Psychogenic non-epileptic seizures (PNES) are the sole diagnosis found in 25-50% of patients referred to epilepsy specialty centers. The extensive diagnostic workup for patients with PNES commonly results in significant immediate and long-term financial and social costs to patients. Delayed diagnosis of PNES leads to worse health outcomes.

Multiple techniques have proven highly effective at provoking PNES episodes with a 50-80% success rate. The ethics of using these techniques has been highly debated because each technique involves some element of patient manipulation. The use of these techniques is not universal, as many cite ethical concerns. However, given recent reports of the significant mental, physical, and financial health impact of untreated PNES, the cost-effectiveness of treatment, and the improvements in patient quality of life that diagnosis provides, its place in care and ethics therein should be readdressed for the good of our patients.

Many have argued that the provocation techniques are paternalistic and should not be performed because of the harm incurred by the deception they utilize. Conversely, many argue provocation techniques safely and effectively diagnose PNES, preventing further psycho-socio-economic harm of undiagnosed and untreated PNES.

PNES provocation techniques are ethically permissible when:

1)    PNES is the most clinically-suspected condition.

2)    Epileptic seizures have been investigated thoroughly and PNES remains highly suspected.

3)    Non-nocebo-based techniques are prioritized.

4)    Techniques are performed in a safe environment in the event epileptic seizures occur.

5)    Non-deceptive and the least suggestive terminology is used.

6)    The goal is to provide timely and accurate diagnosis, offer the most appropriate treatment, and minimize further psycho-socio-economic damage to the patient.