Treatment for Psychogenic Non-Epileptic Seizures (PNES)
The primary treatment for PNES in a 13-year-old with depression and anxiety is cognitive-behavioral therapy (CBT) combined with psychiatric treatment of comorbid conditions, with early psychiatric referral being essential to prevent harmful interventions and optimize the excellent prognosis seen in pediatric patients. 1
Why Early Psychiatric Treatment is Critical
The most serious consequence of untreated or misdiagnosed PNES is exposure to unnecessary and potentially life-threatening medical interventions, with 80% of PNES patients inappropriately prescribed anticonvulsants despite lacking epilepsy. 1 Early psychiatric referral is essential to prevent these harmful treatments and identify the true psychiatric nature of the condition. 1
Pediatric patients have dramatically better outcomes than adults: 72% showed resolution after psychiatric treatment, with 80% becoming event-free at mean follow-up of 31.5 months. 1, 2 This excellent prognosis makes prompt treatment imperative.
Specific Treatment Approach for This Patient
First-Line: Cognitive-Behavioral Therapy
CBT-informed psychotherapy is the established first-line treatment for PNES, requiring a minimum of 7-12 sessions delivered by a trained therapist. 3, 4 The treatment should be multidisciplinary and based on cognitive-behavioral principles. 3
Key CBT components include:
- Psychoeducation explaining PNES as atypical neurophysiological responses to emotional distress and physiological stressors 5
- Behavioral goal setting and self-monitoring 6
- Relaxation techniques 6
- Cognitive restructuring to address maladaptive thought patterns 3
- Graduated exposure therapy for anxiety-provoking situations 3
- Family interventions, as parental involvement is beneficial particularly when parents have anxiety 7, 6
Treatment duration matters: patients attending at least 7 sessions over longer than 3 months showed significant improvement in seizure control, depression, and anxiety, whereas those completing treatment in only 3 months did not show significant change. 4
Treatment of Comorbid Depression and Anxiety
Given this patient's comorbid depression and anxiety, combination treatment with CBT plus an SSRI (specifically sertraline) is recommended as first-line therapy for adolescents aged 6-18 years with anxiety disorders. 8, 7 This combination demonstrates superior efficacy compared to either treatment alone for anxiety symptoms, global function, treatment response, and disorder remission. 8, 7
Sertraline is the first-choice SSRI for adolescents with anxiety disorders, with FDA approval and extensive evidence base. 7 Alternative SSRIs (fluoxetine, escitalopram, citalopram) can be considered if sertraline is not tolerated. 7
Critical Monitoring Requirements
Monitor closely for suicidal ideation and behavior, especially in the first weeks after starting or increasing SSRI dose, as adolescents with depression have increased suicide risk (19% of adolescents aged 13-17.9 years with major depressive disorder attempt suicide). 1, 7 The pooled absolute risk of suicidal ideation with SSRIs is 1% versus 0.2% with placebo. 6
Also monitor for:
- Behavioral activation/agitation early in SSRI treatment 7
- Treatment adherence and seizure frequency using standardized measures 6
- Functional impairment in social, educational, and family domains 6
Explanation to Patient and Family
Families accept the diagnosis and engage in treatment when PNES is explained as how emotional distress, illness, and states of high arousal activate atypical defense responses in the body and brain, with PNES being an unwanted by-product of this process. 5 Emphasize that episodes are involuntary and real—not faked—representing a genuine conversion disorder. 1
The transition from neurology (where diagnosis is made) to mental health services requires careful explanation to ensure family engagement. 5
School Accommodations
Coordinate with school to implement:
- Accommodations for episodes (safe space, ability to leave class briefly) 7
- 504 plan or IEP modifications to address functional impairments 7
- Goal of full-time return to school, achieved in 75% of pediatric PNES patients with treatment 5
Critical Pitfalls to Avoid
Do not continue anticonvulsant medications—these are inappropriate for PNES and expose patients to unnecessary harm. 1 Discontinue any existing anticonvulsants under neurologist supervision.
Do not use benzodiazepines despite their rapid anxiolytic effect, due to risks of dependence, cognitive impairment, and lack of evidence for long-term efficacy in adolescents. 7, 6
Do not delay treatment—early effective treatment predicts better long-term outcomes, and untreated PNES leads to decreased school performance, poor social functioning, increased physical illness, substance abuse, and increased healthcare costs. 1, 7
Do not treat in isolation—coordinate care between mental health provider, neurologist (who should continue following the patient post-diagnosis), primary care, and school. 9, 7
Do not ignore parental anxiety, which can inadvertently reinforce avoidance behaviors; consider parental treatment if indicated. 7, 6
Expected Outcomes
With appropriate treatment, quality of life can be improved even when complete seizure freedom is not achieved. 1 In pediatric studies, 81% of patients had seizure reduction over 50%, with half becoming seizure-free. 3 Measures of anxiety, depression, and dissociation tend to normalize, coping becomes more adequate, and health-related quality of life increases. 3 Patients who become seizure-free improve more on psychological outcome measures than those with continuing seizures. 3