What is the treatment for Psychogenic Non-Epileptic Seizures (PNES)?

Treatment for Psychogenic Non-Epileptic Seizures (PNES)

Psychogenic non-epileptic seizures (PNES) should be treated primarily with psychological interventions, particularly cognitive behavioral therapy (CBT), as part of a multidisciplinary approach that includes clear diagnosis communication and supervised withdrawal of antiepileptic medications when appropriate. 1

Diagnostic Considerations

Before initiating treatment, accurate diagnosis is essential:

• PNES can be distinguished from epileptic seizures by specific characteristics:

  • Apparent loss of consciousness lasting 10-30 minutes (longer than typical epileptic seizures)
  • Eyes closed during unconsciousness
  • Eye fluttering (more likely in PNES than epileptic seizures)
  • Pelvic thrusting movements
  • Asymmetrical and asynchronous movements
  • Repeated waxing and waning in intensity
  • Absence of post-ictal confusion 2, 1

• The gold standard for diagnosis is normal EEG during a typical seizure event 1

Treatment Algorithm

Step 1: Clear Diagnosis Communication

• Explaining the diagnosis to the patient is a necessary first step and should be done with care 3
• The diagnosis should be presented in a non-judgmental manner, emphasizing that symptoms are real but not caused by epilepsy
• Avoid terms like "fake" or "all in your head" which can alienate patients

Step 2: Psychological Interventions

• Cognitive Behavioral Therapy (CBT) is the preferred treatment approach for most patients 3, 4
• Therapy should address:
  • Psychological factors underlying PNES (trauma, anxiety, depression)
  • Coping mechanisms
  • Emotion regulation skills
  • Stress management techniques

Step 3: Medication Management

• Supervised withdrawal of antiepileptic medications when appropriate 1
• Treat comorbid psychiatric conditions (depression, anxiety, PTSD) with appropriate medications
• For patients with both epilepsy and PNES, continue antiepileptic medications for epilepsy management

Step 4: Address Underlying Factors

Treatment should target specific underlying factors identified in the individual:

• Trauma processing for those with history of trauma or abuse
• Anxiety management techniques
• Family therapy when family dynamics contribute to symptoms
• Stress reduction strategies

Evidence for Treatment Effectiveness

Research shows that appropriate psychological interventions can significantly reduce seizure frequency and improve quality of life 1, 4. Wyllie et al. found that 72% of patients' PNES had resolved after psychiatric treatment 2.

However, prognosis varies considerably:

• Approximately 1/3 to 1/4 of patients develop chronic PNES despite treatment 3
• Even after seizure reduction, many patients continue to experience psychiatric symptoms and impaired functioning 5

Common Pitfalls to Avoid

1. Misdiagnosis and inappropriate treatment: PNES is often misdiagnosed as epilepsy, leading to unnecessary anticonvulsant treatment for an average of 7 years before correct diagnosis 5

2. Missing comorbid epilepsy: Some patients have both PNES and epilepsy, making diagnosis and treatment more complex 2, 1

3. Focusing only on seizure reduction: Treatment should address overall quality of life and functioning, not just seizure frequency 5, 4

4. Inadequate follow-up: Continued neurological follow-up is essential even after psychiatric referral 5

5. Extensive medical testing: Misdiagnosis can lead to unnecessary and potentially harmful medical interventions, including invasive procedures and hospital admissions 2, 1

By implementing this comprehensive treatment approach, clinicians can help patients with PNES reduce seizure frequency, improve psychiatric symptoms, and enhance overall quality of life and psychosocial functioning.