Withdrawal of antiepileptic drugs in people with non-epileptic seizures
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《神经病学神经外科学杂志》
Correspondence to:
H A Ring
Developmental Psychiatry Section, University of Cambridge, Douglas House, 18b Trumpington Road, Cambridge, CB2 2AH, UK; har28@cam.ac.uk
The withdrawal of antiepileptic drugs from people with non-epileptic seizures can result in significant benefits
Keywords: antiepileptic drugs; non-epileptic seizures; withdrawal
Non-epileptic seizures (NES) substantially disturb the health and well being of those who suffer from them. In financial terms, the treatment costs of undiagnosed NES may approximate the lifetime costs associated with the treatment of intractable epilepsy. Although difficulties in clarifying the diagnosis are often considerable and the psychological complexity of the condition can appear daunting,1 nevertheless significant reductions in medical costs and healthcare utilisation rates have been reported to follow appropriate diagnosis and management of these patients.2 Studies that contribute to the improved management of this relatively under-researched condition3 are therefore valuable and in the paper by Oto et al (see p 1682 of this issue) the important issue of withdrawal of antiepileptic drugs (AEDs) from people with NES is considered.
Initially, a secure diagnosis must be made and the figures reported by Oto et al demonstrate the attendant difficulties. Briefly, of a total cohort of 235 consecutive patients seen in an NES clinic, 184 had a video-EEG confirmed diagnosis of NES and satisfied the authors’ criteria for "no epilepsy". Of the 99 patients within this latter group actually taking AEDs, 78 were included in the withdrawal study and in three of these individuals a subsequent diagnosis of epilepsy was made. While revealing that diagnosis is not easy, these figures emphasize that with a careful process the correct diagnosis can be made in a sizeable proportion of patients with suspected NES.
Once the diagnosis has been made, it is important to pay attention to how it is relayed to the patient. If done poorly this can alienate the patient, complicating subsequent management.4 Oto et al suggest that the diagnosis is "communicated in a non-judgmental and supportive manner", and this technique is probably an important contributor to the overall success of their approach.
With respect to the benefits of AED withdrawal, as well as removing the burden of inappropriate pharmacological treatment in the great majority of patients and clarifying a diagnosis of epilepsy in a small minority, removing AEDs in people with NES is an important therapeutic manoeuvre in its own right. As the authors note, reductions in NES frequency have been reported in association with various therapeutic approaches and the precise relationship between reduced AEDs and decreased NES remains to be established. However, clinical experience suggests that for patients with NES, getting an ambivalent message from their doctor – "you do not have epilepsy, but we will continue your AEDs" – is likely to undermine psychological treatments and could contribute to increases in anxiety in a patient group for whom anxiety may perpetuate the symptoms of NES.
Oto et al describe a standardized withdrawal protocol that is valuable for several reasons. For clinicians reading the paper it describes a tested approach. For patients (and their GPs) a clearly defined plan will help demonstrate that they are not simply being abandoned following a decision that they do not have epilepsy, but rather that they remain in a controlled therapeutic process, albeit one that has changed direction as new information has come to light. Finally, the authors’ recommendation that after withdrawal follow up should be long and careful enough to identify either emergence of epilepsy or other psychological conditions should be emphasized.
REFERENCES
Gene-Cos N, Ring HA. Making sense of non-epileptic disorders. Epileptic Disord 2005;7:123–130.
Walczak TS, Papacostas S, Williams DT, et al. Outcome after diagnosis of psychogenic nonepileptic seizures. Epilepsia 1995;36:1131–7.
LaFrance WC Jr, Devinsky O. The treatment of nonepileptic seizures: historical perspectives and future directions. Epilepsia 2004;45 (Suppl 2) :15–21.
Shen W, Bowman ES, Markand ON. Presenting the diagnosis of pseudoseizure. Neurology 1990;40:756–9.(H A Ring)
H A Ring
Developmental Psychiatry Section, University of Cambridge, Douglas House, 18b Trumpington Road, Cambridge, CB2 2AH, UK; har28@cam.ac.uk
The withdrawal of antiepileptic drugs from people with non-epileptic seizures can result in significant benefits
Keywords: antiepileptic drugs; non-epileptic seizures; withdrawal
Non-epileptic seizures (NES) substantially disturb the health and well being of those who suffer from them. In financial terms, the treatment costs of undiagnosed NES may approximate the lifetime costs associated with the treatment of intractable epilepsy. Although difficulties in clarifying the diagnosis are often considerable and the psychological complexity of the condition can appear daunting,1 nevertheless significant reductions in medical costs and healthcare utilisation rates have been reported to follow appropriate diagnosis and management of these patients.2 Studies that contribute to the improved management of this relatively under-researched condition3 are therefore valuable and in the paper by Oto et al (see p 1682 of this issue) the important issue of withdrawal of antiepileptic drugs (AEDs) from people with NES is considered.
Initially, a secure diagnosis must be made and the figures reported by Oto et al demonstrate the attendant difficulties. Briefly, of a total cohort of 235 consecutive patients seen in an NES clinic, 184 had a video-EEG confirmed diagnosis of NES and satisfied the authors’ criteria for "no epilepsy". Of the 99 patients within this latter group actually taking AEDs, 78 were included in the withdrawal study and in three of these individuals a subsequent diagnosis of epilepsy was made. While revealing that diagnosis is not easy, these figures emphasize that with a careful process the correct diagnosis can be made in a sizeable proportion of patients with suspected NES.
Once the diagnosis has been made, it is important to pay attention to how it is relayed to the patient. If done poorly this can alienate the patient, complicating subsequent management.4 Oto et al suggest that the diagnosis is "communicated in a non-judgmental and supportive manner", and this technique is probably an important contributor to the overall success of their approach.
With respect to the benefits of AED withdrawal, as well as removing the burden of inappropriate pharmacological treatment in the great majority of patients and clarifying a diagnosis of epilepsy in a small minority, removing AEDs in people with NES is an important therapeutic manoeuvre in its own right. As the authors note, reductions in NES frequency have been reported in association with various therapeutic approaches and the precise relationship between reduced AEDs and decreased NES remains to be established. However, clinical experience suggests that for patients with NES, getting an ambivalent message from their doctor – "you do not have epilepsy, but we will continue your AEDs" – is likely to undermine psychological treatments and could contribute to increases in anxiety in a patient group for whom anxiety may perpetuate the symptoms of NES.
Oto et al describe a standardized withdrawal protocol that is valuable for several reasons. For clinicians reading the paper it describes a tested approach. For patients (and their GPs) a clearly defined plan will help demonstrate that they are not simply being abandoned following a decision that they do not have epilepsy, but rather that they remain in a controlled therapeutic process, albeit one that has changed direction as new information has come to light. Finally, the authors’ recommendation that after withdrawal follow up should be long and careful enough to identify either emergence of epilepsy or other psychological conditions should be emphasized.
REFERENCES
Gene-Cos N, Ring HA. Making sense of non-epileptic disorders. Epileptic Disord 2005;7:123–130.
Walczak TS, Papacostas S, Williams DT, et al. Outcome after diagnosis of psychogenic nonepileptic seizures. Epilepsia 1995;36:1131–7.
LaFrance WC Jr, Devinsky O. The treatment of nonepileptic seizures: historical perspectives and future directions. Epilepsia 2004;45 (Suppl 2) :15–21.
Shen W, Bowman ES, Markand ON. Presenting the diagnosis of pseudoseizure. Neurology 1990;40:756–9.(H A Ring)