What is the recommended treatment for psychogenic non‑epileptic seizures (PNES, also called pseudo‑seizures)?

Treatment for Psychogenic Non-Epileptic Seizures (PNES)

The cornerstone of PNES treatment is psychological therapy—specifically cognitive behavioral therapy (CBT)—combined with psychoeducation, while antiepileptic drugs should be avoided as they provide no benefit and expose patients to unnecessary risks. 1

Critical First Step: Avoid Antiepileptic Drugs

• Do not prescribe anticonvulsants for PNES, as 60-80% of patients are inappropriately given antiepileptic drugs despite lacking epilepsy, exposing them to unnecessary medication risks including respiratory depression, cardiac effects, and CNS toxicity. 1
• The only exception is the 10-20% of PNES patients who also have comorbid true epilepsy, requiring careful diagnostic differentiation before any medication decisions. 1

Primary Treatment: Psychological Interventions

Cognitive Behavioral Therapy (CBT) is the evidence-based first-line treatment:

• CBT has demonstrated efficacy in randomized controlled trials, showing superiority over standard medical care for reducing seizure frequency and improving functional outcomes. 2
• A multidisciplinary inpatient treatment program based on CBT principles achieved 81% of patients with >50% seizure reduction at 6-month follow-up, with half becoming seizure-free. 3
• CBT should be delivered by trained mental health professionals as part of a multidisciplinary team approach involving neurologists, psychiatrists/psychologists, and support staff. 4, 5

Psychoeducation is essential as an adjunctive intervention:

• Educate patients that PNES is a benign condition with tendency toward natural remission, which reduces psychological burden and improves quality of life. 1
• Psychoeducational programs help patients understand the condition and facilitate engagement in treatment. 6, 2
• Information should emphasize that PNES are "real" seizures occurring at a subconscious level, not under voluntary control, to reduce stigma and improve treatment acceptance. 5

Additional Psychological Therapies with Evidence

Beyond CBT, several other modalities show promise:

• Relaxation therapy and techniques based on CBT principles may be considered as adjunctive treatments. 7, 6
• Psychodynamic interpersonal psychotherapy (augmented) and group psychodynamic psychotherapy have shown efficacy in uncontrolled trials. 2
• Group psychoeducation formats can be effective and resource-efficient. 2
• Family counseling should be incorporated to address family dynamics and support systems. 7

Addressing Perpetuating Factors

Identify and manage underlying psychological stressors:

• Screen for anxiety and depression, as they are present in one-third of PNES patients, particularly adolescents, and require targeted treatment. 1
• Address mental stress, as it increases PNES frequency and severity. 1
• Manage sleep deprivation and identify anxiety triggers that precipitate attacks. 1
• Provide advice on avoiding high-risk activities and first aid relevant to the patient and family members. 7

Pharmacological Considerations

While psychotherapy is primary, limited pharmacological data exists:

• Sertraline (an antidepressant) showed significant pre- versus post-treatment decrease in seizure frequency in the active treatment arm of a pilot randomized controlled trial, though it did not differ significantly from placebo. 2
• Venlafaxine (another antidepressant) showed efficacy in uncontrolled trials. 2
• Pharmacotherapy should target comorbid psychiatric conditions (depression, anxiety) rather than the seizures themselves. 2

Special Populations

For patients with intellectual disabilities:

• Treatment should be adapted to cognitive level using modified approaches with gesture and prosody. 6
• Psychoeducational programs should be tailored to the patient's comprehension abilities. 6

Treatment Goals and Outcomes

Focus on quality of life, not just seizure freedom:

• While seizure freedom may not be achieved in all patients with this chronic, paroxysmal disorder, quality of life can be substantially improved with treatment. 8
• Patients who achieve seizure freedom show greater improvement in psychological functioning than those with continuing seizures. 3
• Measures of anxiety, depression, dissociation, coping, and health-related quality of life should be tracked as outcome measures beyond seizure frequency alone. 3

Common Pitfalls to Avoid

• Do not use psychological debriefing for recent traumatic events, as it does not reduce post-traumatic stress, anxiety, or depressive symptoms. 7
• Avoid the trap of extensive invasive testing once diagnosis is established, as PNES patients already undergo excessive testing in 60-80% of cases. 1
• Do not delay psychiatric referral—early engagement with mental health services improves outcomes. 4