eMedicine Specialties > Neurology > Seizures and Epilepsy

Psychogenic Nonepileptic Seizures: Treatment & Medication

Author: Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Contributor Information and Disclosures

Updated: Nov 24, 2009

Treatment

Medical Care

  • The patient's understanding of psychogenic nonepileptic seizures (PNES) and his or her reactions to the diagnosis affect the outcome; therefore, patient education is crucial.
    • Perhaps the most important step in initiating treatment is delivering the diagnosis to patients and their families.
    • Most patients with psychogenic symptoms have previously received a diagnosis of organic disease (eg, 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?"
  • Written information can help supplement verbal explanations, but patient information about psychogenic symptoms is scarce.
    • The American Psychiatric Association provides abundant patient education material on diverse topics but not somatoform disorders.
    • Written materials on PNES are scarce but available. Refer to the Reference section for references.
    • Unless patients and families understand and accept the diagnosis, they will not comply with recommendations. Therefore, communicating the diagnosis is critical.
  • The main obstacle to effective treatment is effective delivery of the diagnosis.
    • Physicians are typically uncomfortable with the diagnosis of PNES, and they tend to be uneasy in formulating a conclusion about it. Therefore, physicians' reports are frequently vague and fail to give clear interpretations. They may write, "no EEG change during the episode, no evidence for epilepsy," or "seizures were nonepileptic."
    • Clinicians (eg, referring neurologist, primary physician) may find such reports unhelpful and difficult to explain to patients and families. As a result, patients often continue to be treated for epilepsy, possibly with the understanding that the test results were inconclusive.
    • The diagnosis of PNES should be explained clearly, with unambiguous terms that patients can understand, such as psychological, stress induced, and emotional.
    • 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 wishy-washy and confusing terms. Unfortunately, the indecisive, timid, unclear, or confusing approach is common. Consequently, patients and their families are typically confused, and the problem is perpetuated.
  • Psychogenic symptoms are, by definition, a psychiatric disease, and a mental health professional should managed them.
    • Treatment includes psychotherapy and use of adjunctive medications to treat coexisting anxiety or depression.
    • Unfortunately, mental health services are not always easily available, especially for noninsured patients.
    • Another 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. 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.

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.
  • Long-term psychotherapy is indicated for patients with PNES, as it is with other manifestations of conversion disorders,
  • The neurologist should work with a psychiatrist who understands PNES.
  • Nowadays, mental health professionals other than psychiatrists often perform psychotherapy. These professionals include psychologists, social workers, and counselors.
  • Psychotropic medications are often needed to treat associated depression and anxiety.

Activity

  • Patients with PNES usually do not require any limitation of activities.
  • Neurologists vary in their recommendations concerning driving.
    • A preliminary study showed no increased risk of motor vehicle accidents among patients with PNES.
    • Nevertheless, restrictions on potentially hazardous activities (eg, climbing, swimming) may be appropriate in some cases.

More on Psychogenic Nonepileptic Seizures

Overview: Psychogenic Nonepileptic Seizures
Differential Diagnoses & Workup: Psychogenic Nonepileptic Seizures
Treatment & Medication: Psychogenic Nonepileptic Seizures
Follow-up: Psychogenic Nonepileptic Seizures
References
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References

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Further Reading

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Keywords

psychogenic seizures, PNES, non-epileptic seizures, psychogenic seizure, nonepileptic seizures, NES, pseudoseizures, nonepileptic episode, nonepileptic events, psychogenic nonepileptic events

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Contributor Information and Disclosures

Author

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Raj D Sheth, MD, Professor of Neurology, Mayo College of Medicine; Chief, Division of Pediatric Neurology, Nemours Children's Clinic
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, and Child Neurology Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Jose E Cavazos, MD, PhD, FAAN, Associate Professor with Tenure, Departments of Neurology, Pharmacology, and Physiology, University of Texas Health Science Center at San Antonio; Co-Director, South Texas Comprehensive Epilepsy Center; Director of the Epilepsy Center, Audie L Murphy Veterans Affairs Medical Center
Jose E Cavazos, MD, PhD, FAAN is a member of the following medical societies: American Academy of Neurology, American Clinical Neurophysiology Society, American Epilepsy Society, American Neurological Association, and Society for Neuroscience
Disclosure: Nothing to disclose.

CME Editor

Paul E Barkhaus, MD, Professor, Department of Neurology, Medical College of Wisconsin; Director of Neuromuscular Diseases, Milwaukee Veterans Administration Medical Center
Paul E Barkhaus, MD is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, and American Neurological Association
Disclosure: Nothing to disclose.

Chief Editor

Helmi L Lutsep, MD, Professor, Department of Neurology, Oregon Health & Science University; Associate Director, Oregon Stroke Center
Helmi L Lutsep, MD is a member of the following medical societies: American Academy of Neurology and American Stroke Association
Disclosure: Co-Axia Consulting fee Review panel membership; Talecris Consulting fee Review panel membership; AGA Medical Consulting fee Review panel membership; Boehringer Ingelheim Honoraria Speaking and teaching; Concentric Medical Consulting fee Review panel membership; Abbott Consulting fee Consulting; Sanofi  Consulting

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