Unmasking the masquerade: the diagnosis and management of psychogenic nonepileptic seizures

Abstract

Background The diagnosis and management of psychogenic non-epileptic seizures (PNES) is often challenging. This literature review was done to investigate available data on PNES to make recommendations for its management.

Aim To research relevant data on the diagnosis and challenges in the management of PNES.

Method The methodology involved a systematic review of relevant studies and review articles by leading authorities in PNES, using the databases of MEDLINE, ScienceDirect, Cochrane, and PubMed. Out of an eventual 211 screened, 15 were selected based on exclusion and inclusion criteria. Concepts such as ‘psychogenic nonepileptic seizures, diagnosis, and management’ were searched with the key term, ‘PNES’.

Results An analysis of 15 articles was undertaken, and the focus was mainly on the diagnostic criterion and the management approaches adopted in the different studies. The results indicated that many of the studies consistently required video EEG (vEEG) as confirmatory tests for the establishment of PNES, in keeping with the staged approach to diagnosis set by the Nonepileptic Seizure Task Force of Epilepsy. Recent studies emphasised early communication and healthy rapport between patients and providers of care in conveying a diagnosis. Pilot studies on the pharmacological and psychological treatments for PNES were promising.

Conclusion The unmasking of the masquerade of PNES is challenging for clinicians in primary and tertiary care. Raising awareness of the condition reduces the burden on health care. Definitive guidelines and more control trials are required. Provocative measures to establish the diagnosis are limited. The feasibility of using the tilt table as a provocative measure is discussed.