The term “fake seizure” is a common but misleading way to describe events that resemble epileptic seizures but are not caused by abnormal electrical activity in the brain. These events are medically recognized as Psychogenic Non-Epileptic Seizures (PNES), a type of functional neurological symptom disorder. PNES are real physical manifestations of underlying psychological distress, not intentional deception. Differentiating between an organic seizure, such as those caused by epilepsy, and a non-epileptic attack requires careful observation of specific characteristics during and after the episode. A definitive diagnosis requires specialized testing, as observation alone is not sufficient to determine the cause.
How Genuine Seizures Manifest
Organic, or epileptic, seizures result from a sudden, uncontrolled electrical discharge in the brain’s nerve cells. The most commonly recognized type is the generalized tonic-clonic seizure, which involves the entire brain. The seizure typically begins abruptly with a loss of consciousness, causing the person to collapse and become completely unresponsive. Following this loss of awareness, the body enters the tonic phase, where the muscles stiffen rigidly for several seconds.
The subsequent clonic phase involves rhythmic, symmetrical jerking of all four limbs at a consistent, rapid pace. During this phase, the eyes are typically fixed open or rolled back, and the person may bite their tongue or lose bladder control. Genuine epileptic seizures are generally brief, lasting less than two minutes from start to finish. The entire sequence of movements is involuntary and beyond the person’s control.
Observable Differences in Non-Epileptic Attacks
PNES exhibit several observable features that deviate from the involuntary, synchronized pattern of a true epileptic event. The movements are frequently asynchronous, meaning limbs may move out of sync, or the intensity of the thrashing may fluctuate. Instead of the uniform, rhythmic jerking seen in epilepsy, PNES movements include a wider variety of behaviors, such as side-to-side head shaking, flailing, or pelvic thrusting. These movements often appear chaotic or inconsistent compared to the physiological rhythm of a clonic seizure.
A significant difference is the state of consciousness during the attack. While a person having a generalized epileptic seizure is unconscious, an individual experiencing PNES may retain some awareness or responsiveness. They might resist attempts to open their eyes, sometimes forcefully squeezing the eyelids shut, which contrasts with the fixed gaze of an epileptic seizure. PNES events also tend to have a more gradual onset and offset, taking longer to build up and resolve than the abrupt start and stop of a typical epileptic event.
The duration of a non-epileptic attack is often significantly longer than that of an epileptic seizure. Most generalized epileptic seizures resolve spontaneously within 120 seconds, but PNES events commonly last for several minutes or longer. This extended duration, combined with the fluctuating nature of the movements, provides distinct visual clues. PNES movements may also be influenced by the environment, sometimes stopping or changing if the person feels they are being watched or addressed directly.
Contextual Clues for Differentiation
The circumstances surrounding the event provide further insight into the nature of the attack. Epileptic seizures are often unprovoked and can occur in any setting, including during sleep or when the person is alone. In contrast, PNES are frequently triggered by emotional stress, conflict, or specific situational factors. These non-epileptic attacks rarely occur during sleep and are much more likely to happen when other people are present.
The period immediately following the event, known as the post-event state, shows clear distinctions. Following a tonic-clonic seizure, the brain’s energy reserves are depleted, resulting in a prolonged post-ictal state. This state is characterized by deep confusion, disorientation, exhaustion, and sometimes a severe headache. This cognitive impairment and fatigue can last from minutes up to many hours, and the person typically has amnesia for the event itself.
In a PNES episode, recovery is often rapid and immediate, with the person quickly returning to a baseline level of functioning. Instead of confusion and deep exhaustion, the post-event behavior may involve crying, emotional distress, or immediately asking questions about what happened. While emotional or physical fatigue may occur, the cognitive fog and prolonged unresponsiveness of the epileptic post-ictal state are absent. This allows for a much faster return to normal conversation and activity.
When to Seek Professional Evaluation
Any event resembling a seizure requires a prompt medical evaluation to determine the underlying cause. While observable characteristics are suggestive, they are not sufficient for a definitive diagnosis. The gold standard for accurately distinguishing between epileptic seizures and PNES is specialized testing: Video-Electroencephalography (Video-EEG) monitoring. This procedure involves continuous video observation of the patient while simultaneously recording the brain’s electrical activity with an EEG.
During a monitored event, an epileptic seizure is accompanied by distinct, abnormal electrical discharges visible on the EEG tracing. Conversely, a PNES event shows normal brain electrical activity despite the physical movements. Obtaining this definitive diagnosis is important because the treatments for the two conditions are completely different. Epilepsy is managed with anti-seizure medications, while PNES requires psychological interventions, such as cognitive-behavioral therapy, to address underlying distress.