A seizure is a sudden, temporary electrical disturbance in the brain that disrupts normal function, causing changes in movement, sensation, behavior, or consciousness. These events are broadly categorized into epileptic seizures (ES), which stem from abnormal electrical activity, and non-epileptic attacks (NEAs), which include psychogenic non-epileptic seizures (PNES). While a layperson cannot offer a medical diagnosis, recognizing the distinct features of each type of event provides valuable information for medical professionals. The final diagnosis requires comprehensive medical testing, often including a video-electroencephalogram (video-EEG).
Physiological Characteristics of True Epileptic Seizures
True epileptic seizures are characterized by involuntary, automatic physical signs resulting from uncontrolled synchronous neuronal firing. A key feature of a generalized tonic-clonic seizure is its predictable, rhythmic, and synchronized pattern of movement affecting both sides of the body simultaneously. The movements typically begin abruptly with a stiffening phase (tonic) followed by a jerking phase (clonic).
The duration of most epileptic seizures is short, often lasting less than two minutes, and rarely exceeding five minutes. Because these events are uncontrolled, they carry a high risk of injury, such as a heavy fall or biting the side of the tongue. Involuntary autonomic signs are frequently present, reflecting widespread brain involvement.
These autonomic signs, which a person cannot consciously control, include changes in heart rate, breathing difficulty, or cyanosis. Cyanosis is a bluish discoloration of the skin due to lack of oxygen. Loss of bladder or bowel control (incontinence) is another common involuntary sign. Pupils may become fixed or dilated, and the eyes might deviate to one side, providing visual evidence of the brain’s electrical disruption.
Behavioral Indicators of Non-Epileptic Attacks
Non-epileptic attacks (NEAs) are episodes that resemble seizures but lack the underlying abnormal electrical brain activity, often having a psychological or stress-related origin, such as PNES. The movements observed during an NEA are typically asynchronous, meaning the limbs move out of sync or shift patterns from one limb to another. Unlike the rhythmic, uniform jerking of an epileptic seizure, NEA movements are often described as thrashing, chaotic, or non-stereotypical.
A common feature of PNES is the presence of purposive, inconsistent movements such as back arching, side-to-side head shaking, or pelvic thrusting. The event duration is often prolonged, frequently lasting five minutes or longer, sometimes extending for 30 minutes or more, which is uncommon for epileptic seizures. During an NEA, the person may exhibit fluctuating responsiveness, such as resisting eye opening or tracking people moving in the room, suggesting preservation of awareness.
Ictal eye closure, where the person keeps their eyes closed throughout the event, is considered one of the most specific signs favoring a non-epileptic attack. Non-epileptic events may occur only when other people are present or may stop or change intensity when a bystander intervenes. Vocalizations, such as crying, screaming, or moaning, can fluctuate and persist throughout the event, in contrast to the single, forceful cry sometimes heard at the onset of a generalized epileptic seizure.
Differences in Post-Event Recovery
The period immediately following a seizure, known as the post-ictal state, is a significant differentiator between epileptic and non-epileptic events. Following a true epileptic seizure, the brain requires time to recover from the massive electrical discharge, resulting in a consistent period of post-ictal confusion or disorientation. The person may be fatigued, lethargic, or fall into a deep sleep.
Other common post-ictal signs include a severe headache, temporary weakness on one side of the body (Todd’s paralysis), or difficulty speaking. This recovery phase is gradual and can last minutes to hours, reflecting the physiological exhaustion of the neurons. The patient typically has amnesia for the event itself and the moments immediately following it.
In contrast, a person who has experienced a non-epileptic attack often shows a rapid and complete return to baseline function. They may immediately become coherent, speak clearly, and return to intentional behavior without the characteristic confusion or need for rest seen in ES. The absence of post-ictal symptoms like fatigue or headache suggests the event was not caused by an abnormal electrical discharge in the brain.
What the Observer Should Do
Regardless of whether the event appears epileptic or non-epileptic, the observer’s primary focus should be on safety, documentation, and seeking appropriate medical attention. Ensure the person is safe by clearing the area of any objects they could hit and gently cushioning their head. Do not attempt to restrain their movements, as this can cause injury, and never place anything inside their mouth.
It is essential to time the event from start to finish, noting the length of the movements and the recovery period. Observing specific details is valuable for medical diagnosis.
Key Observations for Diagnosis
- Note the color of the person’s skin.
- Identify which parts of the body were moving.
- Determine whether the movements were rhythmic or asynchronous.
- If possible, use a phone to record the event, as video evidence is invaluable for accurate diagnosis.
After the movements stop, gently roll the person onto their side into the recovery position, which helps keep the airway clear. If the event lasts longer than five minutes, or if the person is injured or not breathing normally after the event, call for emergency medical help immediately. All suspected seizure events require follow-up with a medical professional.