What is the management approach for pseudoseizures (psychogenic non-epileptic seizures)?

Management of Psychogenic Non-Epileptic Seizures (Pseudoseizures)

The management of psychogenic non-epileptic seizures (PNES) should focus on cognitive behavioral therapy as the primary intervention, along with clear communication about the diagnosis in a sympathetic manner that acknowledges the involuntary nature of the attacks. 1

Diagnostic Considerations

• PNES is considered a conversion disorder—an external somatic manifestation in response to internal psychological stresses
• Key clinical features suggestive of PNES:
  • Often affects young females
  • Higher prevalence of preexisting vasovagal syncope
  • History of physical and/or sexual abuse
  • Apparent loss of consciousness often lasting longer (5-20 minutes)
  • Frequent episodes
  • Closed eyes during episodes (unlike epileptic seizures)
  • Lack of pallor and diaphoresis
  • Usually little physical harm
  • Normal pulse, blood pressure, or EEG during episodes 1

Management Approach

1. Clear Diagnosis Communication

• Candid discussion with the patient about the diagnosis in a clear but sympathetic manner
• Acknowledge the involuntary nature of the attacks
• Avoid terminology that may cause confusion (e.g., "seizure" without clarification) 1
• Use "psychogenic non-epileptic seizures" or "psychogenic pseudosyncope" rather than "psychogenic syncope" (which is pathophysiologically incorrect) 1

2. Psychological Interventions

• Cognitive behavioral therapy (CBT) is the primary recommended treatment 1
  • Uncontrolled studies suggest psychotherapy, particularly CBT, may be beneficial
  • One RCT showed a non-statistically significant trend toward improvement at 3 months 1

3. Multidisciplinary Management

• Psychiatric evaluation to identify and address:
  • Mood disorders (present in up to 32% of patients) 2
  • Anxiety disorders, including separation anxiety
  • History of trauma or sexual abuse (present in up to 32% of patients) 2
  • Family stressors

4. Medication Considerations

• There is no evidence supporting significant benefit from pharmacotherapy specifically for PNES 1
• Address underlying psychiatric comorbidities if present:
  • Depression
  • Anxiety disorders
  • PTSD (more common in PNES than epilepsy) 3
  • Personality disorders 3

Common Pitfalls and Caveats

• Misdiagnosis: PNES is often misdiagnosed as epilepsy, leading to unnecessary and potentially harmful medical interventions 4
• Dual diagnosis: Some patients may have both epileptic seizures and PNES
• Medication management: Supervised withdrawal of antiepileptic medications may be appropriate when no epilepsy is present 4
• Prognosis: With proper diagnosis and treatment, freedom from pseudoseizures can be achieved in up to 72% of patients, with many becoming symptom-free within one month of diagnosis 2

Special Considerations

• Higher psychiatric comorbidity in PNES compared to epileptic seizures (RR: 1.30,95% CI: 1.14-1.48) 3
• Recent research supports a multidisciplinary, holistic approach to improve quality of life even when complete seizure freedom is not achieved 5
• Early therapeutic counseling should be initiated promptly after diagnosis to address underlying psychological factors 6

By following this management approach, clinicians can effectively address both the psychological factors underlying PNES and improve patients' quality of life while avoiding unnecessary medical interventions.