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

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.