Psychogenic non-epileptic seizure

PNES episodes involve sudden changes in movement, sensation, or awareness that closely resemble epileptic seizures. During an episode, a person may exhibit convulsive movements (such as stiffening, jerking, or thrashing of the limbs), appear unresponsive, or display other seizure-like behaviors. Because of this resemblance, PNES can be difficult to distinguish from epilepsy without careful observation and diagnostic tools, such as long-term video-EEG monitoring. These may include eye closure or fluttering during the event, side-to-side movements of the head or body, pelvic thrusting, arching of the back, limb movements that are asynchronous or irregular, and crying or stuttering. People with PNES may also show signs of awareness, respond to touch or voice, or behave in ways that appear influenced by their surroundings. PNES episodes also tend to begin more gradually than epileptic seizures, and typically do not result in confusion or deep sleep afterward (postictal state), which is common following epileptic seizures. Patients with PNES are generally recommended to abstain from driving since an episode while operating a vehicle may result in a crash or injury. Laws with respect to driving may differ in different jurisdictions. ==Causes==

The causes of PNES are not well understood and are complex, and not linked to a single underlying mechanism. A biopsychosocial framework considers the interaction of psychological, neurobiological, and social factors. These influences are often described in terms of predisposing, precipitating, and perpetuating factors. Predisposing factors are those that increase vulnerability, such as trauma history, psychiatric symptoms, somatic symptoms, and neurobiological factors. PNES episodes are not consciously produced and are not under voluntary control. They are distinct from conditions such as malingering or factitious disorder, in which symptoms are intentionally fabricated or induced. An estimated 10% to 30% of individuals with PNES also have coexisting epilepsy, which can complicate both diagnosis and treatment. == Comorbidities ==

Mental health conditions Psychiatric disorders are prevalent in patients with PNES. These include post-traumatic stress disorder (PTSD), anxiety disorders, mood disorders, and/or personality disorders. Chronic pain Patients with PNES are more likely to experience chronic pain than patients with epilepsy, with a gender predisposition towards women. The body's internal (or endogenous) opioid system plays a role in its response to chronic stress or trauma by increasing release of opioids. Other comorbidities Individuals with PNES have been shown to have an elevated prevalence of other conditions, including fibromyalgia, myalgic encephalomyelitis/chronic fatigue syndrome, migraine, asthma, or irritable bowel syndrome. == Mechanisms ==

Neurobiological mechanisms of PNES are not well understood. However, functional neuroimaging has implicated certain structures. Because PNES is considered a disorder of brain function, there has been a growing body of research to investigate functional brain changes in these patients. According to a 2024 literature review of patients with PNES who underwent brain imaging, three neuroanatomical locations were recurrently found to have functional (rather than structural) abnormalities as detailed in the table below. More research needs to be completed to further evaluate the pathophysiology of PNES. ==Diagnosis==

PNES are often difficult to distinguish from epileptic seizures based on clinical observation alone. The gold standard for diagnosis is video-EEG monitoring, which records both the clinical event and corresponding brain activity. In PNES, seizure-like behavior occurs in the absence of epileptiform activity on the EEG. While routine EEGs may be performed during initial evaluation, they are often normal or inconclusive in individuals with PNES and cannot confirm the diagnosis. Certain clinical features may raise suspicion of PNES, but none are definitive, and many overlap with epileptic seizures. Neuroimaging Imaging studies of patients with PNES typically do not reveal any structural disease process that explains their symptoms. While not required to make a diagnosis, brain imaging studies such as computed tomography (CT) and magnetic resonance imaging (MRI) are often ordered. Frontal lobe seizures can be mistaken for PNES, though these tend to have shorter duration, stereotyped patterns of movements, and occurrence during sleep. == Complications ==

Patients with PNES have a lower quality of life on average than patients with epilepsy, with contributing factors including somatic symptoms, psychiatric comorbidities, and cognitive complaints. Many lose the ability to work and in most jurisdictions are not able to drive. Patients with PNES have been found to be more likely on government assistance and to earn less after onset of the condition. Multiple studies around the world have found that patients with PNES have an elevated mortality rate. Mortality rates were particularly elevated in younger patients and among those with coexisting substance use disorders. The cause of elevated mortality is not completely understood, but seems to be more related to comorbidities associated with PNES than the condition itself. ==Treatment==

There is no single treatment for psychogenic non-epileptic seizures (PNES). Instead, management focuses on a multidisciplinary approach that includes patient education, psychotherapy, and treatment of comorbid psychiatric conditions. Early diagnosis and appropriate communication of the diagnosis have been associated with better outcomes. Treatment duration is variable, however some authors focus on a 12-session model. CBT has traditionally been used to treat PNES, with recent evidence supporting its efficacy. A 2024 systematic review and meta-analysis of randomized controlled trials found it associated with seizure freedom, reduced anxiety, and improved quality of life. Once an accurate diagnosis of PNES is made and epilepsy is ruled out, any previously prescribed anti-seizure medications should be discontinued under the supervision of a medical professional. Exceptions include if these medications were used for other purposes such as migraine or if the patient has coexisting epilepsy. Educating patients about the reasoning behind removing such medications and physically discontinuing them can positively impact quality of life and long-term outcome. There is no medication specifically indicated for the treatment of PNES. Psychiatric medications such as antidepressants or anxiolytics may be prescribed to treat comorbid conditions. There is no evidence that PNES can specifically be treated with medications. ==Prognosis==

According to a 2013 review, most studies indicate that seizures persist long-term in over two thirds of people with PNES. Early diagnosis and absence of severe comorbid psychiatric or personality disorders may predict a better prognosis. Not all patients access specialist treatment, particularly in resource-limited settings. One study of untreated patients followed for at least five years found that just over half were seizure-free at follow-up, with shorter duration of illness before diagnosis associated with better outcomes. ==Epidemiology==

PNES has been reported around the world but accurate epidemiological data is limited due to the fact that this condition is frequently misdiagnosed and underdiagnosed. Using modeling based on incidence and outcome data, the same study estimated a point prevalence of 108.5 per 100,000 in the United States in 2019. PNES are rare before the age of eight and become more common during adolescence. The average age at presentation is typically between 11 and 14 years, with most studies reporting a higher prevalence among girls, although some have found a more equal gender distribution in younger children. ==History==

The phenomenon of psychogenic seizures has been recognized (in various forms) for centuries. The earliest documentations are in the medical texts of ancient Egyptian and Greek civilizations in which the term hysteria was first coined. "Hysteria" is derived from the Greek word for womb, which historically was considered the organ causing functional symptoms in women. There was a belief that the womb (uterus) became "frustrated" and travelled to other locations in the body, causing such symptoms. Ancient Greek and Roman physicians, including Aretaeus of Cappadocia, described conditions they linked to reproductive dysfunction and psychological factors. Over the next millennium, the concept of hysteria permeated into other aspects of cultures outside of medicine; it became closely intertwined with witchcraft in the 15th century and was reflected in Italian Renaissance paintings in the 16th century (such as The healing of the possessed woman by Andrea del Sarto). It was considered a disease exclusive to women until the 17th century when English physicians Thomas Willis and Thomas Syndeham reported cases of hysteria in men. This led to a crucial shift in belief as what was initially considered the cause of disease, the uterus, was replaced by the brain, allowing one to view hysteria as a neurologic disorder. In the 19th century, Jean-Martin Charcot provided the first systematic medical descriptions of these episodes, coining the term hystero-epilepsy to distinguish them from epileptic seizures. The psychoanalytic framework of the late 19th and early 20th centuries, particularly through the work of Austrian physician Sigmund Freud and French physician Pierre Janet (students of Charcot), reframed hysteria as a manifestation of unconscious psychological conflict. Additionally, in revision, the DSM-5 was updated to add emphasis to the positive physical signs inconsistent with recognized diseases. The requirement of a history of psychological stressors and that the symptom is not factious was removed as well. ==Society and culture==

PNES challenges conventional boundaries between mental and physical illness, in part because its symptoms are real and disabling, but do not originate from epileptiform brain activity. Historically, the condition has been associated with significant stigma, both social and clinical. Cultural and contextual factors also influence how PNES are perceived. In some societies, seizure-like episodes are understood through religious or spiritual frameworks, such as demonic possession, curses, or witchcraft. These interpretations can shape how individuals experience and explain their symptoms, as well as the kind of care they seek. In highly medicalized settings, the absence of objective findings on EEG or neuroimaging may lead to moral judgments, including assumptions of attention-seeking or malingering. ==Terminology==

The terminology used to describe PNES has evolved, reflecting changes in medical understanding as well as shifting attitudes toward functional disorders. Historically, the term pseudoseizure was widely used, but it has fallen out of favor due to its stigmatizing connotations. The prefix pseudo- implies falseness or deception, and its use has been associated with patient-blaming and the perception that symptoms are faked or not legitimate. Major professional bodies, including the International League Against Epilepsy (ILAE), now discourage the term in both clinical and research settings. The current standard term, psychogenic non-epileptic seizures, has become widely used in clinical and research contexts. However, it has also drawn criticism. The label "psychogenic" implies a purely psychological origin, potentially reinforcing a dualistic distinction between mind and brain that is increasingly challenged by neuroscientific research. While some clinicians favor broader terms like non-epileptic events to avoid confusion with epilepsy, the term seizure better captures the paroxysmal and stereotyped semiology of the episodes. It also allows PNES to be classified consistently with other seizure types, such as febrile or hypoglycemic seizures, which are not epileptic but are still medically recognized. Importantly, studies suggest that many patients prefer the term seizure to alternatives such as attack or fit, and clinicians are encouraged to provide careful explanations to minimize confusion. == References ==