今日の臨床サポート

偽けいれん・偽意識障害

著者: 大高俊一 国際医療福祉大学成田病院 救急科

監修: 林寛之 福井大学医学部附属病院

著者校正/監修レビュー済:2021/05/19
参考ガイドライン:
  1. 日本てんかん学会心因性非てんかん性発作(いわゆる偽発作)に関する診断・治療ガイドライン
患者向け説明資料

概要・推奨   

  1. 診断は基本的に除外診断から始まるが、疾患頻度は高く、疑わしいと思われるときには積極的に考える必要がある(推奨度2)
  1. 病歴と診察がてんかんとPNESとの鑑別に役立つ。しかし1つの所見のみにとらわれずに全体的に判断する必要がある(推奨度2)
  1. しっかりとした精神状態の評価、病歴・身体所見をとって、そのうえで心因性かどうか判断する必要がある(推奨度1)
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尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
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(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
大高俊一 : 特に申告事項無し[2022年]
監修:林寛之 : 特に申告事項無し[2022年]

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文献 

Margot W M de Waal, Ingrid A Arnold, Just A H Eekhof, Albert M van Hemert
Somatoform disorders in general practice: prevalence, functional impairment and comorbidity with anxiety and depressive disorders.
Br J Psychiatry. 2004 Jun;184:470-6.
Abstract/Text BACKGROUND: General practitioners play a pivotal part in the recognition and treatment of psychiatric disorders. Identifying somatoform disorders is important for the choice of treatment.
AIMS: To quantify the prevalence of, and functional impairment associated with, somatoform disorders, and their comorbidity with anxiety/depressive disorders.
METHOD: Two-stage prevalence study: a set of questionnaires was completed by 1046 consecutive patients of general practitioners (aged 25-80 years), followed by a standardised diagnostic interview (SCAN 2.1).
RESULTS: The prevalence of somatoform disorders was 16.1% (95% CI 12.8-19.4). When disorders with only mild impairment were included, the prevalence increased to 21.9%. Comorbidity of somatoform disorders and anxiety/depressive disorders was 3.3 times more likely than expected by chance. In patients with comorbid disorders, physical symptoms, depressive symptoms and functional limitations were additive.
CONCLUSIONS: Our findings underline the importance of a comprehensive diagnostic approach to psychiatric disorders in general practice.

PMID 15172939
S R Benbadis, W Allen Hauser
An estimate of the prevalence of psychogenic non-epileptic seizures.
Seizure. 2000 Jun;9(4):280-1. doi: 10.1053/seiz.2000.0409.
Abstract/Text The prevalence of psychogenic non-epileptic seizures is difficult to estimate. We propose an estimate based on a calculation. We used the following data, which are known or have been estimated, and are generally accepted. A prevalence of epilepsy of 0.5-1%; a proportion of intractable epilepsy of 20-30%; a percentage of these referred to epilepsy centers of 20-50%; and a percentage of patients referred to epilepsy centers that are psychogenic non-epileptic seizures: 10-20%. Using the low estimates, the prevalence of psychogenic non-epileptic seizures would be 1/50 000. Using the high estimates, the prevalence of psychogenic non-epileptic seizures would be 1/3000. The prevalence of psychogenic non-epileptic seizures is somewhere between 1/50 000 and 1/3000, or 2 to 33 per 100 000, making it a significant neurologic condition.

Copyright 2000 BEA Trading Ltd.
PMID 10880289
S R Benbadis, V Agrawal, W O Tatum
How many patients with psychogenic nonepileptic seizures also have epilepsy?
Neurology. 2001 Sep 11;57(5):915-7.
Abstract/Text The proportion of patients with psychogenic nonepileptic seizures (PNES) who also have epilepsy has been reported to vary from 10% to over 50%. The authors reviewed all 32 patients diagnosed with PNES in our EEG-video monitoring unit over a period of 1 year, and only 3 (9.4%) had interictal epileptiform discharges to support a coexisting diagnosis of epilepsy. Thus, the authors believe that only a small proportion of patients with PNES have coexisting epilepsy.

PMID 11552032
M Reuber, G Fernández, J Bauer, C Helmstaedter, C E Elger
Diagnostic delay in psychogenic nonepileptic seizures.
Neurology. 2002 Feb 12;58(3):493-5.
Abstract/Text Delay to diagnosis was studied in 313 consecutive patients with psychogenic nonepileptic seizures (PNES). On average, patients with PNES were diagnosed 7.2 years after manifestation (SD 9.3 years). Younger age, interictal epileptiform potentials in the EEG, and anticonvulsant treatment were associated with longer delays. Other patient factors did not explain the great variability of the time to diagnosis, suggesting that physician factors contributed to delays.

PMID 11839862
Thomas W Lukens, Stephen J Wolf, Jonathan A Edlow, Samina Shahabuddin, Michael H Allen, Glenn W Currier, Andy S Jagoda, American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department
Clinical policy: critical issues in the diagnosis and management of the adult psychiatric patient in the emergency department.
Ann Emerg Med. 2006 Jan;47(1):79-99. doi: 10.1016/j.annemergmed.2005.10.002.
Abstract/Text
PMID 16387222
Jon Stone, Roger Smyth, Alan Carson, Steff Lewis, Robin Prescott, Charles Warlow, Michael Sharpe
Systematic review of misdiagnosis of conversion symptoms and "hysteria".
BMJ. 2005 Oct 29;331(7523):989. doi: 10.1136/bmj.38628.466898.55. Epub 2005 Oct 13.
Abstract/Text OBJECTIVE: Paralysis, seizures, and sensory symptoms that are unexplained by organic disease are commonly referred to as "conversion" symptoms. Some patients who receive this diagnosis subsequently turn out to have a disease that explains their initial presentation. We aimed to determine how frequently this misdiagnosis occurs, and whether it has become less common since the widespread availability of brain imaging.
DESIGN: Systematic review.
DATA SOURCES: Medline, Embase, PsycINFO, Cinahl databases, and searches of reference lists.
REVIEW METHODS: We included studies published since 1965 on the diagnostic outcome of adults with motor and sensory symptoms unexplained by disease. We critically appraised these papers, and carried out a multivariate, random effect, meta-analysis of the data.
RESULTS: Twenty seven studies including a total of 1466 patients and a median duration of follow-up of five years were eligible for inclusion. Early studies were of poor quality. There was a significant (P < 0.02) decline in the mean rate of misdiagnosis from the 1950s to the present day; 29% (95% confidence interval 23% to 36%) in the 1950s; 17% (12% to 24%) in the 1960s; 4% (2% to 7%) in the 1970s; 4% (2% to 6%) in the 1980s; and 4% (2% to 6%) in the 1990s. This decline was independent of age, sex, and duration of symptom in people included in the studies.
CONCLUSIONS: A high rate of misdiagnosis of conversion symptoms was reported in early studies but this rate has been only 4% on average in studies of this diagnosis since 1970. This decline is probably due to improvements in study quality rather than improved diagnostic accuracy arising from the introduction of computed tomography of the brain.

PMID 16223792
Abstract/Text We reviewed the patterns of involvement of the orbicularis oculi and other facial muscles during 654 events recorded in 257 patients undergoing telemetry evaluation. Four hundred fifty-seven episodes represented epileptic seizures and 197 represented psychogenic seizures. Eyes were wide open in more than 90% of patients during the tonic phase of a generalized tonic clonic seizure. Lowering of the lid with partial closure of the eye, without contraction of the orbicularis oculi, was the predominant form of eye closure we observed. Eye closure in any form was uncommon during the ictal stage of epileptic seizures with motor accompaniment and occurred in 21 of 408 cases and in 2 of 49 simple partial seizures somatosensory type. Sustained, forceful eye closure with active opposition to opening was present in 41 of 75 cases of psychogenic seizures with motor symptoms and in 16 of 21 cases of psychogenic unresponsiveness and was much less common with psychogenic seizures with pure sensory symptoms (8 of 72 cases). The mouth is usually wide open during the tonic phase of a generalized convulsion. The presence of a clenched mouth during a "tonic spell" should raise the possibility of psychogenic seizures. Injuries to the tongue due to biting during the epileptic seizures usually affect the side of the tongue. Biting of the lip or tip of the tongue was not seen with epileptic attacks and is also suggestive of psychogenic seizures.

PMID 8797454
Andreja Avbersek, Sanjay Sisodiya
Does the primary literature provide support for clinical signs used to distinguish psychogenic nonepileptic seizures from epileptic seizures?
J Neurol Neurosurg Psychiatry. 2010 Jul;81(7):719-25. doi: 10.1136/jnnp.2009.197996.
Abstract/Text Psychogenic non-epileptic seizures (PNES) represent a diagnostic challenge. When trying to distinguish between PNES and epileptic seizures (ES), clinicians rely on the presence or absence of several clinical signs. The purpose of this review is to establish the extent to which these signs are supported by primary data from the literature. A Medline search was used to identify primary studies that used video-EEG to define the presence or absence of different clinical signs in PNES and ES. The methodological quality of the studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool. 34 studies matched the inclusion criteria. A specific sign was considered well supported by the data from the primary literature if we were able to identify at least two controlled studies demonstrating its usefulness and if the data from other studies were supportive. There is good evidence from the literature that long duration, occurrence from apparent sleep with EEG-verified wakefulness, fluctuating course, asynchronous movements, pelvic thrusting, side-to-side head or body movement, closed eyes during the episode, ictal crying, memory recall and absence of postictal confusion are signs that distinguish PNES from ES. Postictal stertorous breathing proved to distinguish convulsive PNES from generalised tonic clonic seizures (GTCS) and should be added to the list of useful clinical signs. The final clinical diagnosis should encompass all available data and should not rely on any single sign alone.

PMID 20581136
A Shaibani, M N Sabbagh
Pseudoneurologic syndromes: recognition and diagnosis.
Am Fam Physician. 1998 May 15;57(10):2485-94.
Abstract/Text Physicians may encounter patients with a collection of psychologic disorders that present with neurologic symptoms or signs, yet have no identifiable structural or functional etiology within the nervous system. These disorders comprise the so-called pseudoneurologic syndromes, which can mimic almost any organic disease. A careful history and physical examination often can identify the psychologic origin of the symptoms. Presenting syndromes can include pseudoparalysis, pseudosensory syndromes, pseudoseizures, pseudocoma, psychogenic movement disorders and pseudoneuro-ophthalmologic syndromes. These presentations may be distinguished from organic disease by observing signs and symptoms or eliciting test responses that are nonphysiologic and incompatible with organic disease. Once a pseudoneurologic syndrome is identified, patients require compassionate and understanding care to resolve underlying emotional problems.

PMID 9614416
Corinna Daum, Fulvia Gheorghita, Marianna Spatola, Vesna Stojanova, Friedrich Medlin, François Vingerhoets, Alexandre Berney, Mehdi Gholam-Rezaee, Giorgio E Maccaferri, Monica Hubschmid, Selma Aybek
Interobserver agreement and validity of bedside 'positive signs' for functional weakness, sensory and gait disorders in conversion disorder: a pilot study.
J Neurol Neurosurg Psychiatry. 2015 Apr;86(4):425-30. doi: 10.1136/jnnp-2013-307381. Epub 2014 Jul 3.
Abstract/Text BACKGROUND: Conversion disorder (CD) is no longer a diagnosis of exclusion. The new DSM-V criteria highlight the importance of 'positive signs' on neurological examination. Only few signs have been validated, and little is known about their reliability.
OBJECTIVE: The aim was to examine the clinical value of bedside positive signs in the diagnosis of CD presenting with weakness, gait or sensory symptoms by assessing their specificity, sensitivity and their inter-rater reliability.
PATIENTS AND METHODS: Standardised video recorded neurological examinations were performed in 20 consecutive patients with CD and 20 'organic' controls. Ten previously validated sensory and motor signs were grouped in a scale. Thirteen additional motor/sensory 'positive signs', 14 gait patterns and 1 general sign were assessed in a pilot validation study. In addition, two blinded independent neurologists rated the video recordings to assess the inter-rater reliability (Cohen's κ) of each sign.
RESULTS: A score of ≥ 4/14 on the sensory motor scale showed a 100% specificity (CI 85 to 100) and a 95% sensitivity (CI 85 to 100). Among the additional tested signs, 10 were significantly more frequent in CD than controls. The interobserver agreement was acceptable for 23/38 signs (2 excellent, 10 good, 11 moderate).
CONCLUSIONS: Our study confirms that six bedside 'positive signs' are highly specific for CD with good-excellent inter-rater reliability; we propose to consider them as 'highly reliable signs'. In addition 13 signs could be considered as 'reliable signs' and six further signs as 'suggestive signs' while all others should be used with caution until further validation is available.

Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
PMID 24994927
Antonio Carolei, Pietro Amedeo Modesti
Limb-shaking TIA: on the borders of evidence-based medicine.
Intern Emerg Med. 2017 Aug;12(5):675-677. doi: 10.1007/s11739-017-1666-0. Epub 2017 Apr 21.
Abstract/Text
PMID 28432542
Scott T Wilber, Christopher R Carpenter, Fredric M Hustey
The Six-Item Screener to detect cognitive impairment in older emergency department patients.
Acad Emerg Med. 2008 Jul;15(7):613-6. doi: 10.1111/j.1553-2712.2008.00158.x.
Abstract/Text BACKGROUND: Cognitive impairment due to delirium or dementia is common in older emergency department (ED) patients. To prevent errors, emergency physicians (EPs) should use brief, sensitive tests to evaluate older patient's mental status. Prior studies have shown that the Six-Item Screener (SIS) meets these criteria.
OBJECTIVES: The goal was to verify the performance of the SIS in a large, multicenter sample of older ED patients.
METHODS: A prospective, cross-sectional study was conducted in three urban academic medical center EDs. English-speaking ED patients > or = 65 years old were enrolled. Patients who received medications that could affect cognition, were too ill, were unable to cooperate, were previously enrolled, or refused to participate were excluded. Patients were administered either the SIS or the Mini-Mental State Examination (MMSE), followed by the other test 30 minutes later. An MMSE of 23 or less was the criterion standard for cognitive impairment; the SIS cutoff was 4 or less for cognitive impairment. Standard operator characteristics of diagnostic tests were calculated with 95% confidence intervals (CIs), and a receiver operating characteristic curve was plotted.
RESULTS: The authors enrolled 352 subjects; 111 were cognitively impaired by MMSE (32%, 95% CI = 27% to 37%). The SIS was 63% sensitive (95% CI = 53% to 72%) and 81% specific (95% CI = 75% to 85%). The area under the receiver operating characteristic curve was 0.77 (95% CI = 0.72 to 0.83).
CONCLUSIONS: The sensitivity of the SIS was lower than in prior studies. The reasons for this lower sensitivity are unclear. Further study is needed to clarify the ideal brief mental status test for ED use.

PMID 18691212
Scott T Wilber, Samuel D Lofgren, Thomas G Mager, Michelle Blanda, Lowell W Gerson
An evaluation of two screening tools for cognitive impairment in older emergency department patients.
Acad Emerg Med. 2005 Jul;12(7):612-6. doi: 10.1197/j.aem.2005.01.017.
Abstract/Text OBJECTIVES: Screening for cognitive impairment in older emergency department (ED) patients is recommended to ensure quality care. The Mini-Mental State Examination (MMSE) may be too long for routine ED use. Briefer alternatives include the Six-Item Screener (SIS) and the Mini-Cog. The objective of this study was to describe the test characteristics of the SIS and the Mini-Cog compared with the MMSE when administered to older ED patients.
METHODS: This institutional review board-approved, prospective, randomized study was performed in a university-affiliated teaching hospital ED. Eligible patients were 65 years and older and able to communicate in English. Patients who were unable or unwilling to perform testing, who were medically unstable, or who received medications affecting their mental status were excluded. Patients were randomized to receive the SIS or the Mini-Cog by the treating emergency physician. Investigators administered the MMSE 30 minutes later. An SIS score of RESULTS: A total of 149 of 188 approached patients were enrolled; 74 received the SIS and 75 the Mini-Cog. Fifty-five percent were female, the average age was 75 years, and 23% had an MMSE score of CONCLUSIONS: The SIS, using a cutoff of
PMID 15995092
David K Chen, Yuen T So, Robert S Fisher, Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology
Use of serum prolactin in diagnosing epileptic seizures: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology.
Neurology. 2005 Sep 13;65(5):668-75. doi: 10.1212/01.wnl.0000178391.96957.d0.
Abstract/Text OBJECTIVE: The purpose of this article is to review the use of serum prolactin assay in epileptic seizure diagnosis.
METHODS: The authors identified relevant studies in multiple databases and reference lists. Studies that met inclusion criteria were summarized and rated for quality of evidence, and the results were analyzed and pooled where appropriate.
RESULTS: Most studies used a serum prolactin of at least twice baseline value as abnormal. For the differentiation of epileptic seizures from psychogenic nonepileptic seizures, one Class I and seven Class II studies showed that elevated serum prolactin was highly predictive of either generalized tonic-clonic or complex partial seizures. Pooled sensitivity was higher for generalized tonic-clonic seizures (60.0%) than for complex partial seizures (46.1%), while the pooled specificity was similar for both (approximately 96%). Data were insufficient to establish validity for simple partial seizures. Two Class II studies were consistent in showing prolactin elevation after tilt-test-induced syncope. Inconclusive data exist regarding the value of serum prolactin following status epilepticus, repetitive seizures, and neonatal seizures.
RECOMMENDATIONS: Elevated serum prolactin assay, when measured in the appropriate clinical setting at 10 to 20 minutes after a suspected event, is a useful adjunct for the differentiation of generalized tonic-clonic or complex partial seizure from psychogenic nonepileptic seizure among adults and older children (Level B). Serum prolactin assay does not distinguish epileptic seizures from syncope (Level B). The use of serum PRL assay has not been established in the evaluation of status epilepticus, repetitive seizures, and neonatal seizures (Level U).

PMID 16157897
Norman A Poole, Axel Wuerz, Niruj Agrawal
Abreaction for conversion disorder: systematic review with meta-analysis.
Br J Psychiatry. 2010 Aug;197(2):91-5. doi: 10.1192/bjp.bp.109.066894.
Abstract/Text BACKGROUND: The value of drug interviews in the treatment of conversion disorder is at present unknown.
AIMS: To review all the available papers published in English that report on the use of drug interviews for treating conversion/dissociative disorder.
METHOD: Databases (including EMBASE, MEDLINE and PsycINFO) were searched from 1920 to 2009. Selected publications had to report on the use of drug interviews in people diagnosed with a conversion/dissociative disorder. Qualitative and quantitative data were extracted. Predictors of a positive response were ascertained using meta-analytic techniques.
RESULTS: Fifty-five papers meeting inclusion criteria were identified. No studies compared the intervention with a suitable control group. However, two studies reported high response rates when drug interview was used in individuals with treatment-resistant conversion disorder. In the meta-analysis, the use of suggestion and occurrence of emotional catharsis during the interview were positively associated with recovery. Combining two medications and comorbid psychiatric disorder were negatively associated with recovery.
CONCLUSIONS: The evidence for effectiveness of drug interviews is of poor quality but it may be of benefit in the treatment of acute and treatment-resistant conversion disorder. A proactive approach during the interview, making suggestions the individual will respond, could influence outcome. Comorbid psychiatric disorder should be treated conventionally. Experimental studies to determine efficacy are required.

PMID 20679259
M Oto, C Espie, A Pelosi, M Selkirk, R Duncan
The safety of antiepileptic drug withdrawal in patients with non-epileptic seizures.
J Neurol Neurosurg Psychiatry. 2005 Dec;76(12):1682-5. doi: 10.1136/jnnp.2005.064063. Epub 2005 Jun 8.
Abstract/Text BACKGROUND: To determine whether withdrawal of anticonvulsant drugs (AED) can be carried out safely in patients with non-epileptic seizures (NES).
METHODS: Prospective evaluation of safety and outcome in 78 patients with NES who satisfied a standardised set of criteria for excluding the diagnosis of coexisting or underlying epilepsy.
FINDINGS: The patients were taking from one to three AED. Sixty four patients were withdrawn as outpatients, 14 as inpatients. Five patients stopped their drugs abruptly, and two had AED restarted and had to be withdrawn again. Otherwise all patients adhered to withdrawal schedules. A new type of attack in addition to NES was seen in three patients (complex partial seizures in all three cases). NES frequency declined in the group as a whole over the period of the study (follow up 6-12 months) in all individuals except for eight patients in whom there was a transient increase. Fourteen patients reported new physical symptoms after withdrawal; however, no serious adverse events were reported.
CONCLUSIONS: With appropriate diagnostic investigation and surveillance during follow up withdrawal of AED can be achieved safely in patients with NES.

PMID 15944179
Maria Oto, Colin A Espie, Roderick Duncan
An exploratory randomized controlled trial of immediate versus delayed withdrawal of antiepileptic drugs in patients with psychogenic nonepileptic attacks (PNEAs).
Epilepsia. 2010 Oct;51(10):1994-9. doi: 10.1111/j.1528-1167.2010.02696.x. Epub 2010 Aug 17.
Abstract/Text PURPOSE: To determine whether withdrawal of antiepileptic drugs (AEDs) in patients with psychogenic nonepileptic attacks (PNEAs) improves outcome.
METHODS: Randomized controlled trial of AED withdrawal in patients with PNEAs. Patients were randomized to immediate or delayed (9 months) withdrawal of AEDs. We recorded spell frequency, changes in work status, use of emergency medical services, and psychological status at baseline, 9 months, and 18 months.
RESULTS: Of 193 patients screened, 38 fulfilled entry criteria, 13 declined participation, and 25 were randomized. Fourteen patients were randomized to immediate withdrawal (IW) and 11 patients to delayed withdrawal (DW). There was a significant reduction in spell frequency from baseline to 9 months in the IW group but not in the DW group (p = 0.028). There was a significantly greater reduction in use of rescue medication in the IW group compared to the DW group between baseline and 9 months (p = 0.002). Emergency health care utilization dropped to zero in both groups by the end of the study. Psychological measures reflecting internal locus of control increased significantly more in the IW group (p = 0.005).
DISCUSSION: Stringent diagnostic criteria and an increasing tendency for patients to be referred before AED prescription limited the recruitment and the power of the study. Our data nonetheless provide evidence that some outcomes are improved by AED withdrawal in patients with PNEAs.

Wiley Periodicals, Inc. © 2010 International League Against Epilepsy.
PMID 20726877
Kurt Kroenke
Efficacy of treatment for somatoform disorders: a review of randomized controlled trials.
Psychosom Med. 2007 Dec;69(9):881-8. doi: 10.1097/PSY.0b013e31815b00c4.
Abstract/Text OBJECTIVE: To review the evidence from randomized clinical trials (RCTs) that have focused on the treatment of patients with Diagnostic and Statistical Manual of Mental Disorders, 4(th) Edition (DSM-IV) somatoform disorders. Although somatoform disorders are among the most common mental disorders presenting in the general medical setting, the strength of evidence for specific treatments has not been well synthesized.
METHODS: MEDLINE search of articles published in English from 1966 to 2006, using the following search terms: randomized clinical trial, somatoform disorders, somatization disorder, undifferentiated somatoform disorder, hypochrondriasis, conversion disorder, pain disorder, and body dysmorphic disorder.
RESULTS: A total of 34 RCTs involving 3922 patients were included. Two thirds of the studies involved somatization disorder (n = 4 studies) and lower threshold variants, such as abridged somatization disorder (n = 9) and medically unexplained symptoms (n = 10). Cognitive behavioral therapy (CBT) was effective in most studies (11 of 13), as were antidepressants in a small number (4 of 5) of studies. RCTs examining a variety of other treatments showed benefit in half (8 of 16) of the studies, the most consistent evidence existing for a consultation letter to the primary care physician. Effective treatments have been established for all somatoform disorders except conversion disorder (1 of 3 studies showing benefit) and pain disorder (no studies reported).
CONCLUSION: CBT is the best established treatment for a variety of somatoform disorders, with some benefit also demonstrated for a consultation letter to the primary care physician. Preliminary but not yet conclusive evidence exists for antidepressants.

PMID 18040099
Athula Sumathipala
What is the evidence for the efficacy of treatments for somatoform disorders? A critical review of previous intervention studies.
Psychosom Med. 2007 Dec;69(9):889-900. doi: 10.1097/PSY.0b013e31815b5cf6.
Abstract/Text OBJECTIVE: To review published literature for the highest level of evidence on the efficacy of treatment for patients with medically unexplained symptoms.
METHODS: A comprehensive literature search was carried out in Cochrane library, Medline (1971-2007), PsychINFO (1974-2006), and EMBASE (1980-2007) to identify pharmacological, nonpharmacological, psychological, and other interventions, using the search terms "medically unexplained symptoms," "somatisation," "somatization," "somatoform disorders," "psychological therapies," "cognitive behavior therapy," "pharmacological therapies," "management," "therapy," "drug therapy," and "anti-depressants" with Boolean operators AND and OR on the entire text. Searches were confined to literature in English.
RESULTS: Studies were carried out in primary, secondary, and tertiary care settings. The therapists ranged from medical specialists, psychiatrists, and psychologists to primary care physicians. Three types of interventions (antidepressant medication, cognitive behavioral therapy (CBT), and other nonspecific interventions) were supported by evidence on the efficacy of treatment for patients with medically unexplained symptoms. There is more level I evidence for CBT compared with the amount for other approaches. There was only one study reported from the developing world.
CONCLUSIONS: CBT is efficacious for either symptom syndromes or for the broader category of medically unexplained symptoms, reducing physical symptoms, psychological distress, and disability. A relatively small number of studies were carried out in primary care, but the trend has been changing over the last decade. No studies have compared pharmacological and psychological treatments. Most trials assessed only short-term outcomes. Use of divergent selection procedures, interventions, outcome measures, and instruments, and other methodological differences observed in these studies hamper the ability to compare treatment effects across studies.

PMID 18040100
L H Goldstein, T Chalder, C Chigwedere, M R Khondoker, J Moriarty, B K Toone, J D C Mellers
Cognitive-behavioral therapy for psychogenic nonepileptic seizures: a pilot RCT.
Neurology. 2010 Jun 15;74(24):1986-94. doi: 10.1212/WNL.0b013e3181e39658.
Abstract/Text OBJECTIVE: To compare cognitive-behavioral therapy (CBT) and standard medical care (SMC) as treatments for psychogenic nonepileptic seizures (PNES).
METHODS: Our randomized controlled trial (RCT) compared CBT with SMC in an outpatient neuropsychiatric setting. Sixty-six PNES patients were randomized to either CBT (plus SMC) or SMC alone, scheduled to occur over 4 months. PNES diagnosis was established by video-EEG telemetry for most patients. Exclusion criteria included comorbid history of epilepsy, <2 PNES/month, and IQ <70. The primary outcome was seizure frequency at end of treatment and at 6-month follow-up. Secondary outcomes included 3 months of seizure freedom at 6-month follow-up, measures of psychosocial functioning, health service use, and employment.
RESULTS: In an intention-to-treat analysis, seizure reduction following CBT was superior at treatment end (group x time interaction p < 0.0001; large to medium effect sizes). At follow-up, the CBT group tended to be more likely to have experienced 3 months of seizure freedom (odds ratio 3.125, p = 0.086). Both groups improved in some health service use measures and on the Work and Social Adjustment Scale. Mood and employment status showed no change.
CONCLUSIONS: Our findings suggest that cognitive-behavioral therapy is more effective than standard medical care alone in reducing seizure frequency in PNES patients.
CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that CBT in addition to SMC, as compared to SMC alone, significantly reduces seizure frequency in patients with PNES (change in median monthly seizure frequency: baseline to 6 months follow-up, CBT group, 12 to 1.5; SMC alone group, 8 to 5).

PMID 20548043
G R Smith, R A Monson, D C Ray
Psychiatric consultation in somatization disorder. A randomized controlled study.
N Engl J Med. 1986 May 29;314(22):1407-13. doi: 10.1056/NEJM198605293142203.
Abstract/Text The per capita expenditure for health care of patients with multiple physical symptoms but no apparent physical disease (somatization disorder) is up to nine times the average per capita amount. We conducted a randomized controlled trial to determine whether psychiatric consultation would reduce the medical costs of these patients, without effecting a substantial change in patient outcome. Thirty-eight patients were randomly assigned to treatment or control groups and studied prospectively for 18 months. Treatment consisted of a psychiatric consultation and suggestions on management given to primary physicians. After nine months, the control group was crossed over to receive treatment with the same intervention. After the psychiatric consultation, the quarterly health care charges in the treatment group declined by 53 percent (P less than 0.05). In contrast, the charges in the control group showed wide variations but no overall change. The quarterly charges in the control group were significantly higher than those in the treatment group (P less than 0.05). After the control group was crossed over to receive treatment, their quarterly charges declined by 49 percent (P less than 0.05). The reductions in expenditures in both groups were due largely to decreases in hospitalization. We conclude that psychiatric consultation in the care of patients with somatization disorder reduced subsequent health care expenditures without inducing changes in health status or patients' satisfaction with their health care.

PMID 3084975
Abstract/Text BACKGROUND: Patients who somatize but who do not meet criteria for somatization disorder are common in the community. Virtually no research has been conducted to determine how to treat these patients.
METHODS: We conducted a randomized controlled clinical trial of a psychiatric consultation intervention we had previously shown to improve the management of somatization disorder. The study population included 51 physicians treating 56 somatizing patients who had a history of seeking help for six to 12 lifetime unexplained physical symptoms. At the onset of the experiment, physicians randomized to the treatment condition received a consultation letter recommending a specific management approach; physicians randomized to the control/crossover condition received the consultation letter after 12 months. Data on health outcomes and charges were collected every 4 months for 2 years after randomization for 96% of subjects who entered the study.
RESULTS: Patients of physicians who received the intervention reported significantly increased physical functioning, an improvement that remained stable during the year after the intervention. The intervention reduced annual medical care charges by $289 (95% confidence interval, $40 to $464) in 1990 constant dollars, which equates to a 32.9% reduction in the annual median cost of their medical care.
CONCLUSIONS: Somatizing patients with a lifetime history of six to 12 unexplained physical symptoms reported better physical functioning after their primary care physician was provided appropriate treatment recommendations via a psychiatric consultation. Such a consultation is cost-effective because it reduces subsequent charges for medical care, while improving health outcomes in a chronically impaired population.

PMID 7872852

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