SCOPE: Diagnosis, acute management, and long-term treatment of psychogenic non-epileptic spells (PNES). Covers the diagnostic workup including video-EEG confirmation, semiology features distinguishing PNES from epileptic seizures, diagnosis delivery as a therapeutic intervention, psychotherapy (CBT as evidence-based treatment), management of psychiatric comorbidities (PTSD, depression, anxiety), and anti-seizure medication taper. Addresses the ~10% of PNES patients with comorbid epilepsy. Settings: ED (acute event management), HOSP (video-EEG monitoring and diagnosis), OPD (long-term therapy and follow-up). ICU is generally NOT applicable for PNES. For epileptic seizures, see "New Onset Seizure" and "Status Epilepticus" templates. For the broader category of functional neurological disorder, see "FND" template.
PRIORITY KEY: STAT = Immediate | URGENT = Within hours | ROUTINE = Standard | EXT = Extended/atypical cases | - = Not applicable to this setting
Baseline; rule out infection or anemia as contributor to altered consciousness
Normal
STAT
STAT
ROUTINE
-
CMP (BMP + LFTs) (CPT 80053)
Metabolic encephalopathy screen; electrolyte abnormalities can provoke both epileptic and non-epileptic events
Normal
STAT
STAT
ROUTINE
-
Blood glucose (CPT 82947)
Hypoglycemia as event mimic; altered consciousness differential
Normal (70-100 mg/dL)
STAT
STAT
ROUTINE
-
TSH (CPT 84443)
Thyroid dysfunction contributing to anxiety, mood disturbance, or tremor
Normal (0.4-4.0 mIU/L)
URGENT
ROUTINE
ROUTINE
-
Urinalysis (CPT 81003)
UTI as contributor to altered mental status; drug screen
Normal
STAT
STAT
ROUTINE
-
Prolactin (15-20 min post-event) (CPT 84146)
Elevated >2x baseline supports epileptic seizure; NORMAL post-event supports PNES diagnosis; must be drawn within 10-20 min of event onset
Normal in PNES (elevated >2x baseline suggests epileptic seizure)
URGENT
URGENT
-
-
Note: The purpose of laboratory testing in suspected PNES is to exclude metabolic and toxic causes of paroxysmal events, NOT to diagnose PNES itself. PNES is diagnosed by video-EEG capture of a typical event with no epileptiform EEG correlate. Prolactin is most useful when drawn within 10-20 minutes of a convulsive event -- a normal prolactin supports but does NOT confirm PNES (sensitivity ~60% for GTC seizures).
If patient on ASMs, verify compliance and levels before diagnosing "breakthrough seizures" as PNES
Therapeutic (varies by drug)
URGENT
URGENT
ROUTINE
-
Note: Anti-seizure medication levels are important when a patient on established ASMs presents with events -- subtherapeutic levels may indicate noncompliance as a cause of epileptic breakthrough, while therapeutic levels in a patient with events consistent with PNES support the functional diagnosis.
GOLD STANDARD for PNES diagnosis; capture habitual event with simultaneous EEG showing no epileptiform correlate
Normal EEG during clinically typical event = definitive PNES diagnosis (ILAE diagnostic certainty level: "documented")
None significant
-
URGENT
ROUTINE
-
MRI brain with and without contrast (CPT 70553)
Rule out structural lesion; required to exclude epileptogenic pathology, especially if comorbid epilepsy suspected
Normal (no epileptogenic lesion)
Standard MRI contraindications (pacemaker, metallic implants)
URGENT
ROUTINE
ROUTINE
-
Note: Video-EEG monitoring (vEEG) with capture of a habitual event is the DIAGNOSTIC GOLD STANDARD. The ILAE defines diagnostic certainty levels: (1) "Possible" = clinical history alone; (2) "Probable" = witnessed by clinician with semiology features; (3) "Clinically established" = vEEG without event capture but interictal and other data support; (4) "Documented" = vEEG captures typical event with no ictal EEG correlate. ALWAYS aim for "documented" level when possible. Note: ~5% of frontal lobe seizures may not produce clear scalp EEG changes -- clinical correlation essential.
Verbal reassurance and grounding techniques (first-line)
-
Active PNES event; first-line acute management
N/A :: - :: - :: Use calm, reassuring voice; say "You are safe, I am here to help you"; guide grounding (name 5 things you see, 4 you hear, 3 you touch); do NOT restrain, force oral airway, or attempt IV access during event
None
Event duration; response to verbal cues; vital signs; document semiology features
STAT
STAT
ROUTINE
-
Withhold IV benzodiazepines
-
Do NOT administer benzodiazepines for confirmed or suspected PNES; benzodiazepines cause respiratory depression without benefit; leading cause of iatrogenic intubation in PNES
N/A :: - :: - :: Withhold lorazepam, midazolam, diazepam; if epileptic seizure cannot be excluded, treat per status epilepticus protocol while awaiting clarification
If epileptic seizure cannot be excluded, treat as epileptic until proven otherwise
Respiratory status; level of consciousness; document clinical features to aid differentiation
STAT
STAT
-
-
Withhold IV anti-seizure medications
-
Do NOT load IV phenytoin, levetiracetam, or valproate for confirmed or suspected PNES; ineffective and delays correct diagnosis
N/A :: - :: - :: Withhold IV ASM loading; if comorbid epilepsy is established and epileptic seizure possible, continue home ASMs
Comorbid epilepsy with possible epileptic breakthrough
Document event semiology; EEG if available
STAT
STAT
-
-
Nasal ammonia capsule (smelling salts)
INH
Functional unresponsiveness; aids differentiation from epileptic postictal state
1 capsule :: INH :: PRN :: Break capsule 6 inches from nose; grimace or withdrawal response confirms awareness and supports functional diagnosis
None significant
Response to stimulation; document findings
STAT
STAT
-
-
Supportive safety measures
-
Injury prevention during active PNES event
N/A :: - :: - :: Place patient in safe position; pad side rails if in bed; remove nearby sharp objects; do NOT insert bite block or tongue blade; position on side if secretions present
None
Injury check post-event; vital signs
STAT
STAT
-
-
Note: CRITICAL -- The most common iatrogenic harm in PNES is inappropriate treatment with IV benzodiazepines and ASM loading, leading to respiratory depression, intubation, and ICU admission. Recognizing PNES features during the event (eyes closed, asynchronous movements, waxing-waning, prolonged duration >2 min, side-to-side head movements, preserved awareness during bilateral motor activity) is the most important acute intervention. If there is ANY doubt about whether an event is epileptic, treat as epileptic until clarified -- safety first.
All PNES patients after diagnostic confirmation; the single most important therapeutic intervention
N/A :: - :: - :: Explain: "You have a condition called functional seizures (or non-epileptic events). These are REAL events, not fabricated. Your brain is sending the wrong signals, like a software glitch rather than hardware damage. The good news is this is treatable." Show the patient their vEEG results (normal EEG during event). Use the term "functional seizures" rather than "psychogenic" if patient prefers. Validate the reality of symptoms. Express diagnostic confidence. Emphasize treatability. Provide neurosymptoms.org
None
Patient understanding and acceptance; emotional response; therapeutic alliance; repeat key messages across multiple encounters if needed
STAT
STAT
ROUTINE
-
Note: HOW the diagnosis is communicated is the single most important predictor of treatment engagement and outcome. Key principles: (1) Use clear, non-judgmental language; (2) Avoid "psychogenic" in patient-facing communication if it causes stigma -- "functional seizures" is preferred by patients; (3) Show the vEEG evidence to the patient; (4) Explain the diagnosis is made based on WHAT THE EVENTS ARE (functional), not what they are NOT (not epileptic); (5) Express confidence -- uncertainty from the physician leads to patient disengagement; (6) NEVER say "there is nothing wrong with you" or "it's all in your head"; (7) Frame as the beginning of treatment, not the end of the diagnostic journey. See Appendix A for a diagnosis delivery script.
All PNES patients; strongest evidence base (CODES trial); addresses illness beliefs, avoidance, seizure-related cognitions, and perpetuating factors
12-16 sessions :: - :: weekly :: Weekly 50-60 min sessions; PNES-specific CBT model per Goldstein et al. (CODES trial); includes psychoeducation, seizure control techniques, cognitive restructuring of illness beliefs, graded behavioral activation, addressing avoidance, trauma processing if indicated; booster sessions at 3 and 6 months
Active psychosis; severe intellectual disability preventing engagement; active substance dependence (treat first)
Seizure/event frequency diary; PHQ-9; GAD-7; functional measures; treatment engagement
-
-
ROUTINE
-
EMDR (Eye Movement Desensitization and Reprocessing)
-
PNES with PTSD or significant trauma history (present in ~30-50% of patients)
8-12 sessions :: - :: weekly :: Standard EMDR protocol; 60-90 min sessions; process traumatic memories identified as precipitating or perpetuating PNES; may be combined with CBT
Active psychosis; severe dissociative disorder (requires specialist modification); acute suicidality
PNES with high anxiety, somatic hypervigilance, or as adjunct to CBT
8-week program :: - :: weekly :: Standard 8-week MBSR program; weekly 2.5-hour sessions plus home practice; body scan modified to reduce somatic hypervigilance; focus on non-reactive awareness of body sensations
Attendance; knowledge assessment; patient satisfaction; event frequency
-
-
ROUTINE
-
Note: CBT specifically adapted for PNES (CBT-PNES) has the strongest evidence base, demonstrated in the CODES trial (Goldstein et al. Lancet Psychiatry 2020) -- the largest RCT in PNES treatment. CBT-PNES reduced seizure frequency and improved quality of life. Finding a therapist experienced with PNES/functional neurological disorders is critical -- generic CBT without PNES-specific modifications is less effective. The CODES trial manual is available as a guide for therapists.
3D. Pharmacologic Management of Psychiatric Comorbidities¶
Treatment
Route
Indication
Dosing
Contraindications
Monitoring
ED
HOSP
OPD
ICU
Sertraline
PO
Comorbid major depression (present in ~50-85% of PNES patients); comorbid anxiety; PTSD (first-line for all three)
50 mg :: PO :: daily :: Start 50 mg daily; titrate by 50 mg q2-4wk; max 200 mg/day; takes 4-6 weeks for full effect
Concurrent MAOIs (14-day washout); QTc prolongation at high doses
Suicidality monitoring (first 8 weeks); serotonin syndrome symptoms; QTc if risk factors; sexual side effects
-
ROUTINE
ROUTINE
-
Escitalopram
PO
Comorbid generalized anxiety disorder; depression; alternative to sertraline
10 mg :: PO :: daily :: Start 10 mg daily; may increase to 20 mg after 4 weeks; max 20 mg/day
Concurrent MAOIs; QTc prolongation; congenital long QT syndrome
QTc monitoring if risk factors; serotonin syndrome; hyponatremia in elderly
-
ROUTINE
ROUTINE
-
Venlafaxine XR
PO
Comorbid depression with prominent anxiety; chronic pain comorbidity (dual SNRI benefit); alternative when SSRIs ineffective
37.5 mg :: PO :: daily :: Start 37.5 mg daily x 1 week; titrate by 37.5-75 mg q1wk; max 225 mg/day; MUST taper to discontinue (severe discontinuation syndrome)
ECG if dose >50 mg; anticholinergic effects (dry mouth, constipation, urinary retention); sedation; orthostatic hypotension; weight gain
-
ROUTINE
ROUTINE
-
Trazodone
PO
Insomnia (common PNES comorbidity); adjunct for depression; avoids benzodiazepine hypnotics
25 mg :: PO :: qHS :: 25-100 mg PO qHS for insomnia; max 150 mg qHS
Concurrent MAOIs; QTc prolongation
Orthostatic hypotension; priapism (rare -- counsel male patients); sedation; QTc
-
ROUTINE
ROUTINE
-
Melatonin
PO
Insomnia; sleep-wake dysregulation (common in PNES/trauma)
3 mg :: PO :: qHS :: 3-10 mg PO qHS; take 30-60 min before bedtime; max 10 mg
None significant
Sleep quality; daytime drowsiness
-
ROUTINE
ROUTINE
-
Note: There is NO medication that directly treats PNES. Pharmacotherapy targets COMORBID psychiatric conditions (depression, anxiety, PTSD, insomnia) that are highly prevalent in PNES and perpetuate events. CRITICAL: Avoid benzodiazepines (alprazolam, lorazepam, clonazepam) -- they do NOT reduce PNES events, carry addiction risk, and may worsen dissociation. If the patient is already on chronic benzodiazepines, a slow supervised taper is recommended.
Confirmed PNES on levetiracetam without comorbid epilepsy; taper AFTER definitive vEEG diagnosis
250-500 mg reduction :: PO :: q2wk :: Taper by 250-500 mg every 2 weeks; typical taper from 1000 mg BID over 8-12 weeks; monitor for anxiety/mood changes (levetiracetam withdrawal can worsen mood)
Comorbid epilepsy confirmed or suspected (~10% dual diagnosis); do NOT taper without epileptologist input in dual-diagnosis patients
Event frequency diary; mood (levetiracetam withdrawal may improve mood or cause rebound anxiety); verify no epileptiform events during taper
-
-
ROUTINE
-
Gradual ASM taper -- lamotrigine
PO
Confirmed PNES on lamotrigine without comorbid epilepsy
25-50 mg reduction :: PO :: q2wk :: Taper by 25-50 mg every 2 weeks; slower taper than other ASMs (lamotrigine has mood-stabilizing properties -- monitor for mood destabilization)
Comorbid epilepsy; bipolar disorder (lamotrigine may be serving as mood stabilizer)
Event frequency; mood stability (PHQ-9, mood diary); rash (rare during taper but document)
-
-
ROUTINE
-
Gradual ASM taper -- valproic acid
PO
Confirmed PNES on valproic acid without comorbid epilepsy
250 mg reduction :: PO :: q2wk :: Taper by 250 mg every 2 weeks; monitor for mood changes (valproate has mood-stabilizing properties); check levels during taper if comorbid epilepsy cannot be fully excluded
Comorbid epilepsy; bipolar disorder (valproate may be serving as mood stabilizer)
Event frequency; mood; weight (may lose weight with taper); LFTs; tremor (may improve with taper)
-
-
ROUTINE
-
Gradual ASM taper -- carbamazepine/oxcarbazepine
PO
Confirmed PNES on carbamazepine or oxcarbazepine without comorbid epilepsy
100-200 mg reduction :: PO :: q2wk :: Taper by 100-200 mg every 2 weeks; carbamazepine induces its own metabolism (levels may shift during taper); complete taper over 8-12 weeks
Comorbid epilepsy; trigeminal neuralgia (carbamazepine may be treating pain)
Event frequency; mood; sodium level (hyponatremia more common with oxcarbazepine -- may resolve with taper); CBC
-
-
ROUTINE
-
Gradual ASM taper -- topiramate
PO
Confirmed PNES on topiramate without comorbid epilepsy
25-50 mg reduction :: PO :: q1-2wk :: Taper by 25-50 mg every 1-2 weeks; cognitive side effects may improve with taper; monitor for weight changes
Comorbid epilepsy; migraine prophylaxis (topiramate may be treating migraines -- assess before taper)
Event frequency; cognitive function (may improve); weight; migraine frequency if history of headache
-
-
ROUTINE
-
Gradual ASM taper -- phenobarbital
PO
Confirmed PNES on phenobarbital without comorbid epilepsy; REQUIRES SLOW TAPER (barbiturate withdrawal risk)
15-30 mg reduction :: PO :: q2-4wk :: Taper by 15-30 mg every 2-4 weeks; VERY SLOW taper over 3-6 months; barbiturate withdrawal can cause TRUE seizures even in non-epileptic patients; inpatient monitoring may be needed for high doses
Comorbid epilepsy; barbiturate dependence (consider inpatient taper for high doses >120 mg/day)
Event frequency; withdrawal symptoms (anxiety, insomnia, tremor, TRUE seizures); vital signs during taper; may need phenobarbital levels
-
ROUTINE
ROUTINE
-
Note: CRITICAL SAFETY ISSUE -- Approximately 10% of PNES patients have COMORBID epilepsy (dual diagnosis). ASM taper should ONLY be performed after definitive vEEG diagnosis and assessment for dual diagnosis. If there is ANY suspicion of comorbid epilepsy, do NOT taper ASMs without epileptologist input. Taper one drug at a time. Special caution with phenobarbital and benzodiazepines -- withdrawal from these agents can provoke true epileptic seizures even in non-epileptic patients. The ASM taper should be explained to the patient as part of the treatment plan, emphasizing that these medications were prescribed based on earlier understanding and that stopping them is POSITIVE (removing unnecessary medication burden).
Your events are REAL -- they are caused by your brain sending the wrong signals, like a software problem rather than structural brain damage, and they are NOT fabricated or imagined
Y
Y
Y
The good news is that functional seizures are TREATABLE -- many patients improve significantly or become event-free with the right therapy
Y
Y
Y
Visit www.neurosymptoms.org for reliable, expert-written information about functional seizures (recommended by leading neurologists worldwide)
Y
Y
Y
Anti-seizure medications do NOT work for functional seizures -- your neurologist will work with you to safely taper these medications if you are taking them
-
Y
Y
Do NOT take extra doses of anti-seizure medication during or after an event -- this will NOT help and may cause side effects
Y
Y
Y
During an event, use grounding techniques: focus on your surroundings, name objects you see, feel textures in your hands, listen to sounds around you -- these techniques can help shorten events
-
Y
Y
Family members and caregivers: during an event, stay calm, speak reassuringly, do NOT restrain or force anything into the mouth, time the event, and do NOT call 911 unless there is injury or the event is clearly different from usual
Y
Y
Y
Keep a seizure diary recording event frequency, duration, possible triggers (stress, sleep deprivation, conflict), and context to help identify patterns
-
Y
Y
Attend ALL recommended therapy appointments (psychology and physiotherapy are the primary treatments -- more important than any medication)
-
Y
Y
Return to the ED only for events that are clearly DIFFERENT from your usual events, for injury during an event, or for new symptoms such as sudden severe headache, fever, or one-sided weakness
Regular aerobic exercise (30 minutes, 5 days per week) to reduce stress, improve mood, and support overall brain health
-
Y
Y
Sleep hygiene: consistent bed and wake times, 7-9 hours nightly, avoid screens 1 hour before bed, limit caffeine after noon (sleep deprivation is a common PNES trigger)
-
Y
Y
Stress management: identify and address major stressors; use breathing exercises, progressive muscle relaxation, or mindfulness daily
-
Y
Y
Avoid alcohol and recreational drugs (lower event threshold, worsen mood and anxiety, interfere with therapy)
-
Y
Y
Avoid benzodiazepines for anxiety (not helpful for PNES, can worsen dissociation, and carry addiction risk) -- discuss non-benzodiazepine alternatives with your provider
-
Y
Y
Pacing: balance activity and rest throughout the day to avoid the "boom-bust" cycle (overexertion on good days leads to increased events on subsequent days)
-
Y
Y
Maintain social connections and meaningful activities to prevent isolation, which worsens PNES outcomes
-
Y
Y
Driving restrictions: follow state-specific regulations for seizure-like events; most states require a seizure-free interval (varies by state) -- discuss with your neurologist
-
Y
Y
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SECTION B: REFERENCE (Expand as Needed)
═══════════════════════════════════════════════════════════
Bizarre motor automatisms; brief (<30 sec); stereotyped; nocturnal predominance; may not show surface EEG changes
Video-EEG (may need intracranial monitoring); MRI brain with epilepsy protocol; seizure semiology analysis
Vasovagal syncope
Triggered by prolonged standing, pain, or emotional stress; prodrome (lightheadedness, diaphoresis, tunnel vision); brief loss of consciousness; rapid recovery; no postictal confusion
Tilt table test; ECG; history and trigger identification
Cardiac arrhythmia (syncope)
Sudden onset without prodrome; associated with palpitations; may occur during exertion; family history of sudden death
ECG; Holter/event monitor; echocardiogram; cardiac electrophysiology study
Intentional symptom production; external motivation in malingering, sick role in factitious; VERY RARE -- do NOT assume
No reliable test; clinical judgment; inconsistency with incentives; PNES is NOT malingering or factitious
Note: PNES frequently COEXISTS with organic neurological disease. Approximately 10% of PNES patients also have comorbid epilepsy. The presence of an organic diagnosis does NOT exclude PNES, and the presence of PNES does NOT exclude organic disease. Always evaluate for dual diagnosis.
Event resolved; patient hemodynamically stable; no injury requiring treatment; diagnosis communicated (or follow-up arranged for formal diagnosis delivery); outpatient neurology follow-up arranged within 2-4 weeks; patient educated that these events are not life-threatening; family educated on event management (do not call 911 for typical events unless injury or clearly different from usual)
Admit to floor (general neurology or EMU)
Video-EEG monitoring needed for diagnostic confirmation; diagnostic uncertainty requiring observation; recurrent ED presentations for events requiring care coordination and definitive diagnosis; concurrent ASM taper requiring monitoring (phenobarbital, high-dose benzodiazepines)
Admit to ICU
Generally NOT indicated for PNES; consider ONLY if: iatrogenic complication from inappropriate treatment (respiratory depression from benzodiazepines); diagnostic uncertainty with ongoing concern for status epilepticus requiring continuous EEG
Psychiatric admission
Active suicidality; severe psychiatric decompensation; psychosis; inability to maintain safety in outpatient setting
Transfer to higher level of care
Video-EEG monitoring not available at current facility; epilepsy monitoring unit referral; PNES-specialized treatment program not available locally
Outpatient follow-up
ALL patients: neurology follow-up within 2-4 weeks for diagnosis delivery and treatment planning; psychology referral within 1-2 weeks; psychiatry for comorbidity management within 1 month; PCP within 1-2 weeks for medication reconciliation
Validate: "I want you to know that your symptoms are REAL. I believe you."
Name: "Based on the testing we have done, including the video-EEG recording, your events are caused by a condition called functional seizures."
Explain: "Your brain is misfiring -- like a software problem rather than a hardware problem. The brain structures are healthy, but the signals are not working correctly."
Show evidence: "During your event, your brain waves (EEG) remained completely normal. This tells us the events are not caused by abnormal electrical discharges like in epilepsy."
Treat: "The good news is that this condition is treatable. The most effective treatment is a specific type of therapy called CBT, which helps retrain how your brain processes stress and emotions."
Empower: "Many patients improve significantly. You have an active role in your recovery."
Resource: "I recommend visiting www.neurosymptoms.org for excellent patient information about this condition."
v1.1 (January 30, 2026)
- Fixed structured dosing format across all Section 3D medications (10 drugs) to use dose :: route :: frequency :: instructions pattern
- Fixed structured dosing format across all Section 3E ASM taper entries (6 drugs) to populate frequency field
- Fixed structured dosing format across all Section 3C psychotherapy entries (5 modalities) to populate frequency field
- Standardized all dosing cells: start dose only in first field (removed multiple dose levels from dose field)
- Bumped version to 1.1; added REVISED date
Start with validation: acknowledge symptoms are real and distressing
Present the diagnosis name clearly: "functional seizures" (preferred) or "non-epileptic events"
Use the "software vs. hardware" analogy: the brain's structure is normal, but the signaling is disrupted
Show the vEEG evidence: walk the patient through their normal EEG during a captured event
Explain what this MEANS, not just what it IS NOT: avoid defining PNES only as "not epilepsy"
Discuss treatment options: CBT is the evidence-based treatment; medications for comorbidities
Address common fears: "Am I crazy?" (No -- this is a neurological condition); "Will I get better?" (Many patients improve significantly with treatment)
Provide resources: neurosymptoms.org, support groups (FND Hope), written summary of the diagnosis
"No. Your symptoms are real. Your brain is real. The problem is in how your brain processes and sends signals, not in your imagination."
"Does this mean I'm faking?"
"Absolutely not. Functional seizures are involuntary. You cannot control them any more than someone with epilepsy can control their seizures."
"Why is this happening to me?"
"Functional seizures often develop in people who have experienced stress, trauma, or other medical conditions. Your brain developed this pattern of responding, and therapy can help retrain it."
"Will I ever get better?"
"Yes, many patients improve significantly with the right treatment. CBT has been shown in research studies to reduce event frequency."
"Should I stop my seizure medications?"
"We will work together to safely taper those medications over time, since they do not help with functional seizures. This is done gradually and under supervision."