To the Editor In the Viewpoint on treatment of patients with psychogenic nonepileptic attacks (PNEA), Dr Tolchin and colleagues mentioned that 鈥渙nce the diagnosis of PNEA is made, psychotherapy is the treatment of choice.鈥�¹ I would like to raise a question about this statement.

In a clinical trial of 38 patients with psychogenic nonepileptic seizures (PNES) (or PNEA) with a short follow-up period of 16 weeks,² the authors observed that combined cognitive behavioral therapy with drug therapy (ie, sertraline), considered the best current practice, resulted in a 59% reduction in seizures, which was significantly better than that in the treatment-as-usual group. On the other hand, a meta-analysis that synthesized data from 13 studies in 228 patients with PNES³ demonstrated that 47% of patients achieved seizure freedom after completion of a psychological intervention. Therefore, one concern is that the evidence on the effectiveness of the psychotherapy regimens, including cognitive behavioral therapy, in the treatment of PNES is based on small and short-term studies. Well-designed, randomized, large-scale, long-term clinical trials are lacking. In addition, in a recent study of 69 patients with PNES who had never received psychological treatment because of lack of resources, 36 patients (52%) were seizure free during the past 12 months of their follow-up.⁴ There are other studies with different results for outcomes of patients with PNES.⁵ In spite of these different findings, the outcome data for patients who were treated adequately² were not much different from those found in an untreated patient population.⁴ Therefore, cross-cultural clinical trials with longer follow-up periods are necessary to investigate various treatment strategies in patients with PNES. In designing such studies, applying seizure frequency as the only outcome measure in patients with PNES is not good enough.⁴ As long as the exact pathophysiology of PNES is unknown, it is very difficult, if not impossible, to design meaningful clinical trials to discover an effective method or methods of treatment for these patients.