What is the management approach for a patient with a functional neurological disorder and non-epileptic seizures (NES) presenting with nausea, chest tightness, and an unresponsive episode, with normal computed tomography (CT) head, electrocardiogram (ECG), and blood tests?

From the Guidelines

The management of a patient with functional neurological disorder (FND) and non-epileptic seizures presenting with nausea, chest tightness, and an unresponsive episode should focus on a multidisciplinary approach, prioritizing psychotherapy and occupational therapy interventions. After confirming the absence of organic pathology through normal CT head, ECG, and blood tests, treatment should center on psychological therapy, delivered by specially trained clinicians, as the main evidence-based treatment for dissociative (non-epileptic) seizures (DSs) 1. A clear, non-judgmental explanation of the diagnosis to the patient is essential, emphasizing that symptoms are real but not caused by structural brain disease or epilepsy.

Key Interventions

• Referral to a neuropsychiatrist or psychologist with experience in FND is recommended.
• Occupational therapy (OT) can play a crucial role in helping patients with FND, focusing on education, rehabilitation within functional activity, and the use of taught self-management strategies 1.
• OT interventions can include helping the person to a safe space during a seizure-like event, avoiding constant reassurance and physical contact or restraint, and advising others to behave as they would if someone is having a panic attack 1.
• Sensory Grounding Techniques, such as noticing the detail in the environment, cognitive distractions, and sensory-based distractors, can be helpful in preventing dissociation and managing symptoms 1.
• Anxiety management strategies, including breathing techniques, progressive muscle relaxation, grounding strategies, and regular cardiovascular exercise, can be beneficial for patients with FND and comorbid anxiety 1.

Medication Considerations

• Antidepressants such as SSRIs may help manage comorbid anxiety or depression, but their use should be carefully considered and monitored [@Example@].
• Benzodiazepines should generally be avoided due to dependency risks.

Follow-Up and Monitoring

• Regular follow-up is important to monitor progress and adjust treatment as needed.
• Patient education about stress management techniques and self-management strategies can help interrupt the cycle of symptoms and improve quality of life.

From the Research

Management Approach

The management approach for a patient with a functional neurological disorder and non-epileptic seizures (NES) presenting with nausea, chest tightness, and an unresponsive episode, with normal computed tomography (CT) head, electrocardiogram (ECG), and blood tests, involves a comprehensive evaluation and treatment plan.

• The patient's symptoms, such as nausea, can be addressed using a practical 5-step approach, which includes defining the patient's symptoms, determining the acuity of symptoms, considering medication or toxin adverse effects, formulating a differential diagnosis, and directing treatment based on the underlying cause 2.
• For patients with NES, psychotherapy has been shown to be effective in treating functional seizures 3, 4.
• A thorough diagnostic evaluation, including clinical history, semiology of witnessed typical events, and electroencephalography (EEG) findings, is essential to differentiate NES from epileptic seizures 3, 4.
• The patient's presentation, including symptoms such as chest tightness and unresponsive episodes, should be carefully evaluated to formulate a differential diagnosis and guide further evaluation and treatment 2.

Treatment Options

• Psychotherapy, specifically cognitive behavioral therapy-informed psychotherapy, has been demonstrated to be an efficacious treatment for NES 4.
• Treatment of nausea and vomiting should be directed based on the underlying cause, and may involve an empirical trial of antiemetics or further testing to identify an underlying cause 2.
• Management of NES may also involve addressing comorbid neurological and psychological disorders, as well as assessing and integrating medical-neurologic and psychiatric comorbidities into treatment interventions and prognostic considerations 5, 4.

Further Evaluation

• Further evaluation, including neuroimaging studies and EEG, may be necessary to better understand the underlying mechanisms of the patient's symptoms and to guide treatment 4, 6.
• The patient's symptoms, including nausea and chest tightness, should be carefully monitored and addressed to prevent further episodes and improve quality of life 2.