A NEAD for change? Clinician attitudes towards non-epileptic attack disorder

Non-epileptic attacks (also called psychogenic non-epileptic (PNES), functional or dissociative seizures) present similarly to epileptic seizures but without ictal electroencephalographic (EEG) discharges.Non-epileptic attack disorder (NEAD) is classified as a conversion disorder in DSM-5 and a dissociative neurological symptom disorder in ICD-11.It is often associated with long-term disability.People with NEAD access healthcare in a variety of settings and frequently report negative experiences, 1 which often relate to fragmented care and negative clinician attitudes towards NEAD.To explore current understanding of clinician attitudes towards NEAD, we conducted a systematic literature review, 2 which was registered on PROSPERO and adhered to PRISMA 2020 guidelines.Three electronic databases were searched using search terms developed with an academic librarian.Studies reporting general attitudes and beliefs of clinicians regarding NEAD in adults, published in the past 10 years, were included.Data were extracted from each study with a predesigned proforma, using the Mixed Methods Appraisal Tool 3 to assess study quality and bias.In total, 508 citations were identified, of which 80 were selected for possible inclusion.Citation searching identified 12 additional studies; in total, 24 studies met inclusion criteria.These studies spanned nine countries (Brazil, Canada, China, France, Iran, Namibia, South Africa, UK, USA), with two global studies.Sixteen studies collected data via questionnaires, and eight used interviews.The main healthcare professionals (HCP) included were psychiatrists, neurologists, general practitioners and emergency medicine practitioners.Thematic analysis identified seven key themes: terminology; aetiology and comorbidities; confidence in diagnosis and training; views on optimal management; communication regarding diagnosis and treatment; systemic challenges and international differences; and differences among HCP.Across the nine papers assessing terminology, the term most widely used was 'PNES'.Overall, nine different terms were described; these included 'pseudoseizures', 'NEAD', 'functional seizures' and 'hysteria'.Terms for individual episodes included 'seizures', 'events' and 'attacks'.Some clinicians noted that terms including 'psychogenic' or 'pseudo' might be alienating owing to the implication of a non-medical disorder. 4 The data also highlighted that 'non-epileptic' could be perceived negatively, as a 'non-diagnosis'. 5Standardising language could improve recognition, communication and service development and reduce stigma.Perceptions regarding the aetiology of NEAD and common comorbidities were investigated in 22 studies.Clinicians reported that NEAD commonly co-occurred with psychiatric conditions (notably anxiety, depression, personality disorder and post-traumatic stress disorder) and 'physical' causes including epilepsy, head trauma and brain lesions.Clinicians generally agreed that