What is the best course of action for a female patient with a history of bipolar disorder or severe depressive episode, infertility, and recent social shaming, who has been experiencing psychogenic non-epileptic seizure (PNES)-like episodes for the past 2 days?

Management of Acute Psychogenic Non-Epileptic Seizures in a Patient with Bipolar Disorder

For a patient with bipolar disorder experiencing new-onset PNES-like episodes for 2 days, immediately ensure mood stabilization is optimized, rule out true epileptic seizures with video-EEG monitoring if episodes persist beyond 48-72 hours, and initiate psychiatric evaluation with cognitive-behavioral therapy while avoiding benzodiazepines or antiepileptic drugs.

Immediate Clinical Assessment and Diagnostic Approach

Confirm PNES Diagnosis vs. True Epilepsy

• Video-EEG monitoring is the diagnostic gold standard for PNES, showing no epileptiform activity before, during, or after the ictus, and should be obtained if episodes continue beyond initial presentation 1.
• At least 10% of PNES patients have concurrent epileptic seizures or prior epilepsy history, making differentiation critical 1.
• PNES can be triggered as an immunization stress-related response (ISRR) and may manifest as seizure-like episodes in patients with underlying psychiatric conditions 2.
• No single clinical feature is pathognomonic for PNES; diagnostic errors result from overreliance on specific clinical features without EEG confirmation 1.

Assess Current Bipolar Disorder Status

• Verify current mood stabilizer regimen and therapeutic drug levels immediately, as mood destabilization can precipitate PNES episodes 3.
• Patients with severe mental disorders including bipolar disorder are at increased risk for stress-related neuropsychiatric manifestations 2.
• Check adherence to current bipolar medications, as noncompliance leads to relapse rates exceeding 90% 3.

Acute Management Strategy

Optimize Mood Stabilization First

• If the patient is on lithium, verify therapeutic levels (0.8-1.2 mEq/L) and assess thyroid/renal function, as subtherapeutic levels may contribute to psychiatric decompensation 3.
• If on valproate, confirm therapeutic levels (50-100 μg/mL) and check hepatic function, particularly given the acute stress presentation 3.
• For patients on atypical antipsychotics, ensure adequate dosing: aripiprazole 10-15 mg/day, olanzapine 10-15 mg/day, or quetiapine 400-800 mg/day 3.

Address Acute Psychological Stressors

• Provide psychological first aid principles for acute distress related to recent traumatic events (social shaming, infertility stress), as this is recommended for people in acute distress 2.
• PNES patients have high rates of psychiatric comorbidities including depression (present in this case), anxiety, and post-traumatic stress disorder 4.
• Psychological stress exceeding an individual's coping capacity often precedes PNES onset 1.

What NOT to Do

• Do not initiate antiepileptic drugs, as PNES are not caused by abnormal electrical discharges and antiepileptic treatment is inappropriate and costly 5.
• Avoid benzodiazepines for initial treatment of depressive symptoms in absence of current/prior depressive episode meeting full criteria 2.
• Do not use psychological debriefing for recent traumatic events, as this does not reduce post-traumatic stress, anxiety, or depressive symptoms 2.

Definitive Treatment Plan

Psychiatric Intervention

• Cognitive-behavioral therapy (CBT) based on psychological principles should be considered as primary treatment for medically unexplained somatic complaints (PNES) in patients with substantial distress 2.
• If follow-up is possible, graded self-exposure based on CBT principles should be considered for stress-related symptoms 2.
• The PNES diagnosis must be clearly communicated to the patient, though even after correct diagnosis many patients continue to have seizures without proper psychiatric intervention 4.

Antidepressant Considerations for Comorbid Depression

• For moderate to severe depressive episodes in bipolar disorder, tricyclic antidepressants or fluoxetine should be considered, but NEVER as monotherapy 2.
• Antidepressants must always be combined with mood stabilizers (lithium or valproate) to prevent mood destabilization 3.
• Antidepressant treatment should not be stopped before 9-12 months after recovery 2.

Structured Follow-Up Protocol

• Schedule close follow-up within 1-2 weeks to reassess symptoms, verify medication adherence, and determine if mood symptoms are worsening, stable, or improving 3.
• Neurologist continuing to follow post-diagnosis PNES patients is essential, even with concurrent psychiatric care 4.
• Nearly half of PNES patients who become seizure-free remain unproductive with continued psychopathology, requiring extended support 5.

Critical Pitfalls to Avoid

Misdiagnosis and Inappropriate Treatment

• 10-20% of patients referred to epilepsy centers with therapy-resistant epilepsy actually have PNES, and many receive wrong diagnosis with years of inappropriate antiepileptic treatment 4, 6.
• The mean latency between PNES manifestations and correct diagnosis remains 7 years, representing costly delays 4.

Premature Medication Changes

• Avoid abrupt discontinuation of mood stabilizers, as lithium withdrawal increases relapse risk dramatically within 6 months, and over 90% of noncompliant adolescents relapsed 3.
• Do not add multiple psychotropic medications without systematic 6-8 week trials at adequate doses 3.

Overlooking Comorbidities

• Failure to address underlying psychiatric disorders (depression, anxiety, trauma history) leads to continued seizures and serious disability despite correct PNES diagnosis 5.
• Childhood trauma, history of abuse, and PTSD correlate strongly with PNES diagnoses and must be evaluated 4.

Monitoring and Prognosis

• Even after correct diagnosis, a high proportion of PNES patients continue to have seizures, serious disability, and poor quality of life without structured treatment programs 5.
• Seizure remission alone is not a comprehensive measure of outcome; many seizure-free patients remain unproductive with continued psychopathology 4.
• Recent evidence suggests PNES patients benefit from structured treatment programs and extended support from epilepsy centers combined with psychiatric care 5.