What is the management of non-epileptic psychogenic seizures?

Management of Non-Epileptic Psychogenic Seizures

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

Diagnosis

Accurate diagnosis is crucial before initiating treatment. PNES can be distinguished from epileptic seizures by several characteristics:

• Video-EEG monitoring: Gold standard for diagnosis, showing normal EEG during a typical episode 1
• Clinical features suggestive of PNES:
  • Closed eyes during unconsciousness
  • Prolonged duration (>5 minutes)
  • Asymmetrical and asynchronous movements
  • Pelvic thrusting
  • Fluctuating intensity
  • Absence of post-ictal confusion 1

Treatment Approach

1. Clear Communication of Diagnosis

• Present the diagnosis with empathy and clarity
• Explain that PNES is a real medical condition with psychological underpinnings
• Avoid stigmatizing language or suggesting the episodes are "fake" or "made up"

2. Psychological Interventions

• Cognitive Behavioral Therapy (CBT): First-line treatment with strong evidence 1, 2

  • Focuses on identifying triggers and developing coping strategies
  • Addresses underlying psychological factors
  • Typically 12-16 sessions

• Other effective psychological approaches:

  • Psychodynamic therapy
  • Mindfulness-based interventions
  • Trauma-focused therapy (especially for patients with PTSD)
  • Family therapy when appropriate 2

3. Medication Management

• Supervised withdrawal of antiepileptic drugs (AEDs) in patients without comorbid epilepsy 1
• Treatment of comorbid psychiatric conditions:
  • Depression
  • Anxiety disorders
  • PTSD (particularly common in PNES patients) 3
  • Consider appropriate psychiatric medications based on specific comorbidities

4. Multidisciplinary Care

• Coordination between neurology, psychiatry, and psychology
• Regular follow-up to monitor progress
• Address psychosocial functioning and quality of life 1

Treatment Outcomes

• Seizure reduction: 82% of patients experience at least a 50% reduction in seizures with psychological treatment 2
• Seizure freedom: Approximately 47% of patients become seizure-free following psychological intervention 2
• Psychological improvement: Treatment leads to normalization of anxiety, depression, and dissociation measures, improved coping, and enhanced quality of life 4

Special Considerations

• High psychiatric comorbidity: PNES patients have higher rates of psychiatric disorders compared to epilepsy patients (RR: 1.30) 3
• Chronic course: Approximately 1/3 to 1/4 of patients develop chronic PNES despite treatment 1
• Dual diagnosis: Some patients have both PNES and epilepsy, requiring careful management of both conditions 1

Common Pitfalls to Avoid

• Misdiagnosing PNES as epilepsy, leading to unnecessary anticonvulsant treatment
• Assuming all seizure-like events in psychiatric patients are psychogenic
• Missing dual diagnosis of epilepsy and PNES 1
• Failing to address underlying psychological factors and trauma
• Abrupt discontinuation of antiepileptic medications without supervision

The management of PNES requires a comprehensive approach focusing on accurate diagnosis, appropriate psychological interventions, treatment of comorbid psychiatric conditions, and addressing psychosocial functioning to improve overall quality of life.