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

Treatment Approach 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:

• Video-EEG monitoring is the gold standard for diagnosis, with a normal EEG during a typical seizure event confirming PNES 1
• Clinical characteristics that help distinguish PNES from epileptic seizures include:
  • Closed eyes during unconsciousness
  • Prolonged episodes (often >5 minutes)
  • Asymmetrical and asynchronous movements
  • Pelvic thrusting
  • Fluctuating intensity
  • Absence of post-ictal confusion 1

Treatment Algorithm

1. Clear Communication of Diagnosis

   • Present the diagnosis in a non-judgmental, empathetic manner
   • Explain that PNES are real events that are not under conscious control
   • Emphasize that PNES are treatable with appropriate therapy
   • Avoid terms like "fake seizures" or "pseudoseizures" which can be stigmatizing

2. Psychological Interventions (First-Line)

   • Cognitive Behavioral Therapy (CBT) has the strongest evidence base 1, 2
   • Other effective approaches include:
     • Augmented psychodynamic interpersonal psychotherapy
     • Group psychodynamic psychotherapy
     • Group psychoeducation 2

3. Target Specific Underlying Factors

   • Trauma processing for patients with history of trauma
   • Anxiety management techniques
   • Family therapy when family dynamics contribute
   • Stress reduction strategies 1

4. Medication Management

   • Supervised withdrawal of antiepileptic drugs (when PNES is the only diagnosis)
   • Consider antidepressants for comorbid mood disorders:
     • Sertraline has shown some efficacy in pre- versus post-treatment comparisons
     • Venlafaxine has shown promise in uncontrolled trials 2

5. Address Comorbid Conditions

   • Treat underlying psychiatric conditions (depression, anxiety, PTSD)
   • Manage physical comorbidities
   • Address psychosocial stressors

Expected Outcomes

• Approximately 72% of patients' PNES resolve after appropriate psychiatric treatment 1
• However, 1/3 to 1/4 of patients develop chronic PNES despite treatment 1
• Even after seizure reduction, many patients continue to experience psychiatric symptoms and impaired functioning 1

Common Pitfalls to Avoid

1. Misdiagnosis: Patients with PNES are often misdiagnosed with epilepsy and receive unnecessary anticonvulsant treatment for an average of 7 years before correct diagnosis 1

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

3. Assuming all seizure-like events in psychiatric patients are psychogenic: This can lead to missed epilepsy diagnoses 1

4. Lack of follow-up support: Many patients feel "caught in limbo" following their PNES diagnosis due to uncertainties about their condition and lack of professional support 3

5. Focusing solely on seizure frequency: While reducing seizure frequency is important, treatment should also target quality of life, psychiatric symptoms, and psychosocial functioning 1, 2

The multidisciplinary approach to PNES treatment is essential for improving outcomes across multiple domains, including seizure frequency, psychiatric symptoms, and overall quality of life 1.