Psychogenic non-epileptic seizures (PNES) can present a challenge for both patients and providers. Prevalence rates of PNES are hard to accurately define, as symptoms mimic epileptic disorders, and patients may receive an inaccurate diagnosis for several years. ¹ For patients complaining of temporary loss of consciousness, PNES is the third most common diagnostic outcome. ² Further, for patients who present with presumed epilepsy events, estimates of true PNES prevalence range from 5-10% in outpatient settings to 20 – 50% in EMU and emergency departments. ³ PNES is not a benign disorder, though, with significant impacts on daily life and emotional well-being, as well as an elevated mortality rate almost two times the general population. ⁴

Due to the disguised nature of PNES, little is still understood about the causes of these events. Proposed causes for PNES range from a dissociative or psychological function to a hardwired or learned response. ² Understanding the pathology of these events is necessary to provide treatment to key aspects driving PNES.² Emotion or stress management may provide relief if events arise from overwhelming experiences, while exposure-based desensitization may benefit events arising from reflexive behaviors. It is clear that treatment plans for patients with PNES and those with epileptic seizures are distinctly different, and active harm can come from providing the wrong treatment. However, an accurate diagnosis is necessary for managing symptoms appropriately. ⁵

Characteristics of PNES vs. Epilepsy

Researchers and clinicians have attempted to determine characteristics that can differentiate between presumed epilepsy and presumed PNES, with elevated lactate levels and duration of postictal phases identifying epilepsy, and factors such as the frequency of events in 24 hours and concurrent psychological diagnoses predicting PNES.⁴ Yet, these are not steadfast rules. Although 62% of those with PNES have comorbid psychiatric conditions¹, 1 in 3 patients with epilepsy have a lifetime history of psychiatric diagnoses.⁶ Furthermore, common experiences within PNES, such as a history of traumatic event or dissociation, are not necessary for symptoms and will not occur in every presentation.² Thus, the gold standard for distinguishing PNES from epilepsy is by directly observing an event during long-term video-EEG.

Evidence-based Treatment for PNES

Cognitive-behavioral therapy has demonstrated the most reliable efficacy in reducing seizure burden in patients with PNES. ⁵ It also has the added benefit of improving psychological symptoms of depression and anxiety, while improving reported quality of life. ⁵ However, there is a challenge with PNES patients adhering to behavioral therapy. Stigma within epilepsy and PNES can result in patients failing to seek out help⁶ and navigating treatment between the neurologist making the initial diagnosis and behavioral health specialists providing treatment can be challenging.

Overcoming PNES Treatment Obstacles

Research has demonstrated that motivational interviewing by treating neurologists can be an effective and easily implemented intervention to improve adherence to behavioral treatments for PNES.⁷ In these motivational interviews, patients create a detailed plan with concrete steps to treat PNES and identify support systems, as well as strategies that can help overcome anticipated obstacles. The rise of telehealth services in the wake of COVID-19 may also benefit patients with PNES. Preliminary research has demonstrated that remote treatments may be effective in treating PNES, specifically, ⁸ and can reach those that may not have access to mental health services or specialties in treating seizure disorders.

About the Author

Jeremy D. Slater, MD, FAAN, FAES, FACNS is the Chief Medical Officer for Stratus. Dr. Slater has worked in the field of epilepsy for more than 27 years and has served as an investigator for numerous clinical trials and research initiatives. He served as Director of the Texas Comprehensive Epilepsy Program, one of the largest epilepsy surgery programs in the country, and currently heads up MERLN, Stratus’ R&D division.

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