What is the recommended treatment approach for a patient presenting with pseudoseizures, potentially associated with underlying epilepsy, neurological conditions, or mental health conditions such as anxiety or depression?

Treatment Approach for Pseudoseizures (Psychogenic Non-Epileptic Seizures)

The primary treatment for pseudoseizures is cognitive behavioral therapy (CBT) and psychoeducational interventions, NOT anticonvulsant medications, which are ineffective and potentially harmful in this population. 1, 2

Diagnostic Confirmation First

Before initiating treatment, confirm the diagnosis through:

• Video-EEG monitoring remains the gold standard for distinguishing pseudoseizures from true epileptic seizures, as clinical features alone lack adequate sensitivity 3, 4
• Look for preserved consciousness during events, normal ictal and post-ictal EEGs, and absence of epileptiform activity 4, 2
• Key clinical red flags suggesting pseudoseizures include: adult age of onset, altered responsiveness during attacks, variability in clinical presentations between episodes, distractibility, suggestibility, and atypical response to anticonvulsants 5
• Post-ictal EEG is particularly useful when seizure etiology is unclear 4

Primary Treatment Strategy

Immediately discontinue anticonvulsant medications if the patient has been misdiagnosed and is taking them, as these drugs are ineffective for pseudoseizures and may cause toxicity, paradoxical reactions, and abnormal neurological signs 4, 2

Core Psychological Interventions

• Cognitive behavioral therapy (CBT) should be the first-line treatment, as it has the highest level of evidence for this condition 1, 6
• Psychoeducational programs about the condition are essential and can improve quality of life and seizure management 1
• Relaxation therapy and family counseling may be considered as adjunctive treatments 1, 6

Communication of Diagnosis

• The diagnosis must be clearly communicated to the patient as a critical first step in treatment 3
• Explain that this is NOT epilepsy and does not require anticonvulsant medication 7
• Frame the condition as a real neurological phenomenon caused by psychological processes, not "faking" 3

Management of Psychiatric Comorbidities

Address underlying psychiatric conditions, which are present in the majority of patients with pseudoseizures:

Common Comorbidities to Screen For

• Depression and anxiety disorders (extremely common) 3
• Post-traumatic stress disorder (PTSD), particularly in patients with childhood trauma or abuse history 3
• Dissociative disorders 3
• Other somatoform symptoms 3

Pharmacological Management When Indicated

If significant anxiety or depression is present:

• For anxiety: Start escitalopram 10 mg daily or sertraline 25-50 mg daily, titrating gradually at 1-2 week intervals 6
• Monitor for 4-8 weeks at therapeutic doses before declaring treatment failure 6
• SNRIs (venlafaxine or duloxetine) represent appropriate second-line alternatives 6
• Avoid benzodiazepines for chronic management due to risks of cognitive impairment, falls, and dependence 6

For depression: Use SSRIs as first-line agents, with escitalopram preferred due to minimal drug interactions 6

Special Considerations

Patients with Coexisting Epilepsy

• 10-30% of patients with pseudoseizures also have true epilepsy, making diagnosis particularly challenging 3
• Epilepsy may be a risk factor for developing pseudoseizures 3
• Continue appropriate anticonvulsant therapy for documented epileptic seizures while addressing pseudoseizures with psychological interventions 3

Patients with Intellectual Disabilities

• Treatment should be adapted to cognitive level 1
• Use modified approaches incorporating gesture and prosody 1
• Maintain psychoeducational programs tailored to comprehension level 1

Ongoing Management and Monitoring

Neurologist involvement should continue post-diagnosis, even as psychiatric treatment is initiated 3

Expected Outcomes and Realistic Goals

• Treatment goals should extend beyond seizure reduction to include quality of life improvements 1
• Nearly half of patients who become seizure-free remain unproductive, and many continue to have symptoms of psychopathology 3
• High proportion of patients continue to have seizures even after correct diagnosis, requiring persistent multidisciplinary management 3

Follow-up Strategy

• Assess treatment response at 4 and 8 weeks using standardized instruments 6
• Monitor for symptom relief, side effects, and patient satisfaction 6
• If symptoms are stable or worsening after 8 weeks despite good adherence, intensify CBT or adjust pharmacotherapy if treating comorbid conditions 6

Critical Pitfalls to Avoid

• Never continue anticonvulsants for pseudoseizures alone—they are ineffective and cause unnecessary toxicity 4, 2
• Do not dismiss the condition as "not real"—these episodes are genuinely distressing and debilitating 2
• Avoid focusing solely on seizure cessation; address broader psychosocial functioning and quality of life 3
• Do not overlook the possibility of coexisting true epilepsy in patients with documented pseudoseizures 3
• If discontinuing SSRIs, taper gradually over 10-14 days to avoid discontinuation syndrome 6