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Management of Psychogenic Nonepileptic Seizures
Anna Kim, M.D.
Psychogenic nonepileptic seizures are
sudden, involuntary seizure-like at-
tacks. Unlike epileptic seizures, they are
not related to electrographic ictal dis-
charges (1). Descriptions of psychogenic
nonepileptic seizures vary widely, with
elements of these seizures including
change in behavior or consciousness, no
evidence of other medical etiology, and
a psychological component (2). In DSM-
5, psychogenic nonepileptic seizures are
classified as a form of conversion disor-
der, or functional neurological symp-
tom disorder, with the term “functional”
referring to an impairment of normal
bodily functioning (3).
The first description of functional
neurological symptoms in the medical
literature dates to Jean-Martin Charcot
(1825–1893), a neurologist at the Hospi-
tal de la Salpêtrière in Paris. Charcot de-
scribed neurological symptoms that were
similar, yet not identical, to seizures. He
used the term “hystero-epilepsy” to indi-
cate that there was a psychiatric etiology
rather than a neurological one. Sigmund
Freud (1856–1939) later focused on indi-
viduals experiencing these seizures and
emphasized the toll of trauma, both by
external events and internal experiences.
Freud suggested that past psychic inju-
ries became manifested, or “converted,”
into symptoms (3).
EPIDEMIOLOGY
In their review of the epidemiology of
psychogenic nonepileptic seizures, Asadi-
Pooya and Sperling (4) reported that psy-
chogenic seizures are relatively common,
since they are reported to be experienced
by 5%–10% of outpatients in epilepsy
clinics and 20%–40% of inpatients in epi-
lepsy monitoring units. In three studies
reviewed by Asadi-Pooya and Sperling,
the incidence of psychogenic nonepilep-
tic seizures was estimated to be 1.4–4.9
The American Journal of Psychiatry Residents’ Journal  |  May 2018 2
per 100,000 per year, and in one study the
prevalence was calculated to be between
2 and 33 per 100,000.
Epilepsy has a bimodal age curve. Most
cases develop among the young (due to
mitochondrial or genetic disorders) and
the elderly (due to strokes, tumors, or neu-
rodegenerative conditions). Contrastingly,
psychogenic nonepileptic seizures have an
inverse unimodal curve, with 70% of cases
developing among individuals between
the second and fourth decades of life (5).
There is a female-to-male ratio of 2.94,
and the proportion of people with psycho-
genic nonepileptic seizures who also have
epileptic seizures ranges from 5% to 50%
(4). Individuals with a family history of
epilepsy have a higher risk of developing
psychogenic nonepileptic seizures. This is
thought to be due to imitation via “model-
ing” (5). Associated factors include child-
hood physical or sexual abuse, traumatic
brain injury (with comorbid depression,
behavioral impulsivity, or posttraumatic
stress disorder), medical comorbidities,
and brain dysfunction (4). Additionally,
anxiety disorders, dissociative disorders,
and borderline personality disorder are
common comorbid conditions among in-
dividuals with psychogenic nonepileptic
seizures (1). Precipitants of psychogenic
nonepileptic seizures include injury, death
of or separation from family members or
friends, job loss, rape, childbirth, surgical
procedures, natural disasters, relationship
difficulties, and legal problems (6).
ETIOLOGY
Currently, there are substantial limita-
tions in our study and understanding
of the etiology of psychogenic nonepi-
leptic seizures. Obstacles identified in
conducting clinical trials include both
intrinsic and logistical factors. Intrinsic
factors are emotional lability, approach-
avoidance behavior patterns, crisis pre-
sentation, rejection of support, and lack
of motivation. Logistical limitations are
motor vehicle operation restrictions,
cognitive and physical impairments, se-
verity of psychopathology, and unclear
utility of various outcome measures (1).
A neurobiological conceptual frame-
work has been proposed explaining psy-
chogenic nonepileptic seizures as a dys-
function of the brain areas involved in
the emotion processing responsible for
sensorimotor and cognitive processes. In
other words, there is a lack of appropri-
ate integration thought to be related to
vulnerability traits, such as dissociative
tendencies, hyperarousal, alexithymia,
avoidance, and cognitive rigidity (7).
Challenges to this framework are that it
is largely theoretical and that a high level
of psychiatric comorbidity makes it im-
possible to infer that brain abnormalities
observed on neuroimaging are specifi-
cally associated with psychogenic non-
epileptic seizures rather than coexist-
ing pathology (7). Despite this, multiple
studies have examined changes in con-
nectivity between the anterior cingulate
cortex, insula, precentral sulcus, inferior
frontal gyrus, and parietal cortex (8).
PRESENTATION AND DIAGNOSIS
Presenting symptoms vary widely and
include changes in behavior, motor ac-
tivity, sensation, cognition, and auto-
matic functions. Psychogenic nonepilep-
tic seizures can be initially mistaken as
epileptic seizures, and diagnosis is often
delayed by approximately 7 years (1). Di-
agnosis is confirmed by using the gold
standard: video EEG monitoring before,
during, and after ictus (1). However, a
normal EEG recording does not rule out
epileptic seizures, since simple partial
seizures or frontal lobe epilepsy can re-
sult in scalp-negative EEG findings (1).
Neuropsychiatric histories can help in

confirming the diagnosis of psychogenic
nonepileptic seizures (1). Early cor-
rect diagnosis is critical, since it enables
patients to receive needed treatment
promptly and prevents common iatro-
genic complications from inappropriate
treatment with antiepileptic drugs. An
estimated 75% of patients with psycho-
genic nonepileptic seizures receive an-
tiepileptic drug treatment prior to accu-
rate diagnosis (3).
Several clinical features distinguish
psychogenic nonepileptic seizures from
epileptic seizures. Nevertheless, many
features are nonspecific and can occur
in both seizure types. There is no sin-
gle feature that is pathognomonic for
psychogenic nonepileptic seizures, and
of significance, some unusual clinical
features associated with psychogenic
nonepileptic seizures are also associ-
ated with frontal lobe epilepsy (5). Psy-
chogenic nonepileptic seizures tend to
occur during awake hours only, whereas
epileptic seizures can occur at night.
Moreover, psychogenic nonepileptic sei-
zures lack the stereotypical nature that
epileptic seizures possess (5). Specific
clinical features that differentiate psy-
chogenic nonepileptic seizures from ep-
ileptic seizures are presented in Table 1.
Serum prolactin can have diagnostic
utility. The American Academy of Neu-
rology concluded that serum prolac-
tin measured 10–20 minutes postictal
can help in differentiating generalized
tonic-clonic or complex partial seizures
from psychogenic nonepileptic seizures
among adults and older children (9).
TREATMENT
A 2014 Cochrane Review on psychologi-
cal and behavioral treatments concluded
that there is little reliable evidence to
support the use of any treatment, in-
cluding cognitive-behavioral therapy
(CBT), for psychogenic nonepileptic sei-
zures (10). A search conducted by using
CENTRAL [Cochrane Central Register
of Controlled Trials], MEDLINE, Psy-
cINFO, and Scopus revealed three dif-
ferent types of treatments used in 12 dif-
ferent studies: CBT, psychotherapy, and
hypnosis. Of the 12 studies reviewed,
four were randomized and eight were
nonrandomized. The majority of the
The American Journal of Psychiatry Residents’ Journal  |  May 2018 3
TABLE 1. Clinical Characteristics Associated With Epileptic Seizures, Frontal Lobe Epilepsy,
and Psychogenic Nonepileptic Seizuresa
Characteristic
Motor
Writhing, flailing, and whole-body thrashing
Jactitation (rolling from side to side)
Lateral head and body turning
Eye-blinking, swallowing, and slumping
Sensory/autonomic
Intelligible speech
Eyes closed at seizure onset
Forced eye closure (resistance to the eyes
being opened during an episode)
Postictal focal neurologic deficits
Altered breathing patterns
Somatic complaints
Increase in heart rate ≥30 bpm above
baseline
Altered pupillary response
a For further details, see Devinsky et al. (5).
studies did not use satisfactory meth-
ods, and there was a high risk of bias. Al-
though participants in one randomized
trial showed significant reduction in the
number of seizures following CBT, there
was little reliable evidence supporting
use of any specific treatment for psycho-
genic nonepileptic seizures (10).
Although data are limited, it is note-
worthy that CBT is the only psycho-
therapeutic intervention studied as a
treatment for psychogenic nonepileptic
seizures in randomized controlled trials
and, as a result, has the highest level of
efficacy evidence (1).
Goldstein et al. (11) conducted a ran-
domized controlled trial in which both
the active-treatment group and the con-
trol group received standard medical
care, which consisted of seven outpa-
tient appointments in a neuropsychiat-
ric setting with psychoeducation, sup-
port measures, and antiepileptic drug
tapering. Additionally, individuals in
the active-treatment group received 12
sessions of CBT, which focused on en-
gagement in treatment; reinforcement
of independence; distraction, relaxation,
and refocusing techniques at the earli-
est signs of an event; graded exposure
to avoided situations; cognitive restruc-
turing; and relapse prevention. Results
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Frontal Psychogenic
Epileptic Lobe Nonepileptic
Seizures Epilepsy Seizures
Yes
Yes Yes
Yes Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
showed that there was a significantly
lower number of seizure events in the
CBT group (standard medical care me-
dian, 6.75 events per month; CBT plus
standard medical care median, 2 events
per month [p<0.002]) (11).
LaFrance et al. (12) organized a pilot
clinical trial at three academic centers
where participants were randomly as-
signed to CBT-informed psychotherapy,
medication (flexible-dose sertraline),
CBT-informed psychotherapy plus medi-
cation, or treatment as usual. CBT-in-
formed psychotherapy consisted of 12
weekly, 1-hour individual sessions target-
ing behaviors and cognitions in psycho-
genic nonepileptic seizures. Treatment
as usual consisted of regular neurologi-
cal follow-up appointments. The psycho-
therapy (CBT-informed psychotherapy)
arm showed a 51.4% reduction in the num-
ber of seizures experienced (p=0.01) and
significant improvement from baseline
in depression, anxiety, quality of life, and
global functioning (p<0.001). The com-
bined arm (CBT-informed psychotherapy
plus sertraline) showed a 59.3% reduction
in the number of seizures experienced
(p=0.008) and significant improvement in
some measures, including global function-
ing (p=0.007). No improvements were ob-
served in the other study arms.
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KEY POINTS/CLINICAL PEARLS 8. Perez DL, LaFrance WC Jr: Nonepileptic

seizures: an updated review. CNS Spectr
• Video EEG is the gold standard for diagnosis of psychogenic nonepileptic sei- 2016; 21(3):239–246
zures; however, a negative video EEG does not exclude the diagnosis of epi- 9. Chen DK, So YT, Fisher RS; Therapeutics
leptic seizures, and clinical features and a neuropsychiatric history can help and Technology Assessment Subcommittee
distinguish psychogenic nonepileptic seizures from epileptic seizures. of the American Academy of Neurology: Use
of serum prolactin in diagnosing epileptic
• Cognitive-behavioral therapy is the only psychotherapeutic intervention for seizures: report of the Therapeutics and
psychogenic nonepileptic seizures studied in a randomized controlled trial and Technology Assessment Subcommittee of
therefore has the highest level of efficacy evidence. the American Academy of Neurology. Neu-
rology 2005; 65(5):668–675
• Other psychotherapy modalities for psychogenic nonepileptic seizures with
positive results include psychodynamic psychotherapy, group therapy, psy- 10. Martlew J, Pulman J, Marson AG: Psychologi-
cal and behavioural treatments for adults with
choeducation, paradoxical intention, and hypnosis.
non-epileptic attack disorder. Cochrane Data-
base Syst Rev 2014; (2):CD006370. doi:
10.1002/14651858.CD006370.pub2
Other psychotherapy interventions sentation and neuropsychiatric history. 11. Goldstein LH, Chalder T, Chigwedere C, et al:
examined in randomized controlled tri- Treatment includes psychotherapy with Cognitive-behavioral therapy for psychogenic
als include group psychoeducation, in- or without antidepressant use. nonepileptic seizures: a pilot RCT. Neurology
patient paradoxical intention (whereby a The burden of care for patients with 2010; 74(24):1986–1994
patient is encouraged to have an event), psychogenic nonepileptic seizures is 12. LaFrance WC Jr, Baird GL, Barry JJ, et al:
and hypnosis (13–15). These interven- high. In the United States, up to $900 Multicenter pilot treatment trial for psycho-
tions have demonstrated varying de- genic nonepileptic seizures: a randomized
million is spent on emergency depart-
clinical trial: NES Treatment Trial (NEST-T)
grees of improvement in terms of seizure ment utilization, diagnostic evaluations, consortium. JAMA Psychiatry 2014; 71(9):​
events and psychopathology. Psychody- laboratory tests, and antiepileptic drugs 997–1005
namic psychotherapy, in which trauma (6). Further research addressing barriers 13. Chen DK, Maheshwari A, Franks R, et al: Brief
is considered the central feature of psy- and utilizing larger samples and more group psychoeducation for psychogenic non-
chogenic nonepileptic seizures, has been satisfactory methodology is needed. epileptic seizures: a neurologist-initiated pro-
studied by Howlett and Reuber (16), as gram in an epilepsy center. Epilepsia 2014;
55(1):156–166
well as others. Psychodynamic psycho- Dr. Kim is a third-year resident in the De-
therapy has demonstrated efficacy in partment of Psychiatry, Icahn School of 14. Ataoglu A, Ozcetin A, Icmeli C, et al: Paradoxi-
Medicine at Mount Sinai, New York. Dr. Kim cal therapy in conversion reaction. J Korean
reducing seizure frequency and sever- Med Sci 2003; 18(4):581–584
ity, decreasing psychological distress, is also Deputy Editor of the American Jour-
nal of Psychiatry Residents’ Journal. 15. Moene FC, Spinhoven P, Hoogduin KA, et al: A
improving quality of life, and decreasing randomized controlled clinical trial of a hyp-
health care utilization (16–18). nosis-based treatment for patients with con-
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