Psychogenic Nonepileptic Seizure (PNES)

What is psychogenic nonepileptic seizure (PNES)?

Psychogenic nonepileptic seizure (PNES) involves attacks that resemble epilepsy-related seizures in symptoms and signs, but abnormal electrical activity in your brain doesn’t cause them. Instead, the seizures are a physical reaction to underlying psychological distress.

The psychiatric diagnosis for PNES is conversion disorder, as a mental stress is being converted into a physical symptom. Conversion disorder is also known as functional neurological symptom disorder. Many people with PNES have experienced trauma.

People who have PNES aren’t faking the seizures. They have no conscious or voluntary control over them.

Many people with PNES first receive a misdiagnosis of epilepsy. It’s also possible for someone to have both PNES and epilepsy-related seizures. This happens in about 10% to 15% of cases.

Other names for this condition include:

• Psychogenic nonepileptic spells.
• Psychogenic nonepileptic episodes (PNEE).
• Psychogenic nonepileptic attacks.

Who does PNES affect?

PNES most commonly begins in young adulthood, but it can start at any age. PNES is more likely to affect women and people assigned female at birth (AFAB) than men and people assigned male at birth (AMAB).

Factors that may increase your risk of developing PNES include:

• History of sexual abuse.
• History of physical abuse or neglect.
• Coexisting psychiatric conditions, such as depressive disorders, post-traumatic stress disorder (PTSD) or personality disorders.
• A tendency to suppress or hold in your emotions.

PNES is also more prevalent in the veteran population than in the civilian population due to higher trauma exposure in veterans.

How common is PNES?

Researchers aren’t sure how common PNES is. But 20% to 40% of people who see epilepsy specialists for intractable (untreatable) seizures receive a diagnosis of PNES rather than epilepsy.

What are the symptoms of PNES?

The main symptom of PNES is seizure-like attacks. These attacks can vary from person to person in what they look like and how often they happen. They typically look just like epilepsy-related seizures, but they’re seizures triggered by emotional stress.

Some people with PNES may look like they’re experiencing generalized convulsions similar to tonic-clonic seizures with full-body spasms or shaking. Others may have twitching or jerking in their limbs. In some, PNES may mimic absence seizures (a brief lapse in awareness) or drop attacks (syncope-like episodes). PNES episodes can look like any of the various types of epilepsy-related seizures.

While healthcare providers can’t determine if someone is having a PNES attack or an epilepsy-related seizure based on observation alone, seizure symptoms that highly suggest PNES include:

• Convulsive-type seizures that are over 10 minutes long.
• Convulsive-type seizures with retained awareness.
• Rapid side-to-side head movements.
• Out-of-phase limb movements.
• Eyes-closed unresponsiveness.
• Pelvic thrusting.
• Changing patterns of movement.

As PNES is associated with psychiatric conditions, people with PNES often have co-occurring psychiatric symptoms or diagnoses, such as a depressive mood or panic attacks.

What causes PNES?

Researchers think the symptoms of PNES are defense mechanisms that develop in response to underlying psychological distress. Some may be distressed because of unresolved or untreated psychiatric conditions.

Common psychiatric conditions that co-occur with PNES include:

• Post-traumatic stress disorder (PTSD).
• Depressive disorders.
• Dissociative disorders.
• Somatic symptom disorder.
• Personality disorders.

Many people with PNES meet the criteria for conversion disorder (also known as functional neurological symptom disorder). Conversion disorder is a mental health condition that manifests as a physical symptom. The symptoms happen because your brain “converts” the effects of a mental health issue into disruptions of your brain or nervous system.

Some physical conditions such as chronic pain or fibromyalgia may put you at risk for PNES.

A history of childhood trauma, such as sexual or physical abuse, is a known risk factor for the development of PNES. In addition, other major stressors in adulthood, such as complex grief or relationship trauma, can put you at risk for PNES.

How is PNES diagnosed?

It can be difficult for healthcare providers to tell the difference between PNES and epilepsy-related seizures based on observation alone. This is because no one seizure sign is specific to PNES.

The most reliable way for providers to diagnose PNES is by recording a seizure with 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 healthcare provider information about your brain’s activity.

If you have PNES, the video EEG will show normal electrical brain activity during the seizure.

How is PNES treated?

The main treatment for PNES involves diagnosing and treating the underlying psychiatric symptoms contributing to the PNES as well as addressing the PNES symptoms directly. Antiseizure medications don’t help treat PNES.

Treating PNES symptoms

The go-to therapy for PNES is psychotherapy (talk therapy). Psychotherapy involves talking with a mental health professional, such as a psychologist, about situations that cause emotional distress. Your therapist can help you identify and change unhealthy emotions, thoughts and behaviors to cope with stressful events more effectively.

Studies show that cognitive behavioral therapy (CBT), a type of psychotherapy, is most effective in treating PNES or conversion disorder. If possible, it may be beneficial to seek mental health professionals who have experience with CBT and PNES.

PNES-specific therapies often focus on:

• Education about types of seizures.
• Identifying and managing common seizure triggers.
• Past or present stressors affecting the PNES.
• Improved emotion management skills using relaxation training.

Treating underlying psychiatric conditions

Treating co-existing psychiatric conditions is an important part of treating PNES. Treatment varies depending on the type of underlying condition, but, generally, psychotherapy and medications are recommended.

For example, prolonged exposure therapy and eye movement desensitization and reprocessing (EMDR therapy) can help people with PTSD. CBT-based therapies such as dialectical behavioral therapy (DBT) can be effective for people with personality disorders. These additional therapies can occur during or after the PNES treatment.

Your healthcare provider may prescribe medications, such as antidepressants, to help treat the underlying psychiatric condition.

Can I prevent PNES?

PNES generally isn’t preventable. But seeking help as soon as PNES or other mental health symptoms appear can help you manage the symptoms and decrease the disruptions to your life.

What is the prognosis of PNES?

Without proper diagnosis and treatment, PNES is associated with emotional distress, poor quality of life and high rates of unemployment and disability. It’s also associated with higher mortality rates than in the general population. On the other hand, after a clear communication of the PNES diagnosis and education by the medical team, some people with PNES no longer experience seizures.

But for most people, psychotherapy can help with symptoms of PNES. Studies show that after 12 sessions of cognitive behavioral therapy, about half of the participants no longer had seizures after the course of the sessions.

When should I see my healthcare provider about PNES?

If you’ve received a diagnosis of PNES, it’s important to seek treatment to address the diagnosis and treat underlying mental health conditions.

When should I go to ER?

If you’re experiencing thoughts of self-harm or suicide, call 911 or 988 or go to the nearest emergency room. If you’re experiencing new seizure symptoms, it’s important to go to the emergency room.

A note from Cleveland Clinic

Learning that psychological distress and trauma are the cause of your seizures can be confusing and upsetting. Know that you’re not alone. A mental health professional can help you understand PNES in a judgment-free environment. Together, you can come up with a therapy plan to help reduce PNES symptoms and treat any underlying mental health conditions.