FULL-LENGTH ORIGINAL RESEARCH

Brief group psychoeducation for psychogenic nonepileptic

seizures: A neurologist-initiated program in an epilepsy
center
*†David K. Chen, *Atul Maheshwari, †Romay Franks, ‡Gregory C. Trolley, §Jordan S. Robinson,
and *†Richard A. Hrachovy

Epilepsia, 55(1):156–166, 2014

doi: 10.1111/epi.12481

David K. Chen is
Assistant Professor of
Neurology at Baylor
College of Medicine.
SUMMARY
Objective: To evaluate therapeutic efficacy upon augmenting the initial communica-
tion to patients regarding the diagnosis of psychogenic nonepileptic seizures (PNES)
with a novel, brief group psychoeducation administered by the same team that pro-
vided the video–electroencephalography (VEEG) confirmed diagnosis and within
4 weeks of the diagnosis.
Methods: Prior to discharge from the epilepsy monitoring unit (EMU), a standardized
communication strategy was utilized to explain the diagnosis of PNES to all patients
prior to enrollment. Enrolled patients were then randomized to either participation in
three successive and monthly group psychoeducational sessions (intervention group),
or routine seizure clinic follow-up visits (control group). Both groups completed ques-
tionnaires at time of enrollment, and then at approximately 3 months (follow-up 1) and
6 months (follow-up 2) after discharge, assessing for: (1) primary outcomes that include
a measure of psychosocial functioning, as well as interval difference in seizure frequency/
intensity; and (2) secondary outcomes that include interval seizure-related emergency
room visits or hospitalizations, development of new and medically unexplained symp-
toms, and results of an internal measure of knowledge and perception outcomes.
Results: The majority (73%) of patients from the intervention group commenced on
therapy sessions within 4 weeks after learning of the diagnosis. Although we did not
observe significant group difference in seizure frequency/intensity, patients from the
intervention group showed significant improvement on the Work and Social Adjust-
ment Scale (WSAS) scores at both follow-up 1 (p = 0.013) and follow-up 2 (p = 0.038)
after discharge from the EMU. In addition, we observed a trend toward lesser likeli-
hood for seizure-related emergency room visits or hospitalizations for the interven-
tion group (p = 0.184), as well as meaningful insights from an internal measure of
intervention outcomes.
Significance: These findings suggest that our cost/resource effective, brief group psy-
choeducational program, when administered early and by the same team who con-
firmed and communicated the diagnosis of PNES, may contribute to significant
functional improvement among participating patients.
KEY WORDS: Psychogenic nonepileptic seizures, Psychotherapy, Psychoeducation,
Work and Social Adjustment Scale, Psychosocial functioning.

Accepted October 16, 2013; Early View publication December 20, 2013.
*Peter Kellaway Section of Neurophysiology, Department of Neurology, Baylor College of Medicine, Houston, Texas, U.S.A.; †Neurology Care Line,
Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, U.S.A.; ‡Department of Neurology, Baylor College of Medicine, Houston, Texas,
U.S.A.; and §Department of Psychology and Behavioral Sciences, Baylor College of Medicine, Mental Health Care Line, Michael E. DeBakey Veterans
Affairs Medical Center, Houston, Texas,U.S.A.
Address correspondence to David K. Chen, MEDVAMC, 2002 Holcombe Blvd., NCL 127, Houston, TX 77030, U.S.A. E-mail: dkchen@bcm.edu
Wiley Periodicals, Inc.
© 2013 International League Against Epilepsy

156

Psychogenic nonepileptic seizures (PNES) are neurobe-
havioral paroxysms that, although resembling epileptic sei-
zures, are thought to emerge from psychopathologic
etiologies rather than abnormal electrical discharges in the
brain. These paroxysms are typically confirmed in the epi-
lepsy monitoring unit (EMU) based on a combination of the
patient’s historical presentation, event semiology, and
video-electroencephalography (VEEG) recording data.1,2
Upon VEEG confirmation, the explanation of the diagno-
sis of PNES by the neurologist represents an important ini-
tial “stepping stone” in the treatment of PNES, without
which the patient cannot determinately pursue mental health
treatments. Explanations with the support of VEEG results
and from seizure experts may be more influential, as
patients with PNES are paradoxically more likely to resist
the consideration of stress or emotional factors as the cause
of seizures than patients with epilepsy.3 When this explana-
tion is appropriately communicated, the patient’s accep-
tance of the PNES diagnosis can influence the outcome,
sometimes even without additional intervention.4–7 How-
ever, unless the EMU is concurrently staffed by mental
health therapists, the therapeutic impact gained from this
initial diagnostic alliance may diminish as the patient is
referred to outside, unaffiliated institutions for mental
health intervention, often with significant time delay.
Indeed, interventions for PNES provided by psychothera-
pists who are affiliated with a comprehensive epilepsy cen-
ter, when compared to those who are not, have been shown
to yield superior outcomes.8 Motivated by these observa-
tions, we pursued this study to evaluate the potential benefit
when an epilepsy center plays a greater role in the initiation
of preliminary treatment for patients with newly diagnosed
PNES.
Pilot studies have shown promising benefit of individ-
ual cognitive behavioral therapy (CBT) in reducing event
frequency of patients with PNES.9–11 Although this indi-
vidual-based treatment approach may be effective, CBT
requires a significant dedication of time and effort from
both the therapist and patient, requiring typically 9–12
sessions over a period of months for each patient.9 This
resource-intensive and costly intervention may frequently
not be available to patients of lower socioeconomic status
with more limited insurance benefits or resources—the
predominant demographics of patients with PNES.12 It is
therefore not uncommon for these patients to feel “aban-
doned” from both neurologists who are unable to ade-
quately manage the patients’ psychiatric conditions, and
mental health specialists who cannot sufficiently manage
the patients given constraints of the health care delivery
system.
The group-based treatment approach takes advantage of
an economy-of-scale principle to expand the treating
capacity of the therapist who allies group members in the
counseling process. In addition to being cost/resource
157
Brief Group Psychoeducation for PNES
effective, several pilot group therapy studies for PNES
have shown favorable results in terms of either reduced
PNES frequency, enhanced functionality/coping, or dimin-
ished somatic preoccupation.13–16 A limitation, however,
is that none of these group therapy studies utilized ran-
domized controlled methodology in their investigation.
Building on these studies, we pursued a pilot randomized
controlled study of a neurologist-initiated, group interven-
tional program with the goals of improving overall func-
tionality in patients with PNES and/or reducing seizure
frequency/intensity. More specifically, we aimed to
enhance the initial impact from the patient’s learning of
the diagnosis of PNES with a novel, brief group psycho-
education administered by the same team that provided
the VEEG-confirmed diagnosis and within 4 weeks of the
diagnosis.
Methods
Enrollment
We prospectively recruited patients who were admitted
to the epilepsy monitoring unit (EMU) of the Michael E.
DeBakey VA Medical Center from June 2011 through Octo-
ber 2012. To be eligible for inclusion, patients must have
demonstrated VEEG-confirmed nonepileptic events of
interest, which were interpreted to be of psychogenic origin
based on combined features of ictal semiology, psychoso-
cial history, and the results from psychological screening
instruments.
The following exclusion criteria were also applied: (1)
main place of dwelling beyond commutable distance
(patients referred from outside VA medical centers); (2) sus-
pected mixed disorder of PNES and epilepsy (patients with
prior EEG documentation of electrographic seizures or inte-
rictal epileptiform abnormalities); and, (3) Mini-Mental
Status Exam score of <25, when assessed during the EMU
admission.
Prior to enrollment, explanation of the diagnosis of PNES
utilizing a standardized communication strategy was con-
veyed to all patients by the same physician (DKC). We
employed a modified Shen protocol,17,18 emphasizing the
following points: (1) Attacks are not epileptic. (2) Attacks
have a psychogenic cause. (3) Having a psychogenic cause
in no way implies that the patient has sole blame. (4) Inter-
nalized or suppressed conflicts are frequently the driving
forces behind these events. (5) Acceptance of self-responsi-
bility toward progress will be instrumental in achieving
event control (internalizing locus of control).
Upon obtaining informed consent, patients were then
given an initial set of questionnaires to establish baseline
measures that were analogous to subsequent outcome
measures (see below). Consecutively in the order of
enrollment, patients were each independently designated a
computer generated random number whereupon even
Epilepsia, 55(1):156–166, 2014
doi: 10.1111/epi.12481
158
D. K. Chen et al.
number patients were assigned to receive the study inter-
vention, while odd number patients were assigned to the
nonintervention group. All patients were instructed to
carefully document further breakthrough seizures on stan-
dardized event logs.
Brief group psychoeducation (intervention)
Patients allocated to the study intervention underwent a
novel, abbreviated treatment program consisting of three
successive monthly, 1.5 h long group sessions. Patients’
significant others were also encouraged to attend, as opti-
mizing family’s support may be an important treatment tar-
get to enhance coping.13,19 The first session was conducted
in lecture-based format, dedicated to enhancing the under-
standing of PNES and specifically emphasized: (1) the con-
cept that PNES, in themselves, pose no harm to the brain
and other systemic organs; (2) proper safety measures can
effectively minimize risk of bodily injury from PNES; and
(3) the universality of PNES as a condition shared by fellow
group members. These concepts aim to promote the accep-
tance of PNES as legitimate but manageable behavioral dis-
ruptions, rather than as exasperating, life-threatening
events. This initial lecture-based session was offered once
per month to newly enrolled patients with recent VEEG
confirmed diagnosis of PNES. Participants were reminded
of the prescribed two subsequent monthly group sessions as
part of the study protocol, whereupon psychoeducation is
provided through support group format. Of the patients who
participated in our intervention, 73% of these patients
attended this first session within 4 weeks after the VEEG-
confirmed diagnosis of PNES.
During the subsequent support group session no. 1, the
group facilitator directed discussions to underscore the
theme regarding how physical manifestations can fre-
quently arise from underlying emotional causes (e.g., stress
ulcers, stage fright). Correspondingly, emphasis was placed
on group discussions pertaining to the recognition of event
trigger, creating a stress journal, and importance of allocat-
ing constructive channels for release of stress. Sharing of
personal experiences, including previously utilized effec-
tive or ineffective strategies, was encouraged from the
group members.
For support group session no. 2, a second theme was
discussed that focused on empowering patients to take
active roles toward their own recovery. This theme was
highlighted by instructions on distress tolerance tech-
niques (e.g., going to a safe place mentally when
stressed), avoiding or altering event triggers, and alloca-
tion of set daily schedules for relaxation exercises and
daytime naps. Sharing of personal stress management/cop-
ing strategies was again encouraged from group members.
If seizures occurred during any of these sessions, the
group was instructed to assume a neutral attitude by
accepting these events as “expected” reactions, and re-
direct attention back to the discussion of the topics at
Epilepsia, 55(1):156–166, 2014
doi: 10.1111/epi.12481
hand. The goals of this approach were to minimize atten-
tional gain from PNES, mitigate the natural trepidation
when confronted with PNES, and emphasize capability
for continued normal activity despite PNES. Like the ini-
tial lecture-based session, a support group session was
offered on a monthly basis, whereupon the first or second
theme was alternately emphasized during each month’s
session. Patients exited the intervention portion of the
study on a continuously rolling basis after having partici-
pated in a support group that discussed theme 1 and
another support group that discussed theme 2 in either
order (i.e., completing three therapy sessions in total).
Among the patients who attended all three therapy ses-
sions of the study protocol, 65% of them completed the
intervention within 3 months, whereas 35% of them com-
pleted the intervention within 5 months. Typical atten-
dance to each session ranged between 3 and 10
participants (including family members).
The lecture-based and support group sessions were led by
either a neurologist (DKC) or a neurology nurse practitioner
(RF), both of whom have had prior exposures to provision
of group psychoeducation, as well as substantial experi-
ences working with patients with PNES.
Nonintervention assignment (control)
Upon discharge from the EMU, patients returned to our
VA seizure clinics (staffed by DKC, RF, or RAH) for fol-
low-up visits after around 3 months, and then again after
around 6 months. Requests for more frequent follow-up
visits related to worsening of PNES were discouraged so
as to avoid rewarding the illness behavior. Emphasis dur-
ing these visits was placed on conceptual iteration of the
psychological origin for PNES. This concept was rein-
forced by supervised and gradual withdrawal of antiepi-
leptic drug, if applicable. Referrals to mental health
services were offered to patients who had not yet engaged
in these services. Supportive roles serving to consolidate
therapeutic alliances were also emphasized. Whenever
appropriate, referrals to social workers, case managers, or
physical/occupational/vocational rehabilitation services
were pursued.
Outcome measures
For the intervention group, outcome measures were
administered at the completion of all three therapy sessions
(i.e., follow-up 1, immediately at the end of each patient’s
second support group session, between 3 and 5 months after
discharge from EMU), and then again at 3 months after the
completion of the intervention (i.e., follow-up 2, between 6
and 8 months after discharge from EMU). For the control
group, outcome measures were administered near the end of
the first postdischarge seizure clinic visits at 3–5 months
(follow-up 1), and then again near end of the second seizure
clinic visits at 6–8 months (follow-up 2) after discharge
from EMU. Primary outcome measures included the follow-

ing: (1) scores from the Work and Social Adjustment Scale
(WSAS), a five item measure designed to assess impairment
of psychosocial functioning20 (refer to Appendix 1); and (2)
assessments of patients’ perceived progress regarding (a)
event frequency and (b) event intensity since EMU dis-
charge. Patients were encouraged to refer to their standard-
ized event logs when providing their responses. Patients’
responses to (a) and (b) were scored on a Likert scale, with
“1 being much worse – more than twice as bad as before,”
“2 being worse – about twice as bad as before,” “3 being
same as before,” “4 being better – about half as much as
before,” and “5 being much better – less than half as much
as before.”
Three secondary outcomes were measured. (1) We eval-
uated for any additional PNES-related emergency room
visits or hospitalizations during the follow-up interval
(based upon patients’ self-reporting, followed by chart-
review confirmation). (2) We inquired regarding the devel-
opment of any new and disabling symptoms for which
causes have not been readily explained medically (based
upon patients’ self-reporting, followed by chart-review
confirmation). (3) Finally, we analyzed the results of an
internal measure of knowledge and perception, which was
administered to patients prior to as well as upon comple-
tion of the intervention. More specifically, patients were
assessed for their perception of the following concepts
paraphrased as: (a) “my understanding of my attacks has
improved;” (b) “I am able to avoid triggers to my attacks;”
(c) “my attacks do not bother me as much anymore;” (d)
“I am less scared about my attacks;” (e) “I am able to carry
on with most daily activities despite my attacks;” and, (f)
“I have some control over my attacks.” Patients’ responses
to concepts were scored on a Likert scale, with “1 being
strongly disagree,” “2 being disagree,” “3 being neutral,”
“4 being agree,” and “5 being strongly agree.” Appendix 2
provides more detailed information regarding this ques-
tionnaire utilized to measure knowledge and perception
outcomes.
Additional baseline measures
In addition to acquiring patient demographics data, all
EMU patients (prior to confirmation of the diagnosis) were
asked to complete four neuropsychological instruments: (1)
Structured Inventory of Malingered Symptomatology
(SIMS), which screens for over-reporting of uncommon
cognitive and affective symptoms.21 (2) The Health History
Checklist evaluates the somatoform tendency based on the
patient’s endorsement of a list of the somatoform disorder
symptoms from the Diagnostic and Statistical Manual of
Mental Disorders, Third Edition, Revised (DSM-III-R).22
(3) The Health Attitudes Survey (HAS) is an eight-question
instrument designed to assess attitudes and perceptions of
somaticizing patients.23 (4) The Beck Depression Inventory
– II (BDI-II) is a 21-item measure widely used to assess
depression severity.24 Appendix 1 provides more detailed
159
Brief Group Psychoeducation for PNES
information regarding these neuropsychological instru-
ments.
Statistical analyses
Investigations regarding the effect of intervention on the
primary and secondary outcomes were performed by per-
protocol analyses. We utilized the Mann-Whitney-Wil-
coxon test to analyze differences between groups for Likert
scale questions, the Pearson’s chi-square test, or two-tailed
Fisher’s exact test for categorical variables, and the
unpaired t-test for continuous variables. To further test for
differences between the two groups concerning treatment
response, a repeated measures analysis of variance
(ANOVA) was used for the WSAS scores. The within-sub-
jects factor was time point (baseline, 3, 6 months), with
condition of group membership (intervention vs. control) as
the between-subjects factor. For the additional baseline psy-
chological instruments, ANOVA was used to assess for sig-
nificant group differences, where the self-report measures
were used as dependent variables, whereas group designa-
tion was used as the independent factor. Statistical analyses
of psychological instrument data were performed with SPSS
version 17.0.1 (SPSS Inc., Chicago, IL, U.S.A.). All other
data analyses were conducted using Stata/MP version 11.2
for Windows (StataCorp LP, College Station, TX, U.S.A.).
The above-mentioned study protocol was approved by
the institutional review board of Baylor College of Medi-
cine as well as the Research and Development Committee
of the Michael E. DeBakey VA Medical Center.
Results
We identified 107 consecutive patients who received
VEEG-confirmed diagnosis of PNES at our center during
the study period (Fig. 1). After excluding 36 patients who
met the exclusion criteria and seven patients who declined
participation in our study, 64 patients enrolled in the study.
Upon randomization, 34 patients were allocated to the inter-
vention group and 30 patients were allocated to the control
group. After exclusion of patients who were unable to com-
plete at least one survey of outcome measures (14 interven-
tion and 7 control patients), analyses of outcome measures
were performed on 20 intervention and 23 control group
patients. No significant difference in the baseline character-
istics was found between those allocated to the intervention
and control groups (Table 1), including illness burden and
concurrent participation in counseling/therapy outside of
our study intervention. Moreover, upon comparing the base-
line characteristics of patients who did not complete the
entire protocol (14 intervention and 9 control patients)
versus patients who completed the entire protocol (20 inter-
vention and 21 control group patients), none of the measures
significantly differed at p < 0.5.
At the time of enrollment, the baseline WSAS scores
between intervention (mean 23.05, standard error of the
Epilepsia, 55(1):156–166, 2014
doi: 10.1111/epi.12481
160
D. K. Chen et al.
mean [SEM] 1.54) and control (mean 24.17, SEM 1.69)
groups were not significantly different (p = 0.629, Fig. 2).
After completing the three-therapy sessions, the interven-
tion group scored significantly lower on the WSAS (i.e., less
functional impairment) than the control group when mea-
sured at follow-up 1 (intervention: mean 18.4, SEM 1.91;
control: mean 25.52, SEM 1.95, p = 0.013, Fig. 2). At fol-
low-up 2, the benefit of group psychoeducation was sus-
tained as reflected by persistence of the significant
difference in WSAS scores (intervention: mean 18.75, SEM
1.85; control: mean 24.86, SEM 2.15, p = 0.038, Fig. 2).
We also applied repeated measures ANOVA to investigate
effects of group and time, as well as a group 9 time interac-
tion. We did not observe a main effect for the within-sub-
Epilepsia, 55(1):156–166, 2014
doi: 10.1111/epi.12481
Figure 1.
Participant time line and study entry.
*All enrolled patients completed
questionnaires for baseline
assessment. †Outcome measures
assessed between 3 and 5 months
after allocation (i.e., follow-up 1
assessments). ‡Outcome measures
assessed between 6 and 8 months
after allocation (i.e., follow-up 2
assessments). PNES, psychogenic
nonepileptic seizures; MMSE, Mini-
Mental Status Examination.
Epilepsia ILAE
jects factor of time F2,39 = 1.389, p = 0.255. A main effect
was observed for the between-subjects factor of group
F1,39 = 4.136, p = .049. An interaction was observed for
group 9 time, F1,39 = 11.41, p = .002, such that an effect
was seen from baseline to follow-up 1, but was not main-
tained through follow-up 2.
The patients’ endorsement of PNES frequency was not
significantly different between intervention and control
groups at both follow-up 1 (p = 0.359) and follow-up 2
(p = 0.394). Similarly, in terms of the reported intensity
of the attacks in themselves, the comparison between the
intervention and control groups was not significantly dif-
ferent at both follow-up 1 (p = 0.504) and follow-up 2
(p = 0.437).
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Brief Group Psychoeducation for PNES

Table 1. Demographic, psychosocial, seizure burden, and neuropsychological instrument data comparisons between
the intervention and control groups
Intervention group (n = 34) Control group (n = 30)
Age, mean (SD) 50.76 (12.27) 50.70 (11.55)
Gender (% male) 73.5 76.7
Marital status (% married) 55.9 56.7
Years of education, mean (SD) 12.91 (1.68) 13.30 (2.29)
Employment (% employed) 20.6 13.3
Disability (%)a 52.9 63.3
Total no. of axis I + II disorders, mean (SD) 2.00 (1.13) 2.20 (1.14)
GAF, mean (SD) 58.13 (8.16) 54.96 (7.72)
PTSD (%) 35.3 43.3
Concurrent counseling/therapy (%)b 26.5 20
Baseline seizure frequency, n (%)c
Daily 9 (26.5) 5 (16.7)
Weekly 16 (47.0) 15 (50.0)
Monthly 7 (20.6) 8 (26.7)
Rare 2 (5.9) 2 (6.6)
Duration of seizure history, mean months (SD) 106.94 (115.92) 83.96 (102.32)
SIMS, mean (SD) 20.86 (8.62) 19.52 (9.20)
HAS, mean (SD) 19.32 (4.72) 17.00 (5.36)
HHC, mean (SD) 11.89 (5.67) 12.07 (6.74)
BDI-II, mean (SD) 21.36 (10.99) 21.84 (10.58)
SD, standard deviation; GAF, global assessment of functioning; PTSD, posttraumatic stress disorder; SIMS, structured inventory of malingered symptomatology;
HAS, Health Attitude Survey; HHC, Health History Checklist; BDI-II, Beck Depression Inventory-II.
None of the measures significantly differed at p < 0.05.
a
Percentage of patients who, during the study period, were receiving disability-related benefits.
b
Percentage of patients who, during the study period, were receiving any form of mental health–related counseling or therapy from sources outside of our epi-
lepsy center.
c
Daily, one to several seizures per day; weekly, one to several seizures per week; monthly, one seizure every month or every few months; rare, fewer than three
seizures per year.

From an internal measure of intervention outcomes, we

Figure 2.
Patients in the intervention group (maroon squares) demonstrated
significant improvement on the Work and Social Adjustment Scale
(WSAS) across both follow-ups 1 and 2 (*p < 0.05), with the
means dropping below the score of 20—a threshold above of
which reflects moderate to severe functional impairment. Error
bars: Standard error of the mean (SEM).
Epilepsia ILAE
initially observed no significant baseline difference (at time
of enrollment) between responses from patients in the inter-
vention and control groups to all six statements regarding
their perceptions of PNES (Table 2). Subsequently, patients
who completed the intervention, when compared to the con-
trol group, showed significantly more affirmative and sus-
tained endorsements regarding the following statements:
“my attacks do not bother me as much anymore” (p < 0.001
at follow-up 1, and p < 0.001 at follow-up 2); and “I am
able to carry on with most daily activities despite my
attacks” (p = 0.037 at follow-up 1, and p = 0.021 at follow-
up 2). In addition, the intervention group showed signifi-
cantly more affirmative, but nonsustained endorsements
regarding the following statements: “I am able to avoid trig-
gers to my attacks” (p = 0.016 at follow-up 1, but not signif-
icant at follow-up 2); and “I have some control over my
attacks” (p = 0.006 at follow-up 1, but not significant at fol-
low-up 2).
Over the course of 6–8 months of follow-up after dis-
charge from the EMU, one patient from the intervention
group and five patients from the control group required
emergency room visits or hospitalizations for PNES-
related symptoms. In other words, patients from the inter-
vention group showed less utilization of acute health care
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D. K. Chen et al.
Table 2. Comparison of the patients’ perceptions regarding PNES over follow-up intervals between intervention and
control groups
Patients’ perceptions regarding PNES
My understanding of my attacks has improved
I am able to avoid triggers to my attacks
My attacks do not bother me as much anymore
I am less scared about my attacks
I am able to carry on with most daily activities despite my attacks
I have some control over my attacks
PNES, psychogenic nonepileptic seizures.
Bold highlighted p-value represents significantly more affirmative endorsement from the intervention group.
resources when compared to controls, although the mag-
nitude of the difference failed to reach statistical signifi-
cance (p = 0.184). Also during this follow-up interval,
there were no significant differences between the two
groups for the development of new and disabling symp-
toms for which causes have not been readily explained
medically (p = 0.606), the initiation of new counseling/
psychotherapy programs outside of the present study
(p = 0.655), and the initiation of new psychotropic medi-
cations (p = 0.523).
Discussion
In this study, we attempted to augment our initial commu-
nication to patients regarding the diagnosis of PNES with a
subsequent, three-session group psychoeducational pro-
gram administered by our own epilepsy center. The majority
(73%) of participating patients commenced on this interven-
tion within 4 weeks after learning of the diagnosis.
Although we did not observe significant differences in
PNES frequency or intensity, the patients who underwent
the intervention demonstrated significant improvement in
their WSAS scores, reflecting less impairment in important
areas of functioning. Concordant with our results, a pilot
randomized control trial of CBT for patients with PNES
showed a significant improvement in WSAS scores over a
6-month follow-up period.9 Similar to our nonintervention
group, a multicenter prospective study evaluating the out-
come of PNES after communication of the diagnosis with
no additional treatment showed no significant improvement
in WSAS scores at 6 months.25 When we examined for
more specific perceptions that may influence functional sta-
tus, we observed that patients from the intervention group
were significantly more likely to demonstrate sustained
endorsements of the following: (1) PNES as being less both-
ersome to them; and (2) capability of working around PNES
such that essential daily activities can be pursued. These
perceived enhancements of functionality despite persistence
of PNES were further evinced by the observed trend
toward lesser PNES-related emergency room visits or
Epilepsia, 55(1):156–166, 2014
doi: 10.1111/epi.12481
Comparison of means, intervention vs. control groups
Enrollment (p-value) Follow-up 1 (p-value) Follow-up 2 (p-value)
0.927 0.142 0.540
0.896 0.016 0.131
0.631 <0.001 <0.001
0.811 0.064 0.778
0.609 0.037 0.021
0.095 0.006 0.428
hospitalizations, during the 6–8 months following dis-
charge from EMU.
The WSAS has been used in several clinical populations
to measure treatment outcomes, including depression and
obsessive-compulsive disorder in its validation study20 and
with phobic disorders.26 Of more relevance to our study, it
has been used in somatoform disorders, such as chronic fati-
gue syndrome27 and in previous PNES samples.9,25 These
studies demonstrated that the WSAS measure of functional
impairment can distinguish meaningful differences in ill-
ness severity and treatment response. A WSAS score >20
has been suggested to reflect moderate to severe functional
impairment.20 The mean of the WSAS scores from our
intervention group was initially above this threshold at base-
line, and then dropped below this threshold at both follow-
up 1 and follow-up 2 (Fig. 2). This scoring pattern supports
a degree of treatment response that may be clinically mean-
ingful.
There has been some controversy whether therapeutic
attention should be focused more on symptoms (seizure
counts) versus functional status among patients with PNES.
Some investigators have shown that full remission from
PNES needs to be achieved in order to establish significant
improvement in the patient’s overall quality of life.28 Other
investigators have considered the negligible risk of harm to
the brain/other systemic organs as well as the lower risk of
accidental bodily injury from PNES,29 and opined that
effectuating remission of PNES should not necessarily be
the primary treatment goal.30 Supporting this latter senti-
ment is the observation that some patients, despite remission
from PNES, remain poorly functional as demonstrated by
continued dependence on health-related benefits,31–33 or
emergence of substituting somatic symptoms.32,34 One pre-
vious study showed that group psychoeducation for patients
with PNES, while failing to appreciably reduce seizure
counts, can still be effective in terms of improving coping
strategies and reducing PNES-associated psychopathol-
ogy.15 Similarly, our group psychoeducational intervention
was associated with participants’ improvement in important
areas of functioning as well as possible reduction in acute

care utilization (and related iatrogenic injury risk), despite
absence of significant changes in attack frequency/inten-
sity.
The emphasis on cost/resource effectiveness in our brief
group interventional approach compelled us to primarily
focus our therapeutic effort on improving functional status,
while dedicating comparatively less attention toward abol-
ishing symptoms (seizure counts). Although etiologically
heterogeneous, PNES are most commonly conceptualized
as a psychological defense mechanism working to mitigate
inner stressors from conscious awareness,35 or as psychoso-
matic manifestations of inherent personality disorders.36,37
In either case, the underlying psychopathology is deeply
ingrained; therefore, interventions to obviate the need of
such psychosomatic defenses may entail a more extensive
therapeutic alliance—resources that were not available
within our epilepsy center. Rather, our brief group psycho-
educational approach aimed to legitimize these psychoso-
matic defenses and accept PNES occurrences, instead of
conveying expectation to take them away. Our efforts
focused on modifying individual adaptations to PNES,
rather than on dissolving fundamental defense tendencies in
personality. To this end, we endeavored to alter the patients’
perception of how PNES affects them by consolidating the
concept of PNES as internally derived, safe, and manage-
able behavioral disruptions (i.e., PNES are what the patient
does). We likewise focused on dispelling the victimization
mindset of PNES as externally afflicted, life-threatening
conditions (i.e., PNES are not what the patient has). Conse-
quently, among patients who completed our intervention,
the results from the WSAS scores, our internal measure of
intervention outcomes (Table 2), and trend toward lesser
PNES-related acute medical needs reflected some beneficial
perceptual changes regarding PNES. In sum, our neurolo-
gist-initiated group psychoeducation for patients with PNES
was derived from a cost/resource-effective approach and
emphasized on fostering harmonious coexistence with
PNES, rather than cure. We also aspired to cultivate within
each patient a framework of psychological mindedness from
which future therapeutic alliance can build on or be more
readily achieved.
When comparing individual to group therapy of identical
therapy formats, meta-analyses have generally shown no
differential effectiveness between these modalities.38 Effi-
cacy aside, group therapy when compared to individual
therapy can offer some additional advantages, which may
be particularly beneficial to patients with PNES. First, psy-
choeducation conveyed through another fellow patient
within the therapy group, sharing his or her own experi-
ences, may yield at times more legitimacy and impact than a
therapist’s counseling.39 This benefit may be particularly
relevant to patients whose transference is influenced by pre-
vious negative experiences with the health care establish-
ment or authority figures, leading to projected distrust.
Second, a breakthrough in terms of seizure control in one
163
Brief Group Psychoeducation for PNES
patient can have a “ripple effect,” actuating others in the
group to model the coping strategies that led to the break-
through.39 Even for the more ambivalent members of the
group, witnessing improvement in another member may at
least persuade more open-mindedness to the possibility of
change. Finally, whereas individual therapy may be accessi-
ble to only a small number of patients due to resource limita-
tions, group therapy approach expands to the treating
capacity of the therapist such that larger number of patients
may benefit from the intervention.39 This economy-of-scale
treatment principle is particularly meaningful in settings
where nonsocialized medicine is delivered. Moreover,
whereas some group therapy programs have a preset enroll-
ment window, our study protocol was designed to recruit
new group participants on a continuously rolling basis, such
that unnecessary delay (from the initial impact of the neurol-
ogist’s communication of the diagnosis) is avoided and
enrollment opportunity is maximized.
There are several potential biases with our study that may
limit generalization of our results. Among 34 patients who
were randomized to the intervention, 20 patients (59%)
completed the study’s prescribed three group therapy ses-
sions. Comparisons of outcome measures between the inter-
vention and control groups were performed by per-protocol
analyses. Consequently, the demonstrated willingness of
the patients who completed the study protocol, when com-
pared to the ambivalence of those who missed the assigned
sessions and became lost to follow-up, may bias the study
sample toward inclusion of patients who are more motivated
to pursue self-help and achieve clinical improvement.
Another study bias can result from the lack of investigator
and subject blinding, which is logistically difficult to actual-
ize in interventional studies involving psychotherapies.
Moreover, the predominantly male participants as well as
unique intragroup culture and camaraderie within our vet-
eran population may further contribute to a sample bias that
limits the applicability of our results to the broader popula-
tion with PNES, which is predominantly female and civil-
ian.40
Additional study design modifications can enhance the
merit of our study. Because of our small sample size, our
study may not be sufficiently powered to detect significant
differences in the demographic and psychosocial variables
between the intervention and control groups. Therefore,
potential confounds have not been definitively excluded.
Longer postintervention follow-up beyond 6–8 months
would allow for more precise determination regarding the
extent of time over which the efficacy from our brief group
therapy can persist. Beyond our results from PNES fre-
quency/intensity, WSAS, and PNES-related acute medical
resource utilization, further validated instruments such as
measures on health-related quality of life and illness percep-
tions may allow for a more complete assessment of the
patient’s overall health status following our intervention.
Our abbreviated (three-session) group therapy protocol
Epilepsia, 55(1):156–166, 2014
doi: 10.1111/epi.12481
164
D. K. Chen et al.
allows for more readily achievable standardization of inter-
vention across collaborating centers, and future multicenter
studies would strengthen the statistical power and generaliz-
ability of the intervention outcome.
Although the neurologist’s communication of the diagno-
sis to patients with PNES can be known to affect the out-
come for some, such advantage is often lost from
subsequent inaction, as lack of additional intervention has
been shown to result in no meaningful improvement of
functionality.25 Patients with PNES and neurologists alike
are frequently stymied by the limited availability of thera-
peutic options due to cost/resource constraints. Under this
backdrop, we proposed a cost/resource effective, brief
group psychoeducational intervention that can be executed
as a neurologist-initiated program in an epilepsy center. Our
group sessions were facilitated by clinicians in the neurol-
ogy discipline who were psychologically minded, having
had extensive experiences working with patients afflicted
by PNES. Although our patients did not enjoy significant
reduction in seizure burden, we believe that they did none-
theless achieve meaningful functional improvement to
allow for better engagement in life from which future gains
may ensue.
Acknowledgments
The authors are grateful to the staff and patients of the epilepsy
monitoring unit at Michael E. DeBakey VA Medical Center for their
involvement in this study. This research is based on work supported in
part by the Department of Veteran Affairs, Epilepsy Centers of Excel-
lence (ECoE).
Disclosure
None of the authors has any conflict of interest to disclose. We
confirm that we have read the Journal’s position on issues involved in
ethical publication and affirm that this report is consistent with those
guidelines.
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Appendix 1
The Work and Social Adjustment Scale20 (WSAS) is a five-item mea-
sure that assesses an individual’s self-perception of functioning in everyday
activities across several domains (e.g., work, home management, interper-
sonal, and leisure). Each item is rated on a 9-point scale ranging from 0 (not
Appendix 2
QUESTIONNAIRE FOLLOW-UP #: _________
Study Patient ID# ______________________
For each of the questions below, please circle the appropriate response:
1. Strongly Disagree 2. Disagree 3. Neutral
1. My understanding for the cause of my attacks has
improved after Dr. Chen’s VEEG evaluation
2. I am able to avoid “triggers” to my attack and therefore
my attacks are now less frequent and less strong
3. My attacks do not really bother me or affect my life that
much anymore
4. I am less scared about what is happening to me when
I have my attack
5. Despite my attacks, I am still able to carry on with most
of my essential daily activities
6. I have some control over my attacks
7. The amounts of my attacks are about:
165
Brief Group Psychoeducation for PNES
at all a problem) to 8 (very severely impaired), with total scores ranging
from 0 to 40, high scores relating to higher levels of impairment in function-
ing. In its validation study, the measure showed adequate internal reliability
(Cronbach’s a > 0.78).
Structured Inventory of Malingered Symptomatology21 (SIMS) screens
for over-reporting of uncommon cognitive and affective symptoms. The
SIMS is composed of 75 self-report, true-false items that are to be
answered by individuals 18 and older with at least a fifth-grade reading
level. Inter-rater agreement among nine licensed clinical psychologists,
working from an initial pool of 200 questions, was used to categorize
15 individual items into each of five subscales including the following:
neurologic impairment (NI), affective disorders (AF), psychosis (P), low
intelligence (LI), and amnestic disorders (AM). In addition, a total score
is calculated by summing all of the raw scores (range: 0–75).
The Health History Checklist is a list of the somatoform disorder symp-
toms from DSM-III-R.22 Patients were asked to place a check next to a
symptom if it had been a significant problem for them. Endorsement of
13 items or more is considered to be indicative of somatoform disorder
tendencies.
The Health Attitudes Survey23 (HAS) is an eight-question instrument
designed to assess attitudes and perceptions of somaticizing patients and
discriminate them from other patient populations. Questions are answered
based on a 5-point Likert scale ranging from 0 (Strongly Disagree) to 4
(Strongly Agree) for a maximum score of 32.
The Beck Depression Inventory – II24 (BDI-II) is a 21-item measure
that has been widely used to assess depression severity. Each ques-
tion ranges from 0 to 3 and asks questions consistent with current
diagnostic criteria for depression (e.g., feelings of worthlessness, loss
of sleep and appetite, suicidality). Total scores range from 0 to 63,
with higher total scores indicating more severe degree of depressive
symptoms. The test has been shown to have high internal consistency
(a = 0.91).
Date: _________
4. Agree 5. Strongly Agree
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 (Much worse – more than twice as worse as before)
2 (Worse – about twice as worse as before)
3 (Same as before)
4 (Better – about half as much as before)
5 (Much better – less than half as much as before)
Epilepsia, 55(1):156–166, 2014
doi: 10.1111/epi.12481
166
D. K. Chen et al.

8. The intensity or severity of my attacks is about: 1 (Much worse – more than twice as intense as before)
2 (Worse – about twice as intense as before)
3 (Same as before)
4 (Better – about half as intense as before)
5 (Much better – less than half as intense as before)

9. Since your VEEG evaluation, have you required any recent ER visit or hospitalization?

Yes/No If Yes, please explain:

10. Since your VEEG evaluation, have you developed any NEW medical symptoms involving your body that you or your doctors have not been able to
explain?

Yes/No If Yes, please explain:

11. Any NEW mental health intervention since your VEEG evaluation? (circle all that apply)
a New Counselor
b New Psychiatrist
c New Psychiatric Medication (if yes, which one? ________________________)
d New Social Worker
e New Psychologist
f Other intervention that is new (if yes, please explain ______________________)
g No new intervention

If any new mental health intervention, please explain:

Epilepsia, 55(1):156–166, 2014

doi: 10.1111/epi.12481
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