Table 2: Classification of PNES by Underlying Etiologies


Etiology Description Suggested Treatments
1. Acute/Situational Stresses PNES develop after multiple and/or acute stressors overwhelm the patient’s coping ability. There may not be an underlying psychopathology. Supportive psychotherapy, lifestyle changes, group or family therapy as indicated.
2. Anxiety/Panic/ Physical Symptoms Atypical symptoms of anxiety or panic are misdiagnosed as PNES, or the patient misinterprets physical sensations or symptoms. Treatment of panic attacks; reassurance that physical symptoms are not seizures.
3. Depression/ Dissatisfaction In this case, a specific stressor does not precipitate the PNES; rather, the patient is generally unhappy, and the PNES function as distraction or an acceptable way to get support and attention. Antidepressant therapy for depression, CBT to challenge depressive thoughts and basic assumptions about self/illness, encourage active involvement in lifestyle changes and problem solving.
4. Poor interpersonal skills and affect regulation; disturbed family systems Patients with this profile are often diagnosed with borderline personality disorder and often have history of abuse. The patient may come from a family with poor emotional expression, so he or she is unable to identify and effectively express strong emotions. The PNES function to resolve interpersonal crises or threatening emotions or situations. Intensive psychodynamic psychotherapy to help identify and express threatening emotions (conflict, anger and rejection) and set realistic goals for relationships; family therapy when family systems support maintenance of PNES.
5. Psychosis PNES can be a manifestation of psychosis; this is rarely the case and the diagnosis is clear. Treatment of underlying psychosis.
6. PTSD/ Dissociation Patients in this group have active, chronic PTSD and dissociative symptoms. Flashbacks, recollections or sensory triggers often trigger PNES. Often there is a history of severe childhood abuse, and/or current abuse. Exposure-based therapies and SSRIs for PTSD.
6. Reinforced behavior pattern Often seen in cognitively impaired people; they have developed because of the functional advantages that are reinforced by the PNES, e.g. attention or avoiding responsibility. Behavior modification therapy.
6. Somatization/ Somatoform/ Conversion disorders The PNES represent emotional distress converted into physical symptoms; there is often a long history of medical attention for unexplained physical symptoms. The patient can often identify precipitating stressful events; the PNES are therefore a conversion symptom. Cognitive behavioral therapy (CBT) to identify links between stress and NES and develop more adaptive coping; for severe somatization, regular visits not contingent on symptoms, focus on living with symptoms rather than investigating and treating them.

Adapted from Gates [3], Barry & Sanborn [41], Bowman & Markand [17], LaFrance &Devinsky [19], Reuber & House [27] and Rusch et al. [62]