Psychogenic non-epileptic seizures (PNES) are episodes that can appear indistinguishable from an epileptic seizure, but they do not originate from abnormal electrical activity in the brain. They are a common presentation in neurology and epilepsy clinics, yet they are a manifestation of psychological distress. Because they lack an electrical cause, PNES are not a form of epilepsy, though they are frequently misdiagnosed as such. This confusion often leads to significant delays in receiving the correct care, sometimes averaging seven to ten years for patients.
Defining Psychogenic Non-Epileptic Seizures
PNES are a type of functional neurological symptom disorder where psychological conflicts are expressed through physical, seizure-like events. The term “psychogenic” indicates the origin is psychological, meaning the physical symptoms are a genuine, involuntary reaction to mental distress. PNES is not a conscious act of faking a seizure, but rather a manifestation of emotional overload processed physically by the body. The underlying mechanism involves a functional disruption in the brain’s communication system, often described as a “software” problem rather than a “hardware” issue like epilepsy.
Since these episodes are not caused by electrical discharges in the brain, they do not respond to anti-epileptic drugs (AEDs). Treating PNES with these medications is ineffective and exposes the patient to unnecessary side effects, delaying appropriate psychological treatment. When PNES is mistakenly treated as epilepsy, continued seizures may be misinterpreted as “drug-resistant epilepsy,” which prolongs misdiagnosis. Distinguishing the root cause is necessary for effective management.
Distinguishing Features of PNES Events
PNES events display unique characteristics that help differentiate them from true epileptic seizures, though no single feature is definitive. PNES typically have a gradual onset, where movements begin slowly and build in intensity, unlike the sudden onset often seen in epilepsy. The movements are often asynchronous, meaning the limbs move in an uncoordinated, thrashing, or fluctuating pattern, rather than the rhythmic, synchronized jerking of a tonic-clonic seizure.
PNES commonly last many minutes or even hours, which is much longer than most epileptic seizures. The patient may retain some level of awareness or recall of the events, or exhibit closed eyes and resistance to eye opening during the episode. Self-injury is rare; features like biting the tongue or experiencing serious falls occur less frequently in PNES than in epileptic seizures. These observable differences provide initial clues but must be confirmed with objective testing.
The Diagnostic Process: Ruling Out Epilepsy
The definitive diagnosis of PNES requires a specialized medical procedure to confirm the absence of abnormal brain activity during an event. The gold standard is Video-Electroencephalography (Video-EEG) monitoring, performed in an Epilepsy Monitoring Unit. This process simultaneously records the patient’s physical behavior using video while monitoring the electrical activity of the brain with an EEG.
The core purpose of this procedure is to capture a typical episode while the patient is connected to the monitoring equipment. If a seizure-like event occurs and the EEG recording remains normal—showing no evidence of epileptic brain waves—the diagnosis of PNES is confirmed with high accuracy. A neurologist plays a primary role, but a psychiatric consultation is also necessary. This combination of electroclinical analysis and a thorough psychosocial evaluation ensures the correct distinction is made, allowing for the discontinuation of ineffective anti-epileptic medication.
Root Causes and Associated Conditions
The development of PNES is strongly linked to underlying psychological factors, often fitting the criteria for a conversion disorder, which is classified under functional neurological symptom disorder. The seizure acts as an involuntary physical outlet for overwhelming emotional pain or conflict. The symptoms are a way for the body to cope with psychological distress that the individual cannot process or express consciously.
A significant proportion of individuals with PNES have a history of psychological trauma, particularly childhood abuse, which contributes to the condition’s emergence. Associated mental health conditions are highly prevalent. These include Post-Traumatic Stress Disorder (PTSD), anxiety disorders, and depressive disorders. Studies indicate that depressive disorders and PTSD are common co-existing conditions. This complex interplay of biological susceptibility, psychological history, and social stressors forms the etiology of PNES.
Effective Treatment and Management Strategies
Once the diagnosis of PNES is established, the treatment path shifts away from pharmacology and toward psychological intervention. Treatment primarily centers on addressing the emotional conflicts and psychological distress that manifest as seizures. Effective management begins with clear and compassionate communication of the diagnosis, which alone can reduce seizure frequency for some patients.
The most effective psychological treatment is Cognitive Behavioral Therapy (CBT). CBT focuses on helping the patient identify seizure triggers and develop alternative, healthier coping mechanisms for stress and emotion management. Trauma-focused therapies, such as Eye Movement Desensitization and Reprocessing (EMDR), may also be utilized if a history of trauma is present. Treatment is typically multidisciplinary, involving collaboration between the neurologist and a mental health professional to ensure comprehensive care.