Treatment of Psychogenic Non-Epileptic Seizures (PNES)
The primary treatment for PNES is psychiatric referral for psychological therapy, specifically cognitive behavioral therapy (CBT), which achieves seizure freedom in 47% of patients and ≥50% seizure reduction in 82% of patients. 1
Immediate Management: Accurate Diagnosis and Communication
The most critical first step is explaining the diagnosis carefully to the patient using a multidisciplinary approach—this alone is an effective therapeutic intervention. 2
- Avoid prescribing anticonvulsants, as 80% of PNES patients are inappropriately given antiepileptic drugs despite lacking epilepsy 3
- Video-EEG recording of an event is the gold standard for confirming diagnosis 2
- Be aware that 10-20% of PNES patients also have true epilepsy, complicating management decisions 3
Definitive Treatment: Psychiatric Referral
Refer all PNES patients for psychiatric treatment immediately after diagnosis, as 72% of patients achieve resolution of PNES with psychiatric treatment. 3
Specific Psychological Interventions (in order of evidence strength):
- Cognitive Behavioral Therapy (CBT): First-line psychological treatment with strongest evidence 4, 1
- Manual-based psychotherapy for seizures: 12-session protocol reduces seizures by 46% per month 5
- Psychodynamic therapy: Alternative when CBT unavailable 1
- Mindfulness-based interventions: Adjunctive option 1
- Psychoeducation alone: Minimum intervention when formal therapy inaccessible 1
Treatment Delivery Options:
- Video telehealth is equally effective as in-person therapy, eliminating access barriers for rural patients 5
- Treatment via telehealth achieved 46% monthly seizure reduction and significant improvements in depression, anxiety, and quality of life 5
Avoid Common Pitfalls
Do NOT prescribe anticonvulsants for PNES—they provide no benefit and expose patients to unnecessary medication risks including respiratory depression, cardiac effects, and CNS toxicity. 3
- Studies show PNES patients undergo extensive invasive testing (lumbar punctures, radiation exposure) and receive inappropriate anticonvulsants in 60-80% of cases 3
- Anticonvulsant prescription reinforces the incorrect belief that seizures are epileptic, hindering psychological treatment engagement 4
Address Perpetuating Factors
Identify and manage psychological stressors, as mental stress increases PNES frequency and severity. 3
- Screen for anxiety and depression—present in one-third of PNES patients, particularly adolescents 3
- Educate patients that PNES is a benign condition with tendency toward natural remission to reduce psychological burden 3
- Address sleep deprivation and anxiety triggers that precipitate attacks 3
Assess Underlying Psychological Mechanisms
Evaluate for trauma history, dissociative symptoms, and physical symptom reporting patterns, as these are the most consistent correlates of PNES. 6
- Trait dissociation and traumatic event exposure are common but not universal 6
- Physical symptom reporting is consistently elevated in PNES patients 6
- Note the heterogeneity of PNES patients—predisposing, precipitating, and perpetuating factors vary case-by-case 2
Prognosis and Long-term Management
Counsel patients that 25-33% of PNES cases become chronic despite treatment, but the majority improve with appropriate psychological intervention. 4