Working With PNES Clients
Psychogenic nonepileptic seizures (PNES) are one of those conditions where every therapist learns the hard way that their first instinct is often wrong. You get a referral, the client has had multiple negative EEGs, and you're told "it's all in their head." That's not quite right, and treating it like that will blow up in your therapy within a few sessions. The framework most clinicians actually need isn't about the seizures themselves. It's about understanding that PNES is a dissociative conversion disorder — the brain is producing real, involuntary events through a stress-response pathway that bypasses normal consciousness. The client isn't faking it. They're not consciously choosing to have these episodes. But they also aren't epileptic, which means antiseizure medications won't help and can sometimes make things worse by adding side effects on top of an already complicated medication list. Here's what I've found matters more than any manual or protocol: the initial framing you give the client about what these seizures actually are. This is where most people go sideways. You can't say "they're not real" because they are real — the person is genuinely experiencing something terrifying and involuntary. But you also can't validate a medical model of epilepsy because that locks the client into a treatment pathway that won't work. The phrasing has to be precise. Something like "your nervous system is having a crash response to stress, and it's manifesting in a way that looks like seizures but isn't electrical activity in the brain." That distinction matters clinically and practically.
I had a client once who had been diagnosed with epilepsy for seven years. Three different neurologists, six different medications, a vagus nerve stimulator implanted. She came to me through a panic disorder clinic by accident. The first time I told her the seizures weren't epileptic, she left the session and didn't come back for three months. Not because she was angry — she was terrified. She thought I was saying her condition didn't exist. What I should have done differently was spend more time in that first session normalizing the experience before introducing the differential diagnosis. I spent too much time on the neurology and not enough on her lived reality. That cost us three months of progress.
What Actually Works in Practice
CBT adapted for PNES is the most studied intervention. The core components involve psychoeducation about the mind-body connection, identifying and processing emotional triggers, cognitive restructuring around catastrophic interpretations of seizure activity, and gradual exposure to avoided situations. A typical course runs 12 to 20 sessions. Clients who engage consistently show significant reduction in seizure frequency within eight to ten sessions, though full remission often takes longer. The counter-intuitive part most beginners miss: you don't start by processing trauma. Not immediately anyway. If you dive into childhood abuse or complex PTSD in the first three sessions with a client who's having daily seizures, you'll likely increase their dissociation and make the seizures worse. You build stabilization and emotional regulation skills first. Grounding techniques, somatic awareness, and establishing a baseline of safety before you touch the underlying material. The trauma work comes later, usually around session six or seven, when the client has enough distress tolerance to handle it without decompensating. Another thing people get wrong is the assumption that PNES and PTSD always co-occur. They do frequently — studies show roughly 30 to 50 percent comorbidity — but a significant portion of PNES clients don't meet criteria for PTSD. Some have generalized anxiety. Some have depression. Some have conversion disorder without a clear traumatic etiology. Treating the wrong primary diagnosis sends the whole intervention off track.
Get the Full Details
Hypnotherapy and EMDR have shown promise in smaller studies, but the evidence base is thinner. I use EMDR selectively with clients who have clear trauma anchors and good enough stabilization. For clients with severe dissociation, EMDR can trigger prolonged dissociative states that are hard to manage in a standard weekly session. In those cases, I stick with CBT and add in phases of sensorimotor psychotherapy for body-based regulation work.
When This Approach Fails
Let me be blunt about the limitations. PNES treatment has a high dropout rate — somewhere between 30 and 50 percent depending on the study. Clients drop out because they don't believe the diagnosis, because the therapy feels dismissive of their suffering, or because the seizure reduction isn't fast enough to justify the emotional work required. There's no good fix for that second point other than patience and repeated psychoeducation across multiple sessions. Serious comorbid conditions complicate everything. Borderline personality disorder, active substance use, ongoing domestic violence, untreated ADHD — any of these can undermine the therapy entirely. I've seen clients make real progress for six months and then completely relapse because their living situation became unsafe. No amount of CBT skill-building compensates for an environment that's actively triggering dissociative episodes daily. Medication management is another friction point. Many PNES clients are on multiple psychiatric medications alongside antiseizure drugs they don't actually need. Deprescribing is necessary but difficult. Psychiatrists are often reluctant to taper off AEDs without an epileptologist involved, and epileptologists sometimes resist because the diagnosis was made by a different provider. This administrative limbo can delay treatment for months.
If you're working with a client whose seizures are truly refractory to CBT and there's no clear trauma or stress component, consider whether the diagnosis is actually correct. Misdiagnosed epilepsy does exist. I've encountered a handful of cases over the years where the initial PNES diagnosis was wrong — typically clients who had subtle frontal lobe seizures that don't always show up on standard EEGs. If a client shows zero response to targeted CBT after ten sessions and seizure frequency is unchanged, requesting a prolonged video-EEG monitoring stay at a comprehensive epilepsy center is worth the effort.
Practical Session Structure
A typical early-phase session runs like this: check-in on seizure frequency since last visit (I use a simple log sheet), brief mood and anxiety scale, review of grounding skills practice, psychoeducation on one concept, and a short skills exercise. The psychoeducation piece rotates through topics like the fight-flight-freeze response, dissociation as a survival mechanism, the difference between epileptic and nonepileptic seizure physiology, and the role of avoidance in maintaining symptoms. By session ten, the structure shifts. Less psychoeducation, more active processing work if the client is ready. Cognitive work around beliefs like "if I stop having seizures, something terrible will happen" or "my identity is tied to being sick." Exposure work, whether imaginal or in vivo, for situations the client has been avoiding. This is also where you revisit the trauma timeline if that's part of the case formulation. Session fifteen onward is consolidation and relapse prevention. PNES has a recurrence rate that's not trivial — roughly 20 to 30 percent of clients experience a return of seizures within a year of stopping treatment. The best predictor of relapse is incomplete processing of the underlying stressors and insufficient development of alternative coping strategies. Don't wrap up therapy just because the seizures have stopped. Keep the client engaged for at least four to six more sessions after remission to build the skills that prevent return.
The single most important factor in outcomes isn't the specific modality. It's the therapeutic relationship and the client's belief in the treatment rationale. Get that foundation right and everything else follows. Mess it up in the first two sessions and no technique will save you.
