What Are Non-Epileptic Seizures and Why Do They Happen?

Non-epileptic seizures are episodes that look like epileptic seizures but are not caused by the abnormal electrical discharges in the brain that define epilepsy. They are real events with real symptoms, not something a person is faking, and they affect a significant portion of patients referred to epilepsy monitoring units. The condition has gone by many names over the years, including “psychogenic nonepileptic seizures” (PNES) in the medical literature, though a growing number of clinicians and patients now prefer the term “functional seizures” because it carries less stigma and better reflects what is actually going on: a problem with how the nervous system functions, rather than a structural brain disease or a psychiatric fabrication.

What Actually Happens During a Non-Epileptic Seizure

A person having a non-epileptic seizure can shake, go stiff, fall, become unresponsive, or experience altered awareness. To a bystander, the episode often looks indistinguishable from an epileptic seizure. One study from India found the most common physical features were verbal unresponsiveness (in about three-quarters of patients), whole-body rigidity (roughly the same proportion), and limb movements, while features like pelvic thrusting or automatisms were actually rare.¹ That matters because pop-culture descriptions of non-epileptic seizures sometimes exaggerate dramatic or unusual movements, making people think these events should look obviously “different” from epilepsy. In reality, most of the overlap is so strong that even experienced emergency-room physicians get the diagnosis wrong without specialized testing.

That said, some features do tip the scales when researchers pool data across many patients. A meta-analysis found that eyes being closed during the event was a strong indicator favoring a non-epileptic seizure, as were asynchronous limb movements, meaning the arms and legs jerking out of rhythm with each other rather than in the synchronized pattern typical of a generalized tonic-clonic (epileptic) seizure.² Neither of these is definitive on its own, but together with a careful clinical history, they help point the diagnostic conversation in the right direction.

How the Diagnosis Is Made

The gold-standard test is video electroencephalogram (EEG) monitoring, in which a patient is admitted to a hospital unit and continuously recorded on video while brain-wave activity is tracked. The goal is to capture a typical episode on camera and see whether the EEG shows epileptic discharges during it. If the event looks like a seizure on video but the brainwaves remain normal, a non-epileptic seizure is confirmed.³ A separate systematic review reinforced that combined video-EEG remains the benchmark, even as researchers explore whether video alone might sometimes be enough.⁴

This process sounds straightforward, but it has practical limitations. Video-EEG units have limited beds and long waiting lists. A patient might not have a seizure during a short monitoring session. And because some people have both epilepsy and non-epileptic seizures, a single recorded epileptic event does not rule out additional non-epileptic events. In one study, roughly a third of patients with confirmed non-epileptic seizures also had coexisting epilepsy, and their non-epileptic events tended to be recorded earlier in the admission (on average by the second day) while epileptic seizures appeared later (around the fifth day), suggesting that longer monitoring periods are sometimes needed to catch both types.⁵

Blood Tests and Other Bedside Clues

Emergency departments sometimes check serum prolactin levels after a convulsive event. Prolactin, a hormone produced by the pituitary gland, tends to spike after a genuine epileptic convulsion. One study found that using a prolactin cutoff of 24 ng/mL achieved high sensitivity and specificity for distinguishing non-epileptic attacks from other seizure types without convulsions.⁶ However, another cross-sectional study found that median prolactin levels were not significantly different between epileptic and non-epileptic groups, raising questions about how reliable this biomarker is across different settings and seizure subtypes.⁷ In that same study, lactate dehydrogenase (an enzyme released when muscles work hard) was significantly higher after epileptic convulsions, hinting at another potential differentiator.

Heart-rate patterns during and after episodes also differ. During a non-epileptic seizure, heart rate rises and the balance between the “fight-or-flight” and “rest-and-digest” branches of the nervous system shifts toward the fight-or-flight side.⁸ After an epileptic convulsion, however, there tends to be a measurable depression in autonomic function that is not seen following a non-epileptic convulsion.⁹ These physiological signatures are still research tools rather than bedside diagnostics, but they underline an important point: non-epileptic seizures involve genuine, measurable changes in the body, even though they do not involve epileptic brain discharges.

Why Non-Epileptic Seizures Happen

There is no single cause. The condition sits at the intersection of neurology and psychiatry, and most researchers now view it as the nervous system’s maladaptive response to overwhelming stress, trauma, or emotional dysregulation. Childhood trauma is one of the most consistently identified risk factors. A study comparing trauma scores in people with non-epileptic seizures and people with epilepsy found large differences across nearly every domain of childhood adversity, with emotional abuse and emotional neglect showing the biggest gaps.¹⁰ A systematic review looking specifically at abuse histories found that the odds of reporting abuse were consistently higher in people with non-epileptic seizures compared with those who had epilepsy, with most odds ratios falling between roughly 2 and 5.¹¹

But trauma is not present in every case. Some patients develop non-epileptic seizures in the context of chronic pain, medical illness, or major life stress without any identifiable abuse history. Psychological traits also play a role. Alexithymia, the difficulty recognizing and naming your own emotions, has been found in more than a third of people with non-epileptic seizures. In that group, alexithymia correlated with trauma-related symptoms like intrusive memories, avoidance behavior, and dissociation.¹² Dissociation itself, the experience of feeling detached from your body, memories, or surroundings, is another common feature and has been linked to measurable changes in brain connectivity.¹³

Panic also enters the picture. A study found that a composite score of panic symptoms could distinguish people with non-epileptic seizures from those with epilepsy or fainting, with sensitivity and specificity both around 71%.¹⁴ Panic attacks are recognized as both a trigger for non-epileptic events and a differential diagnosis that can confuse the clinical picture.¹⁵

What Brain Imaging Shows

People sometimes assume that because non-epileptic seizures are “not epilepsy,” nothing is wrong with the brain. Neuroimaging research tells a different story. A study using functional and structural brain-network analysis found that people with non-epileptic seizures had altered network organization compared with healthy controls, including decreased overall connectivity strength and changes to the brain’s characteristic small-world structure.¹⁶ Other research has shown increased involvement of brain regions associated with emotion regulation, body awareness, and motor planning, including the insula, cingulate cortex, and supplementary motor area, in the resting-state networks of people with non-epileptic seizures.¹⁷ The strength of these connectivity changes correlated with dissociation scores, suggesting a biological basis for a symptom that is sometimes dismissed as purely psychological.

When Someone Has Both Epilepsy and Non-Epileptic Seizures

This overlap complicates everything. It is more common than many clinicians once thought. One monitoring study found that roughly 7% of all patients with non-epileptic seizures also had epilepsy confirmed on the same admission, and that when the analysis was limited to those who had non-epileptic events recorded, the rate of coexisting epilepsy was about 32%.¹⁸ A separate case-control study found that people who had both conditions were more likely to have epilepsy originating in the frontal lobes, compared with the temporal-lobe origin that is more typical of epilepsy on its own.¹⁹ People with both epilepsy and non-epileptic seizures are not a uniform group either; research has identified subgroups within them, differing by epilepsy type, cognitive level, psychiatric comorbidity, and trauma history.²⁰

The practical consequence for patients is significant. People with coexisting epilepsy often end up on escalating doses of anti-seizure medications that only address the epileptic component, while the non-epileptic seizures continue uncontrolled. Identifying which events are which can save someone from years of unnecessary medication adjustment and its side effects.

How the Diagnosis Is Delivered Makes a Difference

Being told your seizures are “not epilepsy” can feel dismissive, as though a doctor is saying your problem is not real. How this information is communicated matters greatly. A study evaluating a structured approach to delivering the diagnosis found that three months later, 14% of patients were seizure-free and 63% reported their seizure frequency had dropped by more than half, before any formal therapy was even started.²¹ In other words, simply receiving a clear, empathetic explanation of the condition was itself therapeutic for a majority of patients.

The shift toward the term “functional seizures” is partly driven by this insight. Research found that patients considered “functional seizures” more acceptable and less stigmatizing than “psychogenic nonepileptic seizures,” and clinicians were also warming to it.²² The older label implied the problem was “in your head” in a way that discouraged people from seeking treatment. The newer term frames the seizures as a malfunction of the nervous system that can be addressed, which aligns better with the brain-imaging evidence and helps patients engage with care rather than abandon it.

Treatment Options

Because non-epileptic seizures are not driven by abnormal electrical discharges, anti-seizure medications do not treat them. The cornerstone of treatment is psychotherapy, most commonly cognitive behavioral therapy (CBT). A pilot randomized controlled trial found that seizure reduction with CBT was significantly greater than with standard medical care alone, with the CBT group more likely to achieve sustained seizure freedom.²³ An earlier uncontrolled study reported that 11 of 17 people who completed CBT were seizure-free by their final session, along with improvements in depression, anxiety, and quality of life.²⁴

Medication can still play a supporting role by treating the psychiatric conditions that often accompany non-epileptic seizures. A pilot trial of sertraline found a 45% reduction in seizure rates compared with an 8% increase on placebo.²⁵ Venlafaxine showed similar promise in patients with coexisting anxiety or depression, with sustained reductions in both mood symptoms and seizure frequency over the study period.²⁶ These are small studies, and larger trials are needed, but the pattern is consistent: when the emotional and psychological drivers of the seizures are addressed, the seizures tend to improve.

Physical therapy designed for functional neurological disorders has also shown early promise. A feasibility study found a positive correlation between the number of physical therapy sessions attended and clinical improvement, even in patients with concurrent non-epileptic seizures and other neurological conditions.²⁷ The idea is that retraining the body’s movement patterns and stress responses can complement the psychological work done in therapy. Most experts now advocate a multidisciplinary approach combining neurology, psychiatry or psychology, and allied health professionals.

Long-Term Outlook

The prognosis for non-epileptic seizures is honest-to-goodness mixed. A review of outcome studies found that in adults, 40% or fewer achieved seizure remission across most follow-up periods, though children fared considerably better.²⁸ A more recent study reported that about a third of patients were seizure-free at long-term follow-up, but only 37% were regularly employed, and fewer than half described their quality of life as satisfying. Shorter illness duration before diagnosis was associated with better outcomes.²⁹ Factors that predicted worse outcomes included having coexisting epilepsy, additional psychiatric diagnoses, more violent seizure presentations, and social isolation or dependent living situations.³⁰

The economic toll of delayed diagnosis is substantial. One study calculated the annual costs of anti-seizure medications, psychostimulant drugs, and diagnostic procedures for patients who had non-epileptic seizures but were being treated as if they had epilepsy, and concluded that earlier diagnosis and appropriate psychosocial support would meaningfully reduce the financial burden on both patients and health systems.³¹ The average diagnostic delay documented in studies ranges from several years to nearly a decade, depending on the setting.

Non-Epileptic Seizures in Children and Adolescents

Children with non-epileptic seizures tend to respond better to treatment than adults. A study of 60 children and adolescents found that 75% regained normal function and returned to school full-time when families were able to understand and accept the diagnosis. The key was explaining the seizures as the body’s atypical defense response to stress and emotional overload, rather than framing the problem in purely psychiatric terms.³² Outcomes were less favorable in young people who had been experiencing seizures for a long time before diagnosis or who had chronic psychiatric conditions that persisted despite treatment. This reinforces the broader message across age groups: the sooner the condition is correctly identified and addressed, the better the chances of recovery.

Cultural Factors and Diagnostic Delay

How non-epileptic seizures are understood varies across cultures, and this shapes how quickly people get diagnosed. In some communities, the episodes are attributed to spiritual possession, religious experiences, or sorcery. An Indian study found that more than half of patients attributed their seizures to being possessed by a god, ghost, or evil spirit, and the vast majority had visited faith healers before seeing a neurologist.³³ These beliefs do not cause the seizures, but they do affect the path to diagnosis and treatment.

Even within Western medical systems, cultural and institutional factors create delay. A cross-cultural comparison between patients in the United States and Brazil found that the average delay to diagnosis was nearly ten years in Brazil versus about five and a half years in the U.S. Patients in Brazil also had an earlier age of onset and were less likely to report subjective seizure experiences to their doctors.³⁴ These differences suggest that access to specialized monitoring, cultural openness about psychological symptoms, and physician awareness of functional seizures all shape how long a person lives with an incorrect diagnosis.

Cognitive Effects That Often Get Overlooked

People with non-epileptic seizures frequently report problems with memory, concentration, and mental clarity, but these cognitive complaints do not always mirror those seen in epilepsy. A comparative study found that while memory problems were the dominant cognitive issue for people with epilepsy, attention and executive function difficulties were more prominent in those with non-epileptic seizures.³⁵ A separate preliminary study using attentional tasks found subtle differences in how the two groups handled alerting cues, though overall executive control and orientation performance were similar.³⁶ These findings matter because cognitive symptoms in non-epileptic seizures are often attributed to anti-seizure medications the person may be taking unnecessarily. Once the correct diagnosis is made and inappropriate medications are withdrawn, some of those cognitive difficulties may improve, though the attention and executive-function issues tied to the underlying condition can persist and may benefit from targeted rehabilitation.