Executive Summary
Psychogenic non-epileptic seizures (PNES) are real seizure events that can involve fainting, shaking, loss of consciousness, and other disabling symptoms, but they are not caused by the abnormal electrical activity seen in epilepsy. In the discussion, Dr. Danoun emphasizes that these events are not fake, voluntary, or simply “all in the patient’s head.” Instead, they arise through a different brain mechanism than epileptic seizures, which is why diagnosis, explanation, and treatment must also differ.
The diagnostic process begins with a neurologic evaluation, physical examination, event history, and, when available, video of a typical event. Certain event features may raise suspicion for PNES rather than epilepsy, including slower buildup, asynchronous movements, stop-and-start shaking, prolonged duration, closed eyes, and emotional expression during the event. However, the gold standard for diagnosis is video-EEG monitoring in an epilepsy monitoring unit. If a patient’s typical event is captured on video while brain waves remain normal, the diagnosis of PNES can be documented with confidence.
Podcast Experts Featured
Dr. Omar A. Danoun, Epileptologist – Podcast guest discussing psychogenic non-epileptic seizures, diagnosis, mechanisms, and treatment.
Clinical Terms Explained
- Psychogenic Non-Epileptic Seizures (PNES): Real seizure events that can cause shaking, fainting, loss of consciousness, and other disabling symptoms, but that occur without the abnormal electrical activity seen in epilepsy.
- Epileptic Seizures: Seizures caused by abnormal electrical firing in the brain, described in the discussion as an electrical storm or excess electricity that produces symptoms.
- EEG: A recording of brain waves used to evaluate whether seizure events are associated with abnormal electrical activity.
- Video-EEG Monitoring: A diagnostic approach in which a patient is observed on video while EEG records brain activity so clinicians can compare the visible event with the brain wave pattern at that exact time.
- Cognitive Behavioral Therapy (CBT): A psychotherapy approach described as helping patients improve awareness and understanding of thought processes and then develop healthier behavioral responses instead of channeling conflict into seizure events.
- Epilepsy Monitoring Unit: A hospital setting where patients are monitored continuously with video and EEG until a typical event is captured and evaluated.
Understanding Psychogenic Non-Epileptic Seizures
Psychogenic non-epileptic seizures are often misunderstood because they can look very similar to epileptic seizures while arising through a different mechanism. In this discussion, Dr. Danoun makes a central point early: these are seizures, and the symptoms are real. Patients may faint, lose consciousness, shake, or experience other disabling episodes. The difference is not whether the event is real. The difference is what is generating it.
In epilepsy, seizure symptoms are caused by abnormal electrical activity in the brain. In PNES, the patient can have a seizure-like event while the EEG remains normal. That distinction matters clinically because it changes both the explanation given to patients and the treatment path that follows. Dr. Danoun notes that patients with PNES should not simply be told they do not have epilepsy and left there. That may rule out one diagnosis, but it does not explain why they continue to fall, shake, or lose awareness. The need is not only to exclude epilepsy, but to identify and explain what is actually happening.
Why PNES Should Not Be Dismissed
A major theme in the discussion is stigma. Patients with PNES may encounter the false assumption that their symptoms are fake, attention-seeking, voluntary, or exaggerated because the events are psychological in nature rather than epileptic. Dr. Danoun rejects that framing directly. He explains that the seizures are real, even though the mechanism is different from epileptic seizures.
That distinction is important because the word “psychological” is often misunderstood. In the discussion, it does not mean imaginary. It means that the generator of the event differs from the electrical mechanism of epilepsy. Patients can still experience profound loss of control, impaired awareness, injuries, and substantial disability.
Dr. Danoun also notes that PNES can be as disabling as epileptic seizures and, in some cases, even worse. The clinical burden remains real even when the EEG does not show epileptic activity.
How the Diagnosis Begins
The diagnostic process begins with a neurologist. According to the discussion, evaluation includes the clinical history, physical examination, and detailed review of the patient’s symptoms. A video of the event, whether captured on a phone or another device, can be especially helpful because event semiology may offer useful clues.
Dr. Danoun describes several clinical features that may suggest epilepsy versus PNES, while also making clear that these observations are not enough on their own to establish a definitive diagnosis.
Features described as more typical of epileptic seizures include:
- abrupt onset
- stereotyped progression
- spread of symptoms in a more expected pattern
- rhythmic jerking in a consistent plane
- short duration, often around one to two minutes
- post-event confusion or fatigue
- tongue biting or loss of bladder control in some cases
Features described as more suggestive of PNES include:
- slower onset and gradual buildup
- stop-and-start shaking
- asynchronous or changing movement patterns
- prolonged episodes that may last several minutes or longer
- closed eyes during the event
- emotional expression such as crying
- impaired responsiveness with possible retained ability to hear others
These distinctions can help shape clinical suspicion, but the discussion makes clear that the gold standard is not bedside impression alone.
The Gold Standard for Diagnosis
The definitive test described in the podcast is video-EEG monitoring in an epilepsy monitoring unit. In that setting, the patient is connected to EEG while being recorded on video, and clinicians wait for a typical event to occur. Sometimes medications are adjusted or measures such as flashing lights or hyperventilation are used to try to trigger the event.
If the patient has a typical event and the EEG shows the abnormal electrical signature expected in epilepsy, the diagnosis supports epileptic seizures. If the patient has their usual shaking event but the brain waves remain normal, that supports PNES.
