How to treat increased frequency of psychogenic non-epileptic seizures (PNES)?

Management of Increased Frequency of Psychogenic Non-Epileptic Seizures (PNES)

Psychogenic non-epileptic seizures (PNES) with increased frequency should be managed primarily through evidence-based psychotherapies such as cognitive behavioral therapy or neurobehavioral therapy delivered by a trained seizure counselor, rather than with antiepileptic medications. 1

Diagnostic Confirmation

Before initiating treatment for increased PNES frequency, it's essential to confirm the diagnosis:

• Video-EEG monitoring in a seizure monitoring unit is the gold standard for differentiating PNES from epileptic seizures 1
• Rule out concurrent epilepsy, as some patients may have both conditions simultaneously
• Neuropsychiatric and neuropsychological evaluations should be performed to understand underlying factors

Treatment Approach

First-Line Treatment

1. Psychotherapy:

   • Cognitive Behavioral Therapy (CBT) specifically designed for PNES
   • Neurobehavioral therapy administered by a trained seizure counselor
   • Sessions should focus on identifying triggers, stress management, and coping strategies

2. Education:

   • Explain the diagnosis clearly using non-stigmatizing language
   • Emphasize that PNES are real events that are not deliberately produced
   • Teach patients to recognize warning signs and implement coping techniques

Management of Comorbidities

• Treat underlying psychiatric conditions (depression, anxiety, PTSD)
• Address sleep disorders that may be exacerbating PNES frequency
• Manage any chronic pain conditions that may be triggering episodes

Medication Considerations

• Avoid antiepileptic drugs (AEDs) for PNES treatment as they:

  • Are ineffective for PNES management
  • May cause side effects without benefit
  • Reinforce the misperception that the condition is epileptic in nature

• If the patient has concurrent epilepsy and PNES, antiepileptic medications should only be used to treat the epileptic seizures 1

Multidisciplinary Care Model

A stepped care approach is recommended 2:

1. Initial Level: Brief, generalized interventions focused on education and basic coping strategies
2. Intermediate Level: More structured psychotherapy targeting specific psychological factors
3. Advanced Level: Intensive, individualized treatment for complex cases with multiple comorbidities

Management During Acute Episodes

• Maintain a calm environment
• Do not restrict movements unless there is risk of injury
• Avoid unnecessary emergency interventions that may reinforce the behavior
• Do not administer rescue antiepileptic medications (e.g., benzodiazepines) during PNES episodes

Monitoring Progress

• Track seizure frequency using seizure diaries
• Assess quality of life improvements rather than focusing solely on seizure elimination
• Schedule regular follow-up appointments to adjust treatment as needed

Special Considerations

• For patients with refractory PNES despite appropriate psychotherapy, consider more intensive psychological interventions rather than medication trials 3
• PNES should be viewed as a chronic condition that may require ongoing management rather than expecting complete resolution in all cases

Common Pitfalls to Avoid

• Treating PNES with antiepileptic drugs
• Dismissing symptoms as "not real" or "just psychological"
• Failing to address underlying psychological trauma or stressors
• Overmedicalizing the condition with unnecessary tests or interventions
• Not providing adequate education about the difference between epileptic and non-epileptic seizures

By implementing this evidence-based approach focusing on appropriate psychological interventions rather than medication management, patients with increased frequency of PNES can experience significant improvement in both seizure control and quality of life.