Epileptic seizures and non-epileptic seizures can look strikingly similar, but they leave different physical fingerprints. Eye behavior, movement patterns, heart rate changes, and what happens in the minutes after the event all offer clues that clinicians use to separate the two. The catch is that the word “faking” badly mischaracterizes what is usually going on. Most people whose seizures turn out not to be epileptic are not pretending; they are experiencing involuntary episodes driven by psychological distress, and rushing to label them as frauds can cause real harm.
Why “Faking” Is Almost Always the Wrong Word
When people search for how to tell if someone is faking a seizure, they usually mean: how do you distinguish a seizure caused by abnormal brain electrical activity from one that is not? The medical term for the latter is psychogenic nonepileptic seizure, or PNES. Roughly one in four patients admitted to specialized epilepsy monitoring units end up diagnosed with PNES rather than epilepsy.1American Epilepsy Society. THE PRESENCE OF NON-EPILEPTIC SEIZURES IN AN EPILEPSY MONITORING UNIT (EMU) These episodes involve real loss of control, real distress, and real physical symptoms. They are just not caused by the electrical storms in the brain that define epilepsy.
Deliberate faking of seizures, called malingering, does exist but is rare. The vast majority of PNES cases involve people who genuinely believe they are having seizures and have no conscious control over the events. Studies consistently find that people with PNES have very high rates of prior trauma and abuse, with trauma histories reported in anywhere from 44 to 100 percent of PNES samples, rates that run 15 to 40 percent higher than in comparison groups.2Epilepsy & Behavior. Traumatic events and posttraumatic stress disorder in patients with psychogenic nonepileptic seizures: A critical review Research has also linked PNES in patients with repeated trauma to symptoms of complex PTSD, suggesting that these seizures may be one expression of a severe underlying stress disorder.3European Journal of Trauma & Dissociation. Link between psychogenic nonepileptic seizures and complex PTSD: A pilot study Calling these episodes “fake” dismisses the real suffering behind them and, as we’ll see, can actively worsen outcomes.
The Single Most Reliable Visual Clue
If you had to pick one thing to watch for during a convulsive episode, it would be the eyes. During genuine epileptic seizures, patients almost always have their eyes open. During PNES, patients almost always have their eyes closed. This pattern is remarkably consistent. In one study that compared 52 PNES patients with 156 epileptic seizure patients on video monitoring, 50 of the 52 PNES patients kept their eyes shut during their events, while 152 of the 156 epileptic patients had their eyes open.4PubMed. Ictal eye closure is a reliable indicator for psychogenic nonepileptic seizures Another study using provoked seizures found that 90 percent of PNES patients had closed eyes.5Journal of Epilepsy. Closed eyes during a seizure indicate psychogenic etiology: A study with suggestive seizure provocation
A meta-analysis pooling data from multiple studies confirmed the strength of this finding: ictal eye closure was overwhelmingly more likely in PNES than in epileptic seizures, with a positive likelihood ratio above 40.6PubMed Central. Using Semiology to Classify Epileptic Seizures vs Psychogenic Nonepileptic Seizures: A Meta-analysis For perspective, a likelihood ratio that high means the sign is strongly diagnostic. No single physical sign for epileptic seizures performed nearly as well in the opposite direction. So while closed eyes do not guarantee a seizure is non-epileptic, and open eyes do not guarantee epilepsy, this one observation gets you surprisingly far.
Movement Patterns That Look Different
Epileptic generalized seizures tend to produce rhythmic, synchronized jerking on both sides of the body. The movements typically start fast and gradually slow down. PNES often look different. The limbs may jerk out of sync with each other, with the left arm doing something different from the right leg. That same meta-analysis found that asynchronous limb movements were strongly predictive of PNES, with a positive likelihood ratio above 10.6PubMed Central. Using Semiology to Classify Epileptic Seizures vs Psychogenic Nonepileptic Seizures: A Meta-analysis
Other movement features that tend to point toward PNES include side-to-side head thrashing, pelvic thrusting, and episodes that wax and wane in intensity rather than following the build-then-fade pattern of a typical tonic-clonic seizure. PNES episodes also tend to last longer. A typical generalized epileptic seizure rarely exceeds two or three minutes, while PNES events can stretch on for many minutes or even longer. None of these signs on their own are definitive, but a cluster of them during a single event gives clinicians much more confidence in the distinction.
What the Pupils and Reflexes Reveal
During an epileptic seizure, the brain’s electrical storm often triggers measurable changes in the nervous system. Pupils dilate, and certain reflexes become abnormal. In PNES, these neurological signs are typically absent: the pupils remain reactive and normal-sized, and reflexes do not change.7IntechOpen. Treatment and Diagnosis of Psychogenic Nonepileptic Seizures This is a useful bedside check for emergency physicians, although it can be hard to assess in the middle of a violent convulsive event. Trying to pry open the eyes of a patient with PNES may also meet active resistance — a phenomenon sometimes called “forced eye closure” — which itself is another clue.
Heart Rate Tells Its Own Story
Your heart responds differently to an epileptic seizure than to a non-epileptic one. Epileptic seizures trigger a dramatic spike in heart rate because the abnormal brain activity directly activates the autonomic nervous system. A study comparing heart rate changes during epileptic and non-epileptic arousals found that heart rate jumped by a median of about 87 percent within 60 seconds of an epileptic arousal, compared to about 26 percent during a non-epileptic one.8PubMed. Distinction between epileptic and non-epileptic arousal by heart rate change That threefold difference is large enough that heart rate monitoring, which can be done with a simple chest strap or even a smartwatch, could eventually become a practical screening tool.
Heart rate variability analysis tells a similar story. During PNES episodes, the pattern of heart rate changes looks different from what happens during epileptic seizures, with distinct shifts in the balance between the sympathetic (“fight or flight”) and parasympathetic (“rest and digest”) branches of the nervous system.9PubMed Central. Heart Rate Variability Parameters During Psychogenic Non-epileptic Seizures: Comparison Between Patients With Pure PNES and Comorbid Epilepsy This research is still being refined, but the principle matters: an epileptic seizure hijacks the body’s automatic functions in ways that a psychogenic episode typically does not.
Blood Tests After the Event
One of the more commonly discussed clinical tools is checking serum prolactin levels. Prolactin is a hormone that spikes after certain types of epileptic seizures. The American Academy of Neurology reviewed the evidence and found that elevated prolactin drawn within 10 to 20 minutes of an event was highly specific for epileptic seizures, with a specificity around 96 percent for distinguishing them from PNES.10PubMed. Use of serum prolactin in diagnosing epileptic seizures: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology Separately, research in emergency departments confirmed that serum prolactin runs significantly higher after epileptic convulsions than after PNES.11Seizure. Clinical utility of serum prolactin and lactate concentrations to differentiate epileptic seizures from non-epileptic attacks in the emergency room
The caveat is that prolactin is better at ruling epilepsy in than at ruling it out. Its sensitivity is only moderate — around 60 percent for generalized tonic-clonic seizures and lower for partial seizures. So a normal prolactin level after an event does not prove the event was non-epileptic. And at least one smaller study found the difference in prolactin levels between groups was not significant, suggesting the test is not reliable enough to use as the sole basis for a diagnosis.12PubMed. Serum prolactin levels for differentiation of nonepileptic versus true seizures: limited utility In practice, prolactin is a helpful supporting clue but not a standalone answer.
The Gold Standard Diagnosis
All of the signs described above are useful at the bedside, but none are definitive. The gold standard for telling epileptic seizures apart from PNES is video EEG monitoring, where a patient is admitted to a specialized unit, hooked up to continuous brain-wave recording, and monitored by video for days until a typical event occurs.13PubMed Central. Long-term video EEG monitoring for diagnosis of psychogenic nonepileptic seizures If the episode happens while the EEG shows normal brain activity, that confirms the event is not epileptic. This approach catches what bedside signs cannot: it provides simultaneous visual and electrical evidence, leaving little room for ambiguity.14PubMed. Differentiating psychogenic nonepileptic seizures from epileptic seizures: An observational study of patients undergoing video-electroencephalography (VEEG) in Australia
The downside is that video EEG requires a hospital stay averaging about five days, is expensive, and is not available everywhere.15PubMed Central. Outcome of psychogenic non-epileptic seizures following diagnosis in the epilepsy monitoring unit Patients often wait years to get this evaluation. One study found a median delay of three years between the onset of PNES and receiving a definitive diagnosis. That gap matters enormously, because during those years patients are typically treated for epilepsy they do not have.
What Can Go Wrong When the Distinction Is Missed
Getting the diagnosis wrong is not just an academic problem. When someone with PNES is treated as though they are having epileptic seizures, particularly in the emergency room, the consequences can be serious. Emergency physicians understandably err on the side of treating a convulsive episode as epilepsy, which means giving benzodiazepines and sometimes escalating to second-line anti-seizure drugs. In patients with prolonged PNES mistakenly treated as status epilepticus, one large analysis found that about a quarter of those who received benzodiazepines experienced adverse effects including respiratory depression and intubation. A third of those given second-line medications had similar problems. Across clinical trials, roughly one in five patients with prolonged PNES ended up admitted to intensive care.16PubMed Central. Misdiagnosis of prolonged psychogenic non-epileptic seizures as status epilepticus: epidemiology and associated risks
The cumulative effect was dose-dependent: patients who received benzodiazepines before arriving at the hospital and then got more in the ER had higher rates of becoming unresponsive and experiencing severe complications than those treated only after admission. All of those interventions carry real risk and none of them address the actual cause of PNES. On top of the medical risks, years of unnecessary anti-seizure medication come with side effects of their own, and the financial burden is substantial. One Irish study estimated that the annual cost per patient of undiagnosed PNES was roughly €21,000, while the combined cost of proper diagnosis and psychological treatment was less than €9,000.17PubMed. The economic cost of nonepileptic attack disorder in Ireland
Syncope and Other Lookalikes
It is worth noting that the question “is this a real seizure?” has more than two possible answers. Fainting episodes (syncope) can mimic seizures convincingly. When the brain briefly loses blood flow during a faint, it can produce a few seconds of stiffening and jerking that look startlingly like a seizure. This phenomenon, sometimes called convulsive syncope, is a common reason people get misdiagnosed with epilepsy in the first place. A careful history focusing on what happened before the event — standing for a long time, feeling hot, seeing blood — plus testing with tilt table or heart monitors can usually sort it out. The broader point is that “not epileptic” does not automatically mean PNES; cardiac and other medical causes have to be considered too.
What Happens When You Tell Someone Their Seizures Are Not Epileptic
How clinicians communicate the diagnosis of PNES has an outsized effect on what happens next. In one study, nearly all PNES patients had the diagnosis explained to them before leaving the monitoring unit, and 89 percent accepted it. Among those contacted at follow-up (median of about four years later), 46 percent no longer had any episodes at all. Strikingly, about a third reported that their seizures stopped immediately after being told the diagnosis.15PubMed Central. Outcome of psychogenic non-epileptic seizures following diagnosis in the epilepsy monitoring unit Fewer patients had daily seizures after diagnosis than before, and emergency department visits dropped dramatically.
On the other hand, when patients react angrily to the diagnosis, the prognosis tends to be worse.18PubMed. Non-epileptic seizures: patients’ understanding and reaction to the diagnosis and impact on outcome This is one reason the “faking” framing does so much damage. If a patient with PNES is told, explicitly or through the attitude of the people around them, that they are making it up, they are more likely to feel dismissed, become defensive, and disengage from treatment. The most effective approach treats the diagnosis as a positive development: you do not have epilepsy, and the condition you do have is treatable, typically through psychological therapy rather than medication.
Why Bystanders Should Not Try to Make the Call
Everything discussed so far is useful context, but it comes with a strong practical warning: if you witness someone having a convulsive episode, attempting to diagnose it on the spot is not your job and can be dangerous. The bedside signs that clinicians use — eye position, limb synchrony, pupil reactivity — require training to assess properly and are often ambiguous in the chaotic first moments of an event. A person whose seizure turns out to be epileptic and who does not get timely medical attention faces real risk of brain injury, aspiration, or death.
The right approach for a bystander is always the same regardless of what is causing the episode: keep the person safe from injury, turn them on their side, do not put anything in their mouth, note how long the episode lasts, and call for emergency help if the event continues beyond a few minutes or if the person does not regain normal awareness afterward. Whether the event turns out to be epileptic, psychogenic, or syncope, those steps are appropriate for all three.
Wearable Technology and the Future of Detection
Researchers are working to move seizure detection beyond the hospital setting. A pilot study explored a wearable multi-sensor system that continuously records heart electrical activity, body movement, and even a simplified form of brain wave activity from behind the ear. Using machine learning, these systems attempt to detect seizures automatically and could eventually distinguish epileptic from non-epileptic events in real time.19PubMed. Towards a wearable multi-modal seizure detection system in epilepsy: A pilot study The technology is still early-stage, but the converging evidence on heart rate differences, movement patterns, and EEG signatures suggests that a wearable that alerts the user or caregiver to the likely nature of an episode is not far off.
For now, the practical reality remains that definitive diagnosis takes time, specialized equipment, and expert interpretation. The signs described in this article can raise or lower suspicion, inform clinical decision-making, and help family members understand what they are seeing. They cannot replace a formal evaluation, and they should never be used to shame or dismiss someone whose seizures look “wrong.” The odds are overwhelming that the person is not faking — they just have a different condition than the one everyone assumed.