Initial Management of Psychogenic Non-Epileptic Seizures (PNES)
The initial approach to managing PNES centers on establishing the diagnosis through video-EEG monitoring, followed by direct and sympathetic communication of the diagnosis to the patient, emphasizing that the episodes are real, involuntary, and treatable, with immediate referral for cognitive behavioral therapy as first-line treatment. 1
Diagnostic Confirmation
Video-EEG monitoring is the gold standard for diagnosing PNES and must be performed when clinical suspicion exists, as it captures typical events with continuous monitoring and demonstrates normal EEG during episodes (unlike epileptic seizures which show epileptiform discharges). 2, 1
Key Clinical Features Supporting PNES Diagnosis
Before or during video-EEG, recognize these characteristic features that distinguish PNES from true epileptic seizures:
- Duration of loss of consciousness greater than 5 minutes strongly suggests PNES over epileptic seizures (epileptic seizures typically last 74-90 seconds). 2
- Eyes closed during unconsciousness is highly characteristic of PNES, whereas eyes remain open in epileptic seizures. 2, 3
- Asynchronous, side-to-side thrashing movements with many movements that cannot be counted, and repeated waxing and waning in intensity, are typical of PNES. 2, 3
- Pelvic thrusting is characteristic of PNES (though rarely seen in frontal lobe seizures). 2
- Eye fluttering is more likely in PNES than epileptic seizures. 2, 1
Critical Pitfall to Avoid
Do not rely on biomarkers such as neuron-specific enolase, prolactin, and creatine kinase to differentiate PNES from epilepsy, as these are unreliable and should not guide diagnosis. 2, 1, 3
Communicating the Diagnosis
Once PNES is confirmed, communicate the diagnosis directly and sympathetically to the patient using this specific approach recommended by the American College of Cardiology: 1
- Acknowledge that the episodes are real and involuntary, not being faked. 1
- Explain that the episodes represent a conversion disorder (a psychological mechanism, not a neurological disease). 1
- Emphasize that the condition is treatable with appropriate psychological interventions. 1
This communication approach carries a Class IIb recommendation from ACC/AHA/HRS guidelines, and establishing this understanding is critical before initiating treatment. 1
Primary Treatment Initiation
Immediately refer the patient for cognitive behavioral therapy (CBT), which is the first-line treatment for PNES with a Class IIb recommendation from the American College of Cardiology. 1
Medication Management
Do not prescribe pharmacotherapy for PNES itself, as medications have no demonstrated benefit for the condition. 1 However, psychiatric evaluation is indicated to identify and treat comorbid conditions. 2
Psychiatric Evaluation and Comorbidity Management
Arrange psychiatric evaluation because patients with PNES have high rates of psychiatric disorders that require separate treatment: 2
- Depression and anxiety disorders 2
- Somatoform symptoms 2
- Dissociative disorders 2
- Post-traumatic stress disorder (PTSD) 2
The European Society of Cardiology emphasizes that these comorbidities are present in the majority of PNES patients and must be addressed independently. 2
Discontinuation of Antiepileptic Drugs
If the patient was previously misdiagnosed with epilepsy and placed on antiepileptic drugs, work toward discontinuing these medications as they provide no benefit for PNES and expose patients to unnecessary side effects and costs. 4, 5
Ongoing Neurologist Involvement
Maintain neurologist follow-up even after diagnosis and psychiatric referral, as continued neurologist involvement is essential for optimal outcomes in PNES patients. 5 This interdisciplinary approach helps ensure treatment adherence and addresses any diagnostic uncertainty that may arise.
Prognosis and Realistic Expectations
Quality of life can be improved with treatment even when complete seizure freedom is not achieved, with 72% of PNES patients showing resolution after psychiatric treatment in follow-up studies. 1 However, patients should understand that nearly half who become seizure-free may continue to have other symptoms requiring ongoing management. 5