What is the recommended management approach for psychogenic seizures?

Management of Psychogenic Seizures

The recommended management approach for psychogenic seizures includes clear communication of the diagnosis, cognitive behavioral therapy (CBT) as the primary treatment, and addressing underlying psychological factors, with additional psychiatric evaluation and potential use of SSRIs when comorbidities are present. 1

Diagnosis and Initial Management

• Psychogenic seizures (also called psychogenic non-epileptic seizures or PNES) are episodes that outwardly resemble epileptic seizures but occur without epileptiform changes on EEG 2
• Diagnostic confirmation typically requires video-EEG monitoring to document normal EEG during typical events 1
• Key distinguishing features from epileptic seizures:
  • Normal pulse, blood pressure, and EEG during events
  • Often longer duration than epileptic seizures
  • May have atypical motor patterns or fluctuating symptoms
  • Higher prevalence in young females
  • History of physical/sexual abuse is common 2

Communication of Diagnosis

• A candid, clear, but sympathetic discussion with the patient about the diagnosis is a critical first step in management 2
• The discussion should:
  • Acknowledge the involuntary nature of the attacks
  • Emphasize that the condition is real and treatable
  • Explain how the diagnosis was reached
  • Avoid suggesting the patient is "faking" or that symptoms are "all in their head" 1
• Proper communication alone may lead to significant improvement in some patients 1

Treatment Approach

First-line Treatment:

• Cognitive behavioral therapy (CBT) is the only treatment supported by high-quality evidence 1
• CBT helps patients:
  • Identify psychological triggers
  • Develop coping strategies
  • Address underlying trauma or stress
  • Learn techniques to interrupt seizure onset

Additional Therapeutic Options:

• Psychodynamic therapy may be beneficial for patients with underlying trauma 1, 3
• Group therapy can provide peer support and reduce isolation 3
• Self-control relaxation techniques have shown success where other interventions failed 4
• Family therapy should be considered to address family dynamics that may contribute to or maintain symptoms 4

Pharmacological Management:

• Antiepileptic drugs are ineffective for psychogenic seizures and should be avoided 4
• Selective serotonin reuptake inhibitors (SSRIs) may be beneficial when psychiatric comorbidities like depression or anxiety are present 1
• Medication should be considered on a case-by-case basis, not as a standard approach 1

Multidisciplinary Approach

• Psychiatric evaluation should be completed ideally before discharge from the monitoring unit 1
• Coordination between neurology and psychiatry/psychology is essential 5
• Address comorbid conditions that may contribute to symptoms:
  • Depression and anxiety disorders
  • Post-traumatic stress disorder
  • Personality disorders
  • Substance use disorders 3

Prognosis and Follow-up

• With appropriate treatment:
  • Complete seizure freedom: 25-30% of patients
  • Significant reduction in seizures: 40-50% of patients
  • Chronic, persistent symptoms: 25-33% of patients 3
• Outcome measures should include:
  • Seizure frequency and severity
  • Quality of life improvements
  • Functional status
  • Healthcare utilization 5
• Regular follow-up is important to monitor progress and adjust treatment as needed

Common Pitfalls to Avoid

• Misdiagnosing psychogenic seizures as epilepsy, leading to unnecessary antiepileptic medication 2
• Failing to distinguish from other conditions that can mimic seizures:
  • Syncope
  • Movement disorders
  • Sleep disorders 2
• Assuming all seizures in a patient with epilepsy are epileptic (approximately 20% of patients with epilepsy also have psychogenic seizures) 4
• Dismissing symptoms as "not real" or suggesting the patient is intentionally producing symptoms 2
• Abrupt discontinuation of antiepileptic drugs in patients with comorbid epilepsy 6

By implementing this comprehensive management approach, healthcare providers can significantly improve outcomes for patients with psychogenic seizures, reducing both morbidity and healthcare utilization while improving quality of life.