ReviewThe neurologist, psychogenic nonepileptic seizures, and borderline personality disorder
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
References (63)
- et al.
Frequency of panic symptoms in psychogenic nonepileptic seizures
Epilepsy Behav
(2005) - et al.
Pseudoseizures (non epileptic attack disorder): clinical management and outcome in 50 patients
Seizure
(1993) - et al.
Psychogenic seizures in adults: a longitudinal analysis
Seizure
(1993) - et al.
Recent onset pseudoseizures: clues to aetiology
Seizure
(2004) - et al.
Psychiatric disorders, trauma, and MMPI profile in a Spanish sample of nonepileptic seizure patients
Gen Hosp Psychiatry
(2004) - et al.
Pseudoseizures, families, and unspeakable dilemmas
Psychosomatics
(1998) - et al.
Psychopathology and trauma in epileptic and psychogenic seizure patients
Psychosomatics
(1996) - et al.
Psychiatric morbidity and psychodynamics of patients with convulsive pseudoseizures
Seizure
(1995) Pseudoseizures and dissociative disorders: a common mechanism involving traumatic experiences
Seizure
(1997)Etiology and clinical course of pseudoseizures: relationship to trauma, depression, and dissociation
Psychosomatics
(1993)