What is the acute and follow‑up management of a patient presenting with a suspected psychogenic non‑epileptic seizure (PNES)?

Management of Psychogenic Non-Epileptic Seizure (PNES) Episode

Acute Management During the Episode

Do not administer antiepileptic medications during a suspected PNES episode, as these events are not caused by epileptogenic activity and will not respond to anticonvulsants. 1, 2

Immediate Safety Measures

• Ensure patient safety by removing nearby hazards and placing the patient in a position that prevents injury, but do not physically restrain the patient during the event 3
• Do not place anything in the patient's mouth during the episode 3
• Allow the episode to run its course while maintaining a calm, non-judgmental presence 4
• Monitor vital signs and respiratory status, though respiratory compromise is rare in PNES compared to true epileptic seizures 4

Critical Diagnostic Distinction in the Acute Setting

• Video-EEG monitoring with capture of a habitual event is the gold standard for definitively distinguishing PNES from epileptic seizures, as clinical features alone lack sufficient sensitivity 1, 2
• Be aware that 10-30% of patients referred to epilepsy centers have PNES rather than epilepsy, and many have been incorrectly treated with anticonvulsants for years (mean diagnostic delay is 7 years) 1, 2
• Note that 20-30% of PNES patients may also have comorbid epilepsy, so the presence of true epilepsy does not exclude PNES 1, 2

What NOT to Do

• Never administer benzodiazepines or other antiepileptic drugs for suspected PNES, as this reinforces the incorrect diagnosis and exposes patients to unnecessary medication risks 1, 2
• Avoid provocative maneuvers or suggestion during the acute episode, as these can complicate the clinical picture 1

Post-Episode Evaluation and Diagnosis

Essential Diagnostic Workup

• Arrange video-EEG monitoring to capture a typical event, which remains the definitive diagnostic test 1, 2
• Document detailed seizure semiology, including duration, motor manifestations, responsiveness during the event, and post-event behavior 4, 5
• Obtain a comprehensive psychiatric history focusing on trauma exposure, particularly childhood abuse, as strong correlations exist between childhood trauma, PTSD, and PNES 1, 2
• Screen for psychiatric comorbidities including depression, anxiety disorders, somatoform disorders, dissociative disorders, and post-traumatic stress disorder, which occur at high rates in PNES patients 1, 2, 5

Neurological Evaluation

• Perform standard neurological examination and consider neuroimaging (MRI preferred over CT) to exclude structural brain pathology, as some PNES patients have associated right hemisphere pathology, head injury history, or nonspecific EEG abnormalities 1
• Be aware that complex partial seizures of frontal origin can mimic PNES and may be confused with psychogenic events 1

Communication of Diagnosis

The PNES diagnosis must be clearly and empathetically communicated to the patient as soon as it is confirmed. 1, 2, 5

• Present PNES as a "real" medical condition that is as disabling as epileptic seizures, emphasizing that most PNES occur on a subconscious level and patients have no voluntary control over their occurrence 4, 5
• Frame PNES within the DSM-5 construct of Functional Neurological Disorder or the ICD-10/11 framework of dissociative/conversion disorder 1, 2
• Explain that PNES represent a dissociative psychological defense mechanism, often related to trauma, rather than "faking" or malingering 1, 2
• Immediately discontinue any antiepileptic medications that were prescribed under the incorrect diagnosis of epilepsy 1, 2

Follow-Up Management and Treatment

Multidisciplinary Team Approach

A multidisciplinary team including a neurologist with epilepsy expertise, a psychiatrist or psychologist, and support staff is essential for appropriate PNES management. 6, 4, 5

• Continued neurologist follow-up post-diagnosis is essential, even as psychiatric treatment is initiated 1
• Coordinate care between neurology and psychiatry to address both the seizure manifestations and underlying psychiatric comorbidities 6, 5

Evidence-Based Treatment Modalities

Psychotherapeutic interventions remain the most powerful treatment to reduce seizures and improve quality of life in PNES patients. 6, 5

• Initiate cognitive-behavioral therapy (CBT) as a first-line psychotherapeutic approach, which has the strongest evidence base for PNES 6, 5
• Consider trauma-focused therapies when PTSD or significant trauma history is present 2, 5
• Address comorbid psychiatric conditions (depression, anxiety, somatoform disorders) with appropriate psychiatric treatment, including psychotherapy and pharmacotherapy as indicated 1, 2, 5

Treatment Goals and Realistic Expectations

• Recognize that seizure freedom may not be achieved in all patients, as PNES is a chronic, paroxysmal disorder 6
• Focus on quality of life improvement as a primary outcome measure, rather than seizure cessation alone 1, 6
• Be aware that even after seizure remission, nearly half of patients remain unproductive and continue to have symptoms of psychopathology, including other somatoform, depressive, and anxiety disorders 1
• Understand that even with correct diagnosis, a high proportion of PNES patients continue to have seizures and serious disability 1, 2

Prognostic Factors

• Favorable prognostic indicators include female sex, independent lifestyle, normal EEG findings, higher intelligence, and no prior psychotherapy 4
• Patients with these characteristics are more likely to respond to treatment and achieve better long-term outcomes 4

Common Pitfalls to Avoid

• Never dismiss PNES as "not real" or suggest the patient is malingering, as this undermines the therapeutic relationship and delays effective treatment 4, 5
• Avoid prolonged treatment with antiepileptic drugs once PNES is diagnosed, as this exposes patients to unnecessary side effects and reinforces illness behavior 1, 2
• Do not rely solely on clinical seizure characteristics to distinguish PNES from epilepsy, as this approach lacks adequate sensitivity 1
• Recognize that serum prolactin, neuron-specific enolase, and creatine kinase are not reliable for validating PNES diagnosis 1
• Be aware that barriers to treatment transition remain an important challenge, and proactive coordination between neurology and psychiatry is needed to ensure patients engage with appropriate psychotherapeutic services 5