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, accurate diagnosis is essential:

1. Video-EEG monitoring is the gold standard for diagnosis

   • Normal EEG during a typical seizure event confirms PNES 1
   • Distinguishes from true epileptic seizures

2. Key clinical characteristics of PNES:

   • Eyes often closed during unconsciousness
   • Prolonged episodes (often >5 minutes)
   • Asymmetrical and asynchronous movements
   • Pelvic thrusting movements
   • Fluctuating intensity of movements
   • Absence of post-ictal confusion 1

Treatment Algorithm

Step 1: Clear Diagnosis Communication

• Explain the diagnosis compassionately but directly
• Avoid stigmatizing language
• Emphasize that symptoms are real but not caused by epilepsy
• This step alone can lead to seizure reduction in some patients 1, 2

Step 2: Psychological Interventions

1. Cognitive Behavioral Therapy (CBT)

   • First-line psychological treatment
   • Targets maladaptive thoughts and behaviors
   • Focuses on identifying seizure triggers and developing coping strategies 1

2. Other effective psychological approaches:

   • Trauma-focused therapy (if trauma history present)
   • Anxiety management techniques
   • Family therapy
   • Stress reduction strategies 1

Step 3: Medication Management

• Supervised withdrawal of antiepileptic drugs (if no comorbid epilepsy)
• Treatment of psychiatric comorbidities:
  • Depression
  • Anxiety disorders
  • Post-traumatic stress disorder 1, 3

Step 4: Ongoing Monitoring and Support

• Continued neurological follow-up is essential
• Regular psychological support
• Address psychosocial functioning and quality of life 1, 3

Treatment Targets

Effective PNES treatment should address:

1. Underlying psychological factors:

   • Trauma processing (childhood trauma is common) 1, 4
   • Dissociative tendencies 4
   • Somatization patterns 4

2. Seizure management:

   • Reduction in frequency and severity
   • Development of alternative coping mechanisms 1

3. Psychosocial functioning:

   • Improving quality of life
   • Enhancing social and occupational functioning 1, 5

Prognosis and Outcomes

• Approximately 72% of patients show resolution of PNES with appropriate psychiatric treatment 1
• However, 1/3 to 1/4 of patients develop chronic PNES despite treatment 1, 5
• Even after seizure reduction, many patients continue to experience:
  • Psychiatric symptoms
  • Impaired functioning
  • Poor quality of life 1

Common Pitfalls to Avoid

1. Misdiagnosis as epilepsy

   • Can lead to unnecessary anticonvulsant treatment (average 7 years before correct diagnosis) 1

2. Missing dual diagnosis

   • Some patients have both PNES and epilepsy
   • Makes diagnosis and treatment more complex 1

3. Assuming all seizure-like events in psychiatric patients are psychogenic 1

4. Focusing solely on seizure frequency as an outcome measure

   • Overall functioning and quality of life are equally important 5, 6

5. Discontinuing neurological follow-up after psychiatric referral

   • Continued neurological monitoring is essential 3