How to Treat Psychogenic Non-Epileptic Seizures (PNES)

Treatment for psychogenic non-epileptic seizures centers on psychotherapy, not anti-seizure medication. Because these episodes resemble epileptic seizures but arise from psychological rather than electrical brain disturbances, the drugs typically used for epilepsy do not help and can cause harm. The most studied approach is cognitive behavioral therapy, though several other psychotherapy formats show promise. What makes PNES treatment distinctive, and sometimes frustrating for patients and families, is that the very first step of treatment is delivering the diagnosis itself in a way the person can accept and work with.

Why How the Diagnosis Is Communicated Matters

Before any therapy begins, how a clinician explains the diagnosis has a measurable effect on whether someone improves. PNES is routinely misdiagnosed as epilepsy for years, so when patients finally learn their seizures are not caused by abnormal electrical activity, the moment is loaded. A dismissive or confusing explanation can push people away from the mental health care they need. Studies on stigma in this population have found that negative medical encounters discourage people from seeking help and contribute to poor treatment engagement.¹

Even a well-delivered diagnosis can produce modest improvements on its own. In one study, about 16% of patients were seizure-free six months after receiving the diagnosis, and roughly another quarter showed more than a 50% drop in seizure frequency, but self-reported psychological wellbeing had not budged, highlighting the need for further intervention.² A structured approach makes a difference: patients who received a scripted diagnosis along with psychiatric consultation showed decreased seizure frequency and improved quality of life, and those who also got regular follow-up phone calls had additional improvements in mood.³ A brief psychoeducational session after diagnosis led to complete seizure control in about a third of a small group of patients and at least 50% improvement in another quarter.⁴

The takeaway is practical: if you or someone you care about receives a PNES diagnosis, the clinician’s tone and clarity in that moment are not just bedside manner. They are the first piece of treatment.

Cognitive Behavioral Therapy as the Lead Treatment

CBT has the strongest evidence base for PNES of any psychotherapy format. It works by helping people recognize the thoughts, emotions, and physical sensations that precede or trigger their seizures, then developing strategies to interrupt or manage those patterns. A pilot randomized trial found that patients who received CBT plus standard medical care saw their median monthly seizures drop from 12 to 1.5 over six months, while those receiving standard medical care alone went from 8 to 5.⁵ That is a large difference, and the effect was statistically robust.

In another study, 11 of 17 patients who completed a course of CBT reported no seizures by their final session, alongside improvements in psychiatric symptoms, psychosocial functioning, and quality of life.⁶ Case-level research has also demonstrated that CBT can allow supervised withdrawal of anti-epileptic drugs that were inappropriately prescribed while still reducing seizure frequency.⁷

CBT for PNES is not identical to CBT for depression or anxiety, though it draws on the same framework. Therapists typically incorporate seizure diaries, work on identifying early warning signals (“auras” or pre-seizure sensations), and use grounding or relaxation techniques to give patients a sense of agency over episodes that previously felt completely uncontrollable.

Psychodynamic and Interpersonal Therapy

Not everyone responds best to CBT, and not every PNES clinic offers it. Psychodynamic approaches, which focus on unconscious emotional conflicts and interpersonal patterns, have also shown encouraging results. A study of brief augmented psychodynamic interpersonal therapy found that about a quarter of patients became seizure-free at follow-up, and an additional 40% achieved more than a 50% reduction in seizure frequency.⁸ This approach tends to explore how relationship difficulties, unprocessed emotions, and past experiences contribute to seizures.

Intensive short-term dynamic psychotherapy, a more compressed format averaging fewer than four sessions, has also been studied. A pilot found that healthcare costs dropped dramatically after treatment, accompanied by significant reductions in symptoms and interpersonal problems.⁹ The brevity of this format is appealing given that many patients struggle with access to long-term therapy.

Acceptance and Commitment Therapy

ACT takes a somewhat different angle from traditional CBT. Instead of directly challenging unhelpful thoughts, it emphasizes learning to accept difficult internal experiences without being controlled by them, while committing to actions aligned with personal values. For PNES, the rationale is that trying to suppress or fight seizure-related anxiety can paradoxically make things worse, and building psychological flexibility may break that cycle.

A guided self-help ACT program for PNES patients found reliable and clinically meaningful improvements in psychological flexibility, quality of life, and psychological health, along with notable reductions in seizure frequency.¹⁰ ACT has also shown promise in younger patients: a brief eight-session protocol in a 12-year-old led to recovery in psychological flexibility, reduced anxiety and symptom interference, and a marked drop in seizure episodes, with most gains holding at a five-month follow-up.¹¹ Larger trials are still needed, but ACT is increasingly seen as a credible option, particularly for patients who find traditional CBT’s thought-challenging approach a poor fit.

When Trauma Is a Central Driver

A significant proportion of people with PNES have a history of trauma, whether physical abuse, sexual abuse, accidents, or other overwhelming experiences. For these individuals, a treatment that directly targets trauma memories can be more effective than a general anxiety-management approach. EMDR, originally developed for post-traumatic stress disorder, has attracted growing interest in the PNES world.

The evidence is still mostly at the case-study level, but it is consistent. In a study of three patients with confirmed trauma histories, EMDR targeting trauma and dissociative symptoms led to complete seizure cessation in two, and both remained seizure-free for 12 to 18 months.¹² Another case report described a patient whose prolonged seizure episodes had required frequent emergency room visits; after 18 months of weekly EMDR, she achieved complete recovery.¹³ In two adolescents with PNES, EMDR led to elimination of seizures and significant decreases in dissociation scores, with results holding at six months.¹⁴

EMDR is not a replacement for CBT but an option when unresolved trauma is clearly fueling the seizures. Not every PNES patient has a trauma history, and for those who do not, trauma-focused therapy would not be the right starting point.

Stopping Medications That Do Not Help

Many people with PNES arrive at a correct diagnosis while taking one or more anti-seizure drugs prescribed during the years they were misdiagnosed with epilepsy. These medications have no benefit for PNES and carry real side effects including fatigue, cognitive dulling, weight changes, and mood disturbance. The American Academy of Neurology’s 2025 practice guideline on functional seizures states plainly that clinicians should not prescribe benzodiazepines or anti-seizure medications for patients with functional seizures who do not have co-occurring epilepsy and should taper patients off these drugs.¹⁵

Tapering should be done gradually and under medical supervision, because abrupt withdrawal of certain anti-seizure drugs can cause rebound effects. But the direction is clear: getting patients off unnecessary medications is itself a therapeutic step.

There is no medication approved specifically for PNES. When patients have co-occurring depression or anxiety, antidepressants like SSRIs are sometimes used to treat those conditions, which may indirectly improve seizure frequency. But the primary treatment remains psychological, not pharmacological.

What Happens When PNES Is Treated as Epilepsy in the Emergency Room

One of the most consequential treatment failures occurs in the emergency department. When a person with PNES arrives seizing and is treated as though they have epileptic status epilepticus, they may receive repeated doses of benzodiazepines, unnecessary intubation, and ICU admission, all of which carry real medical risks including sedation complications and prolonged hospitalization without any clinical benefit.¹⁶ These are not trivial errors; intubation is an invasive procedure, and the medications used to stop “status epilepticus” can cause respiratory depression.

Recognizing PNES earlier in the emergency setting is critical to avoiding this harm.¹⁷ If you carry a PNES diagnosis, keeping documentation of it readily available, whether a medical bracelet, a card in your wallet, or a clear note in your medical records, can help prevent unnecessary and potentially dangerous interventions during a seizure.

Multidisciplinary Clinics

PNES sits at the intersection of neurology and psychiatry, which means it frequently falls through the cracks. Neurologists may consider their job done once the diagnosis is established, while mental health professionals may have limited experience with the condition. Dedicated multidisciplinary clinics, where neurologists, psychologists, psychiatrists, and social workers coordinate care in one setting, have been developed specifically to address this gap.

Outcomes data from these clinics are encouraging. In a pediatric multidisciplinary PNES clinic, about three quarters of patients showed clinical improvement by three months, with three quarters also receiving mental health services and accepting the diagnosis.¹⁸ At the one-year mark for a similar clinic, about a third achieved complete remission and combined remission and improvement reached 89%, with patients who connected with counseling within the first month significantly more likely to be seizure-free at 12 months.¹⁹ Emergency department visits also plummeted: one study documented a 75% reduction in ED visits after patients were seen in a PNES clinic, with estimated cost savings in the millions.²⁰

If a multidisciplinary clinic is accessible, it is the ideal treatment setting. The reality is that most regions do not have one, and patients are left coordinating between separate providers. Even without a formal clinic, ensuring that your neurologist and therapist communicate directly about your care can replicate some of the benefit.

Treating Children and Adolescents

Children and teenagers with PNES tend to respond better to treatment than adults, likely because their seizure histories are shorter and they have fewer entrenched patterns. A study of 60 young patients found that 75% regained normal function and returned to school full-time when families received clear explanations of PNES, including how emotional distress and states of high arousal can activate atypical responses in the body and brain. Global functioning scores nearly doubled from pre- to post-treatment.²¹ Outcomes were less favorable in children who had chronic PNES or a co-occurring mental health condition that did not resolve with treatment.

A review of psychological interventions for young people with non-epileptic seizures highlighted that the most effective treatment packages were individualized, often incorporating assessment and treatment of co-occurring conditions, school liaison, and parent support alongside direct therapy.²² For families navigating this, the message is that treatment should not be limited to the child alone. Engaging parents, helping them understand the condition, and coordinating with the school are all part of effective care.

What Predicts a Good or Poor Outcome

Not everyone with PNES recovers at the same rate. Research has identified several factors that tilt the odds. One of the most consistent findings is that earlier diagnosis predicts better outcomes. Persisting seizures are associated with a longer duration of PNES before diagnosis, which makes intuitive sense: the longer someone lives with the condition, the more entrenched the patterns become.²³

Age matters too. Patients who were younger at seizure onset and at the time of diagnosis were more likely to achieve complete cessation of PNES and better economic outcomes long-term. Good quality of life at follow-up was predicted by low depressive symptoms, freedom from PNES, and being economically active.²⁴ Long-term psychological studies found that patients whose seizures persisted were older at onset, showed lower extraversion, higher inhibitedness, and worse overall psychological functioning, while those whose seizures stopped scored within the normal range across psychological measures.²⁵

A review of outcome predictors identified additional risk factors for poor prognosis: co-occurring epilepsy, psychiatric comorbidities like depression and anxiety, a dependent lifestyle, and poor interpersonal relationships. Freedom from depression was one of the strongest predictors of a positive outcome.²⁶ This has a practical implication: if you have PNES alongside significant depression, treating the depression aggressively is not optional. It may be the difference between recovery and chronicity.

Remote Treatment and Telehealth

Access is one of the biggest barriers to PNES treatment. The condition is relatively uncommon, and therapists with specific experience are concentrated in academic medical centers. Telehealth has started to change this equation. A study of manual-based seizure therapy delivered via video telehealth found that patients decreased seizure frequency and comorbid symptoms and improved functioning, suggesting that remote psychotherapy is a viable option that eliminates geographic barriers to care.²⁷

This finding became especially relevant during and after the pandemic, when many PNES patients lost access to in-person therapy. For anyone living far from a specialized center, asking whether a therapist offers telehealth sessions is worth exploring. The structured, conversation-based nature of CBT and related therapies translates well to video platforms.

The Financial Side of Getting Treatment Right

PNES is expensive when mismanaged. People cycle through emergency rooms, get admitted to hospitals, undergo repeated neuroimaging, and accumulate pharmacy costs for medications that do not address their condition. Getting the diagnosis right and connecting people with appropriate therapy produces dramatic cost reductions.

In a U.S. healthcare setting, the year after a PNES diagnosis saw an average decline in visits and costs, with the largest savings in neurology care and inpatient stays.²⁸ A European study found that after psychotherapy, 83% of patients achieved more than 50% seizure reduction at 12 months, and total healthcare costs dropped by 63% compared to the pre-treatment period. Seizure-related costs specifically fell by nearly 96%.²⁹ These are not small numbers. The case for investing in PNES-specific therapy is strong even from a purely economic perspective.

Caregivers and Families

PNES does not happen in isolation. Caregivers, usually partners or parents, carry a significant burden. Research on caregiver burden in PNES found that the patient’s quality of life and the caregiver’s own depression were the strongest predictors of how heavily the condition weighed on family members. Caregiver stigma, anxiety, and the patient’s medication side effects also contributed.³⁰

Family members often feel helpless during episodes and uncertain about what to do. Unlike epileptic seizures, where there are clear first-aid protocols, PNES episodes are best managed by staying calm, ensuring the person is safe from physical injury, and waiting for the episode to pass without intervening aggressively. Family psychoeducation, where caregivers learn what PNES is, what triggers it, and how to respond, is consistently identified as a key treatment component, especially for children and adolescents. A caregiver who understands the condition is less likely to call an ambulance unnecessarily, less likely to reinforce avoidance behaviors, and better positioned to support the person’s therapy goals.

Physical Rehabilitation as a Complement

Though psychotherapy is the primary treatment, physical rehabilitation is gaining recognition as a useful addition for some patients. PNES falls under the broader category of functional neurological disorders, and recent literature supports including physical-based approaches tailored to these conditions.³¹ For patients whose seizures are accompanied by motor symptoms, gait disturbance, or prolonged post-seizure fatigue, physical therapy can help rebuild confidence in the body’s ability to function normally. The approach works best when the physiotherapist understands the functional nature of the condition and does not inadvertently reinforce a purely neurological explanatory model.

EEG biofeedback, or neurofeedback, has also been explored as a complementary tool. In one case report involving a patient with both PNES and multiple sclerosis, EEG biofeedback led to cessation of seizure attacks alongside reduced anxiety and improved quality of life.³² The evidence base here is thin, limited to case reports, so neurofeedback is not something to pursue as a standalone treatment. But as part of a broader plan that includes psychotherapy, it may offer additional benefit for some individuals.