Psychogenic non-epileptic seizures (PNES) are episodes that look physically similar to epileptic seizures but do not involve the abnormal electrical brain activity associated with epilepsy. PNES is an involuntary condition where psychological distress manifests as a physical event. These events are real and not consciously faked, representing a genuine neurological appearance rooted in the individual’s mental health. The condition is often classified as a type of functional neurological disorder (FND) because the symptoms stem from a disturbance in brain function, rather than a structural disease.
What PNES Is and How It Presents
The clinical presentation of PNES can vary significantly, often mimicking the full-body shaking seen in tonic-clonic epileptic seizures. Observable signs include asynchronous limb movements, which may involve thrashing or bicycling motions that lack the rhythmic pattern of true epileptic convulsions. Events often begin gradually and may include features like rapid side-to-side head movements or pelvic thrusting, which are less typical of epilepsy.
A notable feature is the duration of the episodes, as PNES events frequently last longer than two minutes, whereas most epileptic seizures are shorter. During the event, an individual may exhibit unresponsiveness while their eyes are closed, sometimes resisting efforts to open them. Other signs can involve weeping, stuttering, or even preserved awareness despite the convulsive activity.
Differentiating PNES from Epileptic Seizures
The distinction between PNES and epileptic seizures (ES) is paramount, as misdiagnosis leads to ineffective and potentially harmful anti-epileptic drug use. Epilepsy is characterized by uncontrolled electrical discharges in the brain, while PNES is a psychological manifestation. A definitive diagnosis requires specialized testing, specifically Video-Electroencephalography (VEEG) monitoring.
VEEG is considered the diagnostic gold standard because it simultaneously records the patient’s physical movements via video and their brain’s electrical activity via EEG. During a confirmed PNES event, the EEG recording will remain normal, showing no epileptiform activity, which rules out epilepsy. Conversely, an epileptic seizure will show abnormal electrical signals on the EEG during the event.
Clinical observations also help differentiate the two conditions, though no single sign is definitive. Epileptic seizures are associated with an abrupt onset, a high likelihood of self-injury like tongue-biting, and a period of deep confusion or sleep afterward, known as the post-ictal state. PNES episodes often show a more gradual onset, rarely result in self-injury, and are typically followed by weeping, fear, or a lack of post-ictal confusion. Patients experiencing PNES may also show responsiveness to external cues, such as verbal commands or loud noises, during the event, which is unlikely during a true epileptic seizure.
The Psychological Roots of Non-Epileptic Seizures
PNES is classified in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as a form of Functional Neurological Symptom Disorder, historically known as conversion disorder. The physical symptoms are an involuntary conversion of internal emotional distress into a neurological symptom. They represent a physical manifestation of a psychological conflict the individual cannot express or resolve internally.
A significant underlying factor in the development of PNES is a history of trauma, including physical, sexual, or emotional abuse or neglect. Studies indicate that PNES patients have a significantly higher rate of past trauma compared to control groups. This condition often co-occurs with other mental health conditions, such as anxiety disorders, major depressive disorder, and Post-Traumatic Stress Disorder (PTSD).
Researchers propose that severe emotional distress, coupled with maladaptive coping mechanisms, leads to the activation of a “seizure scaffold” in the brain. The seizure event is thought to be a dissociative state, allowing the body to cope with overwhelming emotional content by physically expressing the distress. These factors combine in a complex biopsychosocial model, where emotional dysregulation and unresolved stress exceed the individual’s capacity to cope, leading to the functional neurological symptoms.
Comprehensive Treatment and Recovery
The treatment for PNES focuses on psychological intervention, as the condition is rooted in emotional and functional disturbances rather than abnormal electrical activity. The standard therapeutic approach is Cognitive Behavioral Therapy (CBT), specifically a tailored version known as CBT-informed psychotherapy (CBT-ip). This therapy is structured, time-limited, and focuses on addressing the cognitive distortions and behavioral patterns that maintain the seizures.
CBT-ip is highly effective, with studies showing that patients often experience a significant reduction in seizure frequency, and many achieve a 50% or greater reduction in episodes. The therapy works by helping the patient understand their diagnosis, identify seizure triggers, and develop healthier coping strategies for stress and emotional distress. Psychoeducation is a component of recovery, ensuring the patient comprehends that their diagnosis is real and involuntary.
Addressing co-morbid psychiatric conditions is an integral part of comprehensive care, often involving the treatment of underlying depression or anxiety. While psychotropic medications, such as antidepressants, may be used to manage these co-occurring mental health symptoms, they do not directly treat the PNES events themselves. Successful recovery hinges on a multidisciplinary approach involving neurologists and mental health specialists who collaboratively help the patient manage their underlying psychological factors.