What is the diagnosis and treatment approach for pseudoseizures (psychogenic nonepileptic seizures, PNES)?

Diagnosis and Treatment Approach for Psychogenic Nonepileptic Seizures (PNES)

Psychogenic nonepileptic seizures (PNES) require a multidisciplinary diagnostic approach followed by clear communication of the diagnosis and psychotherapeutic treatment to improve quality of life. 1

Diagnostic Features

Clinical Characteristics Suggesting PNES

• Eyes closed during unconsciousness (unlike epilepsy where eyes are typically open) 1
• Apparent loss of consciousness lasting 10-30 minutes (epileptic seizures typically last 1-2 minutes) 1
• Eye fluttering during episodes 1
• Pelvic thrusting movements 1
• Many movements that wax and wane in intensity with changes in nature of movement 1
• Absence of cyanosis (unlike in epileptic seizures) 1
• Absence of stertorous (snoring) breathing (common in epileptic seizures) 1

Historical Clues

• History of earlier potentially traumatizing events 1
• Previous diagnosis of psychosis or depression 1
• Higher prevalence in young females 1
• History of physical and/or sexual abuse 1
• Frequent episodes with little physical harm 1

Diagnostic Approach

Gold Standard Diagnosis

• Video-electroencephalography (video-EEG) monitoring is the definitive diagnostic test 1, 2
• Normal EEG during apparent loss of consciousness strongly suggests PNES 1
• Normal pulse and blood pressure during episodes (unlike true syncope) 1

Differential Diagnosis

• Must rule out epilepsy (particularly frontal lobe seizures which can mimic PNES) 3
• Consider that 10-30% of patients referred to epilepsy centers have PNES rather than epilepsy 3
• Important to note that 65-80% of PNES patients are young females, though older male subgroups exist 3
• Be aware that PNES and epilepsy can coexist in the same patient 4, 3

Treatment Approach

Initial Management

• Clear, sympathetic communication of the diagnosis to the patient is essential, acknowledging the involuntary nature of the attacks 1
• Explain that these are not epileptic seizures but real events that can be treated 1, 2
• Withdraw anticonvulsant medications with appropriate monitoring in patients without evidence of epilepsy 2

Psychotherapeutic Interventions

• Cognitive behavioral therapy (CBT) has shown benefit and should be considered first-line treatment 1, 5
• A multidisciplinary approach involving neurologists, psychiatrists, and psychologists improves outcomes 5, 4
• Treatment should address underlying psychiatric comorbidities such as depression, anxiety, PTSD, and other somatoform disorders 3

Prognosis and Follow-up

• Even after diagnosis, many patients continue to have seizures and poor quality of life 3
• Less than 40% of adults with PNES become seizure-free within 5 years after diagnosis 6
• Emergency healthcare utilization often drops significantly after proper diagnosis explanation, even if seizures continue 2
• Continued neurological follow-up is essential even after psychiatric referral 3

Common Pitfalls and Caveats

• Diagnostic delay averages 7 years from symptom onset to correct diagnosis 3
• Misdiagnosis as epilepsy leads to unnecessary anticonvulsant treatment 3
• Seizure freedom alone is not a comprehensive measure of outcome - many seizure-free patients remain functionally impaired 3
• Some patients may have both PNES and epilepsy, requiring careful management of both conditions 4
• Brain pathology (particularly right hemisphere), head injury, or neurosurgery may contribute to PNES development in some cases 3