Psychogenic Non-Epileptic Seizure Triggers and Treatment
Psychogenic non-epileptic seizures (PNES) are triggered by psychological stressors including trauma, anxiety, mood disturbances, and specific situational factors, and should be treated primarily with cognitive-behavioral therapy while addressing psychiatric comorbidities with targeted pharmacotherapy.
Common Triggers
PNES emerge through a biopsychosocial model involving predisposing, precipitating, perpetuating, and triggering factors 1:
Predisposing factors:
- History of psychological trauma (particularly common)
- Underlying mood disturbances and anxiety disorders
- Personality disorders
- School or family problems (especially in children) 2
Immediate triggers:
- Acute psychological stressors
- Situations that provoke anxiety or emotional distress
- Fatigue, pain, and poor sleep (which compete for cognitive resources) 3
- Specific environmental or interpersonal situations that patients may identify after careful discussion
Critical caveat: Many patients initially report no memory of events prior to PNES, but with therapeutic discussion, most begin to recognize patterns and warning signs 3. Don't accept "I don't know" as a final answer—explore systematically.
Treatment Algorithm
Step 1: Diagnosis Communication (Essential First Step)
Help the person understand the diagnosis clearly 3. This is foundational—without proper explanation that PNES are not epileptic seizures but are real, involuntary manifestations of psychological distress, subsequent treatment fails 2.
Step 2: First-Line Psychological Treatment
Cognitive-behavioral therapy (CBT) is the recommended first-line psychological approach 4. Psychotherapeutic modalities remain the most powerful instrument to reduce seizures and empower patients 5.
Additional psychological strategies include:
- Sensory grounding techniques to prevent dissociation by keeping patients present in the moment 3
- Teaching patients to recognize warning signs and apply strategies to avert episodes
- Developing a seizure action plan for what to do during episodes (safe space, minimal reassurance, no physical restraint) 3
Step 3: Address Contributing Factors
Systematically address:
- Fatigue management through structured daily routines
- Pain control
- Sleep optimization (consider reducing sedating medications with GP) 3
- Anxiety reduction through relaxation techniques
- Reducing cognitive overload with written daily plans 3
Step 4: Pharmacological Treatment for Comorbidities
Medications are NOT for PNES itself but for psychiatric comorbidities 4:
- Antidepressants for depression
- Anxiolytics for anxiety disorders
- Treatment for post-traumatic stress disorder when present 6
Look carefully for:
- Mood disturbances (depression is highly comorbid)
- Anxiety disorders
- Personality disorders
- History of trauma and PTSD 4, 6
Step 5: Multidisciplinary Coordination
PNES management requires coordination between neurology, psychiatry/psychology, and occupational therapy 4, 7. The neurologist establishes diagnosis, psychiatry addresses comorbidities, and psychology delivers psychotherapy.
Key Clinical Pitfalls
Avoid these common errors:
- Constant reassurance during episodes (counterproductive) 3
- Physical contact or restraint during episodes 3
- Encouraging patients to "try to remember" or overly attend to symptoms (paradoxically worsens symptoms) 3
- Treating with antiepileptic drugs (delays proper treatment and causes unnecessary side effects)
- Providing excessive practical assistance (gradually reduce to promote independence) 3
Prognosis Considerations
Quality of life can be improved even when complete seizure freedom is not achieved 5. Prognosis is better in children than adults, with most children becoming PNES-free 2. Early diagnosis and treatment prevent chronicity—maintaining factors turn a temporary disturbance into chronic disability if left untreated 1.
The evidence base remains limited across all treatment modalities 4, 5, but the consensus strongly supports psychological therapy as primary treatment with psychiatric medication reserved for comorbid conditions rather than PNES itself.