From the Guidelines
To effectively manage psychogenic seizures, a multidisciplinary approach focusing on psychotherapy, particularly cognitive behavioral therapy (CBT), is crucial, as it has shown the most evidence for effectiveness in addressing underlying psychological factors and improving patient outcomes. When dealing with psychogenic seizures, also known as psychogenic non-epileptic seizures (PNES) or functional seizures, it is essential to start by obtaining an accurate diagnosis through video-EEG monitoring to distinguish these events from epileptic seizures 1.
Some key features to consider in diagnosing psychogenic seizures 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. Administering a high-knee exercise test may also help physicians make differential diagnoses.
In terms of treatment, psychotherapy is the primary approach, with CBT being the most effective, where patients typically attend weekly sessions for 12-16 weeks, focusing on identifying triggers, developing coping strategies, and addressing underlying psychological factors. Other helpful approaches include dialectical behavior therapy, mindfulness practices, and stress management techniques. Medications, such as SSRIs like sertraline (50-200mg daily) or escitalopram (10-20mg daily), may be prescribed to address comorbid conditions like anxiety or depression, but they are not the primary treatment.
Patient education is also crucial, as understanding that these seizures are real but not caused by abnormal electrical activity in the brain helps reduce stigma and improves outcomes. Family involvement in treatment supports better management, and joining support groups can provide additional coping resources. Regular follow-up with both mental health professionals and neurologists ensures comprehensive care for this challenging condition. It's also important to avoid confusion between syncope and epileptic seizures by using specific terminology, such as 'epileptic seizures' when possible, to prevent mistaking syncope for epilepsy 1.
Key considerations in managing psychogenic seizures include:
- Accurate diagnosis through video-EEG monitoring
- Psychotherapy, particularly CBT, as the primary treatment
- Addressing comorbid conditions like anxiety or depression with medications if necessary
- Patient education and family involvement
- Regular follow-up with mental health professionals and neurologists.
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.