Abstracts

Rationale: We conducted a randomized controlled trial of motivational interviewing (MI) as an intervention to address the common problem of non-adherence among patients with psychogenic nonepileptic seizures (PNES). Patients randomized to receive MI prior to conventional psychotherapy had superior adherence with psychotherapy, PNES frequency, and quality of life when compared to patients randomized to receive conventional psychotherapy alone. In this abstract, we review several clinical cases that illustrate challenges and successful strategies we encountered while conducting MI for patients with PNES in the context of a seizure clinic. Methods: MI was conducted by a board-certified neurologist who had completed 40 hours of MI training with members of the Motivational Interviewing Network of Trainers. MI sessions consisted of four sequential but overlapping processes: 1) engaging (establishing an open, empathic, patient-centered relationship); ii) focusing (helping the participant to identify PNES treatment as a target for behavior change); iii) evoking (using reflective listening to elicit the participant’s motivations for PNES treatment); and iv) planning (developing the participant’s concrete plans for managing PNES, including participating in psychotherapy). Results: Ms. M’s case illustrates the problem of comorbid somatic symptoms among patients with PNES, how these comorbidities complicate the motivational enhancement process, and the frequent use of reflective listening to reveal motivations for change veiled by the patient’s acute somatic concerns. Ms. M complained of a severe headache and hearing breaking glass, preventing her from participating in discussing the diagnosis and treatment of PNES. The symptoms resolved when reflective listing techniques were used to empathize with her symptoms while simultaneously raising her concerns about the impact of her seizures on her family and herself.Mr. C’s case illustrates the problem of ambivalence, in which patients both wish to stop their psychogenic seizures and are simultaneously reluctant to engage in treatment. Like most patients, Mr. C could deliver a long list of ways in which PNES negatively affected his life. Yet after reviewing the benefits of psychotherapy for reducing PNES frequency in neurology clinic, he could not identify steps he might take to treat his PNES. In such cases, more extensive discussion of small, short-term, concrete, and easily achievable behavior changes was useful.Ms. T’s case illustrates the importance of ongoing peer review and training for an MI practitioner. Ms. T suffered from comorbid substance use disorders in addition to PNES. After discussing the case with members of a MI peer review group that included social workers with extensive experience in counseling patients with polysubstance use disorder, the neurologist was able to incorporate several resources and organizations for treating substance use disorder into the MI session.Ms. B’s case illustrates the potential advantage of performing MI in the neurologist’s office. She had previously dropped out of psychotherapy because she felt that she had a “medical” problem rather than a “mental” problem. After formulating a detailed treatment plan with a neurologist that included psychotherapy, she adhered to the plan and willingly participated in several months of weekly psychotherapy. Conclusions: MI is an effective intervention for the common problem of non-adherence with psychotherapy among patients with PNES. Funding: American Academy of Neurology Practice Research Training Scholarship