Paeds · neurology-neurodisability-and-neuromuscular
Non-epileptic events and functional seizures
Also known as Psychogenic non-epileptic seizures in children · Dissociative seizures · Functional seizures in young people · Non-epileptic attack disorder · Functional neurological disorder with seizures · PNES in children and adolescents
Fellowship guide to the child or adolescent whose episodes look like epilepsy but are not: non-epileptic events, and within them the high-stakes entity of functional (dissociative) seizures. The single most important message is that functional seizures are real and involuntary, that antiseizure drugs do not work, and that the correct path is a positive diagnosis by video-electroencephalogram, an honest explanation, supervised withdrawal of unnecessary medication, and cognitive behavioural therapy. The page covers the semiology that distinguishes a functional seizure from an epileptic one and from the physiological mimics, the coexistence of epilepsy in a substantial minority, the management of an acute flurry in the emergency department without escalating sedation, and the safeguarding lens that any clinician must hold over the adolescent carrying this diagnosis.
On this page
Study tools
Your progress
Saved on this device.
Practise this topic
Target exams
Red flags
- An adolescent on two or more escalating antiseizure medications whose events have not changed at all is the classic presentation of a functional seizure misdiagnosed as refractory epilepsy. Capture a typical event on video-electroencephalogram before any further escalation, because every additional drug is iatrogenic harm and delays the cognitive behavioural therapy that actually works.
- Functional seizures and epileptic seizures coexist in around one in five to one in three of those affected. Do not assume that a proven functional seizure means there is no epilepsy, nor that a known epilepsy excludes functional events — each attack must be judged on its own semiology, and the two are treated separately.
- A prolonged, repetitive flurry of functional events in the emergency department is not status epilepticus. Escalating benzodiazepines and anaesthesia will not terminate it and may cause respiratory depression in a conscious patient. Manage the episode with a calm low-stimulation environment, reassurance and removal of the audience, and screen for the precipitant and for self-injury.
- Functional seizures in a child are strongly associated with adverse childhood experiences, including abuse, neglect, bullying and family breakdown. Take a sensitive trauma and psychosocial history and consider a safeguarding assessment — the seizures are often the visible tip of an unspoken burden of distress.
Life stages
Care settings
Clinical exam formats
Board mappings
- Seizure mimics and non-epileptic events
- Psychogenic non-epileptic seizures
- Functional neurological disorder and dissociative seizures
- Management of psychogenic non-epileptic seizures
- Non-epileptic events and functional seizures
- Adolescent with treatment-resistant seizures
- Coexisting epilepsy and non-epileptic attacks
- Long case: adolescent with refractory seizures
- Communication: explaining a functional diagnosis
- Neurology: non-epileptic events
- Mental health and psychosomatic presentations
- Differentiation of epileptic from non-epileptic events
- Functional neurological disorder in children
- Communication scenario: explaining a functional seizure diagnosis
- Seizure mimics and psychogenic non-epileptic seizures
- Mental and behavioural health in chronic illness
- Patient Care: paroxysmal neurological events
- Interpersonal and Communication Skills: functional diagnoses
- Medical Expert: non-epileptic events in children and adolescents
Picture the patient this topic exists for. A fifteen-year-old is referred to the epilepsy service for spells that have occurred several times a week for a year and have not responded to two escalating antiseizure medications. The events last many minutes, her eyes stay closed and resist opening, her limbs thrash in a changing pattern, and she is tearful but fully oriented within a minute of stopping. She is exhausted, stigmatised, and on a drug that gives her no benefit and real side effects. The diagnosis is not refractory epilepsy — it is a functional seizure, and the correct move is to stop the drugs, name the condition, and begin therapy. [2]
This page covers the distinction between non-epileptic events broadly and functional seizures specifically, the semiology and video-electroencephalogram findings that confirm the diagnosis, the coexistence of genuine epilepsy in a substantial minority, the management of the acute emergency-department flurry, the stepwise pathway to recovery, and the safeguarding lens that must always sit over the adolescent carrying this label. It links to the first-seizure leaf for the broader mimics list, to the functional-neurological-symptoms leaf for motor and sensory functional disorders, and to the somatic-symptom leaf for the wider psychosomatic context. [1]
Overview & Definition
The first idea to hold is that a paroxysmal event and an epileptic seizure are not the same thing. An epileptic seizure is the transient appearance of signs or symptoms from abnormal, excessive and synchronous cortical neuronal activity. Many sudden episodes in a child look like that but arise from a completely different mechanism — a faint, a breath-holding spell, a sleep disturbance, a movement disorder, or a psychological process — and these are gathered under the umbrella term non-epileptic events. [1]
The functional, or dissociative, seizure is the most important member of that umbrella for the clinician to master. It is an involuntary episode of altered movement, sensation, consciousness or experience that resembles an epileptic seizure but occurs without the cortical electrical discharge. It sits within functional neurological disorder, the modern name for the group of conditions once called conversion disorder, in which genuine neurological symptoms are produced by a problem of nervous-system function rather than structure. [4]
Two words must be stripped from the clinician's vocabulary at the bedside. The first is "fake" — functional seizures are involuntary, and patients are not pretending or choosing to have them. The second is "all in the mind" — the events are as real to the patient as any seizure, the distress is genuine, and functional neuroimaging shows measurable alterations in the brain networks that generate movement and self-awareness. [6] The harm of the wrong language is immediate: a child told their attacks are "put on" disengages from care, loses trust in clinicians, and is denied the therapy that would help.
The practical consequence is that the clinician facing an unexplained attack holds two parallel questions. The first is whether the event is epileptic. The second, only if it is not, is which non-epileptic mechanism is at work — physiological or functional. Jumping straight to an antiseizure drug on the assumption that any convulsion is epilepsy is the single most common and most damaging error in this area of medicine. [1]
References12ShowHide
- [1]Leibetseder A; Eisermann M; LaFrance WC Jr; et al How to distinguish seizures from non-epileptic manifestations Epileptic Disord, 2020.PMID 33399092
- [2]Doss JL; Robinson JO; et al Psychogenic non-epileptic seizures in youth: Individual and family psychiatric characteristics Front Psychiatry, 2022.PMID 36590633
- [3]Gasparini S; Beghi E; Ferlazzo E; et al Management of psychogenic non-epileptic seizures: a multidisciplinary approach Eur J Neurol, 2019.PMID 30300463
- [4]Espay AJ; Aybek S; Carson A; et al Current Concepts in Diagnosis and Treatment of Functional Neurological Disorders JAMA Neurol, 2018.PMID 29868890
- [5]Lopez MR; LaFrance WC Jr Treatment of Psychogenic Nonepileptic Seizures Curr Neurol Neurosci Rep, 2022.PMID 35674871
- [6]Hallett M; Aybek S; Dworetzky BA; et al Functional neurological disorder: new subtypes and shared mechanisms Lancet Neurol, 2022.PMID 35430029
- [7]Patel H; Blake H; Dunn D Psychogenic Nonepileptic Seizures in Children and Adolescents Indian Pediatr, 2021.PMID 33713062
- [8]Albert DVF; Voeller K; et al Psychogenic Nonepileptic Seizures in Children and Adolescents Semin Pediatr Neurol, 2022.PMID 35450667
- [9]LaFrance WC Jr; Baird GL; Barry JJ; et al Multicenter pilot treatment trial for psychogenic nonepileptic seizures: a randomized clinical trial JAMA Psychiatry, 2014.PMID 24989152
- [10]Goldstein LH; Robinson EJ; Mellers JDC; et al Cognitive behavioural therapy for adults with dissociative seizures (CODES): a pragmatic, multicentre, randomised controlled trial Lancet Psychiatry, 2020.PMID 32445688
- [11]Spiegel D; Lewis-Fernandez R; Lanius R; et al Dissociative disorders in DSM-5 Annu Rev Clin Psychol, 2013.PMID 23394228
- [12]Hamed SA; Attiah FA; Fawzy M Psychogenic nonepileptic seizures in adults with epilepsy: a tertiary hospital-based study Int J Neurosci, 2020.PMID 31771384