Treatment of Psychogenic Non-Epileptic Seizures (PNES)
The cornerstone of PNES management is psychotherapy—specifically cognitive-behavioral therapy (CBT)—combined with immediate discontinuation of all antiepileptic drugs in patients without concurrent epilepsy. 1
Immediate Actions After Diagnosis
Stop Inappropriate Medications
Discontinue all antiepileptic drugs immediately in patients with pure PNES (no concurrent epilepsy), as 60-80% of PNES patients are inappropriately prescribed anticonvulsants that provide zero therapeutic benefit while exposing them to unnecessary risks including respiratory depression, cardiac toxicity, and CNS adverse effects. 1
Recognize that 10-20% of PNES patients also have true epilepsy, which complicates the decision to withdraw anticonvulsants—in these dual-diagnosis cases, video-EEG monitoring is essential to distinguish which events are epileptic versus psychogenic before adjusting medications. 1
Deliver the Diagnosis Clearly
Communicate the PNES diagnosis directly and empathetically to the patient, explaining that these are "real" seizures occurring on a subconscious level and are not under voluntary control, but are caused by psychological processes rather than abnormal electrical brain activity. 2
Educate patients that PNES is a benign condition with a natural tendency toward remission when properly treated, which reduces psychological burden and improves engagement with therapy. 1
First-Line Treatment: Cognitive-Behavioral Therapy
Initiate a structured CBT-based program as the primary intervention, as this is the most evidence-supported psychotherapeutic modality for PNES. 1, 3
CBT Program Structure
Deliver treatment over 12-15 weekly sessions in an outpatient or intensive inpatient format, following cognitive-behavioral principles that address maladaptive thought patterns and behavioral responses to stress. 4, 3
A multidisciplinary inpatient program based on CBT principles achieved 81% seizure reduction >50% and 50% complete seizure freedom at 6-month follow-up, with sustained or improved gains over time. 3
Incorporate relaxation therapy and stress-management techniques as adjunctive components within the CBT framework. 1
Addressing Comorbid PTSD
For patients with concurrent post-traumatic stress disorder (confirmed by clinical interview and standardized testing), prolonged exposure therapy (PE) is highly effective, with 81% of treatment completers achieving complete seizure freedom by the final session. 4
PE therapy delivered over 12-15 weekly sessions not only reduced PNES frequency (p=0.001) but also significantly improved depression scores (p<0.001) and PTSD symptom scores (p<0.001), with gains maintained at long-term follow-up. 4
Childhood trauma and abuse history are strongly correlated with PNES development, making trauma-focused therapies particularly relevant for many patients. 5
Treat Psychiatric Comorbidities
Screen and Manage Mood and Anxiety Disorders
Screen all PNES patients for depression and anxiety, as these conditions are present in one-third of patients (particularly adolescents) and require concurrent treatment. 1
High rates of psychiatric comorbidity exist in PNES, including major depression, generalized anxiety disorder, somatoform symptoms, and dissociative disorders—each requiring targeted psychiatric intervention. 5
Even patients who achieve seizure freedom often continue to have symptoms of psychopathology including depression and anxiety, underscoring the need for comprehensive psychiatric care beyond seizure control alone. 5
Address Perpetuating Psychological Factors
Identify and manage psychological stressors systematically, as mental stress directly increases PNES frequency and severity. 1
Address sleep deprivation and specific anxiety triggers that precipitate attacks, as these are modifiable factors that improve seizure control. 1
Family and Environmental Interventions
Incorporate family counseling into the treatment plan to address family dynamics, provide education about PNES, and create a supportive home environment. 1
Advise patients and families on avoiding high-risk activities (driving, swimming alone, working at heights) and teach appropriate first-aid measures during seizure-like episodes to reduce injury risk. 1
Special Populations
- For patients with intellectual disabilities, adapt treatment to cognitive level using modified approaches with gesture, prosody, and simplified psychoeducational materials about the condition. 6
Interventions to Avoid
Do not use psychological debriefing after recent traumatic events, as evidence demonstrates it does not reduce post-traumatic stress, anxiety, or depressive symptoms in PNES patients. 1
Avoid prescribing benzodiazepines or other sedatives for "seizure control," as these medications do not treat the underlying psychological mechanism and add unnecessary medication burden. 1
Multidisciplinary Follow-Up
Maintain ongoing neurologist involvement post-diagnosis even as psychiatric treatment proceeds, as neurologic oversight is essential for monitoring any new neurologic symptoms and ensuring no epileptic seizures develop. 5
Recognize that seizure freedom alone is not a comprehensive outcome measure—nearly half of seizure-free patients remain unproductive and continue to have impaired quality of life, necessitating holistic assessment of psychosocial functioning. 5, 7
Prognosis and Realistic Expectations
The mean latency from symptom onset to correct diagnosis remains 7 years, highlighting the importance of early video-EEG confirmation to prevent prolonged inappropriate treatment. 5
Even with optimal treatment, complete seizure freedom may not be achieved in all patients—quality of life improvement should be prioritized as a treatment goal alongside seizure reduction. 7
Favorable prognostic factors include female sex, independent lifestyle, normal EEG findings, higher intelligence, and no prior failed psychotherapy attempts. 2
Common Pitfalls
Do not assume PNES patients are "faking"—these are real, disabling seizures occurring on a subconscious level that the patient cannot voluntarily control. 2
Avoid delaying psychiatric referral while pursuing additional neurologic testing once video-EEG has confirmed PNES, as prolonged diagnostic uncertainty worsens outcomes. 5
Do not rely solely on clinical seizure characteristics to distinguish PNES from epilepsy, as this approach lacks sensitivity—video-EEG monitoring remains the gold standard. 5