Epilepsy & Behavior 45 (2015) 164–168
Contents lists available at ScienceDirect
Epilepsy & Behavior journal homepage: www.elsevier.com/locate/yebeh
Brief Communication
Diagnostic assessment and case formulation in psychogenic nonepileptic seizures: A pilot comparison of approaches Xavier F. Jimenez a,⁎, Jocelyn F. Bautista b, George E. Tesar a, Youran Fan c,1 a b c
Department of Psychiatry and Psychology, Cleveland Clinic Foundation, USA Epilepsy Center, Cleveland Clinic Foundation, USA Department of Quantitative Health Sciences, Lerner Research Institute Cleveland Clinic, 9500 Euclid Avenue, JJ3-802, Cleveland, OH 44195
a r t i c l e
i n f o
Article history: Received 6 January 2015 Revised 29 January 2015 Accepted 1 February 2015 Available online 23 March 2015 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 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, it is unclear how this formulation style is perceived amongst clinicians. We predicted preference of a comprehensive, “BPS/PPP” assessment style by those most involved in PNES diagnosis and care (i.e., neurologists and psychologists). Sixty epileptologists, psychiatrists, and psychologists completed a survey featuring a fictional PNES case followed by assessment style options (“Multiaxial,” “Narrative,” and “BPS/PPP”). Epileptologists and psychologists (“nonpsychiatrists”) differed from psychiatrists in PNES case formulation choice, with nonpsychiatrists preferring the robust BPS/PPP approach and with psychiatrists opting for less comprehensive Multiaxial and Narrative assessments (p = 0.0009). Reasons for choosing the BPS/PPP by nonpsychiatrists included ease of organization, clear therapeutic goals, and comprehensive nature. Alternatively, psychiatrists cited time constraints and familiarity as reasons to prefer briefer Multiaxial or Narrative approaches. This pilot assessment of acceptability of a BPS/PPP approach to PNES case formulation, thus, reveals important gaps in formulation priorities between neurologists and psychiatrists. Implications and future directions are explored. © 2015 Elsevier Inc. All rights reserved.
1. Introduction Psychogenic nonepileptic seizures (PNES) are classified in DSM-5 as a conversion (or functional neurological) disorder characterized by paroxysmal episodes resembling epileptic seizures yet lacking electrical correlation as measured by the gold standard diagnostic approach, video-electroencephalography (v-EEG) [1]. Patients with PNES often present significant treatment challenges, with many hinging largely on patient acceptance of the diagnosis and the recommended treatment [2]. While a psychological basis for PNES has long been proposed [3,4], a wide range of nonspecific factors interact to cause PNES. A comprehensive multifactorial model that incorporates predisposing, precipitating, and perpetuating factors (the “3 Ps” or PPP) has been proposed to enhance the clinician's communication of the diagnosis and treatment to their patients with PNES [5]. Only a few of the many biopsychosocial (BPS) factors contributing to PNES include a history of childhood
⁎ 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). 1 Tel.: +216 444-9874
http://dx.doi.org/10.1016/j.yebeh.2015.02.001 1525-5050/© 2015 Elsevier Inc. All rights reserved.
adversity such as parental loss or sexual abuse (predisposing), adult life events or psychiatric comorbidity (precipitating), and fear-avoidance or dysfunctional family unit (perpetuating) [6]. Stone and Carson [7] have fused the BPS and PPP contributions into an assessment style conducive to robust case conceptualization. We propose that adoption of a “common language” informed by this multifactorial, etiologic, and pathomechanistic model of PNES will enhance communication within the multidisciplinary health-care team as well as between caregivers and patients. Improved communication and understanding are expected to result in further improvement of diagnosis, treatment, and both clinician and patient experiences. A first step in achieving this goal is to assess existing acceptability and utility of such a fused “BPS/PPP” case formulation model by clinicians currently involved in the care of patients with PNES (epileptologists, psychiatrists, psychiatry residents, and psychologists). We hypothesized higher preference for a nuanced, BPS/PPP formulation approach amongst those diagnosing PNES (epileptologists) and those treating PNES (behavioral health clinicians, particularly psychologists/therapists) when compared with those making the acute assessments (psychiatrists) and, thus, embarked on testing this premise. Further rationale regarding this purposeful yet seemingly arbitrary distinction between the “psychiatry” group and the “nonpsychiatry” group is elaborated in the Discussion section.
X.F. Jimenez et al. / Epilepsy & Behavior 45 (2015) 164–168
2. Methods The study was approved by the Institutional Review Board of the Cleveland Clinic Foundation. A completed survey indicated consent. An electronic survey consisting of a single case vignette followed by two questions was distributed to four cohorts of licensed independent practitioners at an academic medical center (Cleveland Clinic) with extensive epilepsy and consultation psychiatry services: 1) epilepsy clinicians (epileptologists, epilepsy fellows, and epilepsy advanced nurse practitioners; n = 30); 2) consultation psychiatry group (staff level psychiatrists with experience consulting on PNES; n = 19); 3) psychiatry trainee group (psychiatry residents; n = 30); and 4) psychologists (n = 20). The survey featured a fabricated clinical vignette of a typical patient with PNES on an EMU (Fig. 1). Respondents were
165
asked to rank in order of preference between three possible formulation approaches: Multiaxial, Narrative, and Biopsychosocial Psychiatric formulations (Fig. 1). Respondents were also asked to briefly explain the rationale for their choices. Both descriptive trends of the responses with use of percentages and Fisher exact test analysis of cohorts are presented. 3. Results Please see Fig. 2 for complete results and statistical analyses. The total response rate for the survey was 61% (60/99). The epilepsy clinicians (response rate: 73%, 22/30) preferred the BPS/PPP formulation (62%) over the Multiaxial (33%) and Narrative (5%) formulations; reasons for preferring the BPS/PPP formulation included comprehensive
Fig. 1. Sample PNES vignette case and formulation options presented in a survey.
166
X.F. Jimenez et al. / Epilepsy & Behavior 45 (2015) 164–168
Fig. 2. Results and statistical analyses.
nature, high detail, and explicit therapeutic targets. The staff psychiatry group (response rate: 64%, 12/19) preferred the Narrative formulation (50%) over the BPS/PPP (25%) and Multiaxial (25%) formulations; reasons for preferring the Narrative formulation included brevity and ease of comprehension. The psychiatry trainee group (response rate: 57%, 17/30) preferred the Multiaxial (41%) and Narrative (35%) formulations over the BPS/PPP (24%) formulation; reasons for preferring both the Multiaxial and Narrative formulations included ease of use, brevity, and familiarity. The psychologist group (response rate: 45%, 9/20) preferred the BPS/PPP (78%) formulation over the Narrative (11%) and Multiaxial (11%) formulations; reasons for preferring the BPS/PPP formulation include comprehensive nature, explicit therapeutic targets, and promotion of case conceptualization. Fisher exact test analysis reveals marked statistical significance (p = 0.0009) of preference for the BPS/PPP formulation over other formulations by nonpsychiatrists (epilepsy and psychologist) compared with psychiatrists (staff psychiatry and psychiatry trainee). 4. Discussion Although limited by small numbers, preliminary sampling of epileptologists, consultation psychiatrists, psychiatry residents, and
psychologists in one institution suggests varying priorities and preferences in the psychiatric formulation approach to PNES. Confirming our hypothesis, neurologists and psychologists appear to value the BPS/ PPP model, perhaps reflecting a need for clarity when attempting to manage such a complex condition. On the other hand, psychiatrists and psychiatric trainees preferred more traditional narrative and multiaxial approaches, respectively, out of practical concerns such as time and ease of use. This may reflect unfamiliarity with the BPS/PPP approach, one that has received little formal attention in psychiatric training or pedagogical models. Recognizing the many and varied limitations of this pilot (small samples, single institution, limited/fair response rate, lack of clinical outcome correlation, and unvalidated survey based on single, fictional case), we nonetheless consider these preliminary, statistically-significant patterns revealing of important training and clinical gaps. At a minimum, they suggest differences between the formulation expectations between neurologists, psychologists, and psychiatrists. Amongst the many challenges faced in the evaluation and management of PNES are system-based communication failures occurring commonly amongst health-care professionals involved, including epileptologists presenting the diagnosis; nursing staff on epilepsy monitoring units (EMUs); emergency department professionals triaging
X.F. Jimenez et al. / Epilepsy & Behavior 45 (2015) 164–168
patients presenting with seizures; and consulting or treating behavioral health-care clinicians (psychiatrists, psychologists, psychotherapists, and social workers) [8]. Each of these clinicians may (1) collude with a seemingly unconflicted/unstressed patient by resisting the PNES diagnosis and instead demanding further neurodiagnostic testing [9], (2) be unfamiliar with the treatment(s) required by such patients, or (3) be skilled at treating PNES but unable to form a therapeutic alliance with patients with particularly resistant seizures who may eventually be readmitted to the epilepsy monitoring unit for further “unnecessary” v-EEG monitoring. Examining the actual clinical process involved in PNES evaluation is relevant here, particularly in the interdisciplinary exchange between neurologists and psychiatrists. As epileptologists diagnosing PNES look to mental health referrals for aftercare, they are criticized at times for “dropping” these patients abruptly. Psychiatrists are in turn criticized for lacking any organized approach to PNES, with very little academic or clinical attention directed at the patient population. Authors have noted a complete lack of attention to conversion disorder or PNES in the American Psychiatric Association's public resources [10]. Historically, the DSM-IV somatoform disorders (now reclassified as somatic symptom disorders in DSM-5) met serious underuse as diagnostic constructs; in one recent study examining 28 million patients' insurance records, a mere 0.95% received a diagnosis of conversion disorder [11] despite the well-known much higher incidence of medically unexplained (including neurological) symptoms in clinical practice [12]. Recent calls for the “ideal” mental health provider involved in PNES evaluation suggest a practitioner embedded in EMUs and one comfortable with both PNES/conversion as well as other somatic symptom disorder diagnoses [1]. This is relatively unrealistic because of scarcity of mental health providers and the aforementioned lack of psychiatric clinical or training attention to somatic symptom disorders. Regardless, opposition to the PNES construct has been met even by those closely integrated with EMUs; a study revealed only 18% of queried psychiatrists deemed v-EEG accurate in diagnosing PNES “most of the time,” in contrast to 70% of neurologists feeling very confident in the test [4]. The authors suggest potential suspicion amongst psychiatrists of neurologists' intentions when consulting for PNES evaluations, citing fear of patient “dumping” onto psychiatric services. This aversion may occur despite the fact that many patients with PNES would benefit from solely psychotherapeutic interventions and referrals, adding little to no burden on acute-level consultation psychiatrists and their practices. Ultimately, however, patients with PNES experience poor care transitioning and remain “unclaimed” by any practitioners [13]. Recommendations call for both neurologists and mental health providers to remain involved in PNES aftercare [1,6–8], though it is unclear how often this ideal collaboration actually occurs. Although patient variables are also at play, including, in some cases, lack of motivation, investment in sick role identities, intractable family situations, and secondary gain, these are, nonetheless, issues to weave into the multidimensional BPS assessment of PNES, with themselves serving as potential targets for therapeutic intervention. 5. PNES case formulation Currently, the dominant case formulation process within the practice of psychiatry is the Multiaxial DSM-IV (and now, DSM-5) approach, which involves a linear listing of psychiatric diagnoses, personality disorders/traits, medical comorbidities, psychosocial stressors, and a global assessment of functioning [14]. Other common approaches to formulation include basic narrative assessments in paragraph form. Given both the BPS complexity of PNES and the aim of such psychiatric evaluations to guide future therapeutics, the multiaxial and narrative approaches seem inadequately simplistic. As mentioned, Reuber et al. [5] identified a number of predisposing (trauma and abuse), precipitating (bereavement/loss, social/family conflict, and health issues), and perpetuating (affective disorders, financial/
167
social gain, health issues, and bereavement/loss) factors contributing to symptoms in a group of patients with PNES. Reuber later [6] provided diagrammatic depictions of the 3P approach as well as clinical vignette examples with sample formulations. These formulations are arranged in a narrative form, listing the 3 Ps as well as “triggers.” This approach is valuable and comprehensive yet potentially cumbersome for psychiatrists and trainees accustomed to more linear approaches (such as the multiaxial method). Stone and Carson [7] have presented the biaxial BPS and 3P contributions as a potential formulation method. Case conceptualization is, thus, visually facilitated by boxes that ask for the evaluator to deliberately consider each of the many BPS and 3P variables at play in PNES (see Fig. 2 for our rendition of this). Despite the visual appeal of such a system, testing of its acceptability amongst actual clinical stakeholders had not been performed prior to this pilot assessment. 6. Future directions In summary, differences in preference for psychiatric case formulation type for PNES may be explained by persistently poor understanding of PNES risk factors, psychiatric training gaps, strong aversion to patients with PNES (or the neurologists referring them), clinical doubt, or a combination of these factors. We intend to extend this pilot assessment within our EMU to standardize case formulation of patients with PNES. Further, we hope to sample other EMUs and examine for generalizability of results. In addition, we aim to assess ambulatory psychotherapists and other mental health providers regarding their preference of formulation type, as many therapists receiving PNES referrals may feel at odds as to how to proceed in their care. Examining any differences in outcomes from mental health aftercare between referrals utilizing a BPS/PPP conceptualization versus other formulation styles may also prove informative. Simultaneously, attention must be paid to the amount of psychiatric consultant time and effort needed to complete more robust assessments such as the BPS/PPP approach, determining whether such a model is practical or sustainable in our current models of care. If results are consistent amongst the various clinical stakeholders, educational and training initiatives should follow, particularly amongst psychiatric trainees and also neurologists and epileptologists. Ultimately, the BPS/PPP approach may prove useful in other medically unexplained conditions, including other functional neurological/conversion disorders or functional somatic disorders (fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome, and atypical chest pain) managed in various other medical arenas. Disclosure On behalf of all authors, the corresponding author states that there is no conflict of interest. References [1] LaFrance WC, Reuber M, Goldstein LH. Management of psychogenic nonepileptic seizures. Epilepsia 2013;45(Suppl. 1):53–67. [2] Carton S, Thompson PJ, Duncan JS. Nonepileptic seizures: patients' understanding and reaction to the diagnosis and impact on outcome. Seizure 2003;12:287–94. [3] Moore PM, Baker GA. Non-epileptic attack disorder: a psychological perspective. Seizure 1997;6:429–34. [4] Bowman ES, Markand ON. Psychodynamics and psychiatric diagnoses of pseudoseizure subjects. Am J Psychiatry 1996;153:57–63. [5] Reuber M, Howlett S, Khan A, Grunewald RA. Non-epileptic seizures and other functional neurological symptoms: predisposing, precipitating, and perpetuating factors. Psychosomatics 2007;48(3):230–8. [6] Reuber M. The etiology of psychogenic non-epileptic seizures: toward a biopsychosocial model. Neurol Clin 2009;27:909–92. [7] Stone J, Carson A. Functional neurologic symptoms: assessment and management. Neurol Clin 2011;29:1–18. [8] Smith BJ. Closing the major gap in PNES research. Epilepsy Curr 2014;14(2):63–7. [9] Harden CL, Burgut FT, Kanner AM. The diagnostic significance of video-EEG monitoring findings on pseudoseizure patients differs between neurologists and psychiatrists. Epilepsia 2003;44(3):453–6.
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[10] Benbadis SR. The problem of psychogenic symptoms: is the psychiatric community in denial? Epilepsy Behav 2005;6:9–14. [11] Levenson J. The somatoform disorders: 6 characters in search of an author. Psychiatr Clin N Am 2011;34(3):515–24. [12] Steinbrecher N, Koerber S, Frieser D, Hiller W. The prevalence of medically unexplained symptoms in primary care. Psychosomatics 2011;52(3):263–71.
[13] LaFrance WC, Devinsky O. The treatment of nonepileptic seizures: historical perspective and future directions. Epilepsia 2004;45(Suppl. 2):15–21. [14] American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013[Web, access date: 1 June 2013, dsm.psychiatryonline.org].
Contents lists available at ScienceDirect
Epilepsy & Behavior journal homepage: www.elsevier.com/locate/yebeh
Brief Communication
Diagnostic assessment and case formulation in psychogenic nonepileptic seizures: A pilot comparison of approaches Xavier F. Jimenez a,⁎, Jocelyn F. Bautista b, George E. Tesar a, Youran Fan c,1 a b c
Department of Psychiatry and Psychology, Cleveland Clinic Foundation, USA Epilepsy Center, Cleveland Clinic Foundation, USA Department of Quantitative Health Sciences, Lerner Research Institute Cleveland Clinic, 9500 Euclid Avenue, JJ3-802, Cleveland, OH 44195
a r t i c l e
i n f o
Article history: Received 6 January 2015 Revised 29 January 2015 Accepted 1 February 2015 Available online 23 March 2015 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 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, it is unclear how this formulation style is perceived amongst clinicians. We predicted preference of a comprehensive, “BPS/PPP” assessment style by those most involved in PNES diagnosis and care (i.e., neurologists and psychologists). Sixty epileptologists, psychiatrists, and psychologists completed a survey featuring a fictional PNES case followed by assessment style options (“Multiaxial,” “Narrative,” and “BPS/PPP”). Epileptologists and psychologists (“nonpsychiatrists”) differed from psychiatrists in PNES case formulation choice, with nonpsychiatrists preferring the robust BPS/PPP approach and with psychiatrists opting for less comprehensive Multiaxial and Narrative assessments (p = 0.0009). Reasons for choosing the BPS/PPP by nonpsychiatrists included ease of organization, clear therapeutic goals, and comprehensive nature. Alternatively, psychiatrists cited time constraints and familiarity as reasons to prefer briefer Multiaxial or Narrative approaches. This pilot assessment of acceptability of a BPS/PPP approach to PNES case formulation, thus, reveals important gaps in formulation priorities between neurologists and psychiatrists. Implications and future directions are explored. © 2015 Elsevier Inc. All rights reserved.
1. Introduction Psychogenic nonepileptic seizures (PNES) are classified in DSM-5 as a conversion (or functional neurological) disorder characterized by paroxysmal episodes resembling epileptic seizures yet lacking electrical correlation as measured by the gold standard diagnostic approach, video-electroencephalography (v-EEG) [1]. Patients with PNES often present significant treatment challenges, with many hinging largely on patient acceptance of the diagnosis and the recommended treatment [2]. While a psychological basis for PNES has long been proposed [3,4], a wide range of nonspecific factors interact to cause PNES. A comprehensive multifactorial model that incorporates predisposing, precipitating, and perpetuating factors (the “3 Ps” or PPP) has been proposed to enhance the clinician's communication of the diagnosis and treatment to their patients with PNES [5]. Only a few of the many biopsychosocial (BPS) factors contributing to PNES include a history of childhood
⁎ 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). 1 Tel.: +216 444-9874
http://dx.doi.org/10.1016/j.yebeh.2015.02.001 1525-5050/© 2015 Elsevier Inc. All rights reserved.
adversity such as parental loss or sexual abuse (predisposing), adult life events or psychiatric comorbidity (precipitating), and fear-avoidance or dysfunctional family unit (perpetuating) [6]. Stone and Carson [7] have fused the BPS and PPP contributions into an assessment style conducive to robust case conceptualization. We propose that adoption of a “common language” informed by this multifactorial, etiologic, and pathomechanistic model of PNES will enhance communication within the multidisciplinary health-care team as well as between caregivers and patients. Improved communication and understanding are expected to result in further improvement of diagnosis, treatment, and both clinician and patient experiences. A first step in achieving this goal is to assess existing acceptability and utility of such a fused “BPS/PPP” case formulation model by clinicians currently involved in the care of patients with PNES (epileptologists, psychiatrists, psychiatry residents, and psychologists). We hypothesized higher preference for a nuanced, BPS/PPP formulation approach amongst those diagnosing PNES (epileptologists) and those treating PNES (behavioral health clinicians, particularly psychologists/therapists) when compared with those making the acute assessments (psychiatrists) and, thus, embarked on testing this premise. Further rationale regarding this purposeful yet seemingly arbitrary distinction between the “psychiatry” group and the “nonpsychiatry” group is elaborated in the Discussion section.
X.F. Jimenez et al. / Epilepsy & Behavior 45 (2015) 164–168
2. Methods The study was approved by the Institutional Review Board of the Cleveland Clinic Foundation. A completed survey indicated consent. An electronic survey consisting of a single case vignette followed by two questions was distributed to four cohorts of licensed independent practitioners at an academic medical center (Cleveland Clinic) with extensive epilepsy and consultation psychiatry services: 1) epilepsy clinicians (epileptologists, epilepsy fellows, and epilepsy advanced nurse practitioners; n = 30); 2) consultation psychiatry group (staff level psychiatrists with experience consulting on PNES; n = 19); 3) psychiatry trainee group (psychiatry residents; n = 30); and 4) psychologists (n = 20). The survey featured a fabricated clinical vignette of a typical patient with PNES on an EMU (Fig. 1). Respondents were
165
asked to rank in order of preference between three possible formulation approaches: Multiaxial, Narrative, and Biopsychosocial Psychiatric formulations (Fig. 1). Respondents were also asked to briefly explain the rationale for their choices. Both descriptive trends of the responses with use of percentages and Fisher exact test analysis of cohorts are presented. 3. Results Please see Fig. 2 for complete results and statistical analyses. The total response rate for the survey was 61% (60/99). The epilepsy clinicians (response rate: 73%, 22/30) preferred the BPS/PPP formulation (62%) over the Multiaxial (33%) and Narrative (5%) formulations; reasons for preferring the BPS/PPP formulation included comprehensive
Fig. 1. Sample PNES vignette case and formulation options presented in a survey.
166
X.F. Jimenez et al. / Epilepsy & Behavior 45 (2015) 164–168
Fig. 2. Results and statistical analyses.
nature, high detail, and explicit therapeutic targets. The staff psychiatry group (response rate: 64%, 12/19) preferred the Narrative formulation (50%) over the BPS/PPP (25%) and Multiaxial (25%) formulations; reasons for preferring the Narrative formulation included brevity and ease of comprehension. The psychiatry trainee group (response rate: 57%, 17/30) preferred the Multiaxial (41%) and Narrative (35%) formulations over the BPS/PPP (24%) formulation; reasons for preferring both the Multiaxial and Narrative formulations included ease of use, brevity, and familiarity. The psychologist group (response rate: 45%, 9/20) preferred the BPS/PPP (78%) formulation over the Narrative (11%) and Multiaxial (11%) formulations; reasons for preferring the BPS/PPP formulation include comprehensive nature, explicit therapeutic targets, and promotion of case conceptualization. Fisher exact test analysis reveals marked statistical significance (p = 0.0009) of preference for the BPS/PPP formulation over other formulations by nonpsychiatrists (epilepsy and psychologist) compared with psychiatrists (staff psychiatry and psychiatry trainee). 4. Discussion Although limited by small numbers, preliminary sampling of epileptologists, consultation psychiatrists, psychiatry residents, and
psychologists in one institution suggests varying priorities and preferences in the psychiatric formulation approach to PNES. Confirming our hypothesis, neurologists and psychologists appear to value the BPS/ PPP model, perhaps reflecting a need for clarity when attempting to manage such a complex condition. On the other hand, psychiatrists and psychiatric trainees preferred more traditional narrative and multiaxial approaches, respectively, out of practical concerns such as time and ease of use. This may reflect unfamiliarity with the BPS/PPP approach, one that has received little formal attention in psychiatric training or pedagogical models. Recognizing the many and varied limitations of this pilot (small samples, single institution, limited/fair response rate, lack of clinical outcome correlation, and unvalidated survey based on single, fictional case), we nonetheless consider these preliminary, statistically-significant patterns revealing of important training and clinical gaps. At a minimum, they suggest differences between the formulation expectations between neurologists, psychologists, and psychiatrists. Amongst the many challenges faced in the evaluation and management of PNES are system-based communication failures occurring commonly amongst health-care professionals involved, including epileptologists presenting the diagnosis; nursing staff on epilepsy monitoring units (EMUs); emergency department professionals triaging
X.F. Jimenez et al. / Epilepsy & Behavior 45 (2015) 164–168
patients presenting with seizures; and consulting or treating behavioral health-care clinicians (psychiatrists, psychologists, psychotherapists, and social workers) [8]. Each of these clinicians may (1) collude with a seemingly unconflicted/unstressed patient by resisting the PNES diagnosis and instead demanding further neurodiagnostic testing [9], (2) be unfamiliar with the treatment(s) required by such patients, or (3) be skilled at treating PNES but unable to form a therapeutic alliance with patients with particularly resistant seizures who may eventually be readmitted to the epilepsy monitoring unit for further “unnecessary” v-EEG monitoring. Examining the actual clinical process involved in PNES evaluation is relevant here, particularly in the interdisciplinary exchange between neurologists and psychiatrists. As epileptologists diagnosing PNES look to mental health referrals for aftercare, they are criticized at times for “dropping” these patients abruptly. Psychiatrists are in turn criticized for lacking any organized approach to PNES, with very little academic or clinical attention directed at the patient population. Authors have noted a complete lack of attention to conversion disorder or PNES in the American Psychiatric Association's public resources [10]. Historically, the DSM-IV somatoform disorders (now reclassified as somatic symptom disorders in DSM-5) met serious underuse as diagnostic constructs; in one recent study examining 28 million patients' insurance records, a mere 0.95% received a diagnosis of conversion disorder [11] despite the well-known much higher incidence of medically unexplained (including neurological) symptoms in clinical practice [12]. Recent calls for the “ideal” mental health provider involved in PNES evaluation suggest a practitioner embedded in EMUs and one comfortable with both PNES/conversion as well as other somatic symptom disorder diagnoses [1]. This is relatively unrealistic because of scarcity of mental health providers and the aforementioned lack of psychiatric clinical or training attention to somatic symptom disorders. Regardless, opposition to the PNES construct has been met even by those closely integrated with EMUs; a study revealed only 18% of queried psychiatrists deemed v-EEG accurate in diagnosing PNES “most of the time,” in contrast to 70% of neurologists feeling very confident in the test [4]. The authors suggest potential suspicion amongst psychiatrists of neurologists' intentions when consulting for PNES evaluations, citing fear of patient “dumping” onto psychiatric services. This aversion may occur despite the fact that many patients with PNES would benefit from solely psychotherapeutic interventions and referrals, adding little to no burden on acute-level consultation psychiatrists and their practices. Ultimately, however, patients with PNES experience poor care transitioning and remain “unclaimed” by any practitioners [13]. Recommendations call for both neurologists and mental health providers to remain involved in PNES aftercare [1,6–8], though it is unclear how often this ideal collaboration actually occurs. Although patient variables are also at play, including, in some cases, lack of motivation, investment in sick role identities, intractable family situations, and secondary gain, these are, nonetheless, issues to weave into the multidimensional BPS assessment of PNES, with themselves serving as potential targets for therapeutic intervention. 5. PNES case formulation Currently, the dominant case formulation process within the practice of psychiatry is the Multiaxial DSM-IV (and now, DSM-5) approach, which involves a linear listing of psychiatric diagnoses, personality disorders/traits, medical comorbidities, psychosocial stressors, and a global assessment of functioning [14]. Other common approaches to formulation include basic narrative assessments in paragraph form. Given both the BPS complexity of PNES and the aim of such psychiatric evaluations to guide future therapeutics, the multiaxial and narrative approaches seem inadequately simplistic. As mentioned, Reuber et al. [5] identified a number of predisposing (trauma and abuse), precipitating (bereavement/loss, social/family conflict, and health issues), and perpetuating (affective disorders, financial/
167
social gain, health issues, and bereavement/loss) factors contributing to symptoms in a group of patients with PNES. Reuber later [6] provided diagrammatic depictions of the 3P approach as well as clinical vignette examples with sample formulations. These formulations are arranged in a narrative form, listing the 3 Ps as well as “triggers.” This approach is valuable and comprehensive yet potentially cumbersome for psychiatrists and trainees accustomed to more linear approaches (such as the multiaxial method). Stone and Carson [7] have presented the biaxial BPS and 3P contributions as a potential formulation method. Case conceptualization is, thus, visually facilitated by boxes that ask for the evaluator to deliberately consider each of the many BPS and 3P variables at play in PNES (see Fig. 2 for our rendition of this). Despite the visual appeal of such a system, testing of its acceptability amongst actual clinical stakeholders had not been performed prior to this pilot assessment. 6. Future directions In summary, differences in preference for psychiatric case formulation type for PNES may be explained by persistently poor understanding of PNES risk factors, psychiatric training gaps, strong aversion to patients with PNES (or the neurologists referring them), clinical doubt, or a combination of these factors. We intend to extend this pilot assessment within our EMU to standardize case formulation of patients with PNES. Further, we hope to sample other EMUs and examine for generalizability of results. In addition, we aim to assess ambulatory psychotherapists and other mental health providers regarding their preference of formulation type, as many therapists receiving PNES referrals may feel at odds as to how to proceed in their care. Examining any differences in outcomes from mental health aftercare between referrals utilizing a BPS/PPP conceptualization versus other formulation styles may also prove informative. Simultaneously, attention must be paid to the amount of psychiatric consultant time and effort needed to complete more robust assessments such as the BPS/PPP approach, determining whether such a model is practical or sustainable in our current models of care. If results are consistent amongst the various clinical stakeholders, educational and training initiatives should follow, particularly amongst psychiatric trainees and also neurologists and epileptologists. Ultimately, the BPS/PPP approach may prove useful in other medically unexplained conditions, including other functional neurological/conversion disorders or functional somatic disorders (fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome, and atypical chest pain) managed in various other medical arenas. Disclosure On behalf of all authors, the corresponding author states that there is no conflict of interest. References [1] LaFrance WC, Reuber M, Goldstein LH. Management of psychogenic nonepileptic seizures. Epilepsia 2013;45(Suppl. 1):53–67. [2] Carton S, Thompson PJ, Duncan JS. Nonepileptic seizures: patients' understanding and reaction to the diagnosis and impact on outcome. Seizure 2003;12:287–94. [3] Moore PM, Baker GA. Non-epileptic attack disorder: a psychological perspective. Seizure 1997;6:429–34. [4] Bowman ES, Markand ON. Psychodynamics and psychiatric diagnoses of pseudoseizure subjects. Am J Psychiatry 1996;153:57–63. [5] Reuber M, Howlett S, Khan A, Grunewald RA. Non-epileptic seizures and other functional neurological symptoms: predisposing, precipitating, and perpetuating factors. Psychosomatics 2007;48(3):230–8. [6] Reuber M. The etiology of psychogenic non-epileptic seizures: toward a biopsychosocial model. Neurol Clin 2009;27:909–92. [7] Stone J, Carson A. Functional neurologic symptoms: assessment and management. Neurol Clin 2011;29:1–18. [8] Smith BJ. Closing the major gap in PNES research. Epilepsy Curr 2014;14(2):63–7. [9] Harden CL, Burgut FT, Kanner AM. The diagnostic significance of video-EEG monitoring findings on pseudoseizure patients differs between neurologists and psychiatrists. Epilepsia 2003;44(3):453–6.
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X.F. Jimenez et al. / Epilepsy & Behavior 45 (2015) 164–168
[10] Benbadis SR. The problem of psychogenic symptoms: is the psychiatric community in denial? Epilepsy Behav 2005;6:9–14. [11] Levenson J. The somatoform disorders: 6 characters in search of an author. Psychiatr Clin N Am 2011;34(3):515–24. [12] Steinbrecher N, Koerber S, Frieser D, Hiller W. The prevalence of medically unexplained symptoms in primary care. Psychosomatics 2011;52(3):263–71.
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