Psychogenic Seizure

Psychogenic seizures look and feel like epileptic seizures, but they are not caused by abnormal electrical activity in the brain. Instead, these episodes result from psychological distress and are real, involuntary events that can significantly disrupt daily life.

Table of contents

• What are psychogenic seizures?
• Other names for this condition
• Signs and symptoms
• Causes and contributing factors
• Who is at risk?
• How is it diagnosed?
• Treatment approaches
• Emergency management
• Outlook and prognosis
• How common is it?

What are psychogenic seizures?

Psychogenic nonepileptic seizures, commonly called PNES, are episodes that look and feel like seizures caused by epilepsy but have a completely different origin. Unlike epileptic seizures, PNES are not caused by abnormal electrical activity in the brain. Instead, they are a physical response of the nervous system to psychological distress, physical triggers like injury or pain, stressors in the environment, or past traumatic events^[1].

These seizures are real and involuntary. People experiencing PNES are not “faking” their symptoms and have no conscious or voluntary control over these episodes^[1][3]. The condition is classified as a type of functional neurological disorder, meaning symptoms arise from changes in how the brain functions rather than from structural brain disease^[5].

Healthcare providers sometimes describe functional seizures as a problem with the “software” rather than the “hardware” of the brain, reflecting functional disruption in the brain’s communication system^[1].

Functional seizures (FS), psychogenic nonepileptic attacks, psychogenic nonepileptic episodes, psychogenic nonepileptic spells, non-epileptic attack disorder (NEAD), non-epileptic seizures (NES), functional non-epileptic attacks (FNEA), dissociative seizures

Other names for this condition

This condition is known by several names in medical literature and clinical practice. The most commonly used terms include functional seizures and psychogenic nonepileptic seizures (PNES). Healthcare providers may also refer to these episodes as psychogenic nonepileptic attacks, episodes, or spells^[1].

Other names found in medical literature include non-epileptic attack disorder (NEAD), non-epileptic seizures (NES), functional non-epileptic attacks (FNEA), and dissociative seizures^[5]. In clinical practice, some doctors prefer to describe these simply as “events” or “attacks” to reduce confusion for patients and families^[4].

Signs and symptoms

The main symptom of psychogenic seizures is seizure-like events or episodes. These events can vary significantly from person to person. Some people may experience full-body shaking similar to tonic-clonic seizures (a type of seizure involving stiffening and jerking movements) commonly seen in epilepsy. Others may have twitching or jerking in their limbs, brief lapses in awareness similar to absence seizures, or sudden drop attacks^[1].

Common symptoms during PNES episodes include changing patterns of movement, convulsive-type episodes while remaining aware, unresponsiveness with eyes closed, full-body shaking that lasts longer than 10 minutes, loss of awareness, limb movements that are out of sync with each other, pelvic movements, and rapid side-to-side head movements^[1].

Certain features appear more commonly in PNES than in epileptic seizures, although none are exclusive to PNES. These may include eyes remaining closed during the episode, side-to-side movements of the head or body, irregular or asynchronous limb movements, crying or stuttering, and signs of awareness during the event such as responding to touch or voice^[5]. Episodes also tend to begin more gradually than epileptic seizures and typically do not result in the deep confusion or sleep that commonly follows epileptic seizures^[5].

Before an episode begins, some people experience early warning signs including shaking in the arms, legs, or body (tremors), a tight feeling in the chest, light-headedness, headache, or changes in breathing^[3].

People with PNES also frequently experience symptoms related to underlying mental health conditions, including anxiety, depression, panic attacks, and post-traumatic stress disorder^[1].

Causes and contributing factors

Researchers believe that PNES develops from a complex mix of biological, psychological, and social factors. This is known as the biopsychosocial model of causation^[1][6].

Biological factors that may contribute include a history of head injury, and somatic conditions such as migraine, asthma, irritable bowel syndrome, chronic pain, and insomnia^[6]. Genetics may also play a role in how this condition develops^[1].

Psychological factors commonly associated with PNES include mood disorders, anxiety disorders, post-traumatic stress disorder, and maladaptive coping styles. Exposure to trauma early in life can contribute to the emergence of symptoms due to inability to regulate emotions and cope with distress^[6]. Difficulty understanding and expressing emotions, trouble processing information from the senses to turn it into movement (sensorimotor processing), and unhelpful responses to physical and mental stressors may also be contributing factors^[1].

Social factors include a history of abuse, chronic stress, drug use, family dysfunction, marital discord, and financial instability^[6].

An underlying mental health condition may trigger these seizures. Common conditions include anxiety disorders with panic attacks, depressive disorders, dissociative disorders, mood disorders, personality disorders, post-traumatic stress disorder (PTSD), somatic symptom disorder, and substance use disorder^[1].

In most cases, a combination of factors including physiological susceptibility, early-life trauma, maladaptive response to psychological distress, and ongoing social stressors leads to the development and persistence of PNES^[6].

Who is at risk?

Certain people are at higher risk of developing psychogenic seizures. Those who experienced physical, sexual, or emotional abuse or neglect in their early years are at increased risk^[1]. A history of sexual or physical abuse may be more frequent in patients with convulsive-type PNES^[4].

People who have lived through difficult or traumatic events or who have chronic conditions like chronic pain or fibromyalgia are also at higher risk^[1][6].

PNES most commonly begins in young adulthood and occurs more frequently in women, who account for approximately 70% of cases^[4]. However, the condition can develop at any age. Diagnosis should be made cautiously in children or older adults, as other nonepileptic physiologic events such as sleep disorders or fainting may be more likely in these age groups^[4].

About 15% of patients with PNES also have epilepsy, meaning both conditions can coexist^[4][2].

How common is it?

Psychogenic nonepileptic seizures are relatively common but often misdiagnosed. Among patients referred for treatment of seizures that do not respond to medication (refractory seizures), PNES accounts for approximately 20-30% of cases^[4].

The estimated prevalence in the general population ranges from 2 to 33 per 100,000 people^[4]. PNES most commonly begins in young adulthood and affects women more often than men, with women representing about 70% of cases^[4].

How is it diagnosed?

The current gold standard for diagnosing PNES is video electroencephalography (video-EEG) monitoring, accompanied by a thorough seizure history. Video-EEG records both the clinical event and brain wave activity simultaneously^[2][5][12]. This test shows that during a PNES episode, there is no abnormal electrical activity in the brain, which distinguishes it from epileptic seizures.

In most cases, the expertise of an epilepsy specialist with access to an epilepsy monitoring unit is needed to confirm the PNES diagnosis^[2]. If a patient undergoes video-EEG monitoring, it is important that the neurologist observes all types of seizures the patient experiences and correlates them with the presence or absence of epileptic activity on the EEG^[12].

The diagnosis requires careful evaluation to distinguish PNES from other conditions. Healthcare providers must rule out other causes of seizure-like episodes, such as fainting from heart problems (neurocardiogenic syncope) and periodic limb movements during sleep^[12]. Other conditions that may need to be considered include actual epileptic seizures, fainting (syncope), panic attacks, movement disorders, migraine, and low blood sugar (hypoglycemia)^[5].

For an accurate diagnosis, a comprehensive neurologic and psychosocial evaluation should be performed simultaneously with the video-EEG testing^[10]. A detailed seizure history is vital, with the neurologist obtaining descriptions of each type of seizure, and interviewing family or friends who may have witnessed the events^[12].

Once the diagnosis is confirmed, delivering it with empathy and respect is crucial. This helps patients establish trust with caregivers and follow treatment recommendations^[10].

Treatment approaches

The current gold-standard treatment for PNES is cognitive behavioral therapy (CBT), not medication^[8][1]. CBT is a type of talk therapy that helps people understand and change patterns of thinking and behavior. Studies show that CBT alone can reduce seizure frequency by about 50%, with additional improvements in mood and quality of life^[8].

While antidepressants might be prescribed to treat co-occurring conditions like depression or anxiety, they are not a first-line treatment for the seizures themselves^[8]. Combining CBT with medication may slightly increase seizure reduction, but medication alone does not reduce seizures^[8].

Psychotherapy should be tailored to address the predisposing, perpetuating, and precipitating factors that contributed to the development of PNES^[10][6]. In addition to CBT, group therapy is considered a first-line treatment and has been shown to be effective in decreasing seizure frequency and improving quality of life^[12].

Other psychotherapeutic approaches that have been studied include mindfulness-based psychotherapy, which has shown feasibility in small studies and warrants further investigation^[9].

Treatment of co-occurring psychiatric disorders may result in better quality of life and possible reduction in seizure frequency. Most people with PNES have high rates of psychiatric conditions, and many report symptoms of PTSD^[12]. An inpatient or outpatient psychiatric consultation can be very helpful in assessing and treating these co-occurring symptoms^[12].

The first phase of treatment is patient engagement, which can be challenging given low rates of treatment retention^[9]. Creating educational materials or group programs in collaboration with a psychiatrist may provide significant benefit^[12].

There are barriers to care, including provider misperceptions, lack of acceptance of the diagnosis, poor patient engagement with treatment, and lack of access to mental health care^[10]. Access to mental health care can be especially limited for uninsured patients, and psychiatrists may sometimes doubt the PNES diagnosis even when supported by video-EEG monitoring^[8].

Emergency management

The basics of emergency medical care apply to people having a known or suspected PNES episode. Healthcare providers should monitor airways, breathing, and circulation; provide for patient safety and comfort; avoid using noxious stimuli (such as a sternal rub) to test responsiveness; remain calm and reassuring; and stay with the patient until symptoms start to improve^[6].

If the PNES diagnosis is clear from a previous video-EEG evaluation and if the situation allows, encouraging the patient to engage in deep breathing can help lessen the intensity of the episode. Once the episode has resolved, prompting the patient to identify potential triggers can be instructive and ultimately empowering^[6].

If the seizure diagnosis is not clear, PNES should still be considered before starting increasing doses of anti-seizure medications in an emergency setting^[6].

Outlook and prognosis

The outlook for people with PNES varies. Early diagnosis is important to avoid unnecessary and potentially harmful treatment^[10][2]. Effective treatment is available, highlighting the importance of prompt diagnosis and engagement with appropriate mental health care.

Long-term outcome studies show that a significant proportion of patients remain symptomatic and experience continued impairments in quality of life and functionality^[9]. PNES should be understood as a condition that requires different types of intervention during various phases of treatment, including initial patient engagement, acute intervention, and long-term follow-up^[9].

With appropriate treatment, particularly cognitive behavioral therapy, many people experience a reduction in seizure frequency and improvements in quality of life. However, outcomes are influenced by factors such as early diagnosis, therapeutic engagement, and the presence of coexisting psychiatric conditions^[5].

PNES episodes are not dangerous and do not hurt the brain. They are not life-threatening^[3]. However, they can be very disruptive to daily life. The condition is real and serious, and help is available^[1].