Treatment of Psychogenic Non-Epileptic Seizures (PNES) with Bipolar Manic Episode
For a patient with psychogenic non-epileptic seizures (PNES) and a bipolar hallucinating manic episode, prioritize treating the acute mania with haloperidol or a second-generation antipsychotic combined with a mood stabilizer (lithium or valproate), while simultaneously initiating psychological therapy for the PNES—antiepileptic drugs should NOT be used for PNES as they are ineffective and potentially harmful. 1, 2
Immediate Management of Acute Mania with Psychotic Features
First-Line Pharmacological Treatment
Initiate combination therapy immediately with haloperidol (if resources are limited) or a second-generation antipsychotic (aripiprazole, olanzapine, risperidone, or quetiapine) plus lithium or valproate for acute mania with hallucinations. 1, 2
For rapid control of agitation and psychotic symptoms, aripiprazole 10-15 mg/day or olanzapine 10-15 mg/day provides faster symptom control than mood stabilizers alone. 2
Haloperidol remains an appropriate option in resource-limited settings, though second-generation antipsychotics are preferred when available due to better tolerability. 1
Add benzodiazepines (lorazepam 1-2 mg every 4-6 hours as needed) for severe agitation while antipsychotics reach therapeutic levels—the combination provides superior acute control compared to either agent alone. 2
Mood Stabilizer Selection
Lithium is the preferred mood stabilizer with target levels of 0.8-1.2 mEq/L for acute treatment, offering unique anti-suicide effects (reducing suicide attempts 8.6-fold and completed suicides 9-fold). 2
Valproate is particularly effective for mixed or dysphoric mania and irritability, with target therapeutic levels of 50-100 μg/mL. 2
Baseline laboratory assessment before lithium: complete blood count, thyroid function tests, urinalysis, BUN, creatinine, serum calcium, and pregnancy test in females. 2
Baseline assessment before valproate: liver function tests, complete blood count with platelets, and pregnancy test. 2
Critical Management of PNES Component
What NOT to Do
Do NOT prescribe antiepileptic drugs for PNES—they are ineffective for psychogenic seizures and expose patients to unnecessary side effects and medication costs. 3, 4
Avoid misdiagnosing PNES as epilepsy, which leads to years of inappropriate anticonvulsant treatment (mean diagnostic delay is 7 years). 3
Diagnostic Confirmation
Video-EEG monitoring is the gold standard for differentiating PNES from epileptic seizures—clinical characteristics alone lack sufficient sensitivity. 3, 4
Prolactin, neuron-specific enolase, and creatine kinase are NOT reliable for validating PNES diagnosis. 3
Primary Treatment for PNES
Psychological therapy is the treatment of choice for PNES, with 47% of patients achieving seizure freedom and 82% experiencing at least 50% seizure reduction upon completion. 5, 6, 7
Cognitive-behavioral therapy (CBT) is the most evidence-based psychotherapeutic modality, with additional options including psychodynamic therapy, mindfulness-based interventions, and psychoeducation. 6, 7
Communicate the PNES diagnosis clearly to the patient using a multidisciplinary approach—this diagnostic communication itself is an important and effective therapeutic step. 3, 4
Addressing Psychiatric Comorbidities
Assessment of Underlying Factors
Screen for childhood trauma, history of abuse, PTSD, depression, anxiety, and dissociative disorders—these are highly prevalent in PNES patients and require specific treatment. 3, 4
PNES can be conceptualized as a dissociative phenomenon generated by childhood trauma, requiring trauma-focused therapy. 3
Integrated Treatment Approach
Treat comorbid depression and anxiety with appropriate psychiatric management while the patient is on mood stabilizers for bipolar disorder. 3
Avoid antidepressant monotherapy in bipolar disorder—always combine with mood stabilizers to prevent mood destabilization. 2
Consider SSRIs (sertraline or escitalopram) or bupropion in combination with lamotrigine or lithium if depressive symptoms persist after mood stabilization. 2
Maintenance and Long-Term Management
Continuation of Bipolar Treatment
Continue the antipsychotic for at least 12 months after remission begins, and maintain mood stabilizers (lithium or valproate) for at least 12-24 months after the last episode. 1, 2, 8
Studies show >90% of noncompliant patients relapse versus 37.5% of compliant patients—emphasize medication adherence. 2, 8
Monitor lithium levels, renal and thyroid function every 3-6 months; for valproate, monitor serum drug levels, hepatic function, and hematological indices every 3-6 months. 2
Ongoing PNES Management
Neurologist follow-up remains essential even after PNES diagnosis—many patients continue to have seizures and disability despite correct diagnosis. 3
Nearly half of seizure-free PNES patients remain unproductive with ongoing psychopathology including somatoform, depressive, and anxiety disorders requiring continued psychiatric care. 3
Seizure freedom alone is not a comprehensive measure of outcome—focus on quality of life, functional status, and psychiatric symptom management. 3, 6
Psychosocial Interventions for Both Conditions
Provide psychoeducation to patient and family about both bipolar disorder (symptoms, course, treatment options, medication adherence) and PNES (psychological origin, treatment expectations). 1, 2
Family-focused therapy helps with medication supervision, early warning sign identification for bipolar relapse, and support for PNES management. 2
Cognitive-behavioral therapy addresses both mood symptoms in bipolar disorder and the dissociative mechanisms underlying PNES. 1, 2, 7
Common Pitfalls to Avoid
Treating PNES with antiepileptic drugs wastes years and exposes patients to unnecessary medication risks. 3
Premature discharge from inpatient care before adequate mood stabilization—persistent rapid thoughts, irritability, and poor judgment indicate ongoing acute mania requiring continued stabilization. 8
Inadequate duration of medication trials (less than 6-8 weeks at therapeutic doses) before concluding treatment failure. 2, 8
Failing to address psychiatric comorbidities (trauma, PTSD, depression, anxiety) that perpetuate both PNES and bipolar symptoms. 3
Discontinuing mood stabilizers prematurely—withdrawal dramatically increases relapse risk, especially within 6 months. 2, 8