Treating Non-Epileptic Psychogenic Seizures

Thank you for your quesiton. The new terminology for this is psychogenic non-epileptic seizure (PNES). These events are not caused by abnormal electrical activity in the brain and therefore do not respond to anticonvulsant medications such as benzodiazepines. The pathophysiology is psychological rather than neurological, often associated with stress, trauma, or underlying psychiatric illness (Reuber & Elger, 2003).

From a prehospital standpoint, the administration of midazolam to a patient experiencing PNES is unlikely to cause benefit and may increase the risk of sedation, hypotension, or respiratory depression (Krakow et al., 2016). However, distinguishing PNES from epileptic seizures in the field can be challenging, and patient safety must remain the priority. If there is any uncertainty about the nature of the event, it is appropriate to treat according to the Seizure Medical Directive and reassess.

Indicators that support PNES rather than epileptic seizure include prolonged or fluctuating seizure activity without a postictal phase, maintained awareness during the episode, asynchronous or side-to-side limb movements, eyes tightly closed with resistance to opening, and rapid recovery after the event. Historical or collateral information is also valuable, such as a known diagnosis of PNES or patterns of frequent seizure-like activity without neurologic findings on prior assessment (LaFrance et al., 2013).

When choosing not to treat, documentation should clearly outline the observed features that informed the decision. This may include descriptions such as “patient maintained purposeful movement,” “eyes remained tightly closed,” or “no postictal confusion observed.” The rationale should emphasize that the decision was based on the absence of features consistent with generalized motor seizure activity and the patient’s stable airway, breathing, and circulation.

In summary, midazolam is not harmful in small doses but offers no therapeutic benefit for PNES. The priority should be careful assessment, clear documentation of findings, and maintaining a high threshold for treatment when true epileptic seizure cannot be ruled out.

References
Krakow, B., Kellner, R., Neidhardt, J., & Schröder, C. (2016). Benzodiazepine use in psychogenic nonepileptic seizures: Clinical and safety considerations. Epilepsy & Behavior, 64, 143–148.
LaFrance, W. C., Baker, G. A., Duncan, R., Goldstein, L. H., & Reuber, M. (2013). Minimum requirements for the diagnosis of psychogenic nonepileptic seizures: A staged approach. Epilepsia, 54(11), 2005–2018.
Reuber, M., & Elger, C. E. (2003). Psychogenic nonepileptic seizures: Review and update. Epilepsy & Behavior, 4(3), 205–216.