Understanding Functional Seizures: A Patient’s Guide

What are functional seizures (psychogenic nonepileptic seizures)?

Functional seizures (FS), also known as psychogenic nonepileptic seizures (PNES), are episodes that look and feel like seizures caused by epilepsy but are not caused by abnormal electrical activity in the brain. Instead, these seizures are a physical reaction of the nervous system to:

• Physical triggers, like injury or pain,
• Stressors in the environment,
• Past traumatic events.

If this condition is present, the seizures themselves are real. They are not performed intentionally, and there is no voluntary control over the episodes. Functional seizures can be very disruptive to daily life, but help is available. This condition is often referred to within the broader category of functional neurological disorder (FND) because symptoms are best understood as a change in how brain networks function rather than damage to brain structure. Other names include psychogenic nonepileptic attacks, episodes, or spells.

Symptoms and causes

Symptoms

Functional seizures cause seizure-like events that affect movement, awareness, and emotional state. Events vary between people and may resemble tonic-clonic seizures (full-body shaking), brief lapses in awareness, or other patterns such as twitching, out-of-sync limb movements, or episodes where the eyes remain closed. Some episodes may involve prolonged convulsive-like shaking, changes in awareness, or unusual motor behaviors. In some cases, episodes include pelvic or rapid side-to-side head movements.

In addition to seizure events, many people experience anxiety, depression, panic attacks, post-traumatic stress, or other mental-health conditions that can accompany or contribute to seizures.

Causes

Current research supports a biopsychosocial model: functional seizures arise from interactions of biological vulnerability, psychological factors, and social/experiential triggers. Difficulty processing strong emotions or sensory information, unhelpful stress responses, past trauma, and chronic physical conditions (for example, chronic pain) are all recognized contributors. Genetics may influence vulnerability, but the dominant framework describes how stressors and life events come together with brain function changes to produce symptoms.

Risk factors include a history of physical, sexual, or emotional abuse, exposure to traumatic events, and chronic somatic conditions. PNES most commonly begins in young adulthood but may occur at any age.

Complications

Because episodes can occur without warning, risk of accidents and injury is present (for example, during driving or near hazardous equipment). Some people reduce social contact or stop activities out of fear or embarrassment, which can harm relationships and quality of life. Functional seizures are also associated with increased risk of suicidal thoughts in some individuals;

Diagnosis and tests

How providers diagnose functional seizures

Diagnosing PNES can be challenging because episodes often resemble epileptic seizures. The most definitive diagnostic method is simultaneous video-electroencephalography (video-EEG or vEEG), where a typical event is recorded while the EEG shows no epileptic electrical activity. Capturing an event on vEEG supports a clear differentiation between epileptic seizures and PNES. Many patients receive an initial misdiagnosis of epilepsy before PNES is identified. It is possible, though less common, to have both epileptic and functional seizures.

Management and treatment

Overview

Psychotherapy is the mainstay of treatment. Cognitive behavioral therapy (CBT) has the strongest evidence base and is commonly recommended. Antiseizure medications (anti-seizure drugs) are not effective for PNES and may be discontinued unless they are needed for coexisting epilepsy or other conditions; continuing antiseizure medication after a PNES diagnosis is associated with poorer outcomes. Treatment also addresses co-occurring mental-health conditions and aims to reduce triggers and improve coping.

Cognitive behavioral therapy (CBT)

CBT helps people understand how thoughts, emotions, and physical reactions interact and teaches skills to manage stressors and reduce episodes. Clinical studies and systematic reviews report that CBT reduces seizure frequency for many people with PNES, and CBT is associated with improvements in anxiety, mood, and quality of life in several trials and reviews. Typical CBT-based treatment programs involve regular therapy sessions and practice of skills between appointments.

Other therapy approaches

When CBT is not suitable, other psychotherapies or structured neurobehavioral programs may be offered. Some programs use workbook-based approaches or skills-training models with weekly sessions and home practice (for example, journaling and graded social activities). Treatment goals are individualized and often include learning about the diagnosis, identifying triggers, improving emotion-regulation skills, and rebuilding daily functioning.

When to see a healthcare provider

Counseling and diagnosis can bring up difficult emotions. It is important to contact a healthcare provider with questions or if symptoms become overwhelming, or if safety concerns (including suicidal thoughts) arise.

Outlook / prognosis

Outcomes vary. Some people experience substantial reduction or remission of episodes following a clear diagnosis and engaging in appropriate therapy; others continue to have episodes but may gain improved coping and quality of life. Long-term outcome studies report a range of results—some cohorts show meaningful remission for a sizeable portion of patients, while other studies indicate ongoing symptoms for many. Early, clear diagnosis and appropriate psychological treatment are associated with better outcomes.

A note about learning and treatment

Learning that stress and brain network function play a part in these seizures can be difficult. Treatment teams support patients to understand the diagnosis in a nonjudgmental way and to develop a tailored plan. Therapy often requires practice between appointments; consistent use of learned skills supports progress over time.

Sources

• https://my.clevelandclinic.org/health/diseases/24517-psychogenic-nonepileptic-seizure-pnes
• https://www.frontiersin.org/journals/neurology/articles/10.3389/fneur.2024.1363459/full
• https://pmc.ncbi.nlm.nih.gov/articles/PMC7286438/
• https://www.sciencedirect.com/science/article/pii/S1525505023003827?
• https://pmc.ncbi.nlm.nih.gov/articles/PMC2905892/
• https://pubmed.ncbi.nlm.nih.gov/19853215/
• https://www.epilepsy.com/diagnosis/imitators-epilepsy/psychogenic-nonepileptic-seizures?
• https://www.ninds.nih.gov/health-information/disorders/functional-neurologic-disorder?