Acta Scientific Neurology (ASNE) (ISSN: 2582-1121)

Research Article Volume 5 Issue 5

Psychogenic Nonepileptic Seizures - The Empirical Evidence Weighs in

Catherine A Carlson*

Psychological Services Division, Minnesota Judicial Branch, USA

*Corresponding Author: Catherine A Carlson, Psychological Services Division, Minnesota Judicial Branch, USA.

Received: March 20, 2022; Published: April 29, 2022


An estimated 15% to 30% of patients referred to epilepsy-monitoring units for drug resistant epilepsy walk away with a diagnosis of psychogenic nonepileptic seizures (PNES). Seizures that do not produce an epileptiform discharge on the ictal video-electroencephalogram (vEEG) will likely garner the ‘rule in’ diagnosis of PNES, or Conversion Disorder in modern nomenclature. The absence of an epileptiform discharge is considered proof that the seizure is not epileptic and thus, it presumably has a psychological origin. For decades, the scalp EEG has been hailed as the ‘gold standard’ for distinguishing PNES from epilepsy and a great deal of empirical data has been amassed on the PNES patient population. Though the PNES diagnostic entity is treated as a proven fact, in truth, it rests on but one hypothesis that might explain a negative scalp EEG. Since not all epileptic seizures produce a scalp EEG correlate, an epileptic seizure is a recognized competing hypothesis for a negative scalp finding. In fact, studies that gather data from both scalp and intracranial EEG recordings show that scalp-negative epileptic seizures are not uncommon, but in modern epilepsy-monitoring units, they are at high risk of being mislabeled PNES. To assess for such diagnostic error we must turn to the empirical evidence which shows that the clinical profiles of PNES and epilepsy patient populations are identical. The similarities are striking and the only data the PNES hypothesis can explain is a negative scalp EEG. Conversely, the competing epileptic hypothesis seamlessly accounts for the bulk of the findings on patients with seizures labeled PNES. The diagnostic terrain is further muddied by the ongoing conflation of conscious feigning with conversion disorder which represents a long-standing conceptual error. The data establishes that the PNES patient population consists primarily of patients with epilepsy, along with a smattering of factitious and likely psychotic disorders, thereby exposing the PNES diagnostic entity as a hypothetical construct that does not exist. Diagnostic theory and practice in epilepsy-monitoring units must be revisited

Keywords: Epilepsy; Psychogenic; Electroencephalogram; Conversion; Functional; Dissociative


  1. LaFrance WC Jr and Devinsky O. “The Treatment of Nonepileptic Seizures: Historical Perspectives and Future Direction”. Epilepsia2 (2004): 15-21.
  2. Baslet G., et al. “Psychogenic Non-epileptic Seizures: An Updated Primer”. Psychosomatics1 (2016): 1-17.
  3. Bompaire F., et al. “PNES Epidemiology: What is known, what is new?” European Journal of Trauma and Dissociation 1 (2021): 100136.
  4. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (5th edition) (2013).
  5. Asadi-Pooya AA and Sperling MR. “Epidemiology of psychogenic non-epileptic seizures”. Epilepsy and Behavior 46 (2015): 60-65.
  6. Brown RJ and Reuber M. “Towards an integrative theory of psychogenic non-epileptic seizures (PNES)”. Clinical Psychology Review 47 (2016): 55-70.
  7. Adams C., et al. “You’ve made the diagnosis of functional neurological disorder: now what?” Practical Neurology 4 (2018): 323-330.
  8. Hani AJ and Husain AM. “Scalp Video EEG Monitoring. Chapter 17”. In Practical Epilepsy, Husain AM. Demos Medical Publishing, LLC, NY, NY (2015).
  9. Nielsen G., et al. “Physiotherapy for functional motor disorders: a consensus recommendation”. Journal of Neurology, Neurosurgery, and Psychiatry 86 (2015): 1113-1119.
  10. Devinsky O and Gordon E. “Epileptic seizures progressing into nonepileptic conversion seizures”. Neurology 51 (1998): 1293-1296.
  11. Remaly J. “How can Neurologists Treat Psychogenic Nonepileptic Seizures? Treatments including CBT plus medication, have reduced seizures in randomized trials”. Neurology Reviews12 (2017): 5.
  12. International League Against Epilepsy. “Inside the world of psychogenic seizures: Diagnosis, treatment and stigma”. International League Against Epilepsy Epigraph2 (2019).
  13. LaFrance WC Jr and Benbadis SR. “Differentiating Frontal Lobe Epilepsy from Psychogenic Nonepileptic Seizures”. Neurologic Clinics 29 (2011): 149-162.
  14. McGonigal A., et al. “Correct Diagnosis of Psychogenic Nonepileptic Seizures”. International Journal of Epilepsy 5 (2018): 112-113.
  15. Gasparini S., et al. “Management of psychogenic non-epileptic seizures: a multidisciplinary approach”. European Journal of Neurology 2 (2019): 205-e215.
  16. LaFrance WC Jr., et al. “Minimum requirements for the diagnosis of psychogenic nonepileptic seizures: A staged approach A report from the International League Against Epilepsy Nonepileptic Seizures Task Force”. Epilepsia 11 (2013): 2005-2018.
  17. Xiang X., et al. “Differential diagnosis between epileptic seizures and psychogenic nonepileptic seizures based on semiology”. Acta Epileptologica 1 (2019): 6.
  18. Goldstein LH and Mellers JDC. “Recent developments in our understanding of the semiology and treatment of psychogenic nonepileptic seizures”. Current Neurology and Neuroscience Reports 4 (2012): 436-44.
  19. Devinsky O., et al. “Electroencephalographic studies of simple partial seizures with subdural electrode recordings”. Neurology4 (1989): 527-533.
  20. Wyler AR., et al. “Pseudo-Pseudoepileptic Seizures”. In: Rowan AJ, Gates J, editors. Non-epileptic seizures. Massachusetts: Cambridge University Press (1993): 73-84.
  21. Sinha SR. “Intracranial EEG Monitoring. Chapter 18. Practical Epilepsy. Husain AM. Demos Medical Publishing, LLC, NY, NY (2015).
  22. Williamson PD., et al. “Complex partial seizures of frontal lobe origin”. Annals of Neurology 18 (1985): 497-504.
  23. Gupta PK., et al. “Subtypes of Post-Traumatic Epilepsy: Clinical, Electrophysiological, and Imaging Features”. Journal of Neurotrauma 31 (2014): 1439-1443.
  24. Wyler AR., et al. “Chronic subdural strip electrode recordings in difficult epileptic patients”. Journal of Epilepsy Research 1 (1988): 71-78.
  25. Lieb JP., et al. “A comparison of EEG seizures patterns recorded with surface and depth electrodes in patients with temporal lobe epilepsy”. Epilepsia2 (1976): 137-160.
  26. Spencer SS., et al. “Human hippocampal seizure spread studied by depth and subdural recording: the hippocampal commissure”. Epilepsia 28 (1987): 479-489.
  27. Liampas A., et al. “Psychogenic non-epileptic seizures (PNES) in the context of concurrent epilepsy- making the right diagnosis”. Acta Epileptologica 3 (2021): 23.
  28. Yon MI., et al. “The coexistence of psychogenic nonepileptic and epileptic seizures in the same patient is more frequent than expected: Is there any clinical feature for defining these patients?” Epilepsy and Behavior 105 (2020): 106940.
  29. Ebersole JS and Pacia SV. “Localization of temporal lobe foci by ictal EEG patterns”. Epilepsia 37 (1996): 386-399.
  30. Pacia SV and Ebersole JS. “Intracranial EEG substrates of scalp ictal patterns from temporal lobe foci”. Epilepsia 6 (1997): 642-654.
  31. Lowe MR., et al. “MRI evidence of mesial temporal sclerosis in patients with psychogenic nonepileptic seizures”. Neurology 6 (2001): 823.
  32. Benbadis SR., et al. “MRI evidence of mesial temporal lobe sclerosis in patients with psychogenic nonepileptic seizures”. Neurology 55 (2000): 1061-1062.
  33. Williamson PD. “Frontal lobe seizures. Problems of diagnosis and classification”. Advances in Neurology 57 (1992): 289-309.
  34. Asadi-Pooya AA., et al. “Natural history of patients with psychogenic nonepileptic seizures”. Seizure 66 (2019): 22-25.
  35. McKenzie P., et al. “Early outcomes and predictors in 260 patients with psychogenic nonepileptic attacks”. Neurology1 (2010): 64-69.
  36. Watts AE. “The Natural History of Untreated Epilepsy in a Rural Community in Africa”. Epilepsia3 (1992): 464-468.
  37. Nicoletti A., et al. “Natural history and mortality of chronic epilepsy in an untreated population of rural Bolivia: a follow-up after 10 years”. Epilepsia10 (2009): 2199-2206.
  38. Sillanpää M and Schmidt D. “Long-term outcome of medically treated epilepsy”. Seizure 44 (2017): 211-216.
  39. Duncan R., et al. “Psychogenic nonepileptic seizures that remit when the diagnosis is given: Just good luck?” Epilepsy and Behavior 102 (2020): 106667.
  40. Nightscales R., et al. “Mortality in patients with psychogenic nonepileptic seizures”. Neurology6 (2020): e643-2652.
  41. Alessi R and Valente KD. “Psychogenic nonepileptic seizures: Should we use response to AEDs as a red flag for the diagnosis?” Seizure 10 (2014): 906-908.
  42. Mellers JDC. “The Approach to Patients with Non-Epileptic Seizures”. Postgraduate Medical Journal 81 (2005): 498-504.
  43. Whelan CD., et al. “Structural brain abnormalities in the common epilepsies assessed in a worldwide ENIGMA study”. Brain2 (2018): 398-408.
  44. Szaflarski JP and LaFrance WC Jr. “Psychogenic Nonepileptic Seizures (PNES) as a Network Disorder- Evidence from Neuroimaging of Functional (Psychogenic) Neurological Disorders”. Epilepsy Currents 4 (2018): 211-216.
  45. Laxer KD., et al. “The consequences of refractory epilepsy and it treatment”. Epilepsy and Behavior 37 (2014): 59-70.
  46. Walker MC., et al. “Diagnosis and treatment of status epilepticus on a neurological intensive care unit”. Quarterly Journal of Medicine 89 (1996): 913-920.
  47. Asadi-Pooya AA., et al. “Prolonged psychogenic nonepileptic seizures or pseudostatus”. Epilepsy and Behavior 31 (2014): 304-306.
  48. Reuber M., et al. “Epilepsy surgery in patients with additional psychogenic seizures”. Archives of Neurology 59 (2002): 82-86.
  49. Lucke-Wold BP., et al. “Traumatic brain injury and epilepsy: Underlying mechanisms leading to seizure”. Seizure 33 (2015): 13-23.
  50. Popkirov S., et al. “Scared or scarred: Could ‘dissociogenic’ lesions predispose to nononepileptic seizures after head trauma?” Seizure 58 (2018): 127-132.
  51. Catala A., et al. “Dogs demonstrate the existence of an epileptic seizure odour in humans”. Scientific Reports 9 (2019): 4103.
  52. Kirton A., et al. “Seizure response dogs: Evaluation of a formal training program”. Epilepsy and Behavior 13 (2008): 499-504.
  53. Ortiz R and Liporace J. “Seizure alert dogs”: Observations from an inpatient video/EEG unit”. Epilepsy and Behavior 6 (2005): 620-622.
  54. Krauss GL., et al. “Pseudoseizure dogs”. Neurology 68 (2007): 308-309.
  55. Doherty MJ, and Haltiner AM. “Wag the dog: skepticism on seizure alert canines”. Neurology 68 (2007): 309.
  56. Goldstein LH., et al. “Cognitive behavioural therapy for adults with dissociative seizures (CODES): a pragmatic, multicentre, randomised controlled trial”. The Lancet Psychiatry 6 (2020): 491-505.
  57. Edwards MJ., et al. “Functional/Psychogenic Movement Disorders: Do We Know What They Are?” Movement Disorders 13 (2014b): 1696-1697.
  58. Edwards MJ., et al. “From Psychogenic Movement Disorder to Functional Movement Disorder: It’s Time to Change the Name”. Movement Disorders 7 (2014a): 849-852.
  59. Reuber M and Brown RJ. “Understanding psychogenic nonepileptic seizures- Phenomenology, semiology and the Integrative Cognitive Model”. Seizure 44 (2017): 199-205.
  60. Nicholson TR., et al. “Life events and escape into conversion disorder”. Psychological Medicine 12 (2016): 2617-2626.
  61. Carlson CA. “Journal of Neurology and Psychiatric Disorders 2 (2019): 201.
  62. McGonigal A., et al. “A Clear Diagnostic Framework Exists for Psychogenic Non-epileptic Seizures (PNES)”. Journal of Neurology and Psychiatric Disorders1 (2019): 108.
  63. Galli S., et al. “Conversion, Factitious Disorder and Malingering: A Distinct Pattern or a continuum?” Frontiers of Neurology and Neuroscience 42 (2018): 72-80.
  64. Kanaan R., et al. “In the psychiatrist’s chair: how neurologists understand conversion disorder”. Brain 132 (2009): 2889-2896.
  65. Kanaan RA., et al. “Neurologists’ understanding and management of conversion disorder”. Journal of Neurology, Neurosurgery, and Psychiatry 9 (2011): 961-966.
  66. Dent B., et al. “Psychiatrists’ Understanding and Management of Conversion Disorder: A Bi-National Survey and Comparison with Neurologists”. Neuropsychiatric Disease and Treatment 16 (2020): 1965-1974.
  67. Voon V., et al. “The involuntary nature of conversion disorder”. Neurology 74 (2010): 223-228.
  68. Wilson SB and Emerson R. “Spike detection: A review and comparison of algorithms”. Clinical Neurophysiology 12 (2002): 1873-1881.
  69. Lam AD., et al. “Widespread changes in network activity allow non-invasive detection of mesial temporal lobe seizures”. Brain 139 (2016): 2679-2693.
  70. Pyrzowski J., et al. “Zero-crossing patterns reveal subtle epileptiform discharges in the scalp EEG”. Scientific Reports 11 (2021): 4128.


Citation: Catherine A Carlson. “Psychogenic Nonepileptic Seizures - The Empirical Evidence Weighs in". Acta Scientific Neurology 5.5 (2022): 43-50.


Copyright: © 2022 Catherine A Carlson. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Acceptance rate32%
Acceptance to publication20-30 days

Indexed In

News and Events

  • Certification for Review
    Acta Scientific certifies the Editors/reviewers for their review done towards the assigned articles of the respective journals.
  • Submission Timeline for Upcoming Issue
    The last date for submission of articles for regular Issues is June 25, 2024.
  • Publication Certificate
    Authors will be issued a "Publication Certificate" as a mark of appreciation for publishing their work.
  • Best Article of the Issue
    The Editors will elect one Best Article after each issue release. The authors of this article will be provided with a certificate of "Best Article of the Issue"
  • Welcoming Article Submission
    Acta Scientific delightfully welcomes active researchers for submission of articles towards the upcoming issue of respective journals.

Contact US