Somatic seizures, often referred to as Psychogenic Non-Epileptic Seizures (PNES), are physical manifestations that closely resemble epileptic seizures but do not originate from abnormal electrical activity in the brain. These events are a physical expression of emotional or psychological distress. They are considered a type of functional neurological disorder where symptoms arise from changes in brain function rather than structural damage or epilepsy. PNES are genuine physical events, not consciously faked, and are classified as a conversion disorder within the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).
Understanding Somatic Seizure Manifestations
Somatic seizures can present in various ways, often mimicking the generalized convulsions seen in tonic-clonic epileptic seizures, with individuals experiencing falling and shaking. Less frequently, they may also resemble absence seizures, which involve brief lapses in awareness, or focal impaired awareness seizures.
Observers might notice convulsive movements such as stiffening, jerking, or thrashing of the limbs, or the person may appear unresponsive. Distinct features, though not exclusive to PNES, can include eye closure during the event, side-to-side head or body movements, and limb movements that are asynchronous or irregular. Individuals experiencing PNES may also cry or stutter during an episode.
Unlike epileptic seizures, which typically last less than two minutes and are often followed by confusion or deep sleep, PNES episodes often last longer and generally do not result in a postictal state. Despite appearing unresponsive, some individuals with PNES may retain a degree of awareness, instinctively protecting themselves or responding to stimuli like touch or voice. This preserved consciousness, often evidenced by signs like tracking movement with eyes or resisting attempts to open eyelids, helps distinguish PNES from epileptic seizures.
Exploring the Underlying Origins
The origins of somatic seizures are rooted in psychological distress, such as significant stress, trauma, or anxiety, rather than abnormal brain electrical discharges. Researchers propose that PNES symptoms are caused by a combination of stress affecting the body, mind, and relationships, known as the biopsychosocial model.
A significant proportion of individuals with PNES have a history of traumatic events, such as physical or sexual abuse, loss of a loved one, or major accidents. These traumatic experiences can lead to a dissociation between consciousness and memories, with PNES episodes potentially acting as sensorimotor flashbacks when distressing memories temporarily re-enter awareness. The seizures can serve as an unconscious coping mechanism, a way for the body to express feelings or “drown out” painful memories that the individual cannot consciously process or express.
Psychiatric comorbidities are frequently associated with PNES, with over 50% of patients having conditions such as depression, anxiety disorders, post-traumatic stress disorder (PTSD), and personality disorders. While trauma is a common factor, it is not universally present nor solely sufficient to cause PNES. Other contributing factors can include difficulty understanding and expressing emotions, unhelpful responses to stressors, and problems processing sensory information into movement.
Accurate Diagnosis and Differentiation
Accurately diagnosing somatic seizures and differentiating them from epileptic seizures is a detailed process that relies on a combination of medical history, witness accounts, and specialized tests. The most definitive diagnostic tool is video-EEG (electroencephalography) monitoring, which simultaneously records brain electrical activity and captures the patient’s physical behavior during an event. This allows healthcare professionals to observe seizure-like behavior in the absence of abnormal brain electrical discharges, which is characteristic of PNES.
During video-EEG monitoring, patients are often admitted to a specialized unit where any anti-seizure medications they might be taking are gradually reduced or tapered to encourage typical events to occur. The goal is to capture one or more of their characteristic episodes while monitoring brain waves. While routine EEGs may be performed initially, they are often normal or inconclusive in individuals with PNES and cannot confirm the diagnosis on their own.
Clinical observations during an event also play a role in differentiation. For instance, eye closure, asynchronous limb movements, or pelvic thrusting are more commonly observed in PNES, whereas synchronized movements are more typical of epileptic seizures.
Effective Management Strategies
Managing somatic seizures primarily involves non-pharmacological interventions, with psychotherapy being the main treatment approach. Cognitive-behavioral therapy (CBT) is a widely used and effective psychotherapeutic modality for PNES, aiming to address the maladaptive thoughts, emotions, and behaviors that sustain the physical symptoms. CBT helps individuals identify and correct their responses to emotional triggers, avoidance behaviors, and unhelpful thought patterns.
Other psychotherapeutic modalities, such as psychodynamic therapy, prolonged exposure therapy (especially for those with co-occurring PTSD), and mindfulness-based therapies, have also shown benefit. These therapies help patients process traumatic experiences, confront distressing memories, and cultivate an accepting attitude towards unpleasant experiences, which can reduce the reliance on physical symptoms as a distress-avoidance mechanism. Early recognition and intervention are associated with improved outcomes, with studies indicating that psychiatric treatment can lead to a resolution of PNES in a significant proportion of patients.
A multidisciplinary team approach, involving neurologists, psychiatrists, and psychologists, is highly recommended to address the complex psychological and neurological aspects of PNES. While medications like SSRIs (e.g., sertraline or fluoxetine) may be used to manage co-occurring anxiety or depression, they do not directly treat the seizures themselves and anti-epileptic medications are generally ineffective for PNES. Patient education is also a significant aspect of management, helping individuals understand their condition, participate in their care, and learn coping mechanisms like deep breathing and progressive muscle relaxation to prevent or interrupt episodes.