Long term vs. short term: when is one preferable to the other in the treatment of psychogenic non-epileptic seizures?

Today I want to write about an experience I had a few weeks ago. I was speaking with some of my colleagues at a conference about working with patients who are diagnosed with PNES.  Several of them explained that they had been working with patients who had been having seizures (some of them very frequent and intense) for years.  When I asked what sort of treatment they were using, they explained that most of their patients had a history of severe psychological trauma and they were using what sounded like a predominantly psychodynamic approach. They explained that they were taking therapy very, very slowly because they were concerned that they might hurt the patient if they went too fast.

Let me tell you a tale (believe me, it will make sense in the end) Several years back, a tiny wart developed on the sole of my right foot.  Despite its small size, it became increasingly intolerable and I found myself needing to walk with my foot inclined to one side, which then resulted in pain in my knees and the foot itself because of the way I had to hobble along.

My general practitioner sent me to an expert, a podiatrist. When I met with him, he explained to me that this was indeed a wart and that there were two options: 1) surgery but that it could be very painful and even worse, the time needed to recover from this could span several months, or 2) the daily application of a salve that was some kind of acid and that it would eventually dissolve the pesky verruca (another name for wart). Well, faced with the option of having very painful surgery and months of disability, I chose option 2. For weeks, I dutifully applied the salve but the pain continued and my hobbling was increasing the pain I had in my knees and calves. So, I decided to get a second opinion. The next podiatrist I saw, explained that the verruca was very deep and that it would take years (if ever) to dissolve it with the salve, and that in the meantime, I was ruining the skin around it (it did really look pretty ragged).  He suggested surgery to which I countered with what the first podiatrist had told me.  He explained that the surgery would neither be all that painful (except for the anesthesia shot) and that by the weekend, I would be able to walk and even ski.  Well, I was really fed up, felt increasingly disabled, and had a bike marathon to train for, so I decided to bite the bullet and have the surgery.

So, why am I telling you about this indelicate medical condition I had a few years ago? Because I see the first podiatrist as the equivalent of those therapists I mentioned at the beginning of this blog.  Their fear of hurting the patient leads them to choose the very, very long treatment route.  Rather than excise the trauma that is fueling the many psychiatric symptoms, including the psychogenic seizures, they cautiously work around the trauma hoping to someday feel the patient is finally strong enough to address it.   The problem is that the longer the patient lives with his/her deep wart and everything that comes with it, the worse the condition gets.  While waiting for the patient to “be strong enough,” it allows the patient to live with seizures (sometimes multiple a day, some of which result in injuries, and many which impact the patients’ family life, work, ability to drive and be independent) for years.  I know these therapists want the very best for their patients, but what they may not be considering is that the longer this seizure-symptom persists and become part of the person’s identity, the worse it will be for the patient.

There is a growing body of literature that shows brief and targeted treatments for PNES can effectively treat this psychogenic symptom, including prolonged exposure therapy. I would encourage these therapists to consider referring these patients to someone who works with these types of approaches if they are not responding. Once seizure reduction has been achieved, the patient can always return to the long-term therapist because there are often many other issues to continue to explore and work on.