A treatment process for episodes of altered consciousness or fainting that appear to resemble epilepsy but show no seizure findings on brain electrical activity, often associated with trauma and intense stress; addressed through differential diagnosis with video-EEG and trauma-focused psychotherapy.
Indication
- Loss of consciousness that does not respond adequately to antiepileptic drugs or shows an atypical course
- Recurrent fainting episodes occurring after stress, anxiety, or emotional triggers
- Seizure-like episodes developing on a background of childhood abuse, neglect, or trauma history
- Cases in which no pathological electrical activity is detected during the seizure on video-EEG monitoring
- Patients with comorbid depression, post-traumatic stress disorder, dissociative disorder, or conversion disorder
- Cases involving abnormal movements, altered consciousness, or loss of self-care in a single episode where medical causes have been excluded
Preparation
- Bringing reports of detailed examination, EEG, and, when needed, prolonged video-EEG monitoring previously performed by neurology
- Having brain imaging (MRI, CT) and blood test results available before the initial evaluation
- Listing all antiepileptic and psychiatric medications used along with start and change dates
- Preparing a detailed seizure diary including frequency, duration, triggers, and post-episode symptoms
- Coming with the patient and a relative — observations from family members who witness the episodes are important in the treatment plan
How it's performed
- A detailed psychiatric evaluation is performed; childhood traumas, life events, and dissociative symptoms are inquired about
- The differential diagnosis process conducted concurrently with neurology is completed; the psychogenic nature of episodes is confirmed with video-EEG monitoring if needed
- The diagnosis is explained to the patient and family in non-stigmatizing, understandable language — emphasizing that the episodes are real but are not electrical seizures
- A method suitable for the patient is chosen from approaches such as trauma-focused cognitive behavioral therapy, EMDR, or acceptance and commitment therapy
- Antidepressant treatment is arranged when needed for comorbid depression, anxiety, or post-traumatic stress disorder
- Safety measures during episodes, relaxation, and distraction techniques are taught to the patient and relatives
Post-procedure
- Intensive work with weekly or biweekly psychotherapy sessions in the initial period
- As it is confirmed that antiepileptic medications are unnecessary, gradual tapering is performed together with neurology
- Treatment response is evaluated through the diary recording episode frequency, duration, and severity
- Educational meetings for family members and family therapy sessions when needed
- Planning of preventive sessions in the final phase of treatment to recognize relapse signs early
Risks
- Risk of missing real epilepsy or unnecessary antiepileptic use if the diagnosis is incorrect
- Temporary increase in episode frequency or emotional intensity at the beginning of trauma-focused work
- Patient experiencing stigmatization and social withdrawal when environmental support is insufficient
- Temporary side effects such as nausea, dizziness, or sleep changes in cases using antidepressant treatment
- Risk of episode chronification and permanent functional impairment if treatment adherence is not achieved
FAQ
Are psychogenic seizures 'fake'?
No. The patient does not consciously produce the episodes; they arise as a subconscious stress response. The episodes are real, distressing, and beyond the patient's control. Treatment is based on repairing underlying psychological processes rather than blame.
Why is video-EEG necessary?
Video-EEG records brain electrical activity simultaneously with the episode. By evaluating the episode footage together with EEG findings, epilepsy and psychogenic seizures are definitively distinguished; this is the cornerstone of correct treatment.
Will antiepileptic drugs be discontinued completely?
Only in patients in whom the PNES diagnosis has been confirmed and who do not have concurrent epilepsy, they are tapered gradually under neurological supervision. This process is not done quickly; a planned tapering schedule is followed to avoid withdrawal symptoms.
What is the chance of episodes resolving with treatment?
In a significant portion of cases diagnosed early and followed regularly with trauma-focused psychotherapy, episode frequency markedly decreases or fully resolves. Effective treatment of childhood trauma and comorbid mental disorders increases the chance of success.
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