PNES are complex medical events that physically resemble epileptic seizures but are not caused by abnormal electrical activity in the brain. This diagnosis is often confusing because the physical symptoms are dramatic, yet the underlying cause is psychological, not neurological. Understanding that PNES is a recognized, though often misunderstood, medical disorder is the first step toward effective management. Accurate information is paramount for those seeking appropriate care.
Defining Psychogenic Non-Epileptic Seizures
PNES refers to episodes that physically resemble epileptic seizures but originate from psychological distress or emotional conflict, not from irregular electrical discharges in the brain. These events are classified as a type of Functional Neurological Disorder (FND), meaning the nervous system’s functioning is impaired rather than having a structural disease. PNES is a common misdiagnosis; 20% to 30% of patients referred to epilepsy centers for uncontrolled seizures ultimately receive this diagnosis.
Historically, seizure-like episodes without a clear neurological cause were sometimes linked to the outdated concept of “hysteria.” The older, stigmatizing term “pseudoseizure” is now discouraged in favor of terms like dissociative seizures or functional seizures. These episodes are involuntary physical manifestations of emotional overwhelm and are not consciously faked or controlled by the patient. They are genuine physical reactions to significant internal psychological stress.
Recognizing the Symptoms
The clinical presentation of PNES is highly variable, but certain features distinguish them from epileptic seizures. PNES episodes often display an asynchronous or fluctuating pattern of movement, where limbs may flail or move irregularly. Movements can involve side-to-side head shaking or arching of the back, and they often wax and wane in intensity, lasting significantly longer than most epileptic seizures.
Although a person may appear unresponsive, they frequently retain some awareness or responsiveness to external stimuli, such as voice or touch. Episodes may feature behaviors not typically seen in epilepsy, such as pelvic thrusting, crying, or stuttering during the event, and the eyes are often closed tightly. Recovery from a PNES event is generally rapid and does not include the postictal state of deep confusion or sleep that follows epileptic seizures.
Underlying Causes and Risk Factors
PNES is an involuntary physical expression of psychological distress that the mind has been unable to process. This process is often linked to dissociation, where a person mentally separates themselves from their emotions or experiences. Trauma is a significant risk factor, with a history of physical, emotional, or sexual abuse reported in a high percentage of adult patients.
Other psychological conditions frequently co-occur with PNES, including anxiety disorders, depression, and Post-Traumatic Stress Disorder (PTSD). These coexisting disorders contribute to chronic emotional dysregulation, increasing vulnerability to physical symptoms when faced with a triggering stressor. The seizures are thought to arise from functional disruptions in brain networks responsible for emotional regulation and the perception of bodily sensations.
Confirmatory Diagnosis
Accurately diagnosing PNES is important to avoid years of ineffective treatment with anti-epileptic medications (AEDs). The definitive diagnosis relies on Video-Electroencephalography (VEEG) monitoring, which simultaneously records the patient’s physical movements and brain’s electrical activity. Patients are typically admitted to an Epilepsy Monitoring Unit (EMU) and monitored until a typical event occurs.
PNES diagnosis is confirmed when the video captures a seizure-like event, but the EEG recording shows no abnormal electrical discharges characteristic of epilepsy. This conclusive evidence is essential because clinical observation alone can be misleading. A significant percentage of patients with PNES are misdiagnosed for an average of six to seven years. A thorough patient history, including detailed accounts from witnesses, is also necessary to identify potential psychological factors.
Treatment and Management Strategies
Treatment for PNES focuses on psychological intervention, since standard anti-epileptic medications are ineffective and cause unnecessary side effects. Cognitive Behavioral Therapy (CBT) adapted for PNES is the primary treatment, proving effective in reducing seizure frequency and improving quality of life. The goal of CBT is to help patients understand the link between emotional distress and physical symptoms, recognizing the seizures as an unconscious coping mechanism.
CBT teaches patients to recognize early warning signs of an impending event, regulate intense emotions, and develop adaptive coping strategies to manage internal stress. Studies show that CBT can lead to a significant reduction in seizure frequency, with some patients achieving seizure freedom. Management also involves addressing co-occurring conditions, such as depression, anxiety, and PTSD, often through psychiatric medication and other forms of psychotherapy, like trauma-focused work.