What is the best treatment approach for patients with psychogenic non-epileptic seizures (PNES) and actual seizures, also known as epilepsy?

Treatment Approach for Patients with Psychogenic Non-Epileptic Seizures (PNES) and Epilepsy

For patients with comorbid psychogenic non-epileptic seizures (PNES) and epilepsy, the optimal treatment approach combines cognitive behavioral therapy (CBT) for PNES with appropriate antiseizure medication (preferably levetiracetam) for epileptic seizures.

Diagnostic Considerations

Accurate diagnosis is crucial for proper management:

• Video-EEG monitoring is essential to differentiate between epileptic and non-epileptic events 1
• PNES is often misdiagnosed as epilepsy, leading to inappropriate treatment with multiple antiseizure medications 2
• 70% of PNES patients are women, and the condition significantly impairs quality of life 1

Treatment of Epileptic Seizures

When treating the epileptic component:

• Levetiracetam (30-50 mg/kg IV or equivalent oral dose) is the preferred antiseizure medication due to:

  • Minimal drug interactions
  • Low incidence of hypotension and respiratory depression
  • Favorable efficacy and side effect profile 3
  • Lack of enzyme-inducing properties 3

• Alternative options if levetiracetam is contraindicated:

  • Valproate (20-30 mg/kg IV) - but contraindicated in women of childbearing potential 3
  • Fosphenytoin (18-20 mg/kg IV) - but carries risk of hypotension and cardiac arrhythmias 4

Treatment of Psychogenic Non-Epileptic Seizures

For the PNES component:

• Psychotherapy is the first-line treatment 5, 1

• Specific effective approaches include:

  • Cognitive Behavioral Therapy (CBT)
  • Psychodynamic therapy
  • Mindfulness-based interventions 6

• Meta-analysis results demonstrate effectiveness:

  • 47% of PNES patients become seizure-free after psychological intervention
  • 82% experience at least 50% reduction in seizure frequency 6

Integrated Treatment Algorithm

1. Establish accurate diagnosis:

   • Video-EEG monitoring to differentiate between epileptic and non-epileptic events
   • Thorough psychiatric assessment for comorbidities (90% have comorbid psychiatric disorders) 1

2. For epileptic seizures:

   • Start levetiracetam at 30-50 mg/kg IV or equivalent oral dose 3
   • Monitor for adverse effects (fatigue, dizziness) 7
   • Adjust dose based on seizure control and side effects

3. For psychogenic non-epileptic seizures:

   • Refer for specialized psychotherapy (CBT preferred) 5, 6
   • Ensure proper communication of diagnosis to patient by both neurologist and psychotherapist 1
   • Address underlying psychological factors and trauma if present

4. For psychiatric comorbidities:

   • Treat depression, anxiety, PTSD, or personality disorders if present
   • Consider appropriate psychiatric medications alongside psychotherapy 1

Monitoring and Follow-up

• Regular EEG monitoring every 3-6 months to assess treatment response 3
• More frequent monitoring if clinical deterioration occurs
• Assess antiseizure medication levels to evaluate compliance and efficacy
• Continue psychotherapy until significant reduction in PNES frequency is achieved

Common Pitfalls and Caveats

1. Overmedication: Patients with PNES are often inappropriately treated with multiple antiseizure medications, exposing them to unnecessary side effects 2

2. Inadequate psychological support: Failure to address the psychological component of PNES leads to poor outcomes

3. Stigmatization: Patients may feel their symptoms are dismissed as "not real" when diagnosed with PNES; proper communication of diagnosis is essential

4. Suicidality risk: Antiseizure medications carry an FDA warning about increased risk of suicidal thoughts and behaviors 7, 8, requiring careful monitoring

5. Medication interactions: When treating both conditions, be aware of potential interactions between psychiatric medications and antiseizure drugs

By implementing this comprehensive approach that addresses both the epileptic and psychogenic components, patients with comorbid PNES and epilepsy can achieve significant improvement in seizure control and quality of life.