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.
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.
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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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.
