What is the treatment approach for psychogenic seizures?

Treatment of Psychogenic Nonepileptic Seizures (PNES)

The cornerstone of treatment for psychogenic nonepileptic seizures is cognitive behavioral therapy (CBT), delivered after a clear, empathetic explanation of the diagnosis that emphasizes the involuntary nature of these events. 1

Initial Diagnostic Communication

The first therapeutic intervention is explaining the diagnosis with care. 1, 2

• A candid but sympathetic discussion acknowledging that these attacks are involuntary (not malingering) and represent a conversion disorder—an external somatic manifestation of internal psychological stresses—may be reasonable 1
• This explanation itself appears to have therapeutic benefit, as patients benefit from understanding their condition in a clear manner that validates their experience while clarifying the mechanism 1
• The diagnosis should distinguish PNES from epileptic seizures, noting that during PNES episodes there is no cerebral hypoperfusion or impaired brain function, though the events are "real" and can be equally disabling 3, 2

Primary Treatment: Psychotherapy

Cognitive behavioral therapy is the evidence-based treatment of choice for PNES. 1, 4, 2

• CBT may be beneficial in patients with pseudosyncope/PNES, though evidence shows a non-statistically significant trend toward improvement at 3 months in one RCT 1
• Uncontrolled studies suggest that psychotherapy, particularly CBT, may be beneficial in conversion disorders 1
• Variants of cognitive behavioral therapy have shown to be the preferred type of treatment for most patients, though evidence for efficacy remains limited 2
• Treatment choice should be individualized based on underlying psychological factors identified during assessment 2

Multidisciplinary Team Approach

A multidisciplinary team involving a neurologist with epilepsy expertise, a psychiatrist or psychologist, and support staff is essential for appropriate evaluation and treatment. 3, 5

• This holistic approach is beneficial even when complete seizure freedom is not achieved 4, 5
• The biopsychosocial approach balancing predisposing, precipitating, and perpetuating variables is preferred by neurologists and psychologists managing PNES 6
• Psychiatric assessment should identify specific underlying disorders (history of physical/sexual abuse, concurrent psychiatric conditions) that require targeted intervention 1, 3

Pharmacotherapy Considerations

There are no data that support significant benefit from pharmacotherapy for PNES itself. 1

• Antiepileptic drugs should not be prescribed for PNES, as these are not epileptic seizures 1
• If comorbid depression exists, fluoxetine may be considered as it has a low seizure risk (0.0-0.4%) 7
• Any psychotropic medications should target identified psychiatric comorbidities, not the seizure-like events themselves 1

Clinical Pearls and Pitfalls

Common diagnostic features include young females with higher prevalence of preexisting vasovagal syncope or history of abuse. 1

• Normal pulse, blood pressure, or EEG during an episode can document the diagnosis 1
• Tilt-table testing with transcranial Doppler and EEG monitoring may help when history alone is insufficient 1
• EEG is important to distinguish PNES from epileptic seizures and rule out nonconvulsive status epilepticus 1
• Video-EEG monitoring with precipitation or termination of habitual seizures is often used diagnostically, though results can sometimes be misleading 3

Prognostic Factors

Favorable prognostic indicators include female sex, independent lifestyle, normal EEG findings, higher intelligence, and no prior psychotherapy. 3

• Studies consistently report that one-third to one-quarter of patients become chronic 2
• Quality of life can be improved with treatment even when complete seizure freedom is not achieved 4
• Outcome should be measured not only by seizure frequency and severity but also by quality of life measures that may be of greater importance to patients 2