Epilepsy & Behavior 56 (2016) 149–152

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Brief Communication

Bridging a clinical gap in psychogenic nonepileptic seizures: Mental health provider preferences of biopsychosocial assessment approaches Xavier F. Jimenez a,d,⁎, Jocelyn F. Bautista b,e, Bikat S. Tilahun a,b, Youran Fan c, Paul J. Ford d, George E. Tesar a,b a

Department of Psychiatry and Psychology, Cleveland Clinic Foundation, USA Epilepsy Center, Cleveland Clinic Foundation, USA Department of Quantitative Health Sciences, Cleveland Clinic Foundation, USA d NeuroEthics Program, Cleveland Clinic Foundation, USA e Department of Neurology, Cleveland Clinic Foundation, USA b c

a r t i c l e

i n f o

Article history: Received 26 October 2015 Revised 2 December 2015 Accepted 24 December 2015 Available online xxxx Keywords: Psychogenic nonepileptic seizures Case formulation Psychiatric assessment Biopsychosocial

a b s t r a c t Management of psychogenic nonepileptic seizures (PNES) is complex, requiring multidisciplinary care. A standardized assessment and formulation approach to PNES is lacking, yet use of a comprehensive model may alleviate problems such as mental health aftercare noncompliance. Although a biopsychosocial (BPS) approach to PNES balancing predisposing, precipitating, and perpetuating (PPP) variables has been described and has been recently tested in pilot form, it is unclear how this assessment style is perceived among community mental health practitioners such as psychotherapists (including psychologists, counselors, and social workers). We predicted preference of a comprehensive “BPS/PPP” assessment style by those most involved in PNES care (i.e., community psychotherapists). One hundred and forty-three community-based social workers and counselors completed a survey featuring a fictional PNES case followed by assessment style options (“Multiaxial,” “Narrative,” and “BPS/PPP”). Respondents clearly preferred the robust BPS/PPP approach over lesscomprehensive multiaxial and narrative assessments (p b 0.0001). Reasons for choosing the BPS/PPP by respondents include ease of organization, clear therapeutic goals, and comprehensive nature. This assessment of acceptability of a BPS/PPP approach to PNES assessment among community mental health practitioners may provide a patient-centered mechanism to enhance referrals from the neurological to mental health setting. Implications and future directions are explored. © 2015 Elsevier Inc. All rights reserved.

1. Introduction Psychogenic nonepileptic seizures (PNES) are characterized by paroxysmal episodes resembling epileptic seizures yet lacking electrical correlation as measured by the gold-standard diagnostic approach, videoelectroencephalography (vEEG) [1,2]. Management of PNES is complex, requiring multidisciplinary care starting with a robust biopsychosocial assessment because of the multifactorial nature of the condition. Nonetheless, a standardized multidimensional approach to evaluating PNES is lacking. The use of a comprehensive assessment model may ease the transition of patient care from the diagnosing team to the outpatient treatment provider. Traditional models for assessing and formulating PNES from a psychosocial or psychiatric perspective include the multiaxial approach and a narrative approach. The multiaxial approach derives from the 1980 publication of the third edition of the Diagnostic and Statistical Manual of Mental Disorders and involves a linear listing of psychiatric ⁎ Corresponding author at: Neurological Institute, Cleveland Clinic Foundation, 9500 Euclid Ave, P57, Cleveland, OH 44195, USA. Tel.: +1 216 407 4994 (Office); fax: +1 216 445 7032. E-mail address: [email protected] (X.F. Jimenez).

http://dx.doi.org/10.1016/j.yebeh.2015.12.035 1525-5050/© 2015 Elsevier Inc. All rights reserved.

diagnoses, personality disorders/traits, medical comorbidities, psychosocial stressors, and a global assessment of functioning still in use today [3]. A basic narrative assessment relies on an unstructured paragraph format. Given both the complexity of PNES and the objective of such evaluations directed at guiding future therapeutics, these traditional approaches seem inadequately simplistic. To complicate matters, studies have demonstrated suspicion among psychiatrists of neurologists' intentions when consulting for PNES evaluations (such as fear of patient “dumping” onto psychiatric services) [4]. We thus recently tested clinician preference for a comprehensive assessment model [5] incorporating predisposing, precipitating, and perpetuating factors (the “3 P's,” or PPP) as well as biopsychosocial (BPS) factors contributing to PNES [6] against traditional models, namely multiaxial or narrative. In our pilot evaluation, we found a statistically significant difference in assessment preference for this “BPS/PPP” model between psychiatrists (defined in our cohort as those performing one-time consultation evaluations of PNES in the medical setting) and nonpsychiatrists (defined in our cohort as both neurologists diagnosing patients with PNES as well as psychologists, therapists, counselors, social workers, and other psychotherapists inheriting/treating patients with PNES). Psychiatrists preferred multiaxial and narrative models because of ease of use, brevity,

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and familiarity. Nonpsychiatrists alternatively preferred the BPS/PPP assessment approach, citing its comprehensive nature, high detail, and explicit therapeutic targets. The pilot suggests incongruent priorities and preferences in the psychiatric formulation approach to PNES, a likely impediment to ongoing collaborative efforts with this patient population. As yet to be determined is whether the BPS/PPP assessment approach translates to altered clinical outcomes in the care of patients with PNES. The first step in determining the potential effects of this is to better understand the preferences of mental health practitioners to whom patients with PNES are referred. To address this question, we studied whether the BPS/PPP model is favored by receiving psychotherapists. We hypothesize higher preference for the BPS/PPP over multiaxial and narrative assessment models in a large cohort of community mental health providers and thus embarked on testing this premise.

2) counselor group (n = 500). The study populations were selected from two professional organizations (the National Association of Social Workers Ohio Chapter and the Ohio Counseling Association). Each of these associations distributed a weblink to their respective membership via a listserv; a reminder was sent 2 weeks after the initial distribution. As with the aforementioned pilot version of this study [7], the survey featured a clinical vignette of a typical patient with PNES on an epilepsy monitoring unit (Fig. 1). Respondents were asked to rank in order of preference three assessment approaches: multiaxial, narrative, and biopsychosocial (BPS/PPP) assessments (Fig. 1). Respondents were also asked to briefly explain their ranking choices. Chi-square analysis and goodness-of-fit testing were used to assess statistical significance between preferences. 3. Results

2. Methods The study was approved by the Institutional Review Board of the Cleveland Clinic Foundation. A completed survey indicated consent. An electronically delivered confidential, anonymous, and uncompensated 5-item survey was distributed to two cohorts of practicing psychotherapists across the state of Ohio: 1) social worker group (n = 1042) and

Fig. 2 captures the results of our analysis. A total of 143 psychotherapists completed the survey, 79% of whom had at least 2 years of posttraining clinical experience as a psychotherapist (question 1) and over a third of whom listed cognitive–behavioral psychotherapy as their treatment modality of choice, among others (question 2). One hundred three psychotherapists ranked BPS/PPP first, and 40 ranked

Fig. 1. Survey clinical vignette of PNES followed by three psychiatric assessment styles from which to rank.

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Survey question 1: Years of postgraduate experience? 2: Preferred/leading psychotherapy modality? (check all that apply) 3: Preferred psychiatric assessment style? 4: Reasons for preference (open– ended/qualitative)? 5: Frequency of PNES cases per provider?

Social work* findings (n; %) N = 106 Over 2 years (82; 77%)

Counselor* findings (n; %) N = 37 Over 2 years (31; 84%)

CBT (35; 33%) –Supportive (30; 28%) –MI (15; 14%) –Other (14; 13%)

–CBT (18; 51%) –Supportive (8; 22%) –MI (6; 15%) –Other (9; 24%)

–BPS/PPP first choice (80; 75%) –Multiaxial or narrative first choice (26; 25%) Comprehensive nature, overt treatment targets, humanistic patient description, etc. (not quantified) –1 or less patient every 6 months (57, 54%) –Under 10% of caseload (40, 40%)

–BPS/PPP first choice (23; 62%) –Multiaxial or narrative first choice (14; 38%) Comprehensive nature, overt treatment targets, humanistic patient description, etc. (not quantified)

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–1 or less patient every 6 months (20, 54%) –Under 10% of caseload (13, 36%)

Fig. 2. Results of preferred psychiatric PNES assessment style among therapists (n = 143). PNES: psychogenic nonepileptic seizures; BPS/PPP: biopsychosocial/“3 P's” assessment; CBT: cognitive–behavioral therapy; MI: motivational interviewing. *All therapist preference for BPS/PPP over either multiaxial or narrative: p b 0.001.

either multiaxial or narrative first (p b 0.0001; question 3). Reasons provided for preferring a BPS/PPP approach included its comprehensive nature, overt treatment targets, and humanistic patient description (question 4); these were open-ended questions and were not analyzed statistically. Of note, 54% of respondents stated they saw, managed, or treated unexplained neurological conditions such as conversion disorder or PNES very infrequently (defined as 1 or less patients every 6 months; question 5). 4. Discussion This sampling of community mental health psychotherapy practitioners indicates psychotherapist preference for the multidimensional BPS/PPP assessment approach. Such a preference carries implications for continuity of care; use of a BPS/PPP assessment may reduce patient psychotherapy noncompliance and/or high acute-care utilization if it minimizes confusion about diagnosis or goals of care. A secondary finding of this study is the low percentage of community psychotherapists engaged in treating patients with PNES; this may be due to patient variables (e.g., stigma related to mental health diagnosis and treatment, lack of motivation, investment in sick role identity, overly medicalized or somatic focus); therapist variables (e.g., insufficient experience with PNES due either to low PNES prevalence in the general population or lack of interest in this patient population); or systemic variables (e.g., lack of or inadequate referral mechanism from neurological to mental health settings and lack of adequate health-care coverage for psychotherapy services). Additionally, there may be discomfort in psychotherapists who are unfamiliar with the condition to offer PNES services. Our results imply increased willingness by psychotherapists to accept and/or successfully treat patients with PNES if accompanied by a multidimensional and nuanced assessment, as communicated by respondent comments valuing the information and background the BPS/PPP provides. This may be of value to neurologists and epilepsy services seeking to facilitate transfer of patients with PNES to community psychotherapists. Despite these findings, however, it remains unclear if a BPS/PPP assessment approach would actually enhance clinical outcomes as measured by psychotherapy treatment compliance or other markers. Understanding not only patient characteristics but also provider approaches and in-therapy processes that may influence treatment compliance remains critical. Unfortunately, although several studies have focused on PNES perceptions and attitudes by patients [7], physicians

[8], and entire epilepsy teams [9,10], very little attention has been directed at community psychotherapists. One study of a small group of therapists who had treated patients with PNES suggested that therapeutic success depended on adjusting their approach to the degree of trauma; these providers understood and tolerated high amounts of emotional dysregulation and affective displays of distress, conceptualizing the condition as a form of nonverbal communication requiring nuanced interpretation by the therapist [11]. Ultimately, however, the existing literature is largely silent on this dimension, suggesting an important component for future investigation. Our study carries certain limitations (small numbers, low response rate b 10%, a lack of clinical outcome correlation, and use of an unvalidated instrument involving a fictional clinical case, lack of knowledge of the various training backgrounds and degrees of the respondents). The low response rate in particular lends itself to response bias; it is unclear what motivated certain respondents to complete the study and what characteristics they possess when compared to those who did not respond. Low participation is an inherent challenge with any uncompensated, listserv-delivered survey study. Despite these weaknesses, this study is novel (in terms of sampling actively practicing, real-world community mental health clinicians) and achieved statistical significance in its findings while confirming our hypothesis. 5. Future directions Authors have previously described the many communication and system-based challenges faced in the evaluation and management of PNES as many clinicians are involved, including epileptologists and nursing staff presenting the diagnosis, emergency department professionals triaging patients presenting with seizure-like episodes, and consulting or treating mental health practitioners (psychiatrists, psychologists, psychotherapists, social workers) [6,12]. Adoption of a “common language” informed by the BPS/PPP approach to PNES assessment may enhance communication and understanding and is believed to improve the process of diagnosis and treatment as well as the patient–provider experience. Still, psychiatrists' acceptance of the BPS/PPP approach to PNES is far from complete, as evidenced by our first pilot and past reports of psychiatric skepticism regarding PNES [13], underutilization of the conversion disorder diagnostic construct [14], and gross underinvolvement in medically unexplained syndromes at large [15]. Future initiatives require proper training and education of mental health practitioners with

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multidimensional and biopsychosocial formulations of PNES (or even highly suspected but unconfirmed PNES), avoiding dualistic reductionism (“real versus nonreal seizures”) and offering nuanced psychosocial targets as proposed by the BPS/PPP approach. Such psychosocial considerations are likely to augment ongoing evaluation and treatment of patients with seizures regardless of whether episodes are ultimately classified as epileptic, nonepileptic, or both. In addition, attention must be paid to the degree of psychiatric consultant resources (time, personnel) needed to complete more robust assessments such as the BPS/PPP approach, determining whether such a model is practical or costeffective in our current models of care. With proper knowledge and training in the various psychosocial patterns seen in PNES [16,17], it is expected that evaluators would be equipped to complete a BPS/PPP assessment with only minimally additional time and effort, but this needs to be tested empirically. As mentioned in our pilot assessment [6], the BPS/ PPP approach may prove useful in other complex, medically unexplained conditions, including other functional neurological/conversion disorders or functional somatic disorders (e.g., fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome, atypical chest pain). Mental health practitioners as such should be equipped with a methodology for such conditions lacking robust biomarker confirmation. Alternatively, neurologists and epilepsy centers may choose to incorporate specialized team members (for example, a clinical psychologist) to implement standardized BPS/PPP assessments for their patients with PNES. Regardless of the approach adopted, substantial future work is needed in bridging the clinical, investigational, and academic gaps present in the care of patients with PNES. Acknowledgments We would like to acknowledge and thank both the National Association of Social Workers (Ohio Chapter) and the Ohio Counseling Association for graciously disseminating our survey study to its clinically active members. Disclosure On behalf of all authors, the corresponding author states that there is no conflict of interest.

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Bridging a clinical gap in psychogenic nonepileptic seizures: Mental health provider preferences of biopsychosocial assessment approaches.

Management of psychogenic nonepileptic seizures (PNES) is complex, requiring multidisciplinary care. A standardized assessment and formulation approac...
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