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A Therapeutic Approach to Psychogenic Nonepileptic Seizures

  • Epilepsy (E Waterhouse, Section Editor)
  • Published:
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Opinion statement

The diagnosis of psychogenic nonepileptic seizures (PNES) is usually made in the seizure monitoring unit (SMU; also commonly named the epilepsy monitoring unit) after PNES are recorded on video-EEG. The diagnosis should be discussed with the patient thoroughly. The discussion should focus on how the diagnosis was reached and that the diagnosis is real and treatable. When the diagnosis is communicated well, some patients may improve significantly without further interventions. Next, a psychiatric evaluation should be completed, ideally before discharge from the SMU. After discharge, the patient should undergo cognitive behavioral therapy (CBT), the only treatment for PNES that is supported by high-quality evidence. Other therapies, including psychodynamic therapy and different types of group therapy can be considered in some patients, although high-level evidence to support their use is lacking. Some patients may benefit from selective serotonin-reuptake inhibitors (SSRIs), especially when psychiatric comorbidities are present. This should be considered on a case-by-case basis.

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References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Lesser RP. Psychogenic seizures. Neurology. 1996;46(6):1499–507.

    Article  CAS  PubMed  Google Scholar 

  2. LaFrance Jr WC, Devinsky O. The treatment of nonepileptic seizures: historical perspectives and future directions. Epilepsia. 2004;45 Suppl 2:15–21. doi:10.1111/j.0013-9580.2004.452002.x.

    Article  PubMed  Google Scholar 

  3. Asadi-Pooya AA, Sperling MR. Epidemiology of psychogenic nonepileptic seizures. Epilepsy Behav. 2015. doi:10.1016/j.yebeh.2015.03.015.

    Google Scholar 

  4. Benbadis SR, Allen HW. An estimate of the prevalence of psychogenic non-epileptic seizures. Seizure. 2000;9(4):280–1. doi:10.1053/seiz.2000.0409.

    Article  CAS  PubMed  Google Scholar 

  5. Sigurdardottir KR, Olafsson E. Incidence of psychogenic seizures in adults: a population-based study in Iceland. Epilepsia. 1998;39(7):749–52.

    Article  CAS  PubMed  Google Scholar 

  6. Szaflarski JP, Ficker DM, Cahill WT, Privitera MD. Four-year incidence of psychogenic nonepileptic seizures in adults in Hamilton County, OH. Neurology. 2000;55(10):1561–3.

    Article  CAS  PubMed  Google Scholar 

  7. Duncan R, Razvi S, Mulhern S. Newly presenting psychogenic nonepileptic seizures: incidence, population characteristics, and early outcome from a prospective audit of a first seizure clinic. Epilepsy Behav. 2011;20(2):308–11. doi:10.1016/j.yebeh.2010.10.022.

    Article  PubMed  Google Scholar 

  8. LaFrance WC, Jr. and Schachter, S. C. Historical approaches to treatments for psychogenic nonepileptic seizures. In: Schachter S. C. and LaFarnce WC, Jr., editor. Gates and Rown's Nonepileptic Seizures. Third ed. Cambridge, UK: Cambridge University Press; 2010. p. 237–46

  9. Smith BJ. Closing the major gap in PNES research: finding a home for a borderland disorder. Epilepsy Currents / American Epilepsy Soc. 2014;14(2):63–7. doi:10.5698/1535-7597-14.2.63.

    Article  Google Scholar 

  10. Benbadis SR, Agrawal V, Tatum WO. How many patients with psychogenic nonepileptic seizures also have epilepsy? Neurology. 2001;57(5):915–7.

    Article  CAS  PubMed  Google Scholar 

  11. Reuber M. Psychogenic nonepileptic seizures: answers and questions. Epilepsy Behav. 2008;12(4):622–35. doi:10.1016/j.yebeh.2007.11.006.

    Article  PubMed  Google Scholar 

  12. Sharpe D, Faye C. Non-epileptic seizures and child sexual abuse: a critical review of the literature. Clin Psychol Rev. 2006;26(8):1020–40. doi:10.1016/j.cpr.2005.11.011.

    Article  PubMed  Google Scholar 

  13. Krawetz P, Fleisher W, Pillay N, Staley D, Arnett J, Maher J. Family functioning in subjects with pseudoseizures and epilepsy. J Nerv Ment Dis. 2001;189(1):38–43.

    Article  CAS  PubMed  Google Scholar 

  14. Salmon P, Al-Marzooqi SM, Baker G, Reilly J. Childhood family dysfunction and associated abuse in patients with nonepileptic seizures: towards a causal model. Psychosom Med. 2003;65(4):695–700.

    Article  PubMed  Google Scholar 

  15. LaFrance Jr WC, Alosco ML, Davis JD, Tremont G, Ryan CE, Keitner GI, et al. Impact of family functioning on quality of life in patients with psychogenic nonepileptic seizures versus epilepsy. Epilepsia. 2011;52(2):292–300. doi:10.1111/j.1528-1167.2010.02765.x.

    PubMed  Google Scholar 

  16. Griffith NM, Szaflarski JP. Epidemiology and classification of psychogenic nonepileptic seizures. In: Schachter SC, LaFrance WC, editors. Gates and Rowan’s nonepileptic seizures. Cambridge: Cambridge University Press; 2010. p. 3–16.

    Google Scholar 

  17. Baslet G. Psychogenic nonepileptic seizures: a treatment review. What have we learned since the beginning of the millennium? Neuropsychiatr Dis Treat. 2012;8:585–98. doi:10.2147/NDT.S32301.

    Article  PubMed Central  PubMed  Google Scholar 

  18. 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;74(24):1986–94. doi:10.1212/WNL.0b013e3181e39658.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  19. LaFrance Jr WC, Keitner GI, Papandonatos GD, Blum AS, Machan JT, Ryan CE, et al. Pilot pharmacologic randomized controlled trial for psychogenic nonepileptic seizures. Neurology. 2010;75(13):1166–73. doi:10.1212/WNL.0b013e3181f4d5a9.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  20. LaFrance Jr WC, 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 Psy. 2014;71(9):997–1005. doi:10.1001/jamapsychiatry.2014.817. This pilot RCT provides the best available evidence for the use of CBT in treatment of PNES.

    Article  Google Scholar 

  21. Farias ST, Thieman C, Alsaadi TM. Psychogenic nonepileptic seizures: acute change in event frequency after presentation of the diagnosis. Epilepsy Behav. 2003;4(4):424–9.

    Article  PubMed  Google Scholar 

  22. McKenzie P, Oto M, Russell A, Pelosi A, Duncan R. Early outcomes and predictors in 260 patients with psychogenic nonepileptic attacks. Neurology. 2010;74(1):64–9. doi:10.1212/WNL.0b013e3181c7da6a.

    Article  CAS  PubMed  Google Scholar 

  23. Hall-Patch L, Brown R, House A, Howlett S, Kemp S, Lawton G, et al. Acceptability and effectiveness of a strategy for the communication of the diagnosis of psychogenic nonepileptic seizures. Epilepsia. 2010;51(1):70–8. doi:10.1111/j.1528-1167.2009.02099.x.

    Article  PubMed  Google Scholar 

  24. Shen W, Bowman ES, Markand ON. Presenting the diagnosis of pseudoseizure. Neurology. 1990;40(5):756–9.

    Article  CAS  PubMed  Google Scholar 

  25. Mellers JD. The approach to patients with “non-epileptic seizures”. Postgrad Med J. 2005;81(958):498–504. doi:10.1136/pgmj.2004.029785.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  26. Duncan R. Psychogenic nonepileptic seizures: diagnosis and initial management. Expert Rev Neurother. 2010;10(12):1803–9. doi:10.1586/ern.10.171.

    Article  PubMed  Google Scholar 

  27. LaFrance Jr WC, Reuber M, Goldstein LH. Management of psychogenic nonepileptic seizures. Epilepsia. 2013;54 Suppl 1:53–67. doi:10.1111/epi.12106. A comprehensive consensus review of PNES treatment by a committee of experts for the International League Against Epilepsy Neuropsychobiology Commission.

    Article  PubMed  Google Scholar 

  28. Mayor R, Brown RJ, Cock H, House A, Howlett S, Singhal S, et al. Short-term outcome of psychogenic non-epileptic seizures after communication of the diagnosis. Epilepsy Behav. 2012;25(4):676–81. doi:10.1016/j.yebeh.2012.09.033.

    Article  CAS  PubMed  Google Scholar 

  29. Brigo F, Igwe SC, Ausserer H, Nardone R, Tezzon F, Bongiovanni LG, et al. Terminology of psychogenic nonepileptic seizures. Epilepsia. 2015;56(3):e21–5. doi:10.1111/epi.12911.

    Article  PubMed  Google Scholar 

  30. LaFrance Jr WC, Rusch MD, Machan JT. What is “treatment as usual” for nonepileptic seizures? Epilepsy Behav. 2008;12(3):388–94. doi:10.1016/j.yebeh.2007.12.017.

    Article  PubMed  Google Scholar 

  31. Stone J, Campbell K, Sharma N, Carson A, Warlow CP, Sharpe M. What should we call pseudoseizures? The patient’s perspective. Seizure. 2003;12(8):568–72.

    Article  PubMed  Google Scholar 

  32. Benbadis SR. Psychogenic nonepileptic “seizures” or “attacks”? It’s not just semantics: attacks. Neurology. 2010;75(1):84–6. doi:10.1212/WNL.0b013e3181e6216f.

    Article  PubMed  Google Scholar 

  33. Mayor R, Smith PE, Reuber M. Management of patients with nonepileptic attack disorder in the United Kingdom: a survey of health care professionals. Epilepsy Behav. 2011;21(4):402–6. doi:10.1016/j.yebeh.2011.05.019.

    Article  PubMed  Google Scholar 

  34. Brown RJ, Syed TU, Benbadis S, LaFrance Jr WC, Reuber M. Psychogenic nonepileptic seizures. Epilepsy Behav. 2011;22(1):85–93. doi:10.1016/j.yebeh.2011.02.016.

    Article  PubMed  Google Scholar 

  35. Kanner AM. Who should treat psychogenic nonepileptic seizures? In: Schachter SC, Jr. WCL, editors. Gates and Rowan’s nonepileptic seizures. Third ed. Cambridge: Cambrdige University Press; 2010. p. 260–5

  36. Acton EK, Tatum WO. Inpatient psychiatric consultation for newly-diagnosed patients with psychogenic non-epileptic seizures. Epilepsy Behav. 2013;27(1):36–9. doi:10.1016/j.yebeh.2012.11.050.

    Article  PubMed  Google Scholar 

  37. Kanner AM. More controversies on the treatment of psychogenic pseudoseizures: an addendum. Epilepsy Behav. 2003;4(3):360–4.

    Article  PubMed  Google Scholar 

  38. LaFrance Jr WC, Barry JJ. Update on treatments of psychological nonepileptic seizures. Epilepsy Behav. 2005;7(3):364–74. doi:10.1016/j.yebeh.2005.07.010.

    Article  PubMed  Google Scholar 

  39. Goldstein LH, Deale AC, Mitchell-O’Malley SJ, Toone BK, Mellers JD. An evaluation of cognitive behavioral therapy as a treatment for dissociative seizures: a pilot study. Cogn Behav Neurol Off J Soc Behav Cog Neurol. 2004;17(1):41–9.

    Article  Google Scholar 

  40. Rusch MD, Morris GL, Allen L, Lathrop L. Psychological treatment of nonepileptic events. Epilepsy Behav. 2001;2(3):277–83. doi:10.1006/ebeh.2001.0180.

    Article  PubMed  Google Scholar 

  41. LaFrance Jr WC, Miller IW, Ryan CE, Blum AS, Solomon DA, Kelley JE, et al. Cognitive behavioral therapy for psychogenic nonepileptic seizures. Epilepsy Behav. 2009;14(4):591–6. doi:10.1016/j.yebeh.2009.02.016.

    Article  PubMed  Google Scholar 

  42. Kuyk J, Siffels MC, Bakvis P, Swinkels WA. Psychological treatment of patients with psychogenic non-epileptic seizures: an outcome study. Seizure. 2008;17(7):595–603. doi:10.1016/j.seizure.2008.02.006.

    Article  PubMed  Google Scholar 

  43. Kalogjera-Sackellares D. Psychodynamics and psychotherapy of pseudoseizures. Carmarthen, Wales. Williston: Crown House; 2004.

    Google Scholar 

  44. Howlett S, Reuber M. An augmented model of brief psychodynamic interpersonal therapy for patients with nonepileptic seizures. Psychotherapy. 2009;46(1):125–38. doi:10.1037/a0015138.

    Article  PubMed  Google Scholar 

  45. Mayor R, Howlett S, Grunewald R, Reuber M. Long-term outcome of brief augmented psychodynamic interpersonal therapy for psychogenic nonepileptic seizures: seizure control and health care utilization. Epilepsia. 2010;51(7):1169–76. doi:10.1111/j.1528-1167.2010.02656.x.

    Article  PubMed  Google Scholar 

  46. Zaroff CM, Myers L, Barr WB, Luciano D, Devinsky O. Group psychoeducation as treatment for psychological nonepileptic seizures. Epilepsy Behav. 2004;5(4):587–92. doi:10.1016/j.yebeh.2004.03.005.

    Article  PubMed  Google Scholar 

  47. Barry JJ, Wittenberg D, Bullock KD, Michaels JB, Classen CC, Fisher RS. Group therapy for patients with psychogenic nonepileptic seizures: a pilot study. Epilepsy Behav. 2008;13(4):624–9. doi:10.1016/j.yebeh.2008.06.013.

    Article  CAS  PubMed  Google Scholar 

  48. Prigatano GP, Stonnington CM, Fisher RS. Psychological factors in the genesis and management of nonepileptic seizures: clinical observations. Epilepsy Behav. 2002;3(4):343–9.

    Article  PubMed  Google Scholar 

  49. Chen DK, Maheshwari A, Franks R, Trolley GC, Robinson JS, Hrachovy RA. Brief group psychoeducation for psychogenic nonepileptic seizures: a neurologist-initiated program in an epilepsy center. Epilepsia. 2014;55(1):156–66. doi:10.1111/epi.12481.

    Article  PubMed  Google Scholar 

  50. Stonnington CM, Barry JJ, Fisher RS. Conversion disorder. Am J Psychiatry. 2006;163(9):1510–7. doi:10.1176/appi.ajp.163.9.1510.

    Article  PubMed  Google Scholar 

  51. Moene FC, Spinhoven P, Hoogduin KA, van Dyck R. A randomised controlled clinical trial on the additional effect of hypnosis in a comprehensive treatment programme for in-patients with conversion disorder of the motor type. Psychother Psychosom. 2002;71(2):66–76.

    Article  PubMed  Google Scholar 

  52. Moene FC, Spinhoven P, Hoogduin KA, van Dyck R. A randomized controlled clinical trial of a hypnosis-based treatment for patients with conversion disorder, motor type. Int J Clin Exp Hypn. 2003;51(1):29–50. doi:10.1076/iceh.51.1.29.14067.

    Article  PubMed  Google Scholar 

  53. Ataoglu A, Ozcetin A, Icmeli C, Ozbulut O. Paradoxical therapy in conversion reaction. J Korean Med Sci. 2003;18(4):581–4.

    Article  PubMed Central  PubMed  Google Scholar 

  54. Martlew J, Pulman J, Marson AG. Psychological and behavioural treatments for adults with non-epileptic attack disorder. The Cochrane database of systematic reviews. 2014;2, CD006370. doi:10.1002/14651858.CD006370.pub2.

    PubMed  Google Scholar 

  55. Pintor L, Bailles E, Matrai S, Carreno M, Donaire A, Boget T, et al. Efficiency of venlafaxine in patients with psychogenic nonepileptic seizures and anxiety and/or depressive disorders. J Neuropsychiatry Clin Neurosci. 2010;22(4):401–8. doi:10.1176/appi.neuropsych.22.4.401.

    Article  CAS  PubMed  Google Scholar 

  56. Reilly C, Menlove L, Fenton V, Das KB. Psychogenic nonepileptic seizures in children: a review. Epilepsia. 2013;54(10):1715–24. doi:10.1111/epi.12336.

    Article  PubMed  Google Scholar 

  57. Plioplys S, Doss J, Siddarth P, Bursch B, Falcone T, Forgey M, et al. A multisite controlled study of risk factors in pediatric psychogenic nonepileptic seizures. Epilepsia. 2014;55(11):1739–47. doi:10.1111/epi.12773.

    Article  PubMed  Google Scholar 

  58. Morgan LA, Buchhalter J. Psychogenic paroxysmal nonepileptic events in children: a review. Pediatr Neurol. 2015. doi:10.1016/j.pediatrneurol.2015.03.017.

    Google Scholar 

  59. Irwin K, Edwards M, Robinson R. Psychogenic non-epileptic seizures: management and prognosis. Arch Dis Child. 2000;82(6):474–8.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

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M. Ayman Haykal and Brien Smith declare no conflicts of interest.

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  1. Spectrum Health, 25 Michigan St NE, Grand Rapids, MI, 49503, USA

    M. Ayman Haykal MD & Brien Smith MD

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Haykal, M.A., Smith, B. A Therapeutic Approach to Psychogenic Nonepileptic Seizures. Curr Treat Options Neurol 17, 41 (2015). https://doi.org/10.1007/s11940-015-0371-4

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