Epileptic seizures arise from abnormal electrical discharges in the brain, while non-epileptic seizures look similar on the outside but have no such electrical signature. The most common type of non-epileptic seizure is the psychogenic non-epileptic seizure (often abbreviated PNES), which stems from psychological processes rather than misfiring neurons. Despite their different origins, these two types of events can be remarkably hard to tell apart at the bedside, and the average person with PNES waits years for a correct diagnosis. That delay carries real consequences, from unnecessary medications to invasive emergency procedures that do nothing to help.
What Is Actually Happening in the Brain
During an epileptic seizure, large groups of neurons fire in synchronized bursts. This runaway electrical activity shows up clearly on an electroencephalogram (EEG) as distinctive spike-and-wave patterns. The cause of that abnormal firing varies: structural damage from a stroke or tumor, genetic mutations affecting ion channels, metabolic disorders, infections, or immune-related inflammation. A large cohort study of children with epilepsy found structural causes in about 38% of cases, genetic causes in 11%, metabolic causes in 7%, and no identifiable cause in roughly 40%.
In a psychogenic non-epileptic seizure, the brain’s electrical activity looks normal during the episode. There is no epileptic discharge. Instead, brain-imaging research suggests that the problem lies in how different brain regions communicate with each other. One study using functional connectivity analysis found that people with PNES showed reduced connectivity in areas involved in processing emotions and regulating movement, alongside increased connectivity in regions tied to inhibiting unwanted movements and cognitive processes.1PubMed. Brain functional connectivity in individuals with psychogenic nonepileptic seizures (PNES): An application of graph theory Another study found increased synchronous activity in the left prefrontal cortex of PNES patients, an area linked to executive control and emotion regulation. The researchers proposed that this heightened activation may play a role in converting emotional triggers into physical symptoms.2Scientific Reports. Altered regional activity and inter-regional functional connectivity in psychogenic non-epileptic seizures
This distinction matters because the treatments for each condition are completely different. Antiseizure medications, which work by dampening abnormal electrical activity, have no mechanism to help in PNES because there is no abnormal electrical activity to dampen.
How to Tell Them Apart by Watching
Despite their different origins, epileptic and non-epileptic seizures can look almost identical to an untrained observer. Both can involve convulsive movements, loss of awareness, falls, and postictal confusion. Still, trained clinicians have identified certain observable features that tend to lean one way or the other.
A meta-analysis of semiological signs found that two features are particularly reliable indicators of PNES: eyes being closed during the event and asynchronous (side-to-side alternating or out-of-phase) limb movements.3PubMed Central. Using Semiology to Classify Epileptic Seizures vs Psychogenic Nonepileptic Seizures: A Meta-analysis During epileptic seizures, patients’ eyes are typically open, and limb movements tend to be rhythmic and synchronous. Other clinical features that differ between the two include prodromal symptoms (the sensations before the event), seizure duration, and whether the event can be provoked by suggestion.4The Egyptian Journal of Neurology, Psychiatry and Neurosurgery. Clinical differentiation of psychogenic non-epileptic seizure: a practical diagnostic approach
Tongue biting is another clue, though it works differently than most people assume. Biting the side of the tongue is highly specific for epileptic seizures. One pooled analysis found that lateral tongue biting had a specificity of about 99.8% for epileptic seizures, meaning that when it happens, you can be very confident the event was epileptic. But the sensitivity was low, so most epileptic seizures do not produce lateral tongue biting. Biting the tip of the tongue, by contrast, points more toward a syncopal (fainting) episode than either type of seizure.5Seizure. Letter to the Editor regarding tongue biting and seizures
No single sign clinches the diagnosis on its own. Clinicians rely on a combination of features and the overall clinical context. A person with PNES can still injure themselves during an event, still have incontinence, and still appear genuinely unconscious. These “pseudosleep” states and other hallmark features need careful interpretation rather than snap judgment.
The Diagnostic Gold Standard and Its Supplements
Video EEG monitoring remains the gold standard for distinguishing epileptic from non-epileptic seizures. A camera records what the patient looks like during an event while the EEG simultaneously records brain electrical activity. If a typical episode occurs on camera and the EEG shows no epileptiform discharges during it, that combination strongly supports a PNES diagnosis.6PubMed Central. Long-term video EEG monitoring for diagnosis of psychogenic nonepileptic seizures The catch is that patients sometimes have to stay in the monitoring unit for days before a typical event happens, which makes the test expensive and logistically difficult.
Blood tests can offer additional clues in more urgent situations. Serum prolactin levels tend to rise sharply after generalized tonic-clonic (convulsive) epileptic seizures and certain focal seizures but stay flat after PNES. One hospital-based study in children found that a prolactin level above 24 ng/mL, measured within an hour of the event, was suggestive of a generalized tonic-clonic or complex partial seizure, while lower levels pointed toward non-epileptic events.7Asian Journal of Medical Sciences. Diagnostic role of serum prolactin level in different kinds of seizure and seizure-like episode in children: A hospital-based study Combining prolactin with serum lactate levels may help further, since physical convulsions from epileptic seizures tend to produce lactate buildup from intense muscle activity, while PNES events often do not.8Seizure. Clinical utility of serum prolactin and lactate concentrations to differentiate epileptic seizures from non-epileptic attacks in the emergency room These blood markers are helpful screening tools, but neither replaces video EEG as the definitive test.
Other Conditions That Mimic Seizures
PNES is the most common non-epileptic seizure mimic, but it is not the only one. Convulsive syncope, where a person faints and then has brief jerking movements as the brain is temporarily deprived of blood flow, is a frequent source of misdiagnosis. It looks like a seizure, and even witnesses often describe it as one. One review noted that convulsive syncope is a common cause of questionable epilepsy diagnoses and contributes to the pool of patients who appear to have drug-resistant epilepsy but actually do not have epilepsy at all.9PubMed. How to Differentiate Syncope from Seizure A head-upright tilt test, which provokes the cardiovascular reflex that causes fainting, can help distinguish the two.10PubMed Central. Beyond Syncopal Episodes: A Complicated Hyperkalemic Emergency Manifesting As Complete Heart Block and Seizure Versus Convulsive Syncope Cascade
Sleep disorders add another layer of confusion. Sleep-related hypermotor epilepsy, a genuine epileptic condition that produces vigorous movements during sleep, can look nearly identical to certain parasomnias like sleepwalking or REM sleep behavior disorder. These overlapping nighttime behaviors often require specialized sleep studies with simultaneous EEG monitoring to sort out.11SLEEPJ. Recurrent Injurious Nocturnal Hypermotor Episodes: Diagnostic Assessment of Parasomnia Overlap Syndrome and Sleep-Related Hypermotor Epilepsy Cardiac arrhythmias, transient ischemic attacks, migraine with aura, panic attacks, and certain movement disorders can all mimic seizures as well. The point is that “not epilepsy” does not automatically mean “psychological”; a thorough workup needs to consider the full range of possibilities.
Why Misdiagnosis Takes So Long to Correct
One of the most striking facts about PNES is how long it takes to get a correct diagnosis. A study of nearly 300 patients found that 90% experienced a diagnostic delay, with the average delay stretching to about 8.4 years after symptom onset.12PubMed Central. Diagnostic delay in psychogenic seizures and the association with anti-seizure medication trials Other studies have found similar numbers: one reported an average delay of about 7 years, another found a median time to diagnosis of 3 years with some patients waiting much longer.13PubMed. Diagnostic delay in psychogenic nonepileptic seizures14PubMed. Delay in diagnosis of psychogenic nonepileptic seizures in adults: A post hoc study
During those years of misdiagnosis, patients are typically put on antiseizure medications that do nothing for their condition. They may have their doses escalated when the drugs predictably fail to control the events. They may undergo repeated emergency department visits where they receive aggressive treatments intended for epileptic emergencies. Research on patients whose prolonged PNES events were mistaken for status epilepticus (a life-threatening, sustained epileptic seizure) found alarming rates of iatrogenic harm: about a quarter of PNES patients who received benzodiazepines in one clinical trial experienced adverse effects including respiratory depression and intubation, and about a third of those who received additional second-line medications experienced similar complications.15PubMed Central. Misdiagnosis of prolonged psychogenic non-epileptic seizures as status epilepticus: epidemiology and associated risks Being intubated and admitted to an intensive care unit for an event that was never epileptic in the first place is a serious, avoidable harm.
What Causes Non-Epileptic Seizures
The psychological roots of PNES are well documented but also widely misunderstood. People sometimes assume “psychological” means “faking,” which is wrong. PNES events are involuntary. The person experiencing them is not choosing to have a seizure any more than someone with a panic attack is choosing to hyperventilate. PNES falls under the broader category of functional neurological disorder, where the nervous system produces real symptoms without a structural or electrical cause that current tests can detect.
Trauma, and childhood trauma in particular, stands out as a major risk factor. A systematic review found that the odds of reporting abuse were roughly two to five times higher in people with PNES compared to people with epilepsy.16PubMed. History of abuse and psychogenic nonepileptic seizures: A systematic review Another systematic review found very high rates of trauma (44 to 100% across different PNES samples) and abuse (23 to 77%), with rates running 15 to 40 percentage points higher than in control groups. PTSD was also more prevalent, raising the possibility that PNES may be a dissociative expression of post-traumatic stress.17Epilepsy & Behavior. Prevalence of traumatic events, abuse, and posttraumatic stress disorder in patients with psychogenic nonepileptic seizures: A systematic review
A study comparing childhood trauma scores between PNES and epilepsy patients found large differences for emotional abuse and emotional neglect, and moderate differences for physical abuse, sexual abuse, and physical neglect.18PubMed Central. Childhood trauma in patients with epileptic vs nonepileptic seizures Emotional forms of maltreatment showed the strongest associations. That said, trauma is neither required nor sufficient. Some people develop PNES without any identifiable trauma history, and many trauma survivors never develop PNES. Other contributing factors include anxiety disorders, depression, personality traits related to avoidance coping, and ongoing psychosocial stressors.
Treatment Goes in Completely Different Directions
The treatment paths for epileptic and non-epileptic seizures diverge sharply. Epileptic seizures are managed primarily with antiseizure medications tailored to the seizure type and epilepsy syndrome. When medications fail, surgical options like focal resection of the seizure-producing brain area, or neuromodulation techniques like vagus nerve stimulation, become options.19PubMed Central. Treating epilepsy with options other than antiepileptic medications
For PNES, the first therapeutic step is often just delivering the diagnosis clearly and compassionately. One prospective multicenter study found that after patients were told they had PNES using a structured communication approach, and without any additional treatment, about 16% became seizure-free within six months and another 23% saw their seizure frequency drop by more than half.20PubMed Central. Short-term outcome of psychogenic non-epileptic seizures after communication of the diagnosis Naming the condition and explaining it as a real, treatable problem rather than something “all in your head” has a measurable effect on its own.
Beyond that, cognitive behavioral therapy (CBT) has the strongest evidence base for reducing PNES events. A pilot randomized controlled trial found that CBT added to standard medical care reduced monthly seizure frequency from a median of 12 at baseline to 1.5 at six months, compared to a drop from 8 to 5 with standard care alone.21PubMed Central. Cognitive-behavioral therapy for psychogenic nonepileptic seizures: A pilot RCT CBT for PNES typically focuses on recognizing and managing the emotional triggers that precede events, learning grounding techniques to interrupt the seizure process, and addressing the trauma or stressors that underlie the condition.22PubMed Central. Cognitive Behavioral Therapy (CBT) in Psychogenic Non-Epileptic Seizures (PNES): A Case Report and Literature Review An equally important part of treatment is withdrawing the antiseizure medications that were started under the wrong diagnosis, which removes their side effects and reduces healthcare costs.
The Stigma Problem
People with PNES often face more stigma than people with epilepsy, which is itself a heavily stigmatized condition. One study found that perceived stigma scores were considerably higher in PNES patients (mean score of 4.9 on a standardized scale) compared to epilepsy patients (mean of 3.7 on the same scale).23PubMed Central. Health related quality of life of people with non-epileptic seizures: The role of socio-demographic characteristics and stigma A systematic scoping review found that the odds of perceived stigma in PNES were about four times greater than in epilepsy.24Seizure. Stigma in functional seizures: A systematic scoping review
The stigma extends to caregivers. One study found that 72% of caregivers of people with PNES felt stigmatized, compared to 47% of caregivers of people with epilepsy. Caregiver stigma was linked to higher anxiety and lower quality of life for the patient.25PubMed. Stigma in psychogenic nonepileptic seizures Qualitative data from the scoping review captured the dynamic bluntly: patients with epilepsy were perceived as getting “all these benefits” in terms of healthcare access, effective treatment, and social support, while patients with functional seizures felt they “don’t get anything.”
Part of the stigma comes from the word “psychogenic” itself, which many patients hear as a synonym for “fake” or “crazy.” This is why many clinicians and researchers are shifting toward the term “functional seizures” or “dissociative seizures,” which describe the mechanism without the loaded connotation. The International League Against Epilepsy and several neurology organizations have increasingly adopted this language, though “PNES” remains the most common term in the published literature.
When the Emergency Room Gets It Wrong
Emergency departments are where the stakes of misdiagnosis play out most dramatically. When someone arrives with what appears to be a prolonged seizure, the protocol calls for rapid administration of benzodiazepines to stop the event before brain damage occurs. That protocol is lifesaving when the seizure is epileptic. When it is not, the benzodiazepines serve only to sedate the patient and risk respiratory depression.
Reviews of emergency management in suspected PNES have catalogued the unnecessary interventions these patients receive: repeated boluses of benzodiazepines, antiseizure medications, intubation for non-epileptic “status epilepticus,” and excessive imaging or lab work.26Acta Medica Croatica. PSYCHOGENIC NON-EPILEPTIC SEIZURES IN THE EMERGENCY DEPARTMENT: A REVIEW A case series of patients with status non-epilepticus (prolonged non-epileptic seizures treated as if they were epileptic emergencies) found that benzodiazepine treatment was mostly ineffective, and eight patients ended up intubated as a result of treatment escalation rather than the event itself.27PubMed Central. Status non-epilepticus
The challenge is genuine. Emergency physicians cannot wait for a video EEG before acting when someone appears to be in status epilepticus. But clinicians who are alert to the semiological signs described earlier, who check for eye closure and asynchronous movements, and who have access to the patient’s history, can sometimes identify PNES quickly enough to avoid escalation. A patient who arrives with a known PNES diagnosis and a documented event pattern is far less likely to receive unnecessary intubation, which underscores how important it is to get the diagnosis right in the first place.
Age-Related Patterns
PNES does not look the same at every stage of life. In children and adolescents, the clinical features can differ from adults in terms of event presentation, associated psychological factors, and outcomes.28PubMed Central. Psychogenic nonepileptic seizures in pediatric population: A review Younger patients may be more likely to present with staring spells or subtle behavioral changes rather than dramatic convulsive episodes. The psychological backdrop in pediatric PNES frequently involves academic stress, bullying, family conflict, or adjustment difficulties alongside or instead of overt trauma.
At the other end of the age spectrum, people who develop PNES later in life tend to have different trigger profiles. Research comparing early-onset and late-onset PNES found that patients who had experienced sexual trauma were more likely to develop PNES at a younger age, while those whose PNES began later in life were more likely to report health problems preceding the onset. Psychological profiles differed too: younger-onset patients tended to score higher on avoidance coping measures, while older-onset patients were more likely to report cognitive complaints.29PubMed. Patients with late onset psychogenic non-epileptic seizures (PNES): How do they compare to those with younger onset? Clinicians working with older adults need to be especially careful not to dismiss PNES as a possibility just because the patient is past the typical peak age range, and equally careful not to overlook genuine epilepsy or syncope in patients who have a psychiatric history.
When Both Conditions Coexist
An underappreciated complication is that some people have both epileptic and non-epileptic seizures. Estimates vary, but a meaningful minority of PNES patients also carry a legitimate epilepsy diagnosis. This dual diagnosis creates a clinical puzzle: each event needs to be evaluated on its own terms, and treatment has to address both conditions simultaneously. Antiseizure medications are still needed for the epileptic events, while psychological treatment targets the non-epileptic ones. Video EEG monitoring becomes especially important in these patients, since the clinical appearance of their two seizure types may be nearly indistinguishable to observers, including the patients themselves.
The coexistence of epilepsy and PNES is one reason diagnostic delays stretch so long. A patient whose EEG confirms genuine epilepsy may have additional events that everyone assumes are also epileptic. When those additional events do not respond to medication, the clinical team may keep escalating drug doses rather than considering a second diagnosis. Only when a typical breakthrough event is captured on video EEG and shows no electrical correlate does the picture become clear. For patients in this situation, getting the right diagnosis for each type of event can transform their care.