**5. Conclusion**

The preliminary aim of treatment is to inform and educate the patient and his/her family about the diagnosis. Thus, it will be possible for the patient to be directed to psychiatric care. In addition, unnecessary admission to emergency services, unnecessary treatments and possible adverse effects will be avoided. Antiepileptic drugs may be useful to prevent return in patients with severe abuse or posttraumatic stress disorder, and sometimes it may be appropriate to continue antiepileptic drugs as a mood stabilizer. Although it will continue to be used, the intended use of the antiepileptic drug should be clearly explained to the patient and his/her family in order not to give a double message. It is necessary to cut the antiepileptic drugs gradually when diagnosed except for these conditions [73, 74]. In a prospective study, epileptic seizures were observed in only 3 of 64 patients that antiepileptic medication was discontinued and those informed that seizures were not due to a brain disorder [26]. Especially for patients with dissociative features it is not possible to say that they will certainly not be harmed by seizures. There was no consensus on the recommendation of restrictions on certain activities (such as driving) until these patients had their seizures controlled [64]. PNES treatment has been reviewed by various authors [29, 75, 76]. Most of the studies related to the subject are in the form of small sample case reports and there are few enough powerful or reliable controlled studies. In a study involving psychopharmacological treatment approaches in this area, inpatient group treated with psychological intervention (paradoxical intention) and outpatient group treated with diazepam (5–15 mg/day) were compared. It has been reported that the anxiety is reduced and the symptoms are controlled more effectively in the group treated with paradoxical intention [77]. However, it should be noted that the control group was formed by 15 cases in the study and only 9 cases completed the study. Despite the fact that antidepressants may be effective in other medically unexplained symptoms, there is no adequate data and studies on the use of antidepressant drugs in patients with psychogenic nonepileptic episodes [29, 78, 79]. In all other studies, individual or group-specific psychological treatment methods were discussed [29]. Especially in these studies, cognitive behavioral therapy (CBT), psychodynamic approaches, interpersonal therapy, operant conditioning, eye movement desensitization and reprocessing (EMDR), biofeedback, hypnotherapy, family therapy and multidisciplinary therapies are at the forefront [80–83]. A significant decrease in seizure frequency, anxiety and depression levels, an increase in psychosocial functioning with CBT targeting fear and avoidance behavior have been reported in a 12-session prospec-

144 Seizures

tive study which is one of the best study done up to this day [84].

Psychoanalytically, psychogenic nonepileptic seizures are an attempt to counteract/defend the traumatic experience of the patient, and at the same time to resolve conflicts related to this experience. At the same time, it is a defense that serves also in the control of the anger, instead of harming someone else, they prefer to hurt themselves. Therefore, it will be appropriate to shape treatment in the direction of these principles, especially in patients who have trauma or unresolved grievances in the past. In other words, patients diagnosed with PNES form a heterogeneous group, and psychodynamic psychotherapy may be a good treatment option for the patients with psychic trauma stories and those who could not mourn. The story of what happened to the patient needs to be formed and the meanings of it should be studied. At the outset of treatment, psychoeducation, prevention of secondary gains, raising awareness of the patient about the relation of psychic processes and seizures and developing a good therapeutic As a result, epileptic and psychogenic nonepileptic seizures are two pathological conditions that should be evaluated separately in terms of both etiological, formation mechanism and treatment approach. Detailed history of seizures and careful neurological, psychiatric examination, as it provides for the correct diagnosis and treatment for the patients, it will also prevent many negative consequences that the wrong treatment may bring. Since it has been named as hysterical seizure, there has been considerable progress in the diagnosis of PNES with the use of EEG and vEEG in clinical practice. However, focusing on differential diagnosis for the PNES diagnosis by comparing with cases with epileptic seizure only, and the lack of comparison of the clinical appearance of the different subtypes of PNES are the shortcoming of the work done up to this day. Also, the effects of cultural differences on PNES are unknown. For a better understanding of treatment approaches, there is a need for studies with a large sample involving the control group.
