LAUSR

Psychogenic nonepileptic seizures (PNES) have long occupied a unique place in the border regions between neurology and psychiatry. The correct diagnosis of PNES is made by epileptologists, sometimes after years of misdiagnosed epilepsy. Then, after a correct diagnosis has been established, PNES patients are referred to psychiatry, psychology, or social workers for treatment planning and implementation if such resources are available, but unfortunately therapists with appropriate skill in treatment of functional neurologic disorders are limited. This sometimes-abrupt handoff for patient management occasionally creates an impression that somehow their PNES events are not “real,” when in fact these episodes are very real. Although not due to excessive electrical discharges, PNES is a network disorder that creates involuntary attacks similar to seizures.1 Patients with PNES have increased connectivity interictally between the amygdala and the frontal lobe,2 and during PNES attacks, there is a functional disconnection between brain areas, particularly involving the parietal cortices and the anterior insula.3 Funding to establish best PNES treatment practices and characterizing treatment effectiveness for PNES is limited, with neurology organizations often considering PNES to be a behavioral disorder, while psychiatry and behavioral health organizations view PNES as having its origins in neurology and generality outside their areas of treatment expertise, again reflecting its border region location between disciplines. It is against this backdrop the 2020 Epilepsia Prize winner in Clinical Science makes a meaningful contribution to both clinical care and clinical research.4 Although many PNES comorbidities such as depression and anxiety can be often managed by traditional pharmacotherapeutic approaches, the underlying reasons for the development of PNES frequently are psychological and emotional, with high rates of abuse (see Tolchin et al, Table 2) requiring specialized psychotherapeutic treatment programs and engagement. Unfortunately, many PNES patients are unable to find providers with PNES treatment expertise. Others may be simply unwilling to engage in psychotherapy given misperceptions regarding their underlying causes of their symptoms, and if an appropriate provider is initially identified and treatment started, over half of PNES patients are noncompliant with their treatment program and ultimately drop out. The 2020 Epilepsia Prize winning paper, with a neurologist as the lead author, addresses one important piece of the puzzle to improve PNES treatment effectiveness by evaluating the benefit of motivational interviewing.4 Motivational interviewing can be conceptualized either as an extension of Rogerian client-centered therapy developed in the 1940s or as reflecting the more recent healthcare emphasis of engaging patient-centered treatment approaches. Both conceptualizations are designed to maximally engage patients as treatment partners, reflecting “a collaborative, goal-oriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person's own reasons for change”5 (p. 29). Applying motivational interviewing in PNES in a randomized clinical trial provides the opportunity to evaluate testable hypotheses of whether motivational interviewing affects treatment adherences in PNES, and ultimately is associated with improved PNES treatment outcomes. Tolchin et al do not attempt to identify the best intervention to optimize PNES treatment outcome, addressing instead the benefit of including motivational interviewing added to various heterogeneous treatment approaches. There is currently no single therapeutic approach that has been identified