Psychogenic Non-Epileptic Seizures: Diagnostic Approach and First-Line Treatment
Video-EEG monitoring is the gold standard for diagnosing psychogenic non-epileptic seizures (PNES), and cognitive behavioral therapy (CBT) is the first-line treatment, with direct, sympathetic communication of the diagnosis being essential for patient engagement. 1
Diagnostic Approach
Clinical Recognition
PNES affect 20-30% of patients attending epilepsy centers and over 10% of seizure emergencies, making accurate diagnosis critical. 2, 3 The following clinical features strongly suggest PNES over epileptic seizures:
Movement characteristics:
- Asynchronous, side-to-side thrashing movements (versus symmetrical, synchronous movements in epilepsy) 2, 3
- Repeated waxing and waning in intensity with changes in movement nature 2
- Pelvic thrusting (characteristic of PNES, though rarely seen in frontal lobe seizures) 2
- Eye fluttering 2, 3
Duration and consciousness features:
- Episodes lasting greater than 5 minutes strongly suggest PNES 2
- Eyes closed during unconsciousness (highly characteristic of PNES; eyes remain open in epileptic seizures) 2, 3
Features that do NOT differentiate PNES from epilepsy:
- Tongue biting 2
- Urinary incontinence 2
- Neuron-specific enolase, prolactin, and creatine kinase levels (unreliable and should not be used) 1, 2, 3
Gold Standard Diagnostic Test
Video-EEG monitoring is mandatory when clinical diagnosis remains uncertain. 2, 4 This captures typical events with continuous ECG, EEG, and blood pressure monitoring. 2 In PNES, the EEG remains normal during episodes, while true epileptic seizures show epileptiform discharges. 2, 4
Common pitfalls to avoid during video-EEG:
- Over-interpretation of interictal EEG findings 5
- Failure to recognize that some epileptic seizures (especially frontal lobe seizures and those without loss of awareness) may not show epileptiform ictal EEG patterns 5
- Under-recognition of semiological pointers toward frontal lobe seizures 5
First-Line Treatment
Initial Diagnostic Communication
The diagnosis must be communicated directly and sympathetically to the patient immediately after confirmation. 1 The American College of Cardiology recommends:
- Acknowledge that the episodes are involuntary and real, not being faked 1
- Explain that PNES represent a conversion disorder 1
- Emphasize that the condition is treatable with appropriate psychological interventions 1
This approach carries a Class IIb recommendation with limited evidence level (C-LD), but patients benefit from clear, sympathetic communication. 1
Primary Treatment: Cognitive Behavioral Therapy
CBT is the first-line treatment for PNES. 1 The American College of Cardiology gives this a Class IIb recommendation based on evidence showing a non-statistically significant trend toward improvement at 3 months. 1
Quality of life can be improved with treatment even when complete seizure freedom is not achieved, with 72% of PNES patients showing resolution after psychiatric treatment in follow-up studies. 1
Medication Management
Pharmacotherapy has no demonstrated benefit for PNES itself. 1 Antiepileptic drugs should be discontinued in patients with pure PNES (without coexisting epilepsy), as these patients experience all the side effects and none of the benefits. 4
Psychiatric Evaluation
Psychiatric evaluation is indicated for all patients with PNES. 2 These patients have high rates of comorbid psychiatric disorders, including:
- Depression 2
- Anxiety 2
- Somatoform symptoms 2
- Dissociative disorders 2
- Post-traumatic stress disorder (PTSD) 2
Treatment Approach Algorithm
- Confirm diagnosis with video-EEG monitoring 2, 4
- Communicate diagnosis directly and sympathetically within 24-48 hours of confirmation 1
- Initiate CBT as first-line treatment 1
- Arrange psychiatric evaluation to address comorbid conditions 2
- Discontinue antiepileptic drugs if no coexisting epilepsy 4
- Set realistic treatment goals focused on quality of life improvement, not necessarily complete seizure freedom 1, 6