Psychogenic nonepileptic seizures (PNES) look like epileptic seizures but aren’t caused by abnormal electrical activity in the brain. They are a physical manifestation of psychological distress, where the nervous system reacts to emotional overload, trauma, or stress by producing seizure-like episodes. Between 44% and 100% of people with PNES have a history of significant trauma, and the condition is now formally classified as a type of functional neurological disorder.
How PNES Differs From Epilepsy
During an epileptic seizure, neurons in the brain fire in sudden, synchronized bursts that show up clearly on an EEG. During a PNES episode, that electrical surge doesn’t happen. The shaking, unresponsiveness, or convulsions are real and involuntary, but they originate from the way the brain processes stress and emotion rather than from a malfunction in its electrical signaling. This is not the same as faking. People with PNES are not consciously producing their seizures.
The gold standard for telling the two apart is video-EEG monitoring, where brain activity is recorded during an actual episode. If a seizure occurs on camera with no corresponding electrical changes on the EEG, PNES is the diagnosis. Unfortunately, it takes an average of 7.2 years from the time symptoms first appear for patients to receive an accurate PNES diagnosis, often after years of being treated with epilepsy medications that don’t help.
Roughly 10% of PNES patients also have genuine epilepsy, which makes diagnosis even harder. Some older studies put that overlap as high as 50% or 60%, but more rigorous evaluations suggest the true number is closer to 10%.
Trauma and Emotional Distress
The single strongest predictor of PNES is a history of trauma. Studies consistently find trauma rates of 44% to 100% among PNES patients, with rates of physical or sexual abuse ranging from 23% to 77%. These figures run 15 to 40 percentage points higher than in comparison groups. A history of trauma increases the relative risk of developing PNES by more than eightfold.
The trauma doesn’t have to be a single catastrophic event. Chronic childhood neglect, repeated emotional abuse, bullying, or growing up in an environment of constant threat can all prime the nervous system to respond to stress through physical symptoms. In many cases, the person may not consciously connect their seizures to past experiences, especially when the trauma occurred early in life or has been partially dissociated from conscious memory.
Post-traumatic stress disorder (PTSD) is one of the most common underlying conditions, but it’s far from the only one. Anxiety disorders with panic attacks, depression, dissociative disorders, personality disorders, and somatic symptom disorder all appear frequently in people with PNES.
What Happens in the Brain
Neuroimaging research has started to reveal what’s going on under the surface. Brain scans of people with PNES show abnormal connections between the regions that process emotions and the regions responsible for executive control, meaning the brain’s ability to regulate responses, make decisions, and override automatic reactions. The anterior cingulate cortex, a structure that sits at the crossroads of emotion and cognition, shows particularly disrupted connections.
In practical terms, this means the brain’s emotional alarm system can fire without the usual checks and balances. When stress or a triggering emotion hits, the brain essentially short-circuits. Instead of processing the emotion through normal channels, it converts the distress into a physical event. This is why PNES is classified under functional neurological symptom disorder in the DSM-5 and as a dissociative neurological symptom disorder in the ICD-11. The nervous system is structurally intact but functionally misfiring.
Common Triggers for Episodes
PNES episodes often have identifiable triggers, though not always. The most common fall into three categories:
- Emotional stressors: conflict with a partner, work pressure, financial worry, grief, or anything that activates a strong emotional response the person struggles to process.
- Physical triggers: pain, injury, illness, sleep deprivation, or sensory overload. Some people notice episodes cluster around menstrual cycles or periods of physical exhaustion.
- Environmental reminders of past trauma: a smell, a sound, a location, or a social dynamic that unconsciously recalls an earlier traumatic experience. These triggers can operate below conscious awareness, which is why many people feel their seizures come “out of nowhere.”
Not every episode has an obvious trigger. Over time, the seizure pattern can become its own learned response in the nervous system, firing in situations of even mild stress once the pathway is established.
Depression, Anxiety, and Other Contributing Conditions
People with PNES consistently report higher levels of anxiety and depression than people with epilepsy, despite the fact that epilepsy itself carries a significant mental health burden. Somatization disorder, where emotional distress shows up as unexplained physical symptoms across the body, carries a particularly high association with PNES, increasing relative risk by roughly 13 times.
These conditions aren’t just coincidental. They feed the same cycle. Anxiety raises the baseline level of nervous system activation. Depression erodes coping resources. Together, they lower the threshold at which the brain converts stress into a physical seizure event. And the seizures themselves generate more anxiety and depression, creating a self-reinforcing loop that’s difficult to break without treatment.
How PNES Is Treated
Because PNES is rooted in how the brain processes emotion and stress, the most effective treatments are psychological. Cognitive behavioral therapy (CBT) specifically adapted for PNES produced a 51.4% reduction in seizure frequency in a clinical trial using 12 weekly one-hour sessions. When CBT was combined with a common antidepressant, seizure frequency dropped by 59.3%, along with improvements in overall functioning. Notably, the antidepressant alone did not produce a significant reduction in seizures, and neither did standard medical care without therapy.
Beyond reducing seizure frequency, CBT improved quality of life, social functioning, and symptoms of depression and anxiety. The therapy works by helping people identify the emotional and cognitive patterns that precede seizures, develop healthier stress responses, and gradually process the underlying experiences driving the episodes.
Other therapeutic approaches include trauma-focused therapy for people with PTSD, psychodynamic therapy that explores unconscious emotional conflicts, and techniques that improve awareness of physical stress signals before they escalate into a full episode. Treatment is most effective when the person understands and accepts the diagnosis, which is one reason the years-long diagnostic delay matters so much. Every year spent on the wrong treatment is a year the actual cause goes unaddressed.