What is the management of Psychogenic Non-Epileptic Seizures (PNES)?

Management of Psychogenic Non-Epileptic Seizures (PNES)

Cognitive behavioral therapy (CBT) is the first-line treatment for PNES, while pharmacotherapy has no demonstrated benefit for the condition itself. 1

Diagnostic Communication: The Critical First Step

The diagnosis must be communicated directly and sympathetically to the patient immediately after confirmation. 1 This conversation should emphasize three key points:

• The episodes are real and involuntary - patients are not faking or malingering 1
• PNES represents a conversion disorder with a psychological mechanism, not epilepsy 1
• The condition is treatable with appropriate psychological interventions 1

This communication process itself serves as an important therapeutic intervention and should involve a multidisciplinary approach. 2 The American College of Cardiology gives this approach a Class IIb recommendation, acknowledging that clear but sympathetic delivery improves patient outcomes. 1

Primary Treatment Algorithm

First-Line: Cognitive Behavioral Therapy

CBT should be initiated as the primary treatment modality (Class IIb recommendation). 1 Evidence shows a trend toward improvement at 3 months, though the benefit did not reach statistical significance in available trials. 1

The therapeutic approach should address:

• Predisposing factors - underlying psychological vulnerabilities 2
• Precipitating factors - triggers that initiate episodes 2
• Perpetuating factors - elements maintaining the condition 2

A biopsychosocial formulation balancing these three variable categories is preferred by neurologists and psychologists managing PNES. 3

Psychiatric Evaluation and Comorbidity Management

Psychiatric evaluation is essential because PNES patients have high rates of comorbid conditions including depression, anxiety, somatoform symptoms, dissociative disorders, and PTSD. 4 These comorbidities require separate treatment beyond the PNES-specific interventions. 4

What NOT to Do: Critical Pitfalls

Avoid Pharmacotherapy for PNES

Anticonvulsants and other medications have no demonstrated benefit for PNES itself and should not be prescribed for the condition. 1 This is a crucial distinction from epilepsy management.

However, there is an important caveat: 20-30% of patients in epilepsy centers have both true epilepsy AND PNES. 4 In these cases, anticonvulsants may be necessary for the epileptic component, but they will not treat the PNES episodes. 4

Avoid Relying on Biomarkers

Do not use neuron-specific enolase, prolactin, or creatine kinase levels to differentiate PNES from epilepsy - these biomarkers are unreliable for this purpose. 1, 4 Tongue biting and urinary incontinence similarly do not differentiate PNES from epileptic seizures. 4

Recognize Iatrogenic Harm from Misdiagnosis

Misdiagnosis leads to dangerous interventions: studies show 8 of 10 PNES patients were inappropriately prescribed anticonvulsants, and 6 received them in emergency settings. 5 Aggressive treatment of presumed status epilepticus in PNES patients can cause:

• Respiratory depression from benzodiazepines or propofol 5
• Cardiac complications from unnecessary sedatives 5
• CNS adverse effects requiring intubation and mechanical ventilation 5

Confirming the Diagnosis When Uncertain

Video-EEG monitoring is the gold standard when clinical diagnosis remains uncertain. 1, 4 This captures typical events with continuous monitoring and demonstrates:

• Normal EEG during PNES episodes (no epileptiform discharges) 4
• Epileptiform discharges during true epileptic seizures 4
• Diffuse slowing with delta waves in syncope 4

Video-EEG can identify the 20-30% of "epilepsy center" patients who actually have PNES rather than epilepsy. 1

Clinical Features Supporting PNES Diagnosis

When evaluating suspected PNES, look for these characteristic features:

• Duration of unconsciousness >5 minutes strongly suggests PNES over epilepsy 4
• Eyes closed during unconsciousness is highly characteristic of PNES (eyes remain open in epilepsy) 4
• Asynchronous, side-to-side thrashing movements that cannot be counted 4
• Pelvic thrusting (though rarely seen in frontal lobe seizures) 4
• Eye fluttering more likely than in epileptic seizures 6, 4
• Repeated waxing and waning in intensity with changes in movement nature 4

Prognosis and Realistic Expectations

Fewer than 40% of adults with PNES achieve seizure freedom within 5 years after diagnosis. 7 However, quality of life can be improved with treatment even when complete seizure freedom is not achieved. 8 This represents a chronic, paroxysmal disorder requiring long-term management. 8

Early psychiatric referral is essential: 72% of PNES patients showed resolution after psychiatric treatment in follow-up studies. 5

Special Considerations

PNES episodes involve motor, sensory, mental, or autonomic manifestations that mimic epileptic seizures but lack epileptogenic brain activity - there is no abnormal electrical discharge. 5 This means PNES does not cause the life-threatening physiological sequelae of true seizures, such as severe hypoxia, aspiration, or cardiac arrhythmias from prolonged epileptic activity. 5

The mechanism of dissociation is pivotal in the pathophysiology, and PNES should be understood as a symptom rather than the underlying disease itself. 2