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.

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.

Dr. Danoun describes this as the gold standard because the clinician is not relying only on history or appearance. The team can compare what is seen on video with what is happening electrically in the brain at the same moment. Once a patient’s typical home event is captured and shown not to be epileptic, he describes that diagnosis as documented and highly accurate.

How Common PNES Can Be in Referral Practice

In the discussion, Dr. Danoun states that about one-third of patients referred to the epilepsy monitoring unit for resistant epilepsy are ultimately diagnosed with non-epileptic seizures. He also notes that about one-third of his own patients have non-epileptic seizures.

That point matters because PNES is often perceived as unusual or rare, yet in specialized epilepsy practice it appears regularly. It also helps explain why misdiagnosis can persist for years. As discussed in the interview, some patients are treated for epilepsy for five or six years before further evaluation reveals that the events are non-epileptic.

Possible Mechanisms in the Brain

The discussion presents PNES as involving brain-based mechanisms tied to emotional processing rather than excess electrical firing. Dr. Danoun describes conflicts in emotional areas of the brain getting out of sync and forming abnormal connections with motor pathways.

The conversation specifically references the limbic system, including the hippocampus and amygdala, along with connections to the frontal cortex. Dr. Danoun explains that some people process conflict outwardly through anger or external behavior, while others repress difficult experiences or emotions. In his description, that unresolved internal conflict may eventually seek an outlet, and in PNES the outlet may become physical.

He explains that studies using connectivity and functional MRI have shown heightened connectivity between emotional processing areas and the motor cortex. He compares this to water building behind a dam until an outlet forms. In this model, the brain begins linking emotional conflict with motor output, and seizure events can then occur as that pathway is activated.

This explanation is presented as a mechanism discussed in research, not as a complete answer for every patient. Dr. Danoun also emphasizes that these mechanisms are not yet fully understood.

The Role of Trauma and Biological Susceptibility

Trauma is discussed as relevant in many cases, but not as a universal explanation. Dr. Danoun notes that many patients develop PNES after traumatic life experiences such as accidents or abuse, but he also states that only about half of patients have an identifiable trauma history.

He pushes back against the idea that everyone with PNES has the same background or that a traumatic history must always be found. According to the discussion, men and women can both develop PNES, younger and older patients can develop it, and some patients may begin having events later in life.

He also distinguishes between trauma and current stress. One of the more important points in the interview is that some patients are not actively stressed when the events begin. A person may have experienced major trauma years earlier, but the non-epileptic seizures may emerge later, once they are in a safer environment or relationship. In his description, the brain may respond defensively to the possibility of returning to prior trauma even when the person is no longer in the acute moment of danger.

He also argues that trauma is relative. One person may dismiss a problem that another experiences as overwhelming. That variability, in his view, reflects both personal experience and underlying biological susceptibility. He compares this to the fact that not all people exposed to trauma develop PTSD.

Who May Be More Susceptible

The discussion states that PNES can happen to anyone, but Dr. Danoun notes that it is more common in females than males and may be more common in people with borderline personality disorder. At the same time, he emphasizes that it should not be reduced to a single personality type or demographic profile. He has seen PNES in patients across age ranges, including later adulthood.

That balance matters. The conversation acknowledges patterns without treating them as rigid rules.

How PNES Differs From Anxiety Attacks

The interview also distinguishes PNES from anxiety attacks. Dr. Danoun describes anxiety attacks as psychological events with physiologic responses, such as fear, impending doom, heart racing, sweaty palms, and tremors. In his description, the patient remains aware of what is happening and retains more control.

By contrast, PNES is described as a shaking event that can impair consciousness, cause falls or injuries, and produce a more seizure-like loss of control. He explicitly states that PNES does not simply reduce to anxiety.

This distinction is important because patients are often mislabeled. The conversation makes clear that anxiety, depression, and PTSD may coexist with PNES, but they are not identical to it.

Treatment After Diagnosis

Once PNES is diagnosed, the treatment pathway changes. Dr. Danoun states that antiseizure medications should be stopped if the patient does not also have epilepsy. He then identifies psychotherapy as the key treatment approach, with cognitive behavioral therapy discussed as the most helpful psychotherapy for PNES.

In the conversation, CBT is described in two parts. The first is cognitive: awareness, understanding, and mastery of thought processes. The second is behavioral: learning how to redirect the internal buildup that might otherwise move toward a seizure event. Rather than allowing conflict to channel into motor activity, the patient learns grounding techniques and other healthier ways to respond.

The goal, as described, is not only to revisit difficult experiences, but to help patients process conflict differently and regain control over how that conflict is expressed.

The Role of Structured CBT Programs

Dr. Danoun specifically references the Take Control of Your Seizures workbook and attributes that work to Dr. Kurt LaFrance, whom he describes as a mentor in the field. He notes that the workbook is structured over 12 sessions and that patients work through it weekly with an experienced therapist. He also states that clinical trials were done to support that approach.

A notable detail in the discussion is that trauma is not addressed at the very beginning of treatment. Instead, therapy starts with awareness, mindfulness, and foundational tools. More difficult life experiences are addressed later, after the patient has developed enough structure and skill to approach them productively. He mentions that traumatic experiences are discussed later in the workbook, around session nine.

He also notes that there is a companion guide for therapists, which can help clinicians who may be excellent therapists generally but less experienced in treating PNES specifically.

Why a Holistic Approach Matters

The conversation repeatedly returns to the idea that PNES care should not be reduced to seizure frequency alone. Dr. Danoun describes a broader treatment model that includes family environment, outside stressors, unresolved relational issues, community support, and coexisting psychiatric conditions.

He explains that depression, anxiety, and PTSD commonly occur alongside PNES. However, he also cautions that these conditions do not cause PNES in a simple one-to-one way. They are separate diagnoses. The problem, in his view, is that untreated anxiety or depression can make symptoms harder to control by adding background noise and instability that interferes with recovery.

For that reason, he recommends addressing these conditions as part of treating the patient as a whole. Supportive family understanding and reduction of outside conflict may also improve outcomes.

Why Language Matters

The discussion also addresses naming. Some patients want a clear term for what they are experiencing, and the host notes that some people refer to these events as “stress seizures.” Dr. Danoun disagrees with that label. He explains that stress is too broad and vague a term, and he explicitly states that stress is not the cause of PNES.

He allows that stressful situations can contribute, but he does not consider “stress seizures” an accurate name. His reasoning is that the mechanism involves brain-based changes and emotional processing patterns that are more specific than general stress. He also points out again that many patients are not actively stressed when the events begin.

That naming issue matters because terms shape understanding. A vague label may reinforce stigma or oversimplify the disorder. A clearer explanation can help patients and families better understand why the events are real and why specialized treatment is needed.

What Patients and Families Should Do First

For patients with unexplained seizure-like events, Dr. Danoun’s recommendation is to see a neurologist, ideally an epilepsy specialist. He warns that patients may be misdiagnosed with epilepsy when clinicians do not investigate deeply enough, especially if the presentation is judged mainly by symptoms without definitive testing.

The recommended path in the discussion is neurologic evaluation followed by the best available testing, particularly video-EEG monitoring when needed. For families, education also matters. He encourages understanding the condition so loved ones can respond with greater compassion and support rather than doubt or stigma.

The overall message is direct: PNES is real, can be highly disabling, and requires a diagnostic and therapeutic approach that is distinct from epilepsy.

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This Content Is Most Useful For:

• Epileptologists evaluating seizure-like disorders
• Neurologists diagnosing unexplained seizure events
• Neurocritical care clinicians interpreting seizure presentations
• EEG technologists involved in video-EEG monitoring
• Clinicians working in epilepsy monitoring units

Working in

• Academic Medical Centers
• Multi-Hospital Health Systems
• Single-Site Hospitals with epilepsy monitoring programs
• Private Practice Epilepsy Centers

FAQ

Are psychogenic non-epileptic seizures real seizures?

Yes. In the discussion, Dr. Danoun states that patients with PNES have real seizure events with real symptoms, including fainting, loss of consciousness, and shaking. The difference is that the mechanism is different from epileptic seizures.

How are PNES different from epileptic seizures on EEG?

Epileptic seizures are described as arising from abnormal electrical activity in the brain. In PNES, the patient may have a seizure-like event while EEG and brain waves remain normal during the event.

What is the gold standard for diagnosing PNES?

The gold standard described in the discussion is video-EEG monitoring in an epilepsy monitoring unit. This allows clinicians to capture a typical event while simultaneously evaluating the patient’s brain wave activity.

Do all patients with PNES have a history of trauma?

No. Dr. Danoun states that trauma can be identified in only about half of patients and that PNES can occur in people without a clearly identifiable traumatic life experience.

What treatment is discussed for psychogenic non-epileptic seizures?

The main treatment discussed is psychotherapy, particularly cognitive behavioral therapy. The conversation describes CBT as focusing on awareness, understanding, grounding, and healthier behavioral responses rather than channeling conflict into seizure events.

Content Source

This article is based on a discussion from the CortiCare Podcast featuring Dr. Danoun on psychogenic non-epileptic seizures and how they differ from epilepsy, how they are diagnosed, and how they are treated.