What is the treatment for pseudo seizures (psychogenic non-epileptic seizures (PNES)) with anxiety?

Treatment of Psychogenic Non-Epileptic Seizures (PNES) with Anxiety

Cognitive behavioral therapy (CBT) is the first-line treatment for psychogenic non-epileptic seizures with comorbid anxiety, as it effectively addresses both the underlying psychological mechanisms of PNES and anxiety symptoms.

Understanding PNES

Psychogenic non-epileptic seizures (PNES) are episodes that outwardly resemble epileptic seizures but occur without the abnormal electrical activity in the brain characteristic of epilepsy. These events:

• Are also known as psychogenic pseudosyncope (PPS) when they resemble syncope 1
• Are classified as a conversion disorder or functional neurological disorder
• Often coexist with anxiety disorders
• Should not be confused with epileptic seizures, which require different treatment approaches

Diagnostic Considerations

Before initiating treatment, it's crucial to establish the correct diagnosis:

• Video-EEG monitoring is the gold standard for diagnosis 2
• Normal pulse, blood pressure, or EEG during an episode can help confirm PNES 1
• Patients with PNES often have distinct psychological profiles compared to those with epilepsy, including higher scores on hypochondriasis and hysteria scales 3

Treatment Approach for PNES with Anxiety

First-Line Treatment: Psychological Interventions

1. Cognitive Behavioral Therapy (CBT)

   • Most effective evidence-based treatment for PNES 4, 5
   • Addresses both PNES and anxiety symptoms
   • Typically requires 12-20 structured sessions 1
   • Key components include:
     • Education about anxiety and PNES
     • Behavioral goal setting with contingent rewards
     • Self-monitoring for connections between worries/fears, thoughts, and behaviors
     • Relaxation techniques (deep breathing, progressive muscle relaxation)
     • Cognitive restructuring to challenge distortions
     • Graduated exposure for anxiety
     • Problem-solving and social skills training 1

2. Candid Discussion of Diagnosis

   • Clear but sympathetic explanation of the diagnosis is beneficial 1
   • Acknowledge the involuntary nature of the attacks
   • Avoid suggesting that symptoms are "made up" or "all in their head"

Medication Management

• For Anxiety Component:

  • Selective Serotonin Reuptake Inhibitors (SSRIs) are recommended for patients with anxiety disorders 1
  • Avoid benzodiazepines when possible due to risk of dependence and potential to complicate diagnosis
  • If benzodiazepines are necessary, use lorazepam for short-term management of severe anxiety symptoms 1

• For PNES Episodes:

  • Antiepileptic medications are generally NOT recommended for PNES alone
  • If comorbid epilepsy exists, appropriate antiepileptic drugs should be used for the epileptic component only 6
  • Consider valproate or levetiracetam if there is diagnostic uncertainty or comorbid epilepsy, as these have fewer adverse effects than other options 1

Multidisciplinary Approach

• Psychiatric consultation is essential for evaluation and long-term planning 1
• Consider inpatient treatment for cases with serious complications 1
• Family-directed interventions to improve relationships and communication skills
• School or workplace accommodations as needed

Expected Outcomes

With appropriate treatment:

• Up to 81% of patients can achieve >50% reduction in seizures
• Approximately half may become seizure-free with comprehensive treatment 4
• Measures of anxiety, depression, and dissociation tend to normalize
• Coping mechanisms improve
• Health-related quality of life increases 4

Common Pitfalls and Considerations

• Misdiagnosis: Failing to distinguish between PNES and epileptic seizures leads to inappropriate treatment
• Medication Overuse: Inappropriate use of antiepileptic drugs for PNES can lead to unnecessary side effects
• Inadequate Psychological Support: Focusing solely on seizure reduction without addressing underlying psychological factors
• Stigmatization: Treating PNES as less "real" than epileptic seizures can worsen outcomes
• Comorbidity Management: Failing to address comorbid conditions like anxiety, depression, or trauma

Follow-up and Monitoring

• Regular assessment of seizure frequency and characteristics
• Monitoring of anxiety symptoms using standardized measures
• Evaluation of treatment adherence and effectiveness
• Adjustment of treatment plan as needed based on response

By implementing this comprehensive approach focusing on psychological interventions, particularly CBT, while appropriately managing comorbid anxiety, most patients with PNES can experience significant improvement in both seizure frequency and overall quality of life.