What to know about nonepileptic seizures

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NES stem from psychological, neurological, or physical reasons. There are three major categories of seizures:

• epileptic seizures
• psychogenic nonepileptic seizures (PNES)
• physiologic nonepileptic events

PNES and physiological nonepileptic events are two forms of NES. However, while NES and epileptic seizures share similarities, they are not the same.

Epileptic seizures occur because of an electrical disruption in the brain. When these disruptions occur, they temporarily alter the communication between brain cells. People may develop epilepsy from complications such as prenatal brain damage, head trauma, and some infectious diseases.

Conversely, NES do not involve electrical disruptions in the brain — they usually relate to psychological, neurological, or physical problems or trauma.

According to the Epilepsy Foundation, around 20–30% of people with uncontrolled epilepsy have a form of NES. Most people who have NES also have epileptic seizures.

The signs and symptoms of NES resemble those of epileptic seizures but vary between adults and children.

Adults

When an adult has a nonepileptic seizure, their symptoms may include:

• convulsions
• stiffening or jerky, twitchy movements
• crying out
• biting the tongue
• falling down
• loss of consciousness
• confusion
• loss of bladder control
• staring
• altered senses
• changes in emotions

Children

In children, the signs and symptoms of NES may or may not resemble those in adults. For example, one older review from 2013 noted that younger children are more likely to become unresponsive, while older children show more symptoms related to movement.

An earlier 2008 study involving 17 children with NES aged 7–13 years showed that fewer than one-third exhibited head movements, vocalization, moving the upper and lower limbs, and pelvic thrusting.

With this in mind, more research on children and NES is necessary.

Various psychological, neurological, and physical traumas and conditions can contribute to someone experiencing NES.

For example, a 2016 review of epileptic seizures and NES shows that people with NES were more likely to have a history of physical conditions, including fibromyalgia, chronic fatigue syndrome, and irritable bowel syndrome.

The same review notes that those with NES were more likely to report frequent experiences of conditions, such as asthma and migraines, that typically occur intermittently.

The Epilepsy Foundation lists a number of psychological and neurological conditions associated with NES, including:

• attention problems
• anxiety
• mood disorders
• dissociative disorders
• personality disorders
• psychosis
• post-traumatic stress disorder
• physical, emotional, or sexual abuse
• family stress and conflict
• substance abuse
• behavioral disturbances
• traumatic brain injury

A small 2013 study showed that 45 out of 61 people who experienced NES reported experiencing one or more traumatic events in their lives. Similarly, another small 2014 study found that those with PNES often stated symptoms of dissociation.

Several clinical trials have shown varying levels of success in treating NES with cognitive behavioral therapy (CBT).

The following additional therapies may have some benefit for people with NES:

• Prolonged exposure psychotherapy: A type of CBT that focuses on people with NES and PTSD.
• Interpersonal and psychodynamic psychotherapy: Helps individuals work through unconscious processes.
• Mindfulness-based psychotherapy: Addresses the relationship between the way the person thinks and the way they feel.
• Family therapy: An add-on therapy for families with children who have NES.

NES do not respond to antiseizure medication. However, research suggests that sertraline, an antidepressant, shows promise as a treatment option alongside therapy. Additionally, if a person who has NES also has epileptic seizures, adjusting their antiseizure medication for better epileptic seizure control may help reduce their NES.

Overall, the treatment that doctors recommend for NES treatment, and someone’s response, can depend on the underlying cause. Individuals should discuss their treatment options with their healthcare team.

Because epileptic seizures and NES share many symptoms, even trained medical professionals may find it challenging to diagnose them from one another.

With this in mind, some researchers have advocated for a PNES classification system to help with diagnosis. A 2016 study proposed four NES categories based on their similarities to epileptic seizures, but there is still no universally accepted classification.

The clinical approach first aims to rule out epilepsy with an EEG or video EEG monitoring. An EEG records the characteristic spikes in brain activity associated with epileptic seizures.

However, obtaining an EEG during an episode is challenging. Some researchers suggest more thorough symptom identification, including:

• performing a complete physical and neurological exam
• taking a person’s comprehensive history of medical, neurological, and psychological health
• studying the results of any prior diagnostic testing, which may include bloodwork, brain scans, and any prior EEGs
• reviewing the response to any prior antiseizure medication, if applicable
• talking with family and friends who witnessed a seizure

Additionally, some people could benefit from specialist follow-up once they receive a NES diagnosis.

Studies show that it is crucial for people with NES to maintain a good working relationship with their neurologist. Having good relations with related healthcare providers, such as psychiatrists and counselors, is also advisable. They can best advise the individual on managing their seizures and aftercare.

For example, if a person learns to recognize the warning signs of a seizure, they can make sure they are safe and advise other people. Informing family members and friends means the individual has a support system in place. They can help the individual cope with seizures and provide emotional comfort if they feel stressed, sad, or angry.

If an individual becomes physically injured during a seizure, they should seek medical attention.

People with NES may need to make some life adjustments. Seizures may affect a person’s ability to work and drive vehicles.

Many states require a person to be seizure-free for a specific time before they can drive. Some may require drivers to submit medical reports periodically. These requirements vary by state, and people with NES can find more information at their state’s agency for driver licensing and vehicle registration.

Learning to navigate life with NES may also affect someone’s mental health. During a 2016 review of people with NES, researchers found that individuals experienced a wide range of emotions around their seizures, diagnosis, management, and impact on their daily lives.

Some felt confused about their diagnosis, while others felt relieved to have answers. Similarly, some individuals said they had a robust support system of family and friends, but others admitted they felt like a burden and wanted to isolate themselves.

Therefore, living with NES can affect people differently — the important thing is to seek help and support as necessary.

If someone suspects they are experiencing seizures, they should speak with their doctor as soon as possible for advice. A healthcare professional may refer them to a neurologist, who can use diagnostic techniques, including a video EEG, to see if the seizures are epileptic or not.

A multidisciplinary team typically supports people following a diagnosis of NES. These healthcare professionals may include:

• primary care doctors
• neurologists
• psychiatrists or psychologists
• licensed mental health counselors
• social workers

Each of these professionals has a solid understanding of NES management and the challenges people may face. Their expertise can help individuals navigate their life following a diagnosis.

NES differ from epileptic seizures because they do not involve brain activity that characterizes epileptic seizures. Instead, the seizure stems from some psychological, neurological, or physical condition or trauma. Most people who have NES also have epileptic seizures.

Because the symptoms of epileptic and NES are similar, multiple healthcare professionals may need to work together to reach a diagnosis.

People can start to explore treatment regimes once after receiving a diagnosis of NES. Treatment usually includes psychotherapy, such as cognitive behavioral therapy. It may also include medication. The individual’s healthcare team will work with them to find the most effective treatment.

People with NES also benefit from learning how to manage their seizures. A healthcare team and support system can help those adjust to living with this condition.