Psychogenic Non-Epileptic Seizures (PNES) are episodes that closely resemble epileptic seizures, involving temporary changes in movement, sensation, or awareness. Unlike true epilepsy, these events are not caused by abnormal, uncontrolled electrical discharges in the brain. PNES is categorized as a functional neurological disorder where symptoms are a physical manifestation of underlying psychological distress. The episodes are genuine and involuntary. Because the origin of the seizures is psychological rather than neurological, the treatment approach centers on specialized psychological therapy, not anti-seizure medications. Recovery hinges on accepting this diagnosis and engaging with mental health professionals who specialize in this condition.
Establishing the Diagnostic Foundation
The first and most important step in treating PNES is establishing an accurate diagnosis, as patients are often misdiagnosed with epilepsy for years, sometimes up to a decade. The definitive method for distinguishing PNES from epileptic seizures is through long-term Video-EEG monitoring. During this procedure, the patient’s brain electrical activity is recorded via an electroencephalogram (EEG) while their physical behavior is captured on video. A conclusive diagnosis of PNES is made when a typical seizure-like event occurs on video, but the EEG shows no corresponding epileptiform activity in the brain.
Once the diagnosis is confirmed, the manner in which it is delivered to the patient and family is considered the start of treatment. An empathetic and clear explanation from a neurologist or epileptologist is crucial for the patient to accept that their seizures have a psychological, not electrical, cause. This initial conversation must validate the reality of the patient’s suffering while providing a clear path forward for targeted psychological intervention. Successful treatment relies on a collaborative, multidisciplinary team typically composed of an epileptologist, a psychiatrist, and a specialized psychotherapist.
Primary Psychotherapeutic Intervention
The core treatment for PNES is psychological intervention, with specialized Cognitive Behavioral Therapy (CBT-E) being the most supported approach. This therapy is a structured, time-limited, and goal-oriented program designed to help patients understand the link between their emotions, thoughts, and the physical manifestation of their seizures. A central component of CBT-E is psychoeducation, which helps the patient fully grasp their diagnosis and the mechanisms by which psychological distress translates into a seizure.
Therapy then progresses to identifying the specific internal and external triggers that precede a PNES episode, such as heightened anxiety or interpersonal conflict. Patients learn emotional regulation techniques to manage the intense feelings that can lead to an event, often focusing on mindfulness or distress tolerance skills. A specialized technique is the use of interruption or distraction strategies, which patients are taught to deploy immediately at the first sign of a seizure’s onset. These strategies aim to disrupt the automatic neurological pathway leading to the seizure by redirecting attention and engaging motor skills, preventing the full-blown event from occurring.
This targeted therapy has demonstrated significant success in reducing seizure frequency and severity. Clinical trials of PNES-specific CBT have shown that 47% of patients achieve complete seizure freedom. Furthermore, 82% experience a meaningful reduction in seizure frequency of at least 50%. The therapy works by addressing maladaptive coping mechanisms and helping the individual develop healthier ways to process the underlying emotional conflicts or trauma that contribute to the seizures.
Managing Co-occurring Mental Health Conditions
While the primary psychological intervention targets the seizures directly, a significant part of the treatment involves managing co-occurring mental health conditions that are highly prevalent in the PNES population. Psychiatric comorbidities are frequently present, with rates of depression reported to be as high as 57% to 85%. Treating these separate but overlapping conditions is crucial, as their presence can complicate recovery from PNES. Common comorbidities include:
- Major Depressive Disorder
- Generalized Anxiety Disorder
- Post-Traumatic Stress Disorder (PTSD)
Unlike the seizures themselves, which do not respond to anti-seizure drugs, these co-occurring mood and anxiety disorders may be managed with appropriate psychopharmacological agents. Antidepressants, such as certain selective serotonin reuptake inhibitors or serotonin-norepinephrine reuptake inhibitors, are often prescribed to improve underlying mood and anxiety symptoms. Treating the comorbidities supports the main PNES intervention by lowering the patient’s overall psychological distress and emotional reactivity, which can act as seizure triggers.
For patients with a history of trauma, specialized therapies like Prolonged Exposure (PE) or Eye Movement Desensitization and Reprocessing (EMDR) may be integrated into the treatment plan. These trauma-focused approaches are distinct from the PNES-specific CBT and are used to process the traumatic memories that fuel the underlying psychological vulnerability. By simultaneously addressing the direct seizure mechanism and the surrounding mental health landscape, the overall prognosis and quality of life for the patient improve.
Sustaining Recovery and Preventing Relapse
The recovery phase shifts the focus from acute seizure reduction to long-term maintenance of the skills learned in therapy. This stage involves integrating the emotional regulation and interruption techniques into daily life, making them automatic responses to stress rather than conscious efforts. Identifying high-risk situations, such as periods of extreme stress or life changes, becomes a component of the relapse prevention plan.
Patients work with their therapist to recognize early warning signs of escalating distress that could precede a return of seizures. Continued follow-up care with the multidisciplinary team, including periodic check-ins with the neurologist and psychotherapist, helps to reinforce the recovery and address any emerging challenges. Long-term success is tied to consistent engagement with the psychological treatment and the full adoption of coping strategies, ensuring that the initial treatment gains are solidified for lasting seizure freedom.