In this article, we present a discussion of yet another potential controversy that may arise in the management of patients with psychogenic pseudoseizures. Who should present the diagnosis to the patient once it is established by video-EEG monitoring: the neurologist, the psychiatrist, or both?

THE NEUROLOGIST SHOULD PRESENT
THE DIAGNOSIS OF PSYCHOGENIC
PSEUDOSEIZURES

Cynthia L. Harden, M.D.

When the diagnosis of psychogenic pseudoseizures is presented to the patient for the first time, the ensuing discussion between patient and physician is critical. It marks a turning point in the treatment process, heralding a new course of therapy that involves psychiatric evaluation and follow-up. During this initial discussion, the neurologist must introduce the idea that the episodes under evaluation may have a psychiatric basis. The discussion should clearly convey the message that the behaviors in question support a diagnosis of nonepileptic seizures of presumed psychological origin, for which a psychiatrist is needed to identify the underlying psychological mechanisms. Thus the psychiatric cause must be presented as presumptive, as it can be established only when the patient undergoes a psychiatric evaluation.

Often, neither patient nor physician expected that the diagnostic testing would yield this conclusion. The discussion of psychiatrically related problems can therefore lead patients to ask questions that may be difficult for the neurologist to answer. Nonetheless, I believe that the treating neurologist should present the diagnosis to the patient based on the principle of the therapeutic alliance, the “psychic glue” that binds neurologists to their patients.

The Therapeutic Alliance

The therapeutic alliance is defined as a contract between physician and patient whereby they agree to work together for the patient's therapeutic benefit. The physician brings to this relationship professional knowledge and experience, and provides the assurance that the patient will be helped. The patient expects that the physician will provide a framework for relief of his or her symptoms. In the context of this relationship, patients are also educated on reasonable expectations of their care.

The answer to the question of who should initially discuss the diagnosis of psychogenic pseudoseizures is an empirical, not a theoretical one, and is based on the following argument. The physician who has developed a therapeutic alliance with the patient should be the one to outline a framework for the treatment plan. Further, the physician initially presenting the new diagnosis to the patient must be the person with whom the patient already has developed a trusting relationship. Since it is the neurologist, and not the psychiatrist, who evaluates abnormal episodic behaviors with EEG monitoring, it is therefore the neurologist who must initially discuss this diagnosis with the patient.

The therapeutic alliance is typically discussed in the context of the collaborative bond between a psychotherapist and his or her patient, based on mutual respect, trust, and commitment to the work of treatment (1, 2). Yet this concept applies to any doctor– patient therapeutic relationship, including the diagnostic process associated with psychogenic pseudoseizures. Kossoy and Wilner (3) and others have identified the characteristics of a therapeutic alliance that contribute to a beneficial treatment outcome. These include:

• A consistent relationship, providing continuous and predictable contact
• A commitment to mutual trust
• A warm and empathetic medical provider
• Respect for the input of patients, which then leads to the patients' having a sense of some control over their treatment
• Effective communication between clinician and patient

Challenges to Maintaining the Therapeutic Alliance after the Diagnosis of Psychogenic Pseudoseizures

Following the diagnosis of psychogenic pseudoseizures, there may be a shift in the goals of therapy. This is not without risks! For example, if the neurologist had not anticipated the diagnosis of psychogenic pseudoseizures, he or she might essentially abandon the patient, assuming that someone else will continue the care of the patient.

Such a negative reaction is probably more a reflection of the physician’s attitude and internal conflicts than the patient’s psychiatric condition, in my opinion. Patients with psychogenic pseudoseizures are complicated and sometimes difficult to work with.

Their psychiatric problems may include depression, dissociative disorders such as posttraumatic stress disorder, and somatization disorder, including conversion disorder (4–6), often in the setting of a personality disorder (7). Therefore it is not surprising that a physician unaccustomed to dealing with such patients may hesitate to assume responsibility for presenting the diagnosis and directing the initial management. Further, neurologists are not specifically trained to manage their own feelings of anger, frustration, or even disgust that may result from working with patients with psychogenic pseudoseizures. Such feelings could lead to anger, frustration, or apathy being directed at the patient. Yet, if neurologists are to present the diagnosis of pseudoseizures, they must consciously anticipate the occurrence of such feelings (which are often unconscious), so they do not inadvertently fracture the doctor–patient relationship and therapeutic treatment alliance.

Physicians' negative reactions to patients are mediated by the phenomenon of countertransference. A physician’s countertransference leads to illogical attitudes or feelings toward the patient as a result of the physician’s psychological conflicts (8). For example, patients with eating disorders are known to engender therapeutically unhelpful responses from their physicians including rescue fantasies and feelings of rage and frustration when the patients consistently exhibit self-destructive behavior (9). In the specific case of psychogenic pseudoseizures, physicians may react with anger and defensiveness toward patients because they may believe the patients are malingering or seeking their attention, irrespective of whether the pseudoseizures result from a conversion or dissociative disorder and are hence unconscious (10). Further, because patients with psychogenic pseudoseizures often have personality disorders (11), the psychiatrically naı¨ve physician can be manipulated by the patient and eventually become enraged, without understanding why this has occurred.

Clearly, neurologists and psychiatrists have to deal with a variety of difficult issues when interacting with patients with psychogenic pseudoseizure. Neurologists must consciously work to maintain the doctor– patient relationship even when the goals of treatment have changed. While the psychiatrist may question whether neurological illness has been adequately excluded when the diagnosis of psychogenic pseudoseizures is made (unlike the neurologist), he or she is better trained to foster a beneficial therapeutic alliance with the patient.

In conclusion, the neurologist should be the physician to present the patient with the diagnosis of psychogenic pseudoseizures. He or she should be consciously aware of the negative feelings that may arise from working with such patients and stay focused on the therapeutic goals, even as they change. A positive therapeutic alliance should be maintained, as it will enable the neurologist to guide the patient toward appropriate psychiatric treatment.

THE PSYCHIATRIST SHOULD BE
THERE TOO

Stephen J. Ferrando, M.D.

The evaluation and management of patients with psychogenic pseudoseizures create a major challenge for both the treating neurologist and psychiatrist. There are the obvious implications that psychopathological factors are involved. Additionally, many patients with pseudoseizures also have true epileptic seizures, and no psychiatric diagnosis is pathognomonic for this condition, from the psychiatric perspective. The psychiatric literature discusses the genesis of pseudoseizures as related to unconscious conflicts such as aggression, dissociation, somatoform disorders, depression, character pathology, and early childhood trauma. This heterogeneity may lead to diagnostic quandaries for the neurologist and may evoke strong (countertransference) feelings of frustration, helplessness, and even repulsion, leading to a desire to withdraw from and abandon the patient.

Dr. Harden has stressed the importance of the therapeutic alliance between the patient with psychogenic pseudoseizures and the neurologist. This would dictate that the neurologist be involved primarily in delivering the diagnosis of pseudoseizures and making a referral for a psychological and psychiatric assessment and treatment. I have no debate with this. However, I take issue with the timing of psychiatric involvement. My thesis is that the psychiatrist should become involved early, before the diagnosis of psychogenic pseudoseizures is made and conveyed to the patient. The reasoning for this is severalfold:

First, I maintain that every patient who presents with seizures should undergo psychiatric screening. This is justified by data that suggest up to 55% of patients with epilepsy present with major depressive disorder (12), which may be a manifestation of the underlying brain pathology or a reaction to the diagnosis or both.

Second, certain psychopathological features and elements of the psychiatric history may be predictive of the diagnosis of pseudoseizures, and early psychiatric diagnosis may increase diagnostic clarity and the quality of care. Eisendrath and Valan (13) identified factors that helped to prospectively identify patients subsequently diagnosed with psychogenic pseudoseizures. These included a psychiatric diagnosis of somatization or personality disorder, the presence of childhood loss, and the presence of a model for seizure symptoms.

Third, the involvement of the psychiatrist prior to the delivery of the diagnosis of pseudoseizures to the patient serves to normalize the integration of psychiatric and neurological care. Thus, a team approach is emphasized in the care of any patient that presents with seizure-like activity, especially patients found to have psychiatric comorbidity. This integration of neurological and psychiatric management of patients at the outset and over time not only enhances the diagnosis of psychogenic pseudoseizures, but also allows for identification and discussion of important countertransference reactions that inevitably arise and impede effective management.

Even though it may not be practical to have every patient who presents for video-EEG monitoring undergo psychiatric evaluation, it may be useful to request a psychiatric consultation for those patients who are suspected of having psychogenic seizures. In this manner, the psychiatrist can present him- or herself as a member of an integrated team evaluating the patient’s problem. Once epileptic seizure activity has been ruled out, the neurologist and psychiatrist can then confer on the best way to deliver the diagnosis to the patient.

It is important to note that no single approach suits all patients because of the their multifaceted expression of psychopathology. There are three general therapeutic approaches to patients with somatoform disorders such as psychogenic pseudoseizures that may apply to different patients based on their willingness to accept a psychological explanation for their symptoms (14). Such approaches may be useful for both the neurologist and the psychiatrist in their management of the patient’s condition. For the patient who is willing to accept the link between her or his physical and psychological symptoms, a reattribution approach (15) can be used. In this approach, a three-step process links psychological stressors (e.g., anxiety) to underlying physiological mechanisms (e.g., autonomic activation) to the genesis of physical symptoms (seizurelike activity). A psychotherapeutic approach can be employed

ployed by the psychiatrist seeing a patient with pseudoseizures during the initial contacts (16). In this approach, the psychiatrist attempts to establish a trusting relationship with the patient that is based on taking a neutral approach to the verity of the patient’s seizure symptoms. This, it is hoped, will allow for subsequent engagement in an insight-oriented psychiatric treatment. For patients who present as hostile and rejecting of psychological factors impacting their "seizure" presentation (generally those patients with significant character pathology), a more directive medical model approach may be used (17). Such patients may reject a priori the involvement of a psychiatrist in their management and may be followed up individually by the neurologist on a regular basis. During these medically oriented visits, the neurologist addresses a review of the patient’s symptoms and initiates a workup of symptoms that appear to have a legitimate physiological basis. Such consistent follow-up may serve to minimize the use of emergency services and general health care utilization. Importantly, it also serves to minimize polypharmacy, as many of these patients will seek sedative and opiate medications for their somatic complains. Even those patients who are initially quite negativistic and rejecting of psychiatric interventions, may accept this notion over time when they perceive that their neurologist is taking them seriously and not abandoning them. However, unfortunately, psychiatric involvement will need to be mandated for some patients who persistently refuse.

Whatever the nature of the ongoing management of these patients, it is of utmost importance for the neurologist and psychiatrist to be in close communication so as to coordinate care. Thus, inherent in all of these approaches is that the neurologist continues to follow- up with the patient on some regular basis, while the psychiatric care is initiated and underway. This ongoing relationship between the neurologist and the patient mitigates the patient’s concerns about overlooked neurological symptoms and assuages fears of abandonment and rejection. Simultaneously, the psychiatrist attempts to forge an alliance with the patient and begins to establish a dialogue with them about the impact of psychological and social factors on their life and, ultimately, on their neurological presentation.

There are some interventions that are not helpful for patients with psychogenic pseudoseizures or other somatoform disorders. For instance, reassurance may increase the expression of symptoms because the patient perceives the physician as unconcerned. In addition, direct confrontation is generally not useful (18, 19). Lazare (19) advises against confronting patients

with the information that the symptom is psychological in origin. It is more useful to work indirectly in inquiring about the patient’s life situation and social supports, being mindful of detecting underlying conflict, symbolic meanings of symptoms, and distressing affects against which the symptom serves as a defense.

It is also important that both neurologist and psychiatrist convey to the patient that they see the symptoms as “real” and not something that is “all in her or his head.” This notion is reinforced by the consistent and regular presence of the neurologist and psychiatrist working together along with the patient. Further, the increasingly recognized connection between mind and body can be reinforced to the patient based on an overall holistic integrated approach to care.

In conclusion, the early integration of psychiatric evaluation and management approaches into the care of the patient with psychogenic pseudoseizures is likely to be the optimal approach. Psychiatric screening may assist in identifying patients who are at risk for psychogenic pseudoseizures, as well as diagnosing such potential risk factors as somatization disorder, personality disorder, a history of significant loss, and the presence of symptom models. However, most importantly, such early involvement conveys to the patient the importance of an integrated approach to his or her symptoms regardless of etiology. This may make the diagnosis of pseudoseizures more understandable and acceptable to the patient, and it may be more likely to encourage psychiatric follow-up subsequent to the diagnosis.

ACKNOWLEDGMENT

The authors thank Dr. Stefan P. Stein for his kind review of this manuscript.

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