From the Guidelines
Dealing with psychogenic seizures requires a multidisciplinary approach focused on psychological treatment rather than antiepileptic medications, with cognitive-behavioral therapy (CBT) being the most effective treatment. When managing psychogenic seizures, it is crucial to first obtain an accurate diagnosis through video-EEG monitoring to distinguish these events from epileptic seizures, as the clinical characteristics of psychogenic movement disorders and pseudoseizures can be similar to those of other conditions, such as paroxysmal kinesigenic dyskinesia (PKD) 1. Key features that may suggest a psychogenic disorder include distractibility, variability of clinical presentations of different paroxysms, and suggestibility, as well as red flags such as adult age of onset, altered level of responsiveness during attacks, additional psychogenic physical signs, medically unexplained somatic symptoms, and an atypical response to medications 1. The treatment approach should involve referral to a mental health professional, preferably one experienced in treating psychogenic non-epileptic seizures (PNES), for psychotherapy, with CBT typically requiring 12-16 weekly sessions, and other helpful approaches including dialectical behavior therapy, mindfulness practices, and trauma-focused therapy if relevant. It is also important to note that antiepileptic drugs are not effective for PNES and should be avoided or tapered off if previously prescribed, and patients may benefit from learning specific grounding techniques to use during aura phases to potentially abort oncoming episodes, with patient education and support groups providing additional emotional support during the treatment process 1. With appropriate psychological treatment, approximately 60-70% of patients experience significant reduction or complete resolution of their seizures. Some key points to consider in the management of psychogenic seizures include:
- Obtaining an accurate diagnosis through video-EEG monitoring
- Referral to a mental health professional for psychotherapy
- Use of CBT as the most effective treatment
- Avoidance of antiepileptic medications
- Patient education and support groups as crucial components of treatment.
From the Research
Dealing with Psychogenic Seizures
- Psychogenic nonepileptic seizures (PNES) are a type of functional neurological disorder/conversion disorder that can be challenging to manage 2.
- A multidisciplinary, holistic approach to treatment is beneficial, and psychotherapeutic modalities can be a powerful instrument to empower patients and reduce seizures 2.
- Cognitive Behavioral Therapy (CBT) is known to be an effective intervention for treating PNES and underlying psychiatric symptoms 3.
- Mindfulness-based psychotherapy protocols have also shown promise in feasibility studies and warrant further investigation in larger scale studies 4.
Treatment Approaches
- Treatment of PNES should be based on interdisciplinary collaboration, targeting modifiable risk factors 4.
- Patient engagement is a crucial first phase in treatment, but can be challenging due to low rates of treatment retention 4.
- Acute interventions, such as cognitive-behavioral therapy, can be effective in reducing seizure frequency and improving quality of life 2, 3.
- Long-term follow-up is essential, as a significant proportion of patients remains symptomatic and experiences continued impairments in quality of life and functionality 4, 5.
Management of Seizures
- In-session seizures can occur during psychological therapy, and are more common in patients with PNES than in those with epilepsy 6.
- Seizures can be managed by the treating therapist without help from additional medical staff, but safe management plans should be in place 6.
- The frequency and management of seizures during psychological treatment can vary, and further research is needed to understand the mechanisms triggering these seizures 6.