Webinar, "An Overview of Psychogenic Nonepileptic Seizures," recorded May 29, 2019

Understanding the Cause of PNES

Psychogenic nonepileptic seizures (PNES) are a common disorder and have many different symptoms. In the past decade, many advances have been made in being able to identify and treat PNES.

It is well established that …

PNES is not caused by abnormal brain electrical activity.

PNES resemble, mimic or can appear outwardly like epileptic seizures, but their cause is psychological. PNES in most cases come from a psychological conflict or accompany an underlying psychiatric disorder. There is no known organic or physical cause for PNES.

A number of different disorders can be listed as possible contributors to a person developing PNES. These disorders are seen frequently in people diagnosed with PNES:

  • A history of mood disorders
  • Anxiety
  • Dissociative disorders
  • Post-traumatic stress disorders
  • History of physical, emotional, or sexual abuse
  • Family stressors or conflict
  • Psychosis
  • Personality disorders
  • Attention problems
  • History of traumatic brain injury
  • Substance abuse
  • Behavioral disturbances (anger, aggression, withdrawal)

Diagnosing PNES

PNES can mimic (appear outwardly like) seizures and for that reason PNES are commonly diagnosed and treated at epilepsy centers. The diagnosis is typically made using a combination of information, but PNES is most reliably determined by recording a typical PNES event with video EEG (electroencephalogram) monitoring.

The main question for any person who presents with symptoms that seem to be a seizure is whether what the person is experiencing is in fact an epileptic seizure. The accuracy of diagnosis is critical to a person receiving the correct treatment.

  • Check out "Is this a seizure?" to learn about epilepsy seizures, provoked seizures, and nonepileptic events due to other medical problems.

Anyone presenting with events or symptoms consistent with a possible seizure disorder will require an evaluation that includes

  • A complete medical, neurologic, and psychiatric history
  • A description from any family members who may have witnessed an event
  • Results of prior diagnostic testing (brain imaging, bloodwork, EEG, cardiac testing)
  • Response to prior treatment with antiseizure medications
  • A complete medical and neurologic examination
  • The gold standard (“best”) test to help tell an epileptic seizure from a PNES is video-electroencephalography (vEEG). This test records both the outward appearance of the event on video and the electrical activity of the brain that occurs before, during and after the event. PNES do not have any associated abnormal electrical activity of the brain.

Receiving a PNES Diagnosis

Receiving a new diagnosis of PNES can be difficult to process and understand. A person may have a range of emotions, such as anger, doubt, sadness, confusion or relief.

Remember,

  • Take time to discuss your diagnosis of PNES with your doctor. This will help you better understand why symptoms may happen and how other problems may contribute to your PNES.
  • Openly share your feelings about PNES with your medical team and your family. They can help support you going through the process of accepting the diagnosis and finding the best treatment.

A diagnosis of PNES can also be difficult for family members to understand. To help your family better support you, consider involving them in the discussion with your health care team. Then they can also have their questions answered. It will be reassuring to you and your family to know that with a diagnosis of PNES confirmed, you can now be referred for the most appropriate treatment.

Treatment for PNES

The treatment of PNES is focused on addressing the underlying psychological problem or psychiatric disorder. A person with PNES will not respond to treatment with antiseizure medication. Antieseizure drugs that cause psychiatric symptoms can sometimes worsen PNES. There are no medications that have been proven to treat PNES. For some people with other psychiatric disorders and PNES, medication may be given to treat the psychiatric problem.

Once a diagnosis of PNES is reached, the treatment usually involves a multidisciplinary team that includes your neurologist and a psychologist and/or psychiatrist, a nurse specialist, and your primary care doctor.

Many different types of mental and behavioral health providers are trained to deliver psychological therapies. It's important to find a provider who has a good understanding of PNES and its specific challenges. Mental health providers who deliver treatment for PNES usually include

  • Psychiatrists
  • Psychologists
  • Social workers
  • Licensed mental health counselors

Types of Psychological Therapy

There are several different types of psychological therapy that can be used to treat PNES. Your treatment team will decide on the right choice for you based on your history and the symptoms related to your PNES. These different types of therapy include the following.

Cognitive Behavioral Therapy (CBT)

  • This is a common type of psychotherapy used to treat many different types of psychological disorders including PNES.
  • CBT can be used alone or in combination with other therapies.
  • CBT is often used to treat depression, anxiety and PTSD, which often accompany PNES.
  • It is a tool to help any person learn to better manage stressful life situations.
  • CBT helps people learn skills they can use to change their thoughts and behaviors related to PNES symptoms.
  • CBT is the most studied in relation to treatment for PNES.

Prolonged Exposure Psychotherapy

  • Prolonged exposure (PE) psychotherapy is one type of CBT therapy that can be used to treat people who have been diagnosed with both PNES and PTSD.
  • PE is used to help people confront fears.
  • This type of therapy helps people deal with past experiences that are traumatic.
  • PE aims to help a person deal with difficult memories or past situations in a safe space with the help of a therapist.

Interpersonal and Psychodynamic Psychotherapy

  • Interpersonal and psychodynamic therapy involves working with a therapist to talk through emotional struggles or conflicts that can lead to PNES.
  • By using therapy to talk through emotional issues, a person may improve relationships and social functioning and lower their day-to-day emotional distress. By lowering distress, a person may be less likely to have PNES.
  • This therapy includes working through unconscious processes (things a person might not be aware of) that can influence behavior and contribute to PNES.
  • It can be done individually or in a group setting.

Mindfulness Based Psychotherapy

  • Mindfulness therapy generally involves group sessions where a person learns meditation techniques and basic principles of cognition (thinking, understanding).
  • This therapy addresses the relationship between the way a person thinks and the way they feel.
  • Mindfulness helps people break away from negative thought patterns and behaviors, including those which may lead to PNES.
  • “Homework” is often a component of this type of therapy. It can include practicing the techniques you learn in group sessions individually in the days between group sessions.

Family Therapy (FT)

  • FT can be used as an add-on therapy for families of children or adolescents with PNES.
  • FT can help a family through a difficult period, a transition, or mental or behavioral health problems.
  • FT in PNES also includes separate counseling with parents so that they can learn to identify PNES triggers, coping strategies, and ways to help their child improve and manage symptoms at home, in school and in social settings.

General Health Considerations Important in Treatment of PNES

Taking care of your general health will be an important part of helping you be successful with your PNES treatment. Some general principles to apply include

  • Make a healthy diet and regular meals a part of your daily routine.
  • Try to build in some form of regular exercise each day. Even a simple 20 minute walk each day can make a difference. Consult your doctor before starting an exercise routine, as they can help you choose the level of activity best for you.
  • Sleep is important! Ensure you are getting the required number of hours of quality sleep. If you have trouble sleeping, speak with your health care team. It is important to address sleep problems.
  • Stay involved with and connected to family and friends. Healthy social relationships can bring positive benefits for both mental health and physical health

Staying Connected to Your Neurologist

Your neurologist has played a key role in helping you reach a diagnosis of PNES. They can also help you build a multidisciplinary team that includes the right mental health providers. It is important to keep good communication with your neurologist. Some reasons to continue follow up with your neurologist include

  • It is not uncommon for other neurologic conditions (example, headache) to accompany PNES. Your neurologist can help you manage these problems effectively.
  • 5 to 20% of people with PNES may also have epileptic seizures or may have experienced seizures in the past that are under control on antiseizure drugs.
  • When a diagnosis of PNES is made, it is common that antiseizure medications will be stopped by your provider. It is possible that unsuspected epilepsy may be found when antiseizure medicines are stopped.
  • Uncontrolled PNES can result in emergency room (ER) and intensive care unit (ICU) admissions. It is important for your neurologist to stay involved to help ensure inappropriate treatments are not used.
    • Between 30 to 50% of people with PNES have at some time been incorrectly admitted to an ICU with a diagnosis of status epilepticus.

What is the Prognosis in PNES?

The improvement a person has once a diagnosis of PNES is made and treatment is started can vary. It is important to note

  • Between 20 and 50% of people stop having PNES once the diagnosis is reached and without any specific treatment.
  • People receiving psychological treatments can work with their mental health provider to monitor if there has been improvement in the frequency, duration or intensity of PNES symptoms. Keeping track of progress will help you understand if therapy is helping.
  • Research looking at how people respond to psychotherapy treatment for PNES has shown that about half of people will see an improvement in their PNES after 3 months of psychological therapy.
  • Ongoing research continues to study new therapies for people who do not improve (about 1 in 4 people) with currently available treatment options.
  • Some variables that may predict a higher chance PNES will stop after diagnosis include
    • PNES in children in adolescence
    • A person only having a brief history of PNES
    • A person having a psychiatric disorder that is considered to have minimal or “mild” symptoms. People with severe symptoms face greater challenges.

A Personal Story

Watch as Karen, a veteran, shares her journey with psychogenic non-epileptic seizures. VA doctor’s Hamada Altalib DO, MPH, and W. Curt LaFrance Jr, MD, MPH, talk about the differences between psychogenic seizures and seizures in epilepsy, as well as diagnosing and treating PNES.

Authored By: 
Elaine Kiriakopoulos MD, MSc
Authored Date: 
10/2019
Reviewed By: 
Andres M. Kanner MD
Patty Obsorne Shafer RN, MN
on: 
Tuesday, October 1, 2019