Non-Epileptic Episodes. Brief Overview of Etiology and Treatment

Transcription

1 Non-Epileptic Episodes Brief Overview of Etiology and Treatment

2 Take-home Messages Symptoms and etiology quite heterogeneous Quality of physician-patient relationship affects acceptance of diagnosis and treatment followthrough Mental health interventions are most helpful in establishing hypothesis for etiology and setting up treatment plan Do not discontinue medical care too early

3 Characteristics of NEE NEE is a symptom of underlying condition Wide range of presentations Major convulsive activity to catatonic state Emotionally labile to flat affect

4 Characteristics of NEE Unconscious to conscious Unpurposeful (no intent) to purposeful (with intent) Highly disabling and dangerous to mild and safe

5 Mental Health Diagnoses Associated With NEE Somatoform disorder Conversion disorder Somatization disorder Personality disorder (up to 62% of NEE) Histrionic Borderline Dependent Drake, Jr., M.E. (1992)

6 Mental Health Diagnoses Associated With NEE Dissociative disorder Anxiety disorder Panic disorder Generalized anxiety disorder Post-traumatic stress disorder Factitious disorder Mental retardation Malingering

7 NEE: To What Purpose? Primary vs. secondary gain The concept of faking Somatization Communication Avoidance of conflict/aversive experience Maladaptive coping

8 Other Etiological Conditions Current and remote factors Misinterpretation of somatic symptom Maintenance of family system Embellishment of epileptic seizure

9 Treatment Outcome Results of outcome studies have been difficult to interpret due to a lack of systematic categorization of subjects Improvement rates, with treatment: Meierkord, H. et al. (1991) 40% Walczak, T. et al. (1995) 35% Aboukasm, A. et al. (1998) 44%

10 Mental Health Services and NEE Diagnostic/etiological considerations Mental health assessment focusing on NEE dynamics, diagnosis, treatment plan Consultation with medical team How best to inform patient of diagnosis Relevant patient dynamics How to set up effective follow up Medication issues

11 Treatment Strategies: General Reattribution approach For patient who is willing to accept diagnosis Link triggers/stressors to underlying physiological process to physical symptoms Ex: Family conflict----anxiety----underlying autonomic nervous system symptoms----nee activity Education + reassurance + short-term treatment

12 Treatment Strategies: General Psychotherapeutic approach For patient who is skeptical, untrusting, but willing to work with mental health plus medical providers Emphasis placed on building trust, increasing patient s belief in diagnosis, maintaining patient s dignity, establishing concept of integrated care Insight-oriented psychotherapy; maintain then taper physician involvement over time as needed Longer course of treatment, multiple consultations

13 Treatment Strategies: General Directive medical approach For patient who rejects diagnosis and/or need for integrated treatment Physician continues follow-up, assesses new symptoms as they arise, minimizes excessive use of medicine and emergency care Trust is built over time; patient does not feel abandoned; limits placed on pt s expectations

14 Clinician-Patient Relationship Take time to discuss with patient the diagnosis, its meaning to them, possible etiologies, and treatment plan Patients often need time to assimilate diagnosis. Don t rush into formal treatment too quickly if patient is resistant

15 Clinician-Patient Relationship Be careful about saying the cause is due to stress, or is psychological Describe condition as a mind-body problem, thus both areas need focused upon in treatment Give example of mind-body problem

16 Clinician-Patient Relationship Avoid use of such phrases as good news, bad news, nothing serious, you don t have real seizures, when disclosing diagnosis When appropriate, mention to patient that the team knows his/her symptoms are real, and not just in your head

17 Clinician-Patient Relationship Uncertainty of underlying etiology, if present, should be conveyed in an assuring manner As appropriate, let patient know that specific cause of symptoms may take awhile to determine, but that improvement can occur in meantime Monitor counter-transference

18 Take-home Messages Symptoms and etiology quite heterogeneous Quality of physician-patient relationship affects acceptance of diagnosis and treatment followthrough Mental health interventions are most helpful in establishing hypothesis for etiology and setting up treatment plan Do not discontinue medical care too early