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disorder that might be expected to respond to anxiolytic or antidepressant treatment, some
authorities advocate using such treatments54. However, a small randomised controlled trial of
sertraline recently failed to show significant benefit71.

For the majority of patients some form of psychological treatment is usually recommended79.
There is relatively little evidence on which to base a decision about what form of therapy is
best, although it is widely supposed that the nature of any associated psychiatric comorbidity
(if any) is an important consideration. In patients with learning difficulties operant
behavioural programmes using simple reward systems are often helpful55,56. The early
literature includes a number of compelling descriptions of insight-oriented, dynamic
psychotherapeutic approaches in patients with a history of DS and sexual abuse57,58. Rusch
and colleagues reported treatment outcome in 33 patients59. Treatment, which included
psychodynamic and cognitive behavioural approaches (mostly in combination), was tailored
to reflect aetiology and comorbid psychiatric diagnoses. In a larger, uncontrolled series,
Mayor et al72 have recently reported outcome in 66 patients who received brief inter-personal
(dynamic) therapy ‘augmented’ with cognitive behavioural techniques. One-quarter of

patients were seizure free after six months. Other reports have described psychoeducational

group therapy60 and eye movement desensitisation61. Variations of therapy based on
psychodynamic, insight-oriented and group-based methods are undoubtedly widely practised
and believed to be effective but controlled studies of such interventions are needed.

The paroxysmal nature of DS, prominent somatic symptoms of arousal in many patients and
an association with agoraphobic avoidant behaviour suggest that techniques developed in
cognitive behavioural therapy (CBT) for the treatment of panic disorder might readily be
adapted for DS59,62. A number of uncontrolled studies have now shown that CBT is associated
with significant improvement63,73,74. Most recently, a randomised controlled trial has
demonstrated a significant advantage of CBT compared with standard outpatient care75.
Patients receiving CBT were three times more likely to become seizure free by the end of
treatment. However, improvement was seen in both CBT and standard treatment groups and
by six months follow-up the difference in outcome was no longer statistically significant. A
second small randomised controlled trial has also suggested the effectiveness of CBT in DS81.
A multicentre RCT is now under way in the UK comparing the effectiveness of standardised
medical care with and without CBT82. Controlled studies of longer-term outcome following
treatment are required, as are comparisons of different treatment approaches, including
evaluations of brief simplified treatments which might be delivered more easily outside
specialist neuropsychiatric services. Techniques developed for post-traumatic stress disorder
and dysfunctional personality traits may also be helpful, but these and other techniques also
require evaluation59,64.

A significant proportion (see below) of patients continues to have seizures despite intensive
treatment. A pragmatic approach in such cases is to offer long term-follow up to provide
support for the patient and their family, social interventions to improve quality of life, and
also to limit the cost and morbidity associated with further unnecessary investigations and
medical interventions.

Outcome
A review of outcome studies5 found that after a mean follow-up period of three years
approximately two-thirds of patients continued to have DS and more than half remained
dependent on social security. Psychiatric treatment has been associated with a positive
outcome in some studies, but not others. A poor prognosis is predicted by a long delay in
diagnosis and the presence of psychiatric comorbidity, including personality disorder. Being
unemployed and in receipt of disability benefits has recently been reported to be a predictor
of poor outcome76.