Management of psychogenic non‐epileptic seizures: a multidisciplinary approach

Abstract

The International League against Epilepsy (ILAE) proposed a diagnostic scheme for psychogenic non‐epileptic seizure (PNES). The debate on ethical aspects of the diagnostic procedures is ongoing, the treatment is not standardized and management might differ according to age group. The objective was to reach an expert and stakeholder consensus on PNES management. A board comprising adult and child neurologists, neuropsychologists, psychiatrists, pharmacologists, experts in forensic medicine and bioethics as well as patients’ representatives was formed. The board chose five main topics regarding PNES: diagnosis; ethical issues; psychiatric comorbidities; psychological treatment; and pharmacological treatment. After a systematic review of the literature, the board met in a consensus conference in Catanzaro (Italy). Further consultations using a model of Delphi panel were held. The global level of evidence for all topics was low. Even though most questions were formulated separately for children/adolescents and adults, no major age‐related differences emerged. The board established that the approach to PNES diagnosis should comply with ILAE recommendations. Seizure induction was considered ethical, preferring the least invasive techniques. The board recommended looking carefully for mood disturbances, personality disorders and psychic trauma in persons with PNES and considering cognitive‐behavioural therapy as a first‐line psychological approach and pharmacological treatment to manage comorbid conditions, namely anxiety and depression. Psychogenic non‐epileptic seizure management should be multidisciplinary. High‐quality long‐term studies are needed to standardize PNES management.

Psychological long‐term outcome in patients with psychogenic nonepileptic seizures

“…Similar to previous studies, we could not find a significant association between receiving psychological treatment and PNES cessation. PNES is a complex psychiatric condition that is in need of specific treatments, such as symptom‐oriented cognitive behavioral therapy . The design of our study, which relied on retrospective patients reports did not allow to control for type, duration, or intensity of treatment.…”

“…PNES is a complex psychiatric condition that is in need of specific treatments, such as symptomoriented cognitive behavioral therapy. 30,31 The design of our study, which relied on retrospective patients reports did not allow to control for type, duration, or intensity of treatment. Therefore, the results of our study cannot be used to evaluate specific treatment strategies and their success in PNES.…”

Management of functional neurological disorder

“…There are additional important management steps that can be taken during the first consultation, once the diagnosis of FND is made. It is prudent to develop a plan to stop medications that have been started without ongoing indication and may be causing harm, such as anti-epileptic medications in patients with functional seizures, opiates for chronic pain and psychotropic medications that have not been effective [6]. As the neurologist making the diagnosis, there is a unique opportunity to provide other healthcare providers with information about the diagnosis, thus helping to reduce the chance of future treatment with other potentially harmful medications or procedures.…”

Gut microbiota and psychogenic non-epileptic seizures: i can feel it in the belly

“…PNES are paroxysmal, time-limited alterations in motor, sensory, autonomic or cognitive signs and symptoms that are not accompanied by ictal epileptiform activity, and are of psychological origin [1,2]. They are a specific subtype of a larger category of disorders (somatic symptoms disorders or dissociative disorders).…”

“…They are a specific subtype of a larger category of disorders (somatic symptoms disorders or dissociative disorders). The optimal treatment strategy does includes psychological approaches and neuropharmacological treatment, due to the frequent psychiatric comorbidity in these patients, including mood disturbances, personality disorders, anxiety, depression, and psychic trauma [2]. The main pathophysiological model for PNES suggests an alteration in the influence and connection of brain areas involved in emotion processing onto other brain areas responsible for sensorimotor and cognitive processes.…”