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 Confirmation

Before initiating treatment, proper diagnosis is essential:

• Gold standard: Video-EEG monitoring showing normal EEG during a typical seizure event 1, 2
• Key clinical features differentiating PNES from epileptic seizures:
  • Apparent loss of consciousness lasting 10-30 minutes
  • Eyes closed during unconsciousness
  • Eye fluttering and pelvic thrusting movements
  • Asymmetrical and asynchronous movements
  • Repeated waxing and waning in intensity
  • Absence of post-ictal confusion 1

Treatment Algorithm

1. Clear Diagnosis Communication

   • Explain the diagnosis compassionately and thoroughly
   • This step alone is a necessary first intervention 3
   • Emphasize that PNES are real events, not "fake seizures"

2. Supervised Withdrawal of Antiepileptic Medications

   • Only when appropriate and no comorbid epilepsy exists
   • Must be done gradually under medical supervision 1
   • Note: 10-30% of patients referred to epilepsy centers have PNES and many are incorrectly treated with anticonvulsants 2

3. Psychological Interventions

   • First-line: Cognitive Behavioral Therapy (CBT) 1, 4
   • Target specific underlying factors:
     • Trauma processing (high rates of childhood trauma/abuse)
     • Anxiety management techniques
     • Family therapy
     • Stress reduction strategies 1

4. Treatment of Psychiatric Comorbidities

   • Address common comorbidities:
     • Depression and anxiety
     • Somatoform symptoms
     • Dissociative disorders
     • Post-traumatic stress disorder 2

5. Ongoing Neurological Follow-up

   • Continued neurologist involvement is essential even after diagnosis 2
   • Monitor for development of comorbid epilepsy

Expected Outcomes

• Approximately 72% of patients' PNES resolve after psychiatric treatment 1
• However, 1/3 to 1/4 of patients develop chronic PNES despite treatment 1, 3
• Even after seizure reduction, many patients continue to experience:
  • Psychiatric symptoms
  • Impaired functioning
  • Poor quality of life 1, 2

Common Pitfalls to Avoid

1. Misdiagnosis

   • PNES is often misdiagnosed as epilepsy for an average of 7 years 1
   • This leads to unnecessary anticonvulsant treatment and potential harm

2. Overlooking Dual Diagnosis

   • Some patients have both PNES and epilepsy, making diagnosis and treatment more complex 1
   • Prevalence of epilepsy in PNES patients is higher than in the general population 2

3. Focusing Only on Seizure Reduction

   • Seizure remission alone is not a comprehensive measure of outcome
   • Nearly half of seizure-free patients remain unproductive and continue to have symptoms of psychopathology 2

4. Inadequate Treatment Approach

   • Failing to use a multidisciplinary approach
   • Not addressing underlying psychological factors 1, 4

The evidence consistently supports that a multidisciplinary approach with psychological interventions, particularly CBT, is essential for reducing seizure frequency, improving psychiatric symptoms, and enhancing psychosocial functioning and quality of life in patients with PNES 1, 4.