Psychogenic Nonepileptic Seizure (PNES)

What are functional seizures (psychogenic nonepileptic seizures)?

Functional seizures (FS), also known as psychogenic nonepileptic seizures (PNES), are episodes that look and feel like seizures caused by epilepsy. But they aren’t caused by abnormal electrical activity in your brain. Instead, these seizures are a physical reaction of your nervous system to:

• Physical triggers, like injury or pain
• Stressors in your environment
• Past traumatic event

If you have this condition, the seizures you have are real. You aren’t “faking” it. You don’t have any conscious or voluntary control over these episodes. They can be very disruptive to your life. But help is available.

You may hear your healthcare provider refer to this condition as functional neurological disorder (FND). This is because your symptoms can be explained by functional disruption in your brain’s communication system. Functional seizures are sometimes understood as a problem with the software rather than the hardware of your brain.

Other names for this condition include psychogenic nonepileptic attacks, episodes or spells.

Symptoms of functional seizures (PNES)

The main symptom of FS is seizure-like events (or episodes). These events can look different from person to person.

It may look like you’re having symptoms similar to tonic-clonic seizures, with full-body shaking that’s common in epilepsy. Or you may have twitching or jerking in your limbs. Events may also present as absence seizures (a brief lapse in awareness) or drop attacks. The difference is that there aren’t any abnormal brain waves causing the seizures.

Common symptoms of PNES include:

• Changing patterns of movement
• Convulsive-type episodes with retained awareness
• Eyes-closed unresponsiveness
• Full-body shaking episodes that are over 10 minutes long
• Loss of awareness
• Out-of-sync limb movements
• Pelvic movements
• Rapid side-to-side head movements

In addition to seizure episodes, you may experience other symptoms from underlying mental health conditions, like:

• Anxiety
• Depression
• Panic attacks
• Post-traumatic stress disorder

Functional seizure (PNES) causes

Researchers believe FS symptoms are caused by a mix of stress that affects your body, mind and relationships. This is known as the biopsychosocial model.

In addition, the following personal challenges may be contributing factors:

• Difficulty understanding and expressing emotions
• Trouble processing information from your senses to turn it into movement (sensorimotor processing)
• Unhelpful response to stressors (physical and mental)

Genetics may also play a role in how this condition develops.

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
• Substance use disorder

Risk factors of functional seizures

You may be more at risk of developing this condition if you:

• Experienced physical, sexual or emotional abuse or neglect in your early years
• Lived through a difficult or traumatic event
• Have a chronic condition like chronic pain or fibromyalgia

PNES most commonly begins in young adulthood, but it can start at any age.

Complications of functional seizures

You may have little to no awareness or knowledge of when a seizure happens. For this reason, you could be at risk of accidents and injuries that could be potentially life-threatening in certain situations.

Before you know it, you may isolate yourself and stay away from others out of fear or embarrassment. This can pull you away from your loved ones, friends and the activities you once enjoyed.

Having seizure-like episodes may also significantly affect your mental health. FS increases your risk of developing suicidal thoughts. If you’re having suicidal thoughts, know that there’s someone available who can help you. You can call or text 988. This is the Suicide & Crisis Lifeline (U.S.). You don’t have to be in a crisis to ask for help.

How doctors diagnose functional seizures (PNES)

Diagnosing PNES can be difficult because symptoms look very similar to epilepsy. Your healthcare provider will make an official diagnosis by recording a seizure or an episode with a video EEG (electroencephalogram).

An EEG measures and records your brain’s electrical signals. During an EEG, a technician places small metal disks (electrodes) on your scalp. The electrodes attach to a machine that gives your provider information about your brain’s activity.

If your episodes are functional, an EEG will show normal electrical brain activity during an episode. However, in those who have epilepsy, EEG will show abnormal electrical activity during a seizure.

Many people with these seizures first receive a misdiagnosis of epilepsy. It’s also possible to have both epileptic and functional seizures in rare cases.

How are functional seizures (PNES) treated?

Studies show that cognitive behavioral therapy (CBT), a type of psychotherapy, is most effective in treating PNES.

Your provider will also help you manage any underlying conditions that may trigger episodes. This might include taking an antidepressant in addition to therapy, as directed by your provider.

Antiseizure medications aren’t effective at treating functional seizures.

CBT for PNES

Cognitive behavioral therapy is a counseling approach where you learn about your mind and body’s reaction to various triggers. You’ll also learn how your thoughts affect your emotions and behaviors. A mental health professional can help you identify and modify unhealthy thoughts, emotions and behaviors to cope with stressful events more effectively.

Your provider may recommend other types of counseling approaches to manage episodes or emotional challenges if CBT isn’t right for you.

During your counseling treatment, you’ll meet your provider regularly. Together, you’ll learn more about how your thoughts affect your emotions and seizures. Then, you’ll set and work on achieving goals. When managing functional seizures, you may have some of the following goals:

• Learn more about your diagnosis
• Identify past or present stressors and find ways to relieve them
• Identify and manage common seizure triggers
• Improve emotion management skills (like using relaxation techniques)
• Rebuild your quality of life (relationships, education, career, etc.)

It’s OK if your goals don’t match these exactly. Everyone’s goals are unique to fit their needs.

For adults, your provider may suggest a counseling program called neurobehavioral therapy. This is counseling that uses a workbook and is similar to taking a class. You’ll participate in weekly appointments involving 45 minutes of counseling. You’ll do practice assignments at home. This involves activities like journal-keeping or engaging in a social event. Each week, you can build on what you learned until you’ve mastered specific skills.

When should I see my healthcare provider?

Counseling can bring up a lot of feelings that you hide away or try not to think about. If you feel overwhelmed with your emotions or feel unsafe, know that your counselor is there for you to help you in this journey. It’s important to contact your healthcare providers to help you or address any questions you may have about your treatment.

What can I expect after being treated for functional seizures?

PNES may impact your life. But with a proper diagnosis and treatment, symptoms may improve. Some people report no to fewer seizures after following their provider’s guidance and actively participating in counseling. Your provider can give you the best information on what you can expect in your situation.