When a seizure is not a seizure…let us talk about Pseudoseizures

Nitin K Sethi, MD, MBBS, FAAN


Epilepsy is a common neurological condition in which patients suffer recurrent seizures (also referred to as convulsions).

A generalized convulsion is a rather dramatic event. If it occurs while the patient is standing, frequently the patient gets no warning and falls down striking the ground hard. This is the time injuries occur. As the patient is falling down, he/she is amnestic for the entire episode. Family/bystanders notice that initially the patient stiffens (arms and legs are extended, eyes are rolled up into the head, clenching of the teeth occurs which at times leads to the tongue getting bitten, the patient may at times suffer loss of bladder control). This “tonic” phase is followed by the “clonic” phase during which convulsive movements occur. The seizure stops in a minute or two but the patient remains unresponsive and slowly regains consciousness.

If the above convulsion occurs WHILE the patient is undergoing an EEG test (electroencephalogram), the abnormal brain activity is picked up by the test (see example below) and the diagnosis confirmed.

Based on the misfiring recorded on the EEG, the neurologist can then opine what kind of epilepsy the patient has and where (which part) in the brain the seizures are originating from.

EEG showing abnormal brain waves (spike wave discharges) and beginning of a seizure (IMAGE SOURCE: Wikipedia-the image is used for purely educational purpose)


Pseudoseizure is the term used for events that appear to be epileptic seizures but, in fact, are not. So while the patient may have a dramatic event where in he/she shakes, may roll up the eyes, arch his back, moan, make noises and vocalize, THERE IS NO ABNORMAL EXCESSIVE SYNCHRONOUS CORTICAL ACTIVITY (meaning that on the EEG, the brain waves appear normal without any misfiring).

Pseudoseizures are referred to by various names such as psychogenic non-epileptic events (PNES), non epileptic events (NEE), non epileptic seizures, hysterical seizures.

When pseudoseizures are suspected, a neurologist or epileptologist (epilepsy specialist) shall take a detailed history, may order a MRI scan of the brain and then attempt to capture one of these events on VIDEO-EEG MONITOR (Video-EEG is a special kind of EEG in which simultaneous EEG and video recording of the patient is carried out). The goal is to capture one of the patient’s reported events on video-EEG. If no misfiring of the brain is observed during the event, a diagnosis of pseudoseizures is made.

The non-epileptic (“YOU DO NOT HAVE EPILEPSY” OR “THESE ARE NOT SEIZURES”) nature of the events is then explained to the patient and the family and an attempt is made to try to determine the underlying cause (Why is the patient having these events?). There are many causes of pseudoseizures such as mental stress, sexual or physical abuse, personality disorders, dissociative disorders, affective disorders (mood disorder, anxiety, depression), substance abuse disorder, family conflict, conflict or stress at work, problems in marriage among others.

The treatment is usually a combination of psychotherapy and use of medications (selective serotonin reuptake inhibitors). With support and understanding most patients start to improve and the events either stop completely or become less frequent.


Psychogenic seizures/ Non-epileptic events

Nitin K. Sethi, MD

Assistant Professor of Neurology

New York-Presbyterian Hospital

Weill Cornell Medical Center

New York, NY 10065

 Non-epileptic events

Non-epileptic events are paroxysmal episodes that resemble and are often misdiagnosed as epileptic seizures. Non-epileptic events can be further of two kinds

Psychogenic non-epileptic seizures (PNES)

Non epileptic but not psychogenic (“physiologic”) event

Non-epileptic but not psychogenic (physiologic) events: examples include

  • Tremors
  • Myoclonus which is not cortical (segmental/ spinal)
  • Dystonia
  • Dyskinesias
  • Parasomnias: sleep walking, nocturnal panic attacks, nightmares, sleep terrors
  • Syncope
  • Complicated migraine
  • Transient ischemic attacks
  • Cataplexy
  • Startle induced phenomena

 Psychogenic non-epileptic events

Multiple terminology: pseudoseizures, nonepileptic seizures, nonepileptic events, and psychogenic non-epileptic seizures.

 By definition PNES are psychogenic (psychological) in origin.

Can be

  • a form of conversion disorder or more broadly somatoform disorder—these are involuntary 
  • a form of malingering or factitious disorder—these are voluntary


Frequency/ sex ratio and age of onset

  • Up to one in five patients with apparently medical intractable epilepsy referred to epilepsy centres.
  • Incidence and prevalence varies in different countries: likely on account of differences in social and cultural norms.
  • More frequent in women as compared to men.
  • Typical age of onset is young adulthood


 Making the diagnosis

Misdiagnosis is common!!!

Patients present with history of uncontrolled seizures/ typical events inspite of

multiple inpatient admissions

multiple physicians

multiple anti-epileptic drugs (AEDs)

multiple tests

Making the diagnosis

  • Good history forms the backbone
  • History of typical event
  • From patient
  • From family/ caregiver/bystander

Points to consider:

Does the event occur out of sleep or do the events always occur during daytime when people are around

Specific triggers that are unusual for epilepsy: events are clearly precipitated by emotional stress (“I become angry and then shake”)

Circumstances in which attacks occur: around an audience (family, social events)

Details of the typical event: motor movements characteristics that are inconsistent with epileptic seizures: side-to-side shaking of the head, bilateral asynchronous trashing movements which are out of phase, weeping, verbalization and arching of the back (pelvic thrusting), eyes are closed and cannot be pried open.

History of other coexisting psychogenic conditions: fibromyalgia, chronic fatigue syndrome, IBS.

Good psychosocial history: depression, bipolar disorder, personality disorders (hysterical personality), family dynamics.

History of sexual abuse is specially important.

 Making the diagnosis


 VIDEO-EEG study is the gold standard

  • Helps to make an electroclinical correlation: capture a typical event on the video and interpret the electrographic correlate.
  • No change in the background EEG during the clinical event.
  • Clinical event is inconsistent with known seizure semiology: event starts-stops-then starts again, awareness is preserved in spite of bilateral motor convulsive activity.

 If Video-EEG facility is unavailable: routine EEG, ambulatory EEG, extended EEG—with suggestibility—lower yield

Imaging studies may or may not be normal: correlate the MRI/ CT with the history

Blood tests: prolactin (increased for about 30 minutes after a generalized convulsion)—impractical, hence not too useful.


Not easy!!!

patients frequently do not accept their diagnosis (” I am not crazy” ” I shall see another doctor”)

hence the way one delivers/explains the diagnosis to patients and their families is an art: some physicians are blunt, others are more vague or mask their words

Patients may or may not be agreeable to seeing a psychiatrist

  • Assure continuity of care
  • Be supportive
  • Be non confrontational


Other issues:

can AEDs be tapered off?

Does the patient have co-existing true seizures?

So your doctor may get other professionals involved: social workers, psychiatrists




  • Not all patients become “seizure”/spell free—many in fact do not
  • Males become spell free more than females
  • If they have a previous psychiatric diagnosis or some motive like disability/ unresolved marital stress—they shall not become spell free
  • Events may become less dramatic—less hospitalizations or visits to the doctor
  • They may be lost to follow up and find another doctor

Pseudoseizures: a question and an answer

2010/04/15 at 3:17am

I’m writing because I am feeling desperate. I have been in therapy for 10 years, only five of which I have been treated for pseudo seizures. I am on anti-depressants, which usually make my life quite manageable. My seizures, depression, and anxiety are incredibly exacerbated before my period, often leaving me unable to work, go to school, or function in society. I feel I have tried everything. Are there any doctors, therapists, or other groups doing research on this problem? If the seizures don’t originate in the brain, where the heck are they coming from? How can our brain waves be calm while our bodies are seizing? If therapy doesn’t seem to be solving the problem, what then?

Also, how common is this problem? I am so embarrased by it, I feel like I should be able to control it and it is my fault that I can’t. I feel so alone. Are there any others out there like me?
Ms. Psuedo Seizure.


Dear Ms. Pseudoseizure,
thank you for writing in to me. I have to admit your name (Ms. Pseudo seizure herself) grabbed my attention. Your struggle with this condition and your plea for help is heartrending. What follows is a detailed description of pseudoseizures. I hope this shall help answer some of your questions. My very best to you.Personal Regards,
Nitin Sethi, MD

When a seizure is not a seizure (pseudoseizures)

When a seizure is not a seizure (pseudoseizures)

Nitin K Sethi, MD

Assistant Professor of Neurology

New York-Presbyterian Hospital

Weill Cornell Medical Center

New York, NY 10065

The month of Feb finds me in New Delhi, India. I have been invited to present a talk on psychogenic non-epileptic seizures (PNES). You may now be wondering what does that mean. Well that is what I plan to discuss in this post of mine. Let us look at the term again:

P–stands for psychogenic  meaning the event has a psychological basis to its existence.

NES–stands for non-epileptic seizure meaning the event is not a epileptic seizure.

So let me put it all together in simple language.  Let us assume our character for this short story is Michelle. Now Michelle is a 25-year-old young lady who is married to John. All looks great from outside. Michelle has a good job, a fun life in Manhattan and a good circle of friends. But all is not hunky dory. Michelle and John have been having some problems. John is verbally and lately physically abusive to her. Michelle feels trapped in a loveless marriage but sees no way out.

So one day Michelle and John are at a dinner party.  Seated at their table are few close friends as well as some strangers. As the main course is served, Michelle suddenly leans back, she utters a cry. Then her eyes are noticed to roll up.  John and Michelle’s friends quickly ease her to the ground. She is then noted to have vigorous side to side shaking movements of her head, asynchronous out of phase thrashing movements of her arms and legs. All this time her eyes are open and she is muttering help me, help me.

Michelle is rushed to the hospital where a doctor like me is called to consult on her.  What happened to Michelle?  Seizure or not a seizure, is the question. To help determine the etiology, her doctor orders a video-EEG study.  Michelle is admitted to the hospital and electrodes are pasted on the top of her head to record her brain waves (encephalogram). The encephalogram is time locked to the video camera mounted on the ceiling which records Michelle’s movements. Hence the name VIDEO-EEG.

So imagine Michelle. Sitting in bed, wires attached to her head, surrounded by friends, family and most importantly an extremely concerned John by her bedside. And then it happens again. A dramatic event where she yells a bone chilling cry and then shakes all over.  Now everyone wants to know what is plaguing Michelle.

So what did the video-EEG record?  Was it a seizure or not? Surprisingly when the EEG data is analysed, at the time when Michelle is having her “seizure” the EEG shows no change in the brain waves.  Meaning than Michelle is not having a true seizure, the event is non-epileptic.

Events such as the above are called PNES. They are psychogenic since they have a psychological basis to them. In Michelle’s case they likely reflect her struggles in her marriage and may be a sign for help. Some patients have psychogenic seizures/ pseudoseizures voluntary.  Meaning they might malinger a “seizure” for a secondary gain such as to get social security payments, to escape school and so forth.

PNES  are common and difficult to diagnose and treat.  As you may imagine patients are frequently misdiagnosed. Some are misdiagnosed as true seizures/ epilepsy and started on anti-convulsant drugs which have their own side-effects.  When one drug fails to stop the “seizure”, new drugs are tried.  So frequently these patients are on multiple anti-convulsants and their “seizures” still continue.

PNES do not stop till the underlying psychological issues are tackled. In Michelle’s case simply telling her that she does not have true seizures is not the end of the road. She needs to be referred to a psychiatrist and a therapist. Only then she may be cured.

Non epileptic seizures or pseudoseizures

Non epileptic seizures or pseudoseizures-what are they and what is to be done about them?

Nitin K Sethi, MD

Assistant Professor of Neurology

New York-Presbyterian Hospital

Weill Cornell Medical Center

New York, NY

I thought in this post of mine, I shall discuss pseudoseizures. As the name suggests pseudoseizures means “not true seizures”. We nowdays prefer to refer to them as non-epileptic events (NEE).

So what do we mean when we say someone has pseudoseizures? Let me illustrate with the aid of an example. A patient lets say Ms.XYZ comes to me for initial consultation for her seizure disorder. History is as follows. She has had 2 episodes where-in she was witnessed to have violent jerking movements of her arms and legs. First episode occurred in school after she got into a heated verbal argument with her best friend while the second occurred after a similar confrontation at home with her mother. None of these events were preceded by any aura. As per history she did not bite her tongue or have loss of bladder control though she says she felt tired after the events.

Hmm sounds suspicious for seizures you might rightly say. I tell her I would like to bring her into the hospital to do a video-EEG study to better characterize her seizure type (see my posts on seizure types at http://braindiseases.info). She agrees to the study.

EEG recording is initiated and is read as normal after 24 hours. The next day in the hospital, I tell her and her mother about the results of the normal EEG. A few hours after my discussion with the family, she is noted by the nursing staff to have a violent “seizure”. I review her EEG. On the camera I notice her to suddenly stiffen and then have violent out of phase (uncoordinated) flinging movements of the arms and legs. Her head moves from side to side and I overhear her  yelling “too much, too much, let me go!!! let me go!!!). The event occurs while her mother and her best friend are by her bedside.

I look at the time locked EEG (EEG synchronized with the video in real time). While she is clinically having a “seizure”, her brain waves are normal (the brain is not having a seizure). A correct diagnosis of pseudoseizures (non-epileptic event) is made and she is discharged home with advise to follow up with a psychiatrist.

So what is a pseudoseizure?

1. It is not a true seizure but rather an episode or episodes which clinically look like seizures but are not accompanied by any EEG changes.

2. It usually has a psychological basis. In my experience I commonly see them in people who are passing through tremendous stress be it interpersonal relationships or at the job.

3. A person may have pseudoseizures to achieve a secondary gain (in the case of our patient, attention and love from her mother and best friend).

4. Pseudoseizures are not treated like seizures. These patients do not need anti-seizure medications. They rather at times need a psychiatrist to explore the underlying reasons for the NEE (conflicts in family etc).

5. Some patients who have true seizures (epilepsy) may also have pseudoseizures.