How are pseudoseizures (psychogenic nonepileptic seizures (PNES)) managed?

From the Guidelines

The management of pseudoseizures, also known as psychogenic nonepileptic seizures (PNES), should primarily involve psychotherapy, such as cognitive behavioral therapy (CBT) or psychodynamic therapy, rather than antiepileptic medications. This approach is supported by the fact that accurate diagnosis and appropriate referrals for psychiatric treatment can lead to significant improvement, with 72% of patients' PNES resolving after treatment 1.

Key Components of Management

• Clear communication of the diagnosis to the patient in a non-judgmental manner, emphasizing that these events are real but not epileptic in nature
• Psychotherapy, typically involving 12-16 weekly sessions, focused on identifying triggers, developing coping strategies, and addressing underlying psychological factors such as trauma, anxiety, or depression
• Consideration of medications for comorbid psychiatric conditions, such as SSRIs like sertraline (50-200 mg daily) or fluoxetine (20-80 mg daily) for depression or anxiety
• Avoidance of benzodiazepines, as they may worsen symptoms
• A multidisciplinary approach involving neurologists, psychiatrists, psychologists, and social workers
• Patient education about stress management techniques, including mindfulness meditation, progressive muscle relaxation, and deep breathing exercises

Importance of Accurate Diagnosis

Accurate diagnosis of PNES is crucial, as it can prevent unnecessary medical testing and treatment, including the use of anticonvulsants, which can have significant side effects 1. Research has shown that patients with PNES often undergo extensive medical testing, including invasive procedures, and are frequently prescribed anticonvulsants, despite the lack of evidence for their effectiveness in treating PNES 1.

Prognosis and Outcome

The prognosis for patients with PNES improves significantly when they accept the diagnosis and actively engage in appropriate psychological treatment 1. A study found that 72% of patients' PNES had resolved after psychiatric treatment, highlighting the importance of early and accurate diagnosis, as well as effective treatment 1.

From the Research

Management of Pseudoseizures (Psychogenic Nonepileptic Seizures - PNES)

• The management of PNES typically begins with a thorough discussion of the diagnosis with the patient, emphasizing that the condition is real and treatable 2.
• A psychiatric evaluation is recommended, ideally before discharge from the seizure monitoring unit (SMU), to identify any underlying psychiatric comorbidities 2.
• Cognitive behavioral therapy (CBT) is the only treatment for PNES that is supported by high-quality evidence, and it should be considered as a first-line treatment 2, 3.
• Other therapies, such as psychodynamic therapy and group therapy, may be considered in some patients, although the evidence to support their use is limited 2.
• Selective serotonin-reuptake inhibitors (SSRIs) may be beneficial for some patients, particularly those with psychiatric comorbidities, but this should be considered on a case-by-case basis 2.
• A multidisciplinary, holistic approach to treatment is recommended, as it can help to empower patients and reduce seizures 4.

Treatment Outcomes

• Studies have shown that CBT can be effective in reducing seizure frequency, depression, and anxiety in patients with PNES 3.
• However, the outcomes of treatment can vary depending on the individual patient and the specific treatment approach used 3, 5.
• Some patients may experience significant improvement in their symptoms without further interventions, simply as a result of receiving a clear and non-pejorative explanation of their diagnosis 5.

Challenges in Management

• PNES can be a challenging condition to manage, particularly in patients who also have epilepsy, as it can be difficult to differentiate between epileptic and non-epileptic seizures 6.
• The lack of prompt identification of PNES can lead to unnecessary treatments and anti-seizure drug (ASD)-related side effects, as well as a negative impact on the patient's quality of life 6.
• A thorough diagnostic evaluation, including video-EEG monitoring, is essential to confirm the diagnosis of PNES and to rule out other conditions, such as epilepsy 2, 5, 6.