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Chapter 1

Pseudoseizures (PNES)


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Walker Foland, an emergency physician practicing in Michigan, breaks down why pseudoseizures, now termed PNES (Psychogenic Nonepileptic Seizures), are a real disease.

Walker Foland is an emergency physician practicing in Michigan and in this episode breaks down why pseudoseizures, now termed PNES (Psychogenic Nonepileptic Seizures), are a real disease.

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Are patients with PNES ‘faking it’?

  • PNES is a conversion disorder: an unconscious manifestation of psychological trauma. 
  • Walker treats PNES patients with haloperidol or olanzapine with the thinking that this is psychological, not true epilepsy
  • PNES is not ‘faking it’ or lying



  • Patients with PNES may also have true epileptic seizures
  • Diagnosing PNES, or separating it from epilepsy, may take video EEG monitoring, a neurologist, and sometimes prolonged periods of time to figure things out


How to tell the difference between a grand mal epileptic seizure vs PNES vs faking it?


  • Seizures related to a specific stimulus (sound foods, body movement)
  • Frequency and amplitude of concussions: same frequency through the seizure with varying amplitude.
  • Maintenance of consciousness and may have some of the below
    • may guard the face with passive hand drop
    • resist eyelid opening
    • visual fixation on a mirror
    • Whit Fisher, Dr. Procedurettes, squirts water in the face of patients where there is thought of PNES.  If they grimace, probably not an epileptic seizure.

Faking Seizures

  • Talking
  • Purposeful movement
  • Avoids injury
  • May use convulsions as a way of harming staff
  • Intermittently awake and vocal during the episode

Epileptic seizure

  • Convulsive frequency decreases, amplitude increases as seizure progresses
  • No response to pain
  • Allow passive eye opening


A 2010 article from the Journal of Neurology Neurosurgery and Psychiatry broke down the evidence of what other elements can help distinguish PNES from epileptic seizures. 

  • Duration over 2 minutes suggests PNES, but we’ve all seen epileptic seizures last for a long time, status, and some PNES can be super short
  • Happens in sleep. Evidence suggests that if the event happens in sleep, that is probably episode. PNES episodes happen when awake
  • Fluctuating course such as a pause in the rhythmic movement, epileptic seizures usually don’t pause and then restart, a pause favors PNES
  • Flailing. You’d think the flailing patient has PNES for sure because epilepsy doesn’t flail, but it does! Flailing is much more common in PNES, but not so much so that it’s a clear distinguishing factor
  • Urinary incontinence, more common in epilepsy, but does happen in PNES. 
  • Post-ictal recovery period. Surely, this is the sine qua non of epilepsy.  It is way-way more common following generalized epileptic seizures but happens in around 15% of PNES.
  • The stertorous breathing (noisy, labored) that we see after generalized tonic-clonic epileptic seizures suggests epilepsy and is not a characteristic of PNES


Walker’s take-home points

  • PNES patients aren’t ‘faking it’
  • This is a real disorder, it’s just not epilepsy


Photo Credit Hal Gatewood



Chen, David K., and W. Curt LaFrance Jr. “Diagnosis and treatment of nonepileptic seizures.” CONTINUUM: Lifelong Learning in Neurology 22.1, Epilepsy (2016): 116-131. PMID:26844733

Avbersek, Andreja, and Sanjay Sisodiya. “Does the primary literature provide support for clinical signs used to distinguish psychogenic nonepileptic seizures from epileptic seizures?.” Journal of Neurology, Neurosurgery & Psychiatry 81.7 (2010): 719-725.Full-Text PMID:20581136 

Shen, Wayne, Elizabeth S. Bowman, and Omkar N. Markand. “Presenting the diagnosis of pseudoseizure.” Neurology 40.5 (1990): 756-756. Full-Text PMID:2330101

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