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Psychogenic non-epileptic seizure

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(Redirected from Functional seizures)
See also: Non-epileptic seizure
Psychogenic non-epileptic seizure
Other namesFunctional seizures, dissociative seizures, non-epileptic attack disorder (NEAD), non-epileptic seizures (NES), functional non-epileptic attacks (FNEA)
SpecialtyNeurology, psychiatry
SymptomsSeizure-like episodes without EEG evidence of epilepsy; may include unresponsiveness, shaking, or altered awareness
ComplicationsMisdiagnosis as epilepsy, unnecessary medication, impaired quality of life, psychiatric comorbidity
DurationVariable; can persist without treatment
Diagnostic methodClinical evaluation, video-EEG monitoring
Differential diagnosisEpileptic seizures, syncope, panic attacks, movement disorders, migraine, hypoglycemia
TreatmentPatient education, psychotherapy (especially cognitive behavioral therapy), treatment of comorbid conditions

Psychogenic non-epileptic seizures (PNES), also referred to as functional seizures or dissociative seizures,[1][2] are episodes that resemble epileptic seizures but are not caused by abnormal electrical activity in the brain.[3][4] Instead, they are classified as a type of functional neurological disorder (FND), in which symptoms arise from changes in brain function rather than structural disease or epilepsy. During a PNES episode, seizure-like behavior occurs in the absence of epileptiform activity on electroencephalogram (EEG).[5]

PNES can be difficult to distinguish from epileptic seizures based on clinical observation alone. Diagnosis is typically confirmed through video-EEG monitoring, which records both the clinical event and the absence of epileptiform activity. These episodes are involuntary and genuine, not consciously produced. Management primarily involves psychological treatment, particularly cognitive behavioral therapy (CBT). Outcomes vary and are influenced by factors such as early diagnosis, therapeutic engagement, and coexisting psychiatric conditions.

Signs and symptoms

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PNES episodes involve sudden changes in movement, sensation, or awareness that closely resemble epileptic seizures. During an episode, a person may exhibit convulsive movements (such as stiffening, jerking, or thrashing of the limbs), appear unresponsive, or display other seizure-like behaviors. Because of this resemblance, PNES can be difficult to distinguish from epilepsy without careful observation and diagnostic tools, such as long-term video EEG monitoring.

Certain features are more commonly seen in PNES than in epileptic seizures, although none are exclusive.[6] These may include eye closure during the event, side-to-side movements of the head or body, limb movements that are asynchronous or irregular, and crying or stuttering. People with PNES may also show signs of awareness, respond to touch or voice, or behave in ways that appear influenced by their surroundings.[7][8] PNES episodes also tend to begin more gradually than epileptic seizures,[9] and typically do not result in confusion or deep sleep afterward (postictal state), which is common following epileptic seizures.

PNES episodes also tend to result in fewer physical injuries. Complications such as tongue-biting, loss of bladder or bowel control, injuries from falls, or burns are much less common. Even when a person appears unresponsive, they may retain some awareness and instinctively protect themselves. Signs such as tracking movement with the eyes or resisting gentle attempts to open the eyelids can suggest preserved consciousness.[8][6] These features may support the diagnosis of PNES, although no single sign is definitive.

The duration of an event can also help differentiate PNES from epileptic seizures. Most epileptic seizures last less than two minutes, whereas PNES episodes often last longer. A seizure lasting more than five minutes is considered a life-threatening medical emergency, a risk not associated with PNES.

Causes

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The causes of PNES are complex and not linked to a single underlying mechanism. The condition is best understood within a biopsychosocial framework, which considers the interaction of psychological, neurobiological, and social factors. These influences are often described in terms of predisposing, precipitating, and perpetuating factors.[1][10][11]

Predisposing factors may include early adversity, difficulties with emotional processing or regulation, and certain psychological traits. These traits do not directly cause PNES but may increase vulnerability when combined with biological and environmental influences. Precipitating factors are events that occur near the time of symptom onset, such as acute psychological stress, interpersonal conflict, or stress related to physical illness or injury. Perpetuating factors are those that contribute to the continuation of symptoms after they begin. These may include initial misdiagnosis as epilepsy, repeated medical investigations that inadvertently reinforce illness-focused behavior, and avoidance of situations associated with distress or fear. Ongoing mental health difficulties can also play a role, while disruptions to social, educational, or occupational functioning may further hinder recovery.[11]

While a history of trauma is commonly reported among individuals with PNES, it is neither necessary nor sufficient for the disorder to occur.[12] Psychiatric comorbidities are common, particularly post-traumatic stress disorder (PTSD), depressive and anxiety disorders, personality disorders, and other functional neurological symptoms.[13][1]

PNES episodes are not consciously produced and are not under voluntary control. They are distinct from conditions such as malingering or factitious disorder, in which symptoms are intentionally fabricated or induced.[14][15][11]

An estimated 10% to 30% of individuals with PNES also have coexisting epilepsy, which can complicate both diagnosis and treatment.[11]

Diagnosis

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PNES are often difficult to distinguish from epileptic seizures based on clinical observation alone. The gold standard for diagnosis is video-EEG monitoring,[16] which records both the clinical event and corresponding brain activity. In PNES, seizure-like behavior occurs in the absence of epileptiform activity on the EEG. While routine EEGs may be performed during initial evaluation, they are often normal or inconclusive in individuals with PNES and cannot confirm the diagnosis. Certain clinical features may raise suspicion of PNES, but none are definitive, and many overlap with epileptic seizures.[6]

In the DSM-5, psychogenic non-epileptic seizures are classified under functional neurological symptom disorder (conversion disorder). The diagnosis is based on the presence of neurological symptoms that are incompatible with known neurological conditions and are not better explained by another disorder, and cause significant distress or impairment.[17]

Serum prolactin levels were once considered a possible aid in distinguishing epileptic from non-epileptic seizures, particularly if measured shortly after a seizure. However, due to limited accuracy and lack of specificity, this test is no longer recommended in routine clinical practice.

Differential diagnosis

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The primary step in differential diagnosis is to exclude epilepsy, along with other organic causes of non-epileptic seizures, including syncope, migraine, vertigo, anoxia, hypoglycemia, and stroke. However, 10–30% of people with PNES also have comorbid epilepsy.[18] Frontal lobe seizures can be mistaken for PNES, though these tend to have shorter duration, stereotyped patterns of movements, and occurrence during sleep.[16]

Psychiatric conditions may also resemble PNES. Panic attacks, dissociative episodes, and other functional neurological symptoms can involve unresponsiveness, shaking, or altered awareness that mimic seizures. PNES may co-occur with disorders such as post-traumatic stress disorder (PTSD) or functional movement disorders, and diagnostic clarity often requires careful assessment of context, semiology, and psychiatric history.

Factitious disorder and malingering may be considered in rare cases where there is evidence of intentional symptom production. These are distinct entities with different motivations; in the vast majority of cases, PNES occur involuntarily and without conscious intent.

Treatment

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There is no single treatment for psychogenic non-epileptic seizures (PNES). Instead, management focuses on a multidisciplinary approach that includes patient education, psychotherapy, and treatment of comorbid psychiatric conditions.[19][20] Early diagnosis and appropriate communication of the diagnosis are critical, as delayed recognition and misdiagnosis with epilepsy are associated with worse outcomes.[1]

Patient understanding of the new diagnosis is crucial for their treatment, which requires their active participation.[20] The first step in treatment is often a clear, compassionate explanation of the diagnosis, emphasizing that the seizures are real, not intentionally produced, and potentially reversible. Studies suggest that how the diagnosis is delivered can significantly affect patient engagement and prognosis.[21]

Psychotherapy is the mainstay of treatment. Cognitive behavioral therapy (CBT) is the most widely studied and evidence-supported treatment for PNES, and has demonstrated modest benefits in reducing seizure frequency and improving quality of life.[22] Other therapeutic approaches may include trauma-focused therapy, interpersonal therapy, or psychodynamic psychotherapy, depending on individual needs and comorbidities. A brief psychological intervention known as Retraining and Control Therapy (ReACT) has been studied in children and adolescents with PNES; however, more research is needed to determine its long-term effectiveness and applicability.[23]

There is no medication specifically indicated for the treatment of PNES. However, psychiatric medications such as antidepressants or anxiolytics may be prescribed to treat comorbid conditions.[21]

Antiseizure medications are not effective for PNES and are generally discontinued after the diagnosis is confirmed, unless the individual also has coexisting epilepsy. Long-term use of antiseizure drugs in PNES has been associated with unnecessary side effects and healthcare costs.

Prognosis

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The long-term outcome of PNES varies widely. While some individuals experience a significant reduction in seizure frequency or complete remission following diagnosis and treatment, others continue to have persistent symptoms and associated impairment.[1][24] Several factors are associated with a better prognosis in PNES: early diagnosis, acceptance of the diagnosis and willingness to engage in therapy, good therapeutic alliance with healthcare providers, and absence of severe comorbid psychiatric or personality disorders.[21] In contrast, chronic or untreated PNES, significant psychiatric comorbidities, ongoing psychosocial stressors, and resistance to mental health treatment are linked to poorer outcomes.[24]

Epidemiology

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Data on the epidemiology of PNES in the general population remain limited. Available estimates suggest that PNES is an uncommon diagnosis in community settings but is frequently encountered in specialized epilepsy care. A 2021 systematic review calculated the annual incidence at approximately 3.1 per 100,000, based on population-based studies from Iceland, Scotland, and the United States.[25] Using modeling based on incidence and outcome data, the same study estimated a point prevalence of 108.5 per 100,000 in the United States in 2019.[25] Among adults referred to epilepsy monitoring units (EMUs) for refractory seizures, 20–40% are diagnosed with PNES, while outpatient epilepsy clinics report rates of 5–10%.[25]

The condition is more frequently diagnosed in women, with female-to-male ratios reported between 2.7 and 4.4. Estimates are influenced by diagnostic delays, differences in healthcare access, and limited availability of population-based studies.[25]

Children

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Data on the epidemiology of PNES in children are limited, and most studies are based on selected populations undergoing video-EEG monitoring. Reported prevalence in pediatric video-EEG units ranges widely, from 3.5% to 20%. Community-based prevalence estimates are sparse, but some sources have cited figures between 2 and 33 per 100,000, though these are largely extrapolated from adult data.[26] PNES are rare before the age of eight and become more common during adolescence. The average age at presentation is typically between 11 and 14 years, with most studies reporting a higher prevalence among girls, although some have found a more equal gender distribution in younger children.[26]

History

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The phenomenon of psychogenic seizures has been recognized (in various forms) for centuries. Seizure-like episodes without apparent neurological cause have been associated with hysteria since antiquity, particularly in women. Ancient Greek and Roman physicians, including Aretaeus of Cappadocia, described conditions they linked to reproductive dysfunction and psychological factors. In the 19th century, Jean-Martin Charcot provided the first systematic medical descriptions of these episodes, coining the term hystero-epilepsy to distinguish them from epileptic seizures.[27]

The psychoanalytic framework of the late 19th and early 20th centuries, particularly through the work of Sigmund Freud, reframed hysteria as a manifestation of unconscious psychological conflict.[27] In this context, it was proposed that repressed traumatic experiences could be "converted" into physical symptoms, such as convulsions or loss of consciousness; this conversion theory became the dominant explanation for such episodes throughout much of the 20th century and shaped early diagnostic categories of conversion disorder. The DSM-IV lists conversion disorders instead of the current FND.[28] Additionally, in revision, the DSM-5 was updated to add emphasis to the positive physical signs inconsistent with recognized diseases. The requirement of a history of psychological stressors and that the symptom is not fake was removed as well.

Society and culture

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PNES challenge conventional boundaries between mental and physical illness, in part because their symptoms are real and disabling, but do not originate from epileptic brain activity. Historically, the condition has been associated with significant stigma, both social and clinical.[29][30] Cultural and contextual factors also influence how PNES are perceived. In some societies, seizure-like episodes are understood through religious or spiritual frameworks, such as demonic possession, curses, or witchcraft.[31] These interpretations can shape how individuals experience and explain their symptoms, as well as the kind of care they seek. In highly medicalized settings, the absence of objective findings on EEG or neuroimaging may lead to moral judgments, including assumptions of attention-seeking or malingering.[29] These beliefs can contribute to internalized stigma, reduced help-seeking, and poorer health outcomes. Culture-specific understandings of illness, along with structural factors such as access to interdisciplinary care, can shape both the experience of PNES and the social responses it provokes.[30] Stigmatizing language — such as 'pseudo,' 'false,' or 'hysterical' — has contributed to perceptions that PNES is feigned or under voluntary control.[30][29]

Terminology

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The terminology used to describe PNES has evolved over time, reflecting changes in medical understanding as well as shifting attitudes toward functional disorders. Historically, the term pseudoseizure was widely used, but it has fallen out of favor due to its stigmatizing connotations. The prefix pseudo- implies falseness or deception, and its use has been associated with patient-blaming and the perception that symptoms are faked or not legitimate. Major professional bodies, including the International League Against Epilepsy (ILAE), now discourage the term in both clinical and research settings.

The current standard term, psychogenic non-epileptic seizures, has become widely used in clinical and research contexts. However, it has also drawn criticism. The label "psychogenic" implies a purely psychological origin, potentially reinforcing a dualistic distinction between mind and brain that is increasingly challenged by neuroscientific research.[29] It also suggests that identifiable psychological causes, such as trauma or stress, are always present — an assumption not borne out in all cases. Furthermore, the term nonepileptic defines the condition by what it is not, offering little positive information to patients and sometimes hindering acceptance of the diagnosis.[5]

Alternative terms, including functional seizures and dissociative seizures, are increasingly used in clinical practice. These labels are more neutral with regard to etiology and align PNES with the broader category of functional neurological disorder, as recognized in the DSM-5.

Debate also surrounds the appropriate root term: seizure, attack, or event.[32] While some clinicians favor broader terms like non-epileptic events to avoid confusion with epilepsy, the term seizure better captures the paroxysmal and stereotyped semiology of the episodes. It also allows PNES to be classified consistently with other seizure types, such as febrile or hypoglycemic seizures, which are not epileptic but are still medically recognized. Importantly, studies suggest that many patients prefer the term seizure to alternatives such as attack or fit, and clinicians are encouraged to provide careful explanations to minimize confusion.[5]

References

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