Elsevier

Epilepsy & Behavior

Volume 11, Issue 4, December 2007, Pages 492-498
Epilepsy & Behavior

Review
The neurologist, psychogenic nonepileptic seizures, and borderline personality disorder

https://doi.org/10.1016/j.yebeh.2007.09.010Get rights and content

Abstract

Patients with psychogenic nonepileptic seizures (PNES) are common in tertiary epilepsy centers, emergency departments, and neurological practices. Psychiatric discussion of patients with PNES has emphasized the role of trauma and dissociation. Personality disorder has been considered, but its extensive implications for neurological management have not been fully appreciated. We propose that the most difficult aspects of management stem not from the convulsive episodes, but from the personality disorder that frequently accompanies them. Although it is not the neurologist’s role to treat personality disorder, the conduct of the physician–patient relationship can have potent consequences for good or ill on the outcome. We present a brief guide to current concepts of personality disorder; discuss the literature concerning its association with PNES, and offer practical guidelines for the conduct of the neurologist–patient relationship. This perspective offers resolutions to longstanding controversies, including how to communicate the diagnosis, discontinuing medication, and ongoing neurological contact.

Section snippets

Introduction: Psychogenic nonepileptic seizures

Although various psychiatric disorders, notably Panic Disorder, can present as psychogenic nonepileptic seizures (PNES) [1], most patients are diagnosed with Conversion Disorder (DSM-IV) or Dissociative Disorder (ICD-10). Of these, some resolve quickly but in many, symptoms and disability persist for months or years, estimates ranging from 20 to75% [2], [3], [4], [5]; it is this chronic group on whom we focus here. Disability and impaired quality of life persist even when PNES resolve [6],

Personality disorder

There are several good reasons to focus on personality disorder: it is common in PNES; patients with personality disorder have high rates of somatization generally; and there are “paraclinical” phenomena characterizing the presentation of patients with PNES that, in mental health services, are routinely recognized as pathognomonic of personality disorder but, in neurological settings, are easily overlooked.

Personality disorders are enduring patterns of inner experience and behavior that deviate

Association of personality disorder with PNES

Clinical studies using formal diagnostic measures report rates of co-occurrence of personality disorder and PNES ranging from 10 to 86% (Table 1), with a trend toward higher rates in samples with a greater proportion of chronic patients [11]. Although there are methodological limitations and a need for further research, the existing evidence concerning personality disorder in PNES is reasonably consistent and accords with clinical experience.

No single type of personality disorder is seen

Paraclinical phenomena: BPD features in PNES clinical presentations

Personality dysfunction in PNES is not limited to BPD, but the most salient management challenges arising with PNES stem from these traits. Psychiatric staff are familiar with a range of common manifestations of BPD, not symptoms elicited at clinical interview, but observable patterns emerging in the relationship between patient and treating team (“paraclinical phenomena”). In neurological settings, their significance is usually not recognized. We do not suggest neurologists should be able to

Understanding the manifestations of BPD

As with any complex human syndrome, theoretical approaches are numerous, but there are considerable areas of convergence. We limit our discussion to three key features.

Current approaches to treatment of PNES: The relevance of personality disorder

The PNES treatment literature remains sparse, with few methodologically adequate treatment trials [46]. Current approaches, using modalities such as pharmacotherapy, cognitive-behavioral therapy, psychodynamic therapy, group therapy, family therapy, hypnosis, or multidisciplinary programs, show promising results at first glance, but are comparable to previous naturalistic studies. Some studies show no benefit of referral for psychological treatment, with outcomes equivalent to those of

Principles of a psychologically informed approach to neurological care of patients with PNES

We do not suggest neurologists become psychotherapists; and we certainly do not suggest neurologists accept prime responsibility for management of personality disorder. However, the neurologist’s approach can have potent impact, for good or ill. Also, many patients with PNES do not accept referral for psychological care, with neurologists left having to “do the best they can.” Indeed, psychiatric care may be unavailable. Unfortunately, in many countries somatoform disorders are poor relations

Implications for neurological training and service provision

By acquiring certain minimal psychiatric skills, neurologists can do much to improve the outcome for patients with PNES and to avoid iatrogenic harm. Psychiatric training of neurologists has previously been advocated [61]. Neurology trainees and trainers support opportunities for enhanced learning about psychiatry, particularly regarding somatization [62]. However, optimal training to effectively manage patients with personality disorders entails not just “book knowledge”: it demands

Conclusions

We have proposed that the concept of personality disorder, specifically BPD, has much to offer in understanding and managing patients with chronic PNES; and suggested the personality dysfunction, more than the seizures, underlies the main clinical challenges presented by patients with chronic PNES and is the core of their suffering and disability. We have sketched implications for management, service provision, medical training, and research. Although further research is needed, the association

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