What is the management of psychogenic non-epileptic seizures (PNES)?

From the Guidelines

To effectively manage psychogenic seizures, a multidisciplinary approach focusing on psychotherapy, particularly cognitive behavioral therapy (CBT), is crucial, as highlighted by the most recent and relevant guidelines. Dealing with psychogenic seizures, also known as psychogenic non-epileptic seizures (PNES) or functional seizures, requires a comprehensive understanding of their psychological nature. The primary distinction between PNES and epileptic seizures lies in their cause, with PNES stemming from psychological distress, trauma, or anxiety rather than abnormal electrical activity in the brain 1.

Key Considerations

• Distinguishing PNES from other conditions, such as paroxysmal kinesigenic dyskinesia (PKD), is essential, as both can manifest with similar symptoms but have different underlying causes and treatments 1.
• Features of distractibility, variability of clinical presentations, and suggestibility are red flags for suspecting a psychogenic disorder, alongside factors like adult age of onset, altered level of responsiveness during attacks, and atypical responses to medications 1.
• A high-knee exercise test may aid in differential diagnosis, particularly in cases where the distinction between PKD and psychogenic movement disorders is challenging 1.

Treatment Approach

• Psychotherapy, specifically CBT or trauma-focused therapy, is the cornerstone of treatment, addressing the psychological mechanisms underlying PNES 1.
• Medications such as SSRIs (e.g., sertraline 50-200mg daily or fluoxetine 20-80mg daily) can be beneficial in managing associated anxiety or depression but do not directly treat the seizures themselves.
• Mindfulness techniques, deep breathing exercises, and progressive muscle relaxation can help prevent or interrupt episodes when warning signs appear.
• Educating family members about PNES and how to respond calmly without unnecessary emergency interventions is vital, as is joining support groups for additional emotional support.

Importance of Accurate Diagnosis

• Seeking an accurate diagnosis from a neurologist, typically through video-EEG monitoring, is essential to distinguish PNES from epileptic seizures 1.
• Avoiding the ambiguous use of the term "seizure" and instead using "epileptic seizures" when referring to attacks caused by abnormal electrical activity can help prevent confusion between syncope, epileptic seizures, and PNES 1.

From the Research

Dealing with Psychogenic Seizures

Dealing with psychogenic seizures requires a comprehensive approach that incorporates various treatment modalities. The following are some key points to consider:

• Psychotherapeutic modalities, such as cognitive-behavioral therapy (CBT), are effective in reducing seizure frequency and improving quality of life in patients with psychogenic nonepileptic seizures (PNES) 2, 3, 4.
• A multidisciplinary, holistic approach is beneficial in managing PNES, as it addresses the complex psychological and neurobiological aspects of the disorder 2, 5.
• Self-control relaxation paradigms and mindfulness-based interventions have been shown to be effective in reducing seizure frequency and improving symptoms in patients with PNES 5, 4.
• Family therapy can be an important component of treatment, as it provides a constructive means for the patient's family to participate in the reduction of psychogenic seizures 5.
• Pharmacological interventions are not effective in altering the etiology of psychogenic seizures and can cloud the cognitive skills necessary to ameliorate the seizure behavior 5.
• In-session seizures can occur during psychological therapy, and therapists should be prepared to manage them safely and effectively 6.

Treatment Outcomes

Treatment outcomes for PNES can vary depending on the specific intervention and the individual patient. Some key findings include:

• Cognitive Behavioral Therapy-informed psychotherapy (CBT-ip) has been shown to be effective in reducing seizure frequency, depression, and anxiety in patients with PNES 3.
• Mindfulness-based interventions have been found to be feasible and effective in reducing symptoms in patients with PNES 4.
• Long-term follow-up is essential in managing PNES, as a significant proportion of patients remains symptomatic and experiences continued impairments in quality of life and functionality 4.

Management Strategies

Effective management of PNES requires a comprehensive approach that incorporates various treatment modalities. Some key strategies include:

• Patient engagement and education are critical in the treatment of PNES, as they help patients understand their condition and participate in their care 2, 4.
• Interdisciplinary collaboration is essential in managing PNES, as it ensures that patients receive comprehensive care that addresses their complex psychological and neurobiological needs 2, 4.
• Acute interventions, such as CBT and mindfulness-based interventions, can be effective in reducing seizure frequency and improving symptoms in patients with PNES 3, 4.
• Long-term follow-up and support are essential in managing PNES, as they help patients maintain their treatment gains and manage their symptoms over time 4.