The neurologist, psychogenic nonepileptic seizures, and borderline personality disorder

Patients with psychogenic nonepileptic seizures (PNES) are common in tertiary epilepsy centers, emergency departments, and neurological practices. Psychiatric discussion of patients with PNES has emphasized the role of trauma and dissociation. Personality disorder has been considered, but its extensive implications for neurological management have not been fully appreciated. We propose that the most difficult aspects of management stem not from the convulsive episodes, but from the personality disorder that frequently accompanies them. Although it is not the neurologist’s role to treat personality disorder, the conduct of the physician–patient relationship can have potent consequences for good or ill on the outcome. We present a brief guide to current concepts of personality disorder; discuss the literature concerning its association with PNES, and offer practical guidelines for the conduct of the neurologist–patient relationship. This perspective offers resolutions to longstanding controversies, including how to communicate the diagnosis, discontinuing medication, and ongoing neurological contact.