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Psychogenic Nonepileptic Seizures Treatment & Management

  • Author: Selim R Benbadis, MD; Chief Editor: Helmi L Lutsep, MD  more...
 
Updated: Oct 09, 2015
 

Approach Considerations

Treatment of PNES varies and can include psychotherapy and use of adjunctive medications to treat coexisting anxiety or depression. Psychogenic symptoms are, by definition, a psychiatric disease, and a mental health professional should manage them.

The main obstacle to effective treatment is effective delivery of the diagnosis. The physician delivering the diagnosis must be compassionate, remembering that most patients are not faking, but also firm and confident to avoid the use of ambiguous and confusing terms. Most patients with psychogenic symptoms have previously received a diagnosis of organic disease (e.g., epilepsy); therefore, patients' reactions typically include disbelief and denial, as well as anger and hostility. For example, they may ask "Are you accusing me of faking?" or "Are you saying that I am crazy?"

Patients who accept their diagnosis and follow through with therapy are more likely to experience a successful outcome; therefore, patient education is crucial.

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Medical Care

Goldstein et al reported that, compared with standard medical care, cognitive-behavioral therapy significantly reduced seizure activity in patients with psychogenic nonepileptic seizures.[13] Another study by LaFrance Jr. et al. found that a cognitive behavior therapy-informed psychotherapy significantly reduces the seizures in patients with PNES.[22] This study evaluated the efficacy of medication (flexible-dose sertraline hydrochloride) only, cognitive behavioral therapy informed psychotherapy (CBT-ip) only, CBT-ip with medication (sertraline), and treatment as usual. The CBT-ip group showed a 51.4% seizure reduction and significant improvement from baseline in secondary measures including depression, anxiety, quality of life, and global functioning. The CBT-ip with sertraline group showed 59.3% seizure reduction and the sertraline-only group did not show a reduction in seizures.[22]

Unfortunately, mental health services are not always easily available, especially for noninsured patients. A critical obstacle is that psychiatrists tend to be skeptical about the diagnosis of psychogenic symptoms. Even in PNES, for which EEG video monitoring allows for near-certain diagnosis, psychiatrists tend to disbelieve the diagnosis.[14] A useful approach to combat this skepticism is to provide the treating psychiatrist with video recordings of the findings, can be more convincing than written reports.

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Consultations

From a practical point of view, the role of the neurologists and other medical specialists is to determine whether organic disease exists. Once the symptoms are shown to be psychogenic, the exact psychiatric diagnosis and its treatment are best handled by the psychiatrist. The neurologist should work with a psychiatrist who understands PNES.

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Contributor Information and Disclosures
Author

Selim R Benbadis, MD Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, Tampa General Hospital, University of South Florida College of Medicine

Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Medical Association, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cyberonics; Eisai; Lundbeck; Sunovion; UCB; Upsher-Smith<br/>Serve(d) as a speaker or a member of a speakers bureau for: Cyberonics; Eisai; Glaxo Smith Kline; Lundbeck; Sunovion; UCB<br/>Received research grant from: Cyberonics; Lundbeck; Sepracor; Sunovion; UCB; Upsher-Smith.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Jose E Cavazos, MD, PhD, FAAN, FANA, FACNS Professor with Tenure, Departments of Neurology, Pharmacology, and Physiology, Assistant Dean for the MD/PhD Program, Program Director of the Clinical Neurophysiology Fellowship, University of Texas School of Medicine at San Antonio; Co-Director, South Texas Comprehensive Epilepsy Center, University Hospital System; Director, San Antonio Veterans Affairs Epilepsy Center of Excellence and Neurodiagnostic Centers, Audie L Murphy Veterans Affairs Medical Center

Jose E Cavazos, MD, PhD, FAAN, FANA, FACNS is a member of the following medical societies: American Academy of Neurology, American Clinical Neurophysiology Society, American Neurological Association, Society for Neuroscience, American Epilepsy Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Brain Sentinel, consultant.<br/>Stakeholder (<5%), Co-founder for: Brain Sentinel.

Chief Editor

Helmi L Lutsep, MD Professor and Vice Chair, Department of Neurology, Oregon Health and Science University School of Medicine; Associate Director, OHSU Stroke Center

Helmi L Lutsep, MD is a member of the following medical societies: American Academy of Neurology, American Stroke Association

Disclosure: Medscape Neurology Editorial Advisory Board for: Stroke Adjudication Committee, CREST2.

Additional Contributors

Raj D Sheth, MD Chief, Division of Pediatric Neurology, Nemours Children's Clinic; Professor of Neurology, Mayo College of Medicine; Professor of Pediatrics, University of Florida College of Medicine

Raj D Sheth, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Pediatrics, American Epilepsy Society, American Neurological Association, Child Neurology Society

Disclosure: Nothing to disclose.

References
  1. LaFrance WC, Benbadis SR. Avoiding the costs of unrecognized psychological nonepileptic seizures. Neurology. 2006 Jun 13. 66(11):1620-1. [Medline].

  2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994.

  3. Benbadis SR, Tatum WO. Overintepretation of EEGs and misdiagnosis of epilepsy. J Clin Neurophysiol. 2003 Feb. 20(1):42-4. [Medline].

  4. Benbadis SR, Lin K. Errors in EEG interpretation and misdiagnosis of epilepsy. Which EEG patterns are overread?. Eur Neurol. 2008. 59(5):267-71. [Medline].

  5. Benbadis SR. Errors in EEGs and the misdiagnosis of epilepsy: importance, causes, consequences, and proposed remedies. Epilepsy Behav. 2007 Nov. 11(3):257-62. [Medline].

  6. Syed TU, Lafrance WC Jr, Kahriman ES, et al. Can semiology predict psychogenic nonepileptic seizures? a prospective study. Ann Neurol. 2011 Jun. 69(6):997-1004. [Medline].

  7. Benbadis SR. A spell in the epilepsy clinic and a history of "chronic pain" or "fibromyalgia" independently predict a diagnosis of psychogenic seizures. Epilepsy Behav. 2005 Mar. 6(2):264-5. [Medline].

  8. Elzawahry H, Do CS, Lin K, Benbadis SR. The diagnostic utility of the ictal cry. Epilepsy Behav. 2010 Jun 1. [Medline].

  9. Benbadis SR, LaFrance WC Jr, Papandonatos GD, Korabathina K, Lin K, Kraemer HC. Interrater reliability of EEG-video monitoring. Neurology. 2009 Sep 15. 73(11):843-6. [Medline]. [Full Text].

  10. Hubsch C, Baumann C, Hingray C, Gospodaru N, Vignal JP, Vespignani H, et al. Clinical classification of psychogenic non-epileptic seizures based on video-EEG analysis and automatic clustering. J Neurol Neurosurg Psychiatry. 2011 Sep. 82(9):955-60. [Medline].

  11. Benbadis SR, O'Neill E, Tatum WO, Heriaud L. Outcome of prolonged video-EEG monitoring at a typical referral epilepsy center. Epilepsia. 2004 Sep. 45(9):1150-3. [Medline].

  12. Benbadis SR. Mental heath organizations and the ostrich policy. Neuropsychiatry. 2013. 1:5-7.

  13. Goldstein LH, Chalder T, Chigwedere C, Khondoker MR, Moriarty J, Toone BK, et al. Cognitive-behavioral therapy for psychogenic nonepileptic seizures: a pilot RCT. Neurology. 2010 Jun 15. 74(24):1986-94. [Medline]. [Full Text].

  14. Harden CL, Burgut FT, Kanner AM. The diagnostic significance of video-EEG monitoring findings on pseudoseizure patients differs between neurologists and psychiatrists. Epilepsia. 2003 Mar. 44(3):453-6. [Medline].

  15. LaFrance WC Jr, Keitner GI, Papandonatos GD, et al. Pilot pharmacologic randomized controlled trial for psychogenic nonepileptic seizures. Neurology. 2010 Sep 28. 75(13):1166-73. [Medline]. [Full Text].

  16. Benbadis SR. Psychogenic non-epileptic seizures. Wyllie E, Gupta A, Lachhwani DK, eds. The Treatment of Epilepsy: Principles and Practice. 4th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2005. 623-30.

  17. Benbadis SR. The problem of psychogenic symptoms: is the psychiatric community in denial?. Epilepsy Behav. 2005 Feb. 6(1):9-14. [Medline].

  18. Ameri8can Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association; 2013.

  19. Mellers JD. The approach to patients with "non-epileptic seizures". Postgrad Med J. 2005 Aug. 81(958):498-504. [Medline]. [Full Text].

  20. LaFrance WC Jr, Baker GA, Duncan R, Goldstein LH, Reuber M. Minimum requirements for the diagnosis of psychogenic nonepileptic seizures: a staged approach: a report from the International League Against Epilepsy Nonepileptic Seizures Task Force. Epilepsia. 2013 Nov. 54(11):2005-18. [Medline].

  21. Bravo TP, Hoffman-Snyder CR, Wellik KE, Martin KA, Hoerth MT, Demaerschalk BM, et al. The effect of selective serotonin reuptake inhibitors on the frequency of psychogenic nonepileptic seizures: a critically appraised topic. Neurologist. 2013 Jan. 19(1):30-3. [Medline].

  22. LaFrance WC Jr, Baird GL, Barry JJ, Blum AS, Frank Webb A, Keitner GI, et al. Multicenter pilot treatment trial for psychogenic nonepileptic seizures: a randomized clinical trial. JAMA Psychiatry. 2014 Sep 1. 71(9):997-1005. [Medline].

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Psychogenic nonepileptic attacks. The event is provoked by an induction (or provocative) technique. Note the typical irregular nonclonic nontonic and asynchronous movements (including bicycling) with stop-and-go phenomenon.
 
 
 
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