Tolchin Benjamin, Baslet Gaston, Martino Steve, Suzuki Joji, Blumenfeld Hal, Hirsch Lawrence J, Altalib Hamada, Dworetzky Barbara A
The Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Conn. (Tolchin, Blumenfeld, Hirsch, Altalib); Neurology Service, Epilepsy Center of Excellence, Department of Veterans Affairs (VA) Connecticut Healthcare System, West Haven, Conn. (Tolchin, Altalib); the Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston (Tolchin, Dworetzky); the Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet, Suzuki); the Department of Psychiatry, Yale University School of Medicine, New Haven, Conn. (Martino); and Psychology Service, VA Connecticut Healthcare System, West Haven, Conn. (Martino).
J Neuropsychiatry Clin Neurosci. 2020 Spring;32(2):125-131. doi: 10.1176/appi.neuropsych.19020045. Epub 2019 Aug 30.
Psychogenic nonepileptic seizures (PNES) are a highly disabling disorder frequently encountered by neurologists, psychiatrists, and emergency medicine physicians. There is accumulating evidence for the efficacy of psychological therapies, yet the majority of patients do not complete treatment. A range of health care system-based, clinician-based, and patient-based barriers to treatment exists, including stigma, poor clinician-patient communication, and patient ambivalence about the diagnosis and treatment of PNES. These barriers frequently lead to treatment nonadherence. Motivational interviewing (MI) is a patient-centered counseling style targeting ambivalence about behavior change, which has been shown to be effective in improving psychotherapy adherence and outcomes among patients with PNES. The authors review MI processes and techniques that may be useful to health care providers helping patients with PNES and other functional neurological disorders to engage in psychotherapy. The authors examine common challenges arising during MI for patients with PNES, including somatic symptoms distracting from clinician-patient communication, ambivalence about making concrete plans for treatment, and psychiatric comorbidities. Strategies for overcoming these obstacles are reviewed, including the use of complex reflections to enhance patient engagement; the use of an ask-tell-ask format and specific, measurable, achievable, relevant, and time-limited (SMART) goals to facilitate treatment planning; and close collaboration between the neurology and psychotherapy teams.
心因性非癫痫性发作（PNES）是一种严重致残的疾病，神经科医生、精神科医生和急诊医学医生经常会遇到。越来越多的证据表明心理治疗是有效的，但大多数患者并未完成治疗。存在一系列基于医疗保健系统、临床医生和患者的治疗障碍，包括耻辱感、医患沟通不良以及患者对PNES诊断和治疗的矛盾心理。这些障碍经常导致治疗依从性差。动机性访谈（MI）是以患者为中心的咨询方式，针对行为改变的矛盾心理，已被证明在提高PNES患者的心理治疗依从性和治疗效果方面有效。作者回顾了MI的过程和技巧，这些可能对帮助PNES患者和其他功能性神经系统疾病患者接受心理治疗的医疗保健提供者有用。作者研究了PNES患者在MI过程中出现的常见挑战，包括躯体症状干扰医患沟通、对制定具体治疗计划的矛盾心理以及精神共病。还回顾了克服这些障碍的策略，包括使用复杂的反思来提高患者的参与度；使用询问-告知-询问的格式和具体、可衡量、可实现、相关且有时限（SMART）的目标来促进治疗计划；以及神经科和心理治疗团队之间的密切合作。
