The term “fake seizure” commonly describes a Non-Epileptic Attack (NEA), most frequently a Psychogenic Non-Epileptic Seizure (PNES). These episodes are involuntary and resemble a true epileptic seizure but are not caused by the abnormal electrical activity defining epilepsy. PNES is classified as a functional neurological disorder, where symptoms arise from changes in brain function often linked to psychological or emotional factors, rather than a structural disease. Distinguishing between a genuine epileptic seizure (ES) and a PNES based solely on observation is challenging, but reliable differences exist in movement patterns, duration, and post-event state.
Hallmarks of Genuine Epileptic Seizures
A true epileptic seizure, particularly a Generalized Tonic-Clonic Seizure, follows a distinct physiological pattern caused by a massive, synchronized electrical discharge across both sides of the brain. The event begins with the tonic phase, where all muscles stiffen, often causing the person to fall and sometimes emit a cry as air is forced past the vocal cords. The person is completely unconscious during this period and will not respond to external stimuli.
This stiffening is followed by the clonic phase, characterized by rhythmic, synchronous jerking of the limbs at a consistent rate. During this convulsive period, breathing can be impaired, potentially leading to a bluish tinge around the mouth due to oxygen deprivation. Physiological markers often include loss of bladder control or biting the tongue, especially on the side.
The most telling feature is the post-ictal state, the period immediately following the convulsive movements. After an ES, the person does not immediately regain full awareness; they are typically deeply confused, disoriented, and often fall into an exhausted sleep that can last minutes to hours.
Observable Indicators of Non-Epileptic Attacks
Non-Epileptic Attacks (PNES) present with movements that are asynchronous or disorganized, lacking the consistent rhythm of an epileptic event. The shaking may start and stop abruptly or fluctuate in intensity, with movements in one limb not matching those in the other. Common movements can include side-to-side head shaking, pelvic thrusting, or an arching of the back rarely seen in typical tonic-clonic seizures.
During a PNES event, the individual may appear unresponsive but often displays signs of preserved consciousness or selective awareness. They may resist attempts to open their eyes, sometimes forcibly squeezing the eyelids shut, which requires muscle control and is uncommon in ES. Although they may not respond to voice, some individuals may instinctively track movements or respond to painful stimulation, indicating a level of awareness.
The movements in PNES frequently appear charged with emotion, sometimes involving crying or stuttering during the event itself. Unlike the explosive onset of many epileptic seizures, PNES episodes often begin more gradually, sometimes following a period of heightened anxiety or stress.
Critical Differences in Presentation
The duration of the event is a significant distinguishing factor, as genuine epileptic seizures rarely last beyond two to three minutes. Conversely, Non-Epileptic Attacks often have a much longer or highly variable duration, frequently lasting five, ten, or even thirty minutes without the immediate medical danger of a prolonged ES. An epileptic seizure lasting over five minutes is a medical emergency known as status epilepticus.
The risk of serious injury also differs significantly. While a person having an ES may suffer severe tongue biting (typically on the side) or head trauma from an uncontrolled fall, serious injury is rare in PNES. The movements in PNES, while sometimes violent, are less likely to result in self-harm.
The setting can also offer a clue, though this is not definitive, as PNES are more likely to occur when other people are present. Most importantly, the post-event state after a PNES is markedly different from the profound confusion seen after an ES. Individuals with PNES often have a rapid recovery, becoming alert and oriented almost immediately after the movements stop. This immediate return to baseline awareness contrasts sharply with the deep confusion and sleepiness that defines the epileptic post-ictal state.
When to Seek Medical Assessment
Self-diagnosis of any seizure-like event is unreliable and dangerous due to the risk of mismanaging a serious underlying condition. Because the physical presentation of epileptic seizures and Non-Epileptic Attacks can overlap, immediate medical attention is necessary for any first-time seizure event or for a seizure lasting longer than five minutes. An accurate diagnosis is paramount for effective treatment, as PNES does not respond to the anti-seizure medications used for epilepsy.
The definitive method for distinguishing between the two conditions is specialized testing, most notably video-electroencephalography (video-EEG) monitoring. This procedure records the physical behavior of the event via video while simultaneously monitoring the brain’s electrical activity with an EEG. A diagnosis of PNES is confirmed when a typical episode is captured on video without any corresponding abnormal electrical activity on the EEG. This specialized assessment ensures that the correct treatment pathway—whether pharmacological for epilepsy or psychological for PNES—is initiated.