What is the recommended evaluation and management for functional neurological episodes such as psychogenic non‑epileptic seizures?

Evaluation and Management of Functional Neurological Episodes (Psychogenic Non-Epileptic Seizures)

Diagnose functional neurological episodes using positive clinical signs during video-EEG monitoring, then immediately initiate a structured treatment plan combining direct diagnostic communication, cognitive behavioral therapy, and physical rehabilitation—do not wait for psychiatric consultation to begin the therapeutic process. 1, 2, 3

Diagnostic Evaluation

Gold Standard Diagnostic Test

• Video-EEG monitoring is the definitive diagnostic test to capture typical episodes while demonstrating normal EEG activity, which confirms the diagnosis and differentiates from epilepsy in the 20-30% of "epilepsy center" patients who actually have PNES 3, 4

Key Clinical Features During Episodes (Eyewitness or Video Documentation)

Features suggesting functional episodes rather than epilepsy:

• Eyes closed during unconsciousness (highly specific for functional episodes; epileptic seizures typically occur with eyes open) 5
• Eye fluttering (more likely PNES than epileptic seizure) 5
• Duration >5 minutes suggests functional episodes or psychogenic pseudosyncope 5
• Pelvic thrusting movements (suggests PNES, though can rarely occur in frontal lobe seizures) 5
• Repeated waxing and waning in intensity with changes in movement nature (characteristic of PNES) 5
• Asynchronous, asymmetrical movements (more consistent with functional episodes than epilepsy) 5
• Many movements that "cannot be counted" versus few movements (~10) which suggests syncope 5

Critical Diagnostic Pitfall to Avoid

• Do not rely on biomarkers such as prolactin, creatine kinase, or neuron-specific enolase to differentiate PNES from epilepsy—these lack sufficient sensitivity and specificity 3
• Tongue biting and urinary incontinence do not differentiate epileptic seizures from PNES 5

Comprehensive Biopsychosocial Assessment Required

• Document symptom history and specific presentation patterns 1
• Assess medical and psychological history, including trauma, anxiety, and depression 1, 6
• Evaluate functional impact on daily activities, social relationships, and occupational functioning 1
• Identify predisposing, precipitating, and perpetuating factors on a case-by-case basis 4

Initial Diagnostic Communication (Critical Therapeutic Step)

The way you communicate the diagnosis is itself a powerful therapeutic intervention and must be done correctly:

• Acknowledge that functional episodes are real, involuntary, common, and disabling—the patient is not faking and symptoms are outside their conscious control 1, 2, 3
• Explain using positive clinical signs: "We diagnosed this based on specific physical signs during your episodes, not because we couldn't find anything else" 1, 2
• Use accessible analogies: "This is a software problem, not a hardware problem" or "the train is off the tracks"—emphasizing the potentially reversible miscommunication between brain and body 1, 2
• Emphasize treatability: Clearly state that this condition responds to appropriate psychological and physical interventions 3
• Deliver this communication directly and sympathetically in a multidisciplinary setting when possible 3, 4

Treatment Approach

Primary Treatment: Cognitive Behavioral Therapy

• CBT is the first-line psychological treatment for PNES, though complete seizure freedom may not be achieved in all patients 3, 7
• Focus on identifying triggers, warning signs, and patterns that precede episodes 5
• Implement sensory grounding techniques to prevent dissociation when warning signs appear: noticing environmental details (colors, textures, sounds), cognitive distractions (word games, counting backwards), and sensory-based distractors (flicking rubber band on wrist) 5, 2
• Address perpetuating factors including anxiety, depression, and unhelpful coping behaviors 1, 2

Physical Rehabilitation (Occupational and Physical Therapy)

• Engage in tasks that promote normal movement patterns, good alignment, and even weight-bearing 1, 2
• Use distraction techniques during task performance—avoid having patients focus on the affected body part to normalize automatic movement 1, 2
• Retrain normal movement patterns within functional activities 2

Management During Episodes

• Create a safety plan with the patient for what to do if an episode occurs during therapy 5
• Move the person to a safe space where injury is unlikely 5
• Avoid constant reassurance, physical contact, or restraint during episodes 5, 2
• Let them know they are safe but minimize ongoing verbal interaction 5
• Recognize that patients may hear and understand during episodes even if unable to respond 5

Anxiety Management Strategies

• Educate about the physiological fight-or-flight response, particularly for patients who don't identify as feeling anxious 2
• Teach breathing techniques, progressive muscle relaxation, visualization, distraction, thought reframing, and mindfulness 2
• Integrate enjoyable activities into daily routine 2

Medication Considerations

• Pharmacotherapy has no demonstrated benefit for PNES itself 3
• Consider medications only for comorbid psychiatric conditions (depression, anxiety) if present 6
• Review and potentially reduce sedating medications that may worsen cognitive symptoms 5

Critical Pitfalls to Avoid in Management

• Minimize use of aids and adaptive equipment, especially acutely—these interrupt normal automatic movement patterns and promote maladaptive functioning 5, 2
• Do not allow patients to overly attend to symptoms (e.g., trying hard to remember forgotten information)—this is counterproductive, similar to how a forgotten name returns once you stop trying 5, 2
• Avoid making FND a diagnosis of exclusion—use positive clinical signs 1
• Do not provide insufficient explanation of the diagnosis—this is a common reason for treatment failure 1

Outcome Measurement and Prognosis

• Quality of life can improve with treatment even without complete seizure freedom—72% of PNES patients show resolution after psychiatric treatment in follow-up studies 3
• Measure core symptom change, life impact (quality of life, disability, general functioning), and health economics/cost-utility 5, 1
• Treatment success is more likely when patients have some understanding and agreement with the diagnosis, have agreed to referral, can identify rehabilitation goals, are motivated to make changes, and understand the initial focus is improving function 1

Multidisciplinary Approach

• A holistic, multidisciplinary team approach is beneficial involving neurology, psychiatry/psychology, and physical/occupational therapy 7
• The multidisciplinary process of communicating the diagnosis is itself an important and effective therapeutic step 4
• Coordinate care to address the full spectrum of predisposing, precipitating, and perpetuating factors 4