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]