What are the treatment options for a patient experiencing psychogenic epileptic seizures?

Treatment of Psychogenic Epileptic Seizures

Psychogenic non-epileptic seizures (PNES) should be treated primarily with psychological interventions—specifically cognitive behavioral therapy, psychoeducational programs, and relaxation techniques—NOT with antiepileptic drugs. 1

Critical Distinction: PNES vs. True Epilepsy

The fundamental treatment principle hinges on accurate diagnosis, as PNES and epileptic seizures require completely different therapeutic approaches:

• PNES patients typically preserve consciousness during events, which distinguishes them from true epileptic seizures 1
• Antiepileptic drugs should NOT be routinely prescribed for PNES, as these are not epileptic events and do not respond to anticonvulsants 1
• EEG and neuroimaging help confirm the diagnosis by ruling out true epilepsy, though these should be performed in specialized facilities with adequate expertise 2

Primary Treatment Approach for PNES

Psychological Interventions (First-Line)

Cognitive behavioral therapy (CBT) forms the cornerstone of PNES treatment, addressing both seizure reduction and quality of life improvements 1, 3:

• Psychoeducational programs help patients understand the non-epileptic nature of their events, which improves quality of life and seizure management 1
• Relaxation therapy and techniques based on CBT principles should be implemented 2, 1
• Family counseling may be considered as adjunctive treatment to address psychosocial factors 2

Evidence Base

While CBT and mind-body approaches have consistently demonstrated positive effects on enhancing psychological well-being, the effects on seizure control remain inconsistent due to small clinical trials 3. However, given the non-epileptic nature of PNES, psychological interventions remain the appropriate treatment modality rather than pharmacotherapy.

Special Considerations

Patients with Intellectual Disabilities

• Treatment should be adapted to cognitive level using modified approaches with gesture and prosody 1
• Psychoeducational programs should be tailored to the patient's comprehension abilities 1

Routine Patient Education

Information and advice on avoiding high-risk activities and first aid should be routinely provided to patients and family members 2, 4, even though PNES differs from epilepsy, as the events themselves can still pose safety risks.

Common Pitfalls to Avoid

Do NOT treat PNES with antiepileptic drugs 1. This is the most critical error in management, as:

• PNES does not respond to anticonvulsants
• Unnecessary medication exposure causes adverse effects without benefit
• It reinforces the patient's belief that they have epilepsy rather than a psychological condition

Do NOT delay psychological referral once PNES is diagnosed. Early intervention with appropriate psychological therapy improves outcomes and prevents prolonged disability.

Treatment Algorithm

1. Confirm diagnosis through specialized EEG/video monitoring to document events without epileptiform activity 2
2. Communicate diagnosis clearly to patient and family through psychoeducational approach 1
3. Initiate CBT as primary treatment modality 1, 3
4. Add adjunctive interventions: relaxation therapy, family counseling as needed 2, 1
5. Monitor quality of life and functional outcomes, not just seizure frequency 1
6. Discontinue any antiepileptic drugs if previously prescribed inappropriately 1