What is the treatment approach for patients with psychogenic (nonepileptic) seizures?

Treatment Approach for Psychogenic Nonepileptic Seizures (PNES)

The primary treatment approach for psychogenic nonepileptic seizures (PNES) should be psychotherapy, as pharmacological interventions do not address the underlying psychological mechanisms and may impair cognitive skills needed for recovery. 1

Diagnosis and Differentiation

Before initiating treatment, proper diagnosis is essential:

• EEG is crucial to differentiate PNES from epileptic seizures, as PNES lacks characteristic epileptiform changes on EEG 1
• Video-EEG monitoring is the gold standard for diagnosis, allowing direct observation of events without epileptiform activity 2
• Clinical features that suggest PNES include:
  • Eyes closed during episodes (vs. typically open in epileptic seizures) 3
  • Pelvic thrusting movements 3
  • Eye fluttering (more common in PNES than epileptic seizures) 3
  • Waxing and waning intensity with changes in movement patterns 3
  • Longer duration of loss of consciousness (often >5 minutes) compared to typical epileptic seizures 3

Treatment Approaches

Psychotherapeutic Interventions

• Psychotherapy remains the most effective primary treatment modality for PNES 4
• Specific psychological treatments that may be beneficial include:
  • Cognitive Behavioral Therapy (CBT) principles 3
  • Relaxation therapy techniques 3
  • Psychoeducational programs about the condition 3
  • Family counseling to address relationship dynamics 3, 1

Multidisciplinary Approach

• A holistic approach involving multiple specialists yields better outcomes 4:
  • Neurologist: to confirm diagnosis and rule out epilepsy
  • Psychiatrist: to address comorbid psychiatric conditions
  • Psychologist: to provide therapy
  • Primary care physician: to coordinate care

Addressing Comorbid Conditions

• Treatment of comorbid psychiatric conditions is essential, as they affect PNES outcomes 2:
  • Anxiety disorders (associated with poorer outcomes) 2
  • Depression (particularly impacts outcomes in patients older than 26 years at onset) 2
  • Trauma-related disorders (as trauma exposure is common in PNES patients) 5

Prognostic Factors

Several factors predict poorer outcomes in PNES treatment:

• Older age at symptom onset 2
• Comorbid epilepsy (significantly reduces chances of PNES cessation) 2
• Presence of anxiety disorders 2
• Comorbid depressive disorders, especially in older patients 2
• Physical symptom reporting (somatization) 5

Treatment Goals and Expectations

• Complete seizure freedom may not be achievable for all patients, as PNES can be a chronic, paroxysmal disorder 4
• Quality of life improvement should be considered an important treatment outcome 2
• Successful treatment is associated with:
  • Improved quality of life scores 2
  • Greater likelihood of financial independence 2

Important Caveats and Considerations

• Avoid antiepileptic drugs for PNES as they:

  • Do not address the underlying psychological mechanisms 1
  • May impair cognitive function needed for psychological treatment 1
  • Can reinforce the patient's belief they have epilepsy

• Patient education about the diagnosis is crucial:

  • Explain that PNES are real events, not "fake seizures"
  • Emphasize that psychological factors can produce physical symptoms
  • Provide hope that treatment can improve outcomes

• Consider heterogeneity among PNES patients:

  • Inconsistent research findings likely reflect different PNES subtypes 5
  • Treatment may need to be tailored based on specific psychological mechanisms

• Neurobiological aspects:

  • Recent research shows altered brain connectivity in PNES patients, particularly decreased clustering coefficients in the gamma band 6
  • Decreased linkage between frontal and other brain regions suggests neurological processes underlying the condition 6