Psychogenic Nonepileptic Seizure: Symptoms, Types, Causes and Treatment

Psychogenic nonepileptic seizures (PNES) are episodes that resemble epileptic seizures but have a psychological rather than neurological cause. They are often misunderstood, misdiagnosed, and can be deeply disruptive to those affected. In this comprehensive guide, we explore the symptoms, types, causes, and evidence-based treatments for PNES, drawing on the latest research to provide clarity and support for patients, families, and healthcare professionals.

Symptoms of Psychogenic Nonepileptic Seizure

Understanding the symptoms of PNES is crucial for early recognition, accurate diagnosis, and effective management. Unlike epileptic seizures, PNES symptoms are not caused by abnormal electrical activity in the brain but are physical manifestations of psychological distress. The range of symptoms can be broad and sometimes overlap with those of true epilepsy, contributing to the complexity of diagnosis.

Symptom	Description	Frequency/Feature	Sources
Unresponsiveness	Verbal or behavioral non-response	Most common (74% cases)	3
Rigidity	Stiffening of the whole body	72% of cases	3 5
Limb Movements	Repetitive arm/leg movements, sometimes asynchronous	Upper limb (55%), lower limb (39%)	3 5
Vocalization	Sounds, shouting, or vocal outbursts	Less than 25% of cases	3
Head Movements	Nodding or side-to-side movements	Less than 25% of cases	3
Closed Eyes	Eyes remain closed during events	Key distinguishing sign	5
Dissociation	Altered awareness, feeling detached	High dissociation scores	1 4 2
Emotional Signs	Crying, emotional outbursts, post-event distress	Often observed	2 4
Automatism	Repetitive purposeless actions	Seen in some (few cases)	3

Table 1: Key Symptoms

Explaining PNES Symptoms

Motor and Non-Motor Features

• Motor Features: Most PNES episodes involve visible movements such as limb thrashing, whole-body rigidity, or unusual posturing (e.g., claw-like fingers, hyperextension of back and limbs). Unlike epileptic seizures, these movements are often asynchronous and may look more dramatic or prolonged. Pelvic thrusting, a feature sometimes seen in epilepsy, is rare in PNES 3 5 9.
• Non-Motor Features: These include unresponsiveness, verbal unresponsiveness, and dissociative episodes where the person may appear "out of it" or disconnected from their environment. Emotional outbursts, crying, or distress during or after an event are also common 3 4.

Distinguishing Features from Epilepsy

Certain signs help differentiate PNES from epileptic seizures:

• Eyes closed during the event is more typical of PNES, whereas epileptic seizures usually occur with eyes open 5.
• Duration and frequency: PNES may last longer and occur more frequently than epileptic seizures 3.
• Response to environment: Some individuals may react to external stimuli during an episode, which is less common in epilepsy.

Psychological and Emotional Symptoms

• People with PNES often experience high levels of anxiety, depression, and dissociative symptoms, sometimes even outside of seizure episodes 1 4 8.
• Dissociation—feeling detached from one’s body or reality—is a prominent feature and may even precede or accompany an episode 1 2 4.

Cultural and Individual Variations

• Symptom presentation may be influenced by cultural beliefs; for example, some patients attribute their symptoms to possession or supernatural causes 3.
• The subjective experience of altered awareness or "impaired consciousness" varies, and not all episodes involve a dramatic loss of awareness 2.

Types of Psychogenic Nonepileptic Seizure

PNES is not a single, uniform condition. Instead, it includes a variety of seizure-like episodes that can be classified based on their clinical features (semiology). Recognizing these types helps clinicians tailor diagnosis and treatment for each individual.

Type	Description	Prevalence/Examples	Sources
Motor	Involves movement: thrashing, rigidity, tremors	Most common	3 5 9
Nonmotor	Altered awareness, unresponsiveness, dissociation	Present in many cases	3 9
Mixed	Combination of motor and nonmotor features	Some patients	9
Emotional	Crying, hyperventilation, panic, fear	Frequently seen	2 4

Table 2: Major PNES Types

Classification Systems

Motor Seizures

• Characterized by physical movements, which may include:
  • Whole-body or limb thrashing
  • Stiffening (rigidity)
  • Uncoordinated or asynchronous movements
  • Facial grimacing, head nodding, or claw-like hand posturing 3 5 9
• These movements can mimic generalized or focal epileptic seizures but typically lack stereotypy and may wax and wane during an event.

Nonmotor Seizures

• Episodes primarily involving:
  • Unresponsiveness or "zoning out"
  • Loss of awareness without major movement
  • Dissociative states, where the person seems disconnected from their surroundings 3 9
• Patients may have amnesia for the event or describe feeling detached ("out of body" experience) 1 2 4.

Mixed Semiology

• Many individuals display a combination of motor and nonmotor features in a single episode 9.
• For example, a seizure might begin with unresponsiveness and progress to limb movements or vocalizations.

Emotional and Affective Seizures

• Some episodes are dominated by expressions of emotion—crying, screaming, panic attacks, or hyperventilation 2 4.
• These can sometimes be confused with panic disorder or other psychiatric conditions.

Age and Cultural Factors

• In children and adolescents, nonmotor features and behavioral changes may be more prominent 11.
• Cultural beliefs may shape the way symptoms are described or interpreted by individuals and families 3.

Causes of Psychogenic Nonepileptic Seizure

The origins of PNES are multifactorial, involving psychological, social, and biological factors. Understanding the underlying causes is essential for effective intervention and prevention of chronic disability.

Factor	Role in PNES	Key Findings/Notes	Sources
Psychological	Emotional distress, trauma, psychiatric comorbidities	Depression, anxiety, dissociation	1 4 8 12
Life Stressors	Trigger or maintain episodes	Family/marital conflict, bereavement	4 8
Neurobiological	Altered brain connectivity, possible genetic links	Research ongoing, MRI findings	12 13 14
Coping Styles	Emotion-focused>problem-solving	Maladaptive coping common	4
Cultural Factors	Influence symptom expression and beliefs	Attribution to possession, spirits	3

Table 3: Causative Factors in PNES

Psychological and Psychiatric Factors

• Comorbid Psychiatric Conditions: Most individuals with PNES have coexisting psychiatric disorders, such as depression, anxiety, post-traumatic stress disorder (PTSD), or personality disorders, especially borderline type 1 8.
• Dissociation: High levels of dissociative experiences are a hallmark, often linked to past trauma, stressful life events, or emotional dysregulation 1 2 4.
• Trauma and Life Stress: While a high proportion of patients report recent stressful life events (bereavement, family conflict), not all have experienced severe trauma or abuse 4 8.

Neurobiological and Genetic Factors

• Brain Connectivity: Imaging studies suggest altered functional and structural connectivity, particularly in the limbic system (emotion regulation) and areas involved in motor control 12 13.
• Genetic Links: Emerging research indicates that a minority of PNES patients may have genetic variants linked to neurological or psychiatric disorders, though the significance is not yet clear 14.

Coping Mechanisms and Emotional Processing

• Emotion-Focused Coping: Many individuals with PNES use coping strategies focused on avoidance or emotional expression rather than problem-solving, which may perpetuate symptoms 4.
• Impaired Emotion Regulation: Difficulty processing or expressing emotions can trigger or sustain episodes, and overwhelming emotions may be "converted" into physical symptoms 2.

Cultural and Social Influences

• Cultural Attribution: In some societies, PNES may be attributed to supernatural causes (spirits, possession), affecting help-seeking and treatment 3.
• Gender and Age: PNES is more common in women (75-85% of cases) and usually begins in young adulthood 8.

Treatment of Psychogenic Nonepileptic Seizure

Effective treatment of PNES requires a multidisciplinary approach that addresses both the physical and psychological aspects of the disorder. Early diagnosis, patient-centered communication, and evidence-based interventions are key to improving outcomes.

Treatment	Approach/Intervention	Evidence of Effectiveness	Sources
CBT-PNES	Cognitive-behavioral therapy specific to PNES	Significant seizure reduction, improved QoL	15 16 17
Psychotherapy	General psychotherapy (various modalities)	Helpful for comorbid psychiatric symptoms	15 19
Medication	Antidepressants (e.g., sertraline)	Limited effect on seizures unless comorbid depression	15
Education	Clear communication about diagnosis	Improves treatment engagement	19
Discontinuation of AEDs	Stop antiepileptic drugs if no epilepsy	Reduces unnecessary medication use	8 19
Multidisciplinary Care	Neurology, psychiatry, psychology	Best outcomes with integrated care	19

Table 4: Treatment Options for PNES

Psychological Interventions

Cognitive-Behavioral Therapy for PNES (CBT-PNES)

• CBT-PNES is the most studied and effective intervention to date:
  • Reduces seizure frequency by over 50% in clinical trials 15 16 17.
  • Improves mood, anxiety, quality of life, and psychosocial functioning.
  • Involves structured sessions focusing on identifying triggers, modifying thought patterns, and developing healthy coping skills.

Other Psychotherapies

• Approaches such as psychodynamic therapy, mindfulness-based therapies, and supportive counseling may also help, especially for complex psychiatric comorbidities 15 19.

Pharmacologic Interventions

• Antidepressants (e.g., sertraline): May help mood symptoms but do not reduce seizures unless combined with psychotherapy 15.
• Antiepileptic Drugs (AEDs): Should be discontinued in patients without concurrent epilepsy to avoid unnecessary side effects 8 19.

Education and Communication

• Clear, empathetic communication of the PNES diagnosis is vital for patient acceptance and engagement in treatment 19.
• Education includes explaining the nature of PNES, its difference from epilepsy, and the rationale for recommended therapies.

Multidisciplinary and Maintenance Care

• Best outcomes are achieved with coordinated care involving neurologists, psychiatrists, psychologists, and primary care providers 19.
• Ongoing follow-up to monitor progress, adjust interventions, and address any new or persistent issues is important.

Barriers and Access

• Many patients face challenges accessing specialized diagnostic tools (e.g., video-EEG) and experienced therapists 18.
• Cultural beliefs and stigma may delay diagnosis and treatment, highlighting the need for increased awareness and education 3 18.

Conclusion

PNES is a complex and often misunderstood condition at the intersection of neurology and psychiatry. Timely recognition, accurate diagnosis, and evidence-based, compassionate care can transform outcomes for affected individuals.

Key Points:

• PNES episodes mimic epilepsy but are psychological in origin and not associated with abnormal brain electrical activity.
• Common symptoms include unresponsiveness, limb movements, rigidity, emotional outbursts, and dissociative experiences.
• Types of PNES are classified as motor, nonmotor, mixed, and emotional/affective, with features sometimes shaped by culture and age.
• Causes are multifactorial: psychological distress, trauma, maladaptive coping, altered brain connectivity, and cultural factors all play a role.
• Evidence-based treatments, especially cognitive-behavioral therapy tailored to PNES, are effective in reducing seizure frequency and improving quality of life.
• Multidisciplinary and individualized approaches, along with clear patient education, are essential for optimal care.

By bridging the gap between neurology and mental health, we can offer hope and practical solutions for those living with PNES.