First do no harm: Preventing harm and optimizing care in psychogenic nonepileptic seizures

• Published in: Epilepsy & behavior 2020-01, Vol.102, p.106642-106642, Article 106642
• Main Authors: Johnsen, Clark, Ding, Helen T.
• Format: Article
• Language: English
• Subjects: Epilepsy; Interdisciplinary; Neurology; Psychiatry; Psychogenic nonepileptic seizures; Therapeutic alliance, diagnostic delay
• ISSN: 1525-5050; 1525-5069
• DOI: 10.1016/j.yebeh.2019.106642

Psychogenic nonepileptic seizures (PNES) are challenging clinical occurrences consisting of any combination of altered movement, sensation, or awareness that resemble epileptic seizures (ES) but do not coincide with electrographic ictal discharges and are presumed to be neuropsychiatric–neurobehavioral in origin. Securing the PNES diagnosis is a crucial first step and is best confirmed by recording events on video-electroencephalogram (v-EEG) and finding an absence of ictal EEG changes and the presence of normal awake EEG rhythms before, during, and after the event. However, obstacles to timely diagnosis and referral to psychiatric treatment frequently occur, placing these patients at risk for harm from unnecessary medications and procedure as well as placing high burden on medical systems. Although providers across all disciplines share the responsibility by maintaining high suspicion of PNES in relevant clinical settings and engaging swiftly and empathically in securing and sharing the diagnosis with patients and families, psychiatric and neurologic providers are uniquely positioned to help lead patients towards safe and effective long-term care through a cohesive approach that is rooted in therapeutic alliance, interdisciplinary collaboration, and realistic treatment goals. •Psychogenic non-epileptic seizures patients often encounter a fractured diagnostic course due to the variety of settings in which they present.•Mental healthcare providers, neurologists, emergency room and primary care physicians each share unique care roles in diagnosis and treatment.•For all providers, the therapeutic alliance is central to creating a safe and effective treatment environment.•A shift in focus from episode cessation toward mindfulness, a “safety first,” approach and harm prevention is presented.•A better understanding of how to recognize and treat this frequently challenging entity will optimize care and prevent harm.