of the low suspicion index for such symptoms. It is also evident that whenever the disease is accurately diagnosed, there is a significant reduction in the subsequent cost of health care.

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Treatment

With the advancements in the diagnosis of PNES, the focus was shifted on the effectiveness of the existing treatment methods. Epileptologists and neurologists have placed their concerns on the treatment and the caregivers who are most qualified to affect the provision of the therapy. It was evident when the ILEA Neuropsychology Commission charged the experts’ committee to develop a report detailing the treatment options for PNES. The committee agreed that with regards to therapy, there was a need for outcomes that are effective in the long perspective. Most of the previous reports have utilized the extent of reduction in seizures, as well as seizures remission in measuring how successful the treatment of PNES has been (Smith, 2014).

A good number of retrospective studies have shown that nearly a third of all the PNES patients think that the disease can stop without attending caregivers for intervention to the end of the second quarter of a year following their diagnosis. Smith (2014) reports a study in which 71% of people who were affected by the disease continued experiencing seizures four years after they had been diagnosed with the disease. Similar to the earlier studies, Smith’s study showed that approximately 50 percent of people, whose seizures stopped, was not productive and had to be registered to receive benefits provided by the state. They continued being disabled suffering from certain PNES symptoms. The symptoms that are normally observed for a long time include somatization, tendencies to dissociate, as well as a personality disorder.

A question can, therefore, be asked on whether seizure remission can provide a comprehensive measure towards obtaining better outcomes, whether psychological or medical. Smith (2014) stressed the need for the reorganization of PNES as a psychiatric symptom which is a simple representation of the underlying morbidity. The researcher proposes such version due to the fact that there is a need for replacement of the approach using PNES as a primary diagnosis in establishing predictiveness for research-based upon the psychiatric disorder. In cases where PNES gives a representation of asymptomatic expression observed as the final one that can originate from different mechanisms of psychopathology, there is a need for the clinicians to understand the diversity well in order to provide more accurate treatment. In this case, the treatment given to each patient will be based on the various sub-groups with division in accordance with their psychiatric comorbidity.

Other studies have also suggested the need for the assessment of formal psychiatry prior to therapy. The process has to be carried out by a professional in issues of mental health, psychologists, neuropsychiatrists or general psychiatrists. The expert should be a person with experience in handling the disorder based on a specific case. He/she must also be aware of the way the diagnosis of the specific patient was made and, therefore, know how the case should subsequently be managed (Lesser, 2003).

Research on PNES Treatment

According to Smith (2014), irrespective of the fact that PNES was recognized and included in the medical literature in the 1700s, the treatment of the disorder has been postponed. It is true despite the advancements realized in diagnosing the disorder. Moreover, the disorder is neither categorized in the discipline of neurology nor that of psychiatry. Such lack of official ownership reduces the efficiency of therapeutic studies that are carried out on PNES (Arciniegas, et al. 2013).

The literature regarding the diagnosis, prevention, and treatment is, thus, not as extensive as is the case with other related disorders. Thus, future researchers on PNES should continue focusing on given areas. Since many of the articles that are published on PNES have their main focus on its diagnosis, most advancements have been witnessed in the current aspect. For instance, some of the areas that have been researched well include ictal semiology, psychological makeup, psychiatric comorbidities, and neuropsychological testing. Evidently, much of the focus has been placed on clinical features, making PNES distinct from epileptic seizures. The idea is that there does not exist a single sign that can help separate PNES from epilepsy (Bennett, 2011).

Considering such revelations, there is a common understanding that the development of an effective treatment for the disorder needs to be treated with much urgency. Consequently, there were many efforts put towards it. For instance, Smith (2014) identifies a workshop conducted in 2005 that gathered the researchers from across the globe. The agenda was the treatment of non-epileptic seizures. They discussed how the treatment for people with PNES could be improved and made more effective. The workshop members developed various benchmarks to guide researchers who were interested in carrying out research on PNES. It addressed issues related to pediatrics, classification, how to design treatment trials, how to present the diagnosis, as well as outcome measures.

Treatment Methods

Approach considerations. There are a number of approaches that can be implemented in the treatment of PNES, ranging from psychotherapy to using the adjunctive medication in the treatment of depression or anxiety as it may be coexisting alongside with the disorder. Since psychogenetic symptoms are categorized under psychiatric diseases, they should be managed by professionals in the field of mental health. It should be done irrespective of the approach that is used during the treatment of the disorder. However, people involved in the treatment must be aware of how effective the diagnosis of any case they are dealing with was delivered. They need to find out how compassionate the physician who delivered the diagnosis was. Since a high percentage of patients being diagnosed with the disorder must have received organic disease diagnosis like epilepsy, they are more likely to deny or react with disbelief to the news that they are not epileptics. However, medical workers involved in the diagnosis process must encourage their patients to accept the outcome of the process and begin their therapeutic programs. It means that irrespective of the treatment approach chosen, patients need to receive appropriate education level and be well acquainted with basic knowledge of their condition and a role in the realization of a successful outcome (Benbadis, 2015).

Psychotherapy. It is generally understood that psychotherapy still remains the most effective and, therefore, recommended way of treating PNES. It is, however, unfortunate that a good percentage of people suffering from mental illness refuse to accept help from mental health service providers. In addition, it is difficult to monitor them. In some cases, they are admitted to undergoing a similar medical procedure with the initiation of therapy even later than it is needed. However, researchers still have to establish the type of psychotherapy that will help realize the best results. The problem, in this case, is that there are many studies, as well as case reports, on uncontrolled treatment but most of them have performed the outcome evaluations using broad interventions or group therapy. Most of such studies have also involved the matching of the symptoms expressed by patients to the kind of treatment they receive. It is the fully powered randomized control trial nature of such studies that have limited the existing recommendations regarding preferred approaches to the treatment of PNES (Taylor & Vaidya, 2009).

One of the major therapeutic approaches is categorized under cognitive behavior therapy (CBT). So far, the approach has been identified as the most effective psychotherapy approach. It has been evaluated based on a fear escape model. The focus of the model is on behavioral, cognitive, physiological and emotional PNES’ aspects. A study carried out by Smith (2014) point at the same findings. The study that had more than 12 sessions of psychotherapy delivered alongside with other patients receiving outpatient care revealed that CBT gives patients high probability of recovering from seizure by the end of a half a year’s monitoring. In fact, individuals who underwent the normal outpatient psychiatric care showed 3 times reduced speed in their recovery from a seizure. It requires deep knowledge to know whether a patient needs medication only, standard medication, CBT only or medication, and CBT. The study indicated that when only CBT was used in treating the arm, the reduction of seizures was of a significant level. The functioning of the patient also showed great improvement. The case was similar to the patient’s score when symptoms were put on a scale. On the other hand, there was a great seizure reduction improvement, as well as comorbidities experienced in patients who were administered with combined treatment. Finally, the cases in which only medication was used revealed improvement in depression. Unfortunately, the patients who had received standard medical care showed no improvement, indicating that PNES cannot be treated through supportive therapy.

Smith (2014) identifies psychodynamic therapy as another approach that can be used in the treatment of PNES. He noted that the approach is based on the consideration of trauma as a central feature in PNES. However, he reports that the cases in which the approach has been used have not been recording their controlled data. On the other hand, a case in which it had been used with 50 people suffering from PNE showed that there was a reduced severity, as well as the frequency of seizures. In addition, a decrease in psychological distress, as well as a better life quality was achieved. Irrespective of the fact that it has not been tested in RCT, data obtained from people suffering from PNES who were going through PIT showed that it had benefits in the long term and was not expensive, as well.

Group therapy. Group therapy has increasingly been used in the treatment of PNES patients as evident in most studies. Vega-Zelaya, et al. (2014) report a study in which a psychoeducational structure and psychodynamic theories were used in the evaluation of how effective group psychotherapy is. The researchers involved patients in weekly psychotherapy sessions conducted in groups. The sessions continued for 10 weeks with each session taking an hour. The groups were encouraged to discuss such topics as PNES, abuse, anger, as well as trauma. Other topics were anxiety and depression, tendencies of somatization, paths towards health, quality of life and techniques of coping with stress. In addition, they reviewed each topic. Even after the study period, the sessions went on albeit in a less structured, though a more supportive format. Equally, they did not have particular topics to be handled. The study results showed that education presents one of the most effective approaches for the treatment of the disorder since there was over 50 percent of the patients whose seizures remitted. Specifically, of the 9 PNES subjects, there was a decrease in seizure frequency in six patients, representing 67 percent (Vega-Zelaya, et al. 2014).

Paradoxical intention therapy. The authors also reported a study in which paradoxical intention therapy had been used. In the study, the researchers had tested the paradoxical intention of the inpatient against oral outpatient benzodiazepine. During the therapeutic sessions, the patients were encouraged to take part in discussing their unwanted conversion symptoms. The major focus of the study was placed on the conversion symptoms and not the frequency of their crises. As the treatment sessions ended, both groups showed a meaningful decrease with reference to their anxiety scores (Vega-Zelaya, et al. 2014).

Hypnosis. Based on the theoretical vital nature of the dissociation in the etiology of PNES, it can only be expected that hypnosis can offer useful intervention towards helping the patients. A study had been conducted to find out how effective the approach is in treating the disorder. The 49 patients who took part in the study were divided into three different groups. One group had 10 sessions with the treatment of conversion disorder with hypnosis, others focused on motor type, while the last group was required to wait to be the control group. The study showed that patients suffering from the disorder experience a higher level of dissociation, as well as hypnotisability. The measurements were taken using the Dissociative Experience Scale. Equally, hypnotisability was lower among the patients put in the control group compared to the PNES group (Vega-Zelaya, et al. 2014).

Pharmacotherapy. The use of drugs in treating PNES has not been exploited much due to the fact that there were not any consistent neurobiological models to explain the physiopathology of PNES. In fact, the negative factor, in this case, is that there were no agreed guidelines on the treatment of the disorder due to the lack of large and controlled trials, in which the efficiency of varies treatment modalities have been evaluated. However, it was indicated that selective reuptake inhibitors can be effective in the treatment of the disorder. It is based on the fact that such factors as anxiety and depression, which are witnessed in PNES patients, are associated with serotonergic neurotransmission alterations (Vega-Zelaya, et al. 2014).

Currently, there have been a number of reports in which pharmacological treatment of PNES was successful. The study was funded by the National Institute of Neurological Disorders and Stroke. During the study placebo and selective serotonin reuptake inhibitor were used on PNES’ patients. The study aimed at assessing the magnitude of reduction in seizure frequency when PNES patients are treated with sertraline. It was done to perform an analysis of the full-scale RCT effectiveness. The results showed that the patients who took sertraline showed a 45 percent reduction in biweekly rates of seizures, while those who were controlled only showed 8 percent increase. However, even with such findings, the sample was too small to support a conclusion on the outcome. Other drugs that have been tried are diazepam and venlafaxine.

Studies have also shown that if there is a manual for psycho-educational intervention aimed at supporting the treatment of PNES, their rate of cessation increases. It remains true even in cases where the training is conducted by professionals who have only attained minimal pieces of training. Equally, studies have shown that conducting a group therapy can help improve the patient’s well-being psychologically. On the other hand, if there is a meaningful level of dysfunction in the patient’s family, there is a need for family therapy (Smith, 2014).

Conclusion

In conclusion, PNES is increasingly becoming a common neuropsychiatric symptom. However, the disorder faces numerous cases of misdiagnosis, mistreatment, and avoidance by most health care professionals. The problem is becoming more complicated due to the fact that there are no well-established guidelines on the treatment of the disorder. It has led to difficulty in the evaluation of various treatment modalities based on the fact that there are no fully powered randomized, control trials for evaluation. However, as have been seen, preliminary studies performed on the subject matter showed that the use of CBT in the treatment of the disorder can greatly improve the outcome. The problem is that there has never been a fully-powered control trial due to the fact that the treatment of the disorder has not been prioritized. Thus, there is an urgent need for neurologists to cooperate with other professionals dealing with mental health in a framework that is multicenter. It will ensure that PNES, which has been known as a “borderland disorder”, finds its discipline.

Another challenge that has been common with reference to the disorder is the fact that mental health-related services are never readily available, especially to the patients who have no insurance covers. Equally, psychiatrists express much skepticism dealing with a symptomatic diagnosis of PNES disorder. The challenge has been real irrespective of monitoring diagnosis through VEEG video, which has proved to be very effective in producing certain results. Thus, there is a need for the psychiatrists involved in the treating process to use videos to record the findings. It will help make the research more convincing than in the case where the data was presented in a written form. With the well-elaborated description of the disorder in DSM-5, it can only be expected that there will be improvements in its diagnosing.