The CODES trial randomized adults with dissociative seizures to standardized medical care alone or to standardized medical care plus dissociative-seizure-specific cognitive behavioural therapy. Although the primary outcome of monthly seizure frequency at 12 months did not differ significantly between groups, the cognitive behavioural therapy group did better on multiple secondary outcomes including longest seizure-free period, psychosocial functioning, somatic symptom burden, health-related quality of life and clinician-rated and self-rated global change. It remains the largest randomized evidence base for this condition.
The prodromal symptoms he describes, derealization, tingling and breathlessness, are typical dissociative and hyperventilation-related warning phenomena and are a therapeutic opportunity. Patients can be taught to recognize them and to use grounding and distraction techniques, such as focusing on external sensory detail, controlled breathing, or moving and talking, to abort or shorten an attack. Identifying situational triggers such as crowded places allows graded exposure rather than avoidance, and family members can be taught what to do and what not to do during an attack, including avoiding emergency ambulance calls for typical events.
On the ABPN blueprint this item maps to the Treatment and management axis, because it tests selection of an evidence-based therapy and adjunctive self-management. Antidepressants may be added where there is comorbid depression or anxiety, but they are not a substitute for the psychological work.
Incorrect Answers
- A. Regular benzodiazepines promote tolerance and dependence and have no evidence base in dissociative attacks.
- C. Antiseizure medication has no efficacy for dissociative attacks and reintroducing it reinstates a mistaken diagnostic model.
- D. Blanket avoidance of triggers entrenches the disorder; graded exposure with grounding techniques is preferred.
- E. Inpatient psychiatric admission is rarely required and risks reinforcing illness behaviour; outpatient treatment has not in fact been optimized.
Testing Pearls
- The CODES trial showed benefit of dissociative-seizure-specific CBT on multiple secondary outcomes.
- Monthly seizure frequency at 12 months did not differ significantly between arms in CODES.
- Teach recognition of prodromal dissociative symptoms and use grounding or distraction.
- Identify triggers for graded exposure rather than lifelong avoidance.
- Educate family to avoid emergency escalation for typical attacks.
References
- Jankovic J, Mazziotta JC, Newman NJ, Pomeroy SL, editors. Bradley and Daroff's Neurology in Clinical Practice. 8th ed. Philadelphia, PA: Elsevier; 2022. p. 2090.
- Goldstein LH, Robinson EJ, Mellers JDC, Stone J, Carson A, Reuber M, et al. Cognitive behavioural therapy for adults with dissociative seizures (CODES): a pragmatic, multicentre, randomised controlled trial. Lancet Psychiatry. 2020;7(6):491-505.
- Stone J. Functional neurological disorders: the neurological assessment as treatment. Pract Neurol. 2016;16(1):7-17.
