Non-epileptic events and functional seizures

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]

References12Show ledgerHide ledger

1. [1]Leibetseder A; Eisermann M; LaFrance WC Jr; et al How to distinguish seizures from non-epileptic manifestations Epileptic Disord, 2020.PMID 33399092
2. [2]Doss JL; Robinson JO; et al Psychogenic non-epileptic seizures in youth: Individual and family psychiatric characteristics Front Psychiatry, 2022.PMID 36590633
3. [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. [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. [5]Lopez MR; LaFrance WC Jr Treatment of Psychogenic Nonepileptic Seizures Curr Neurol Neurosci Rep, 2022.PMID 35674871
6. [6]Hallett M; Aybek S; Dworetzky BA; et al Functional neurological disorder: new subtypes and shared mechanisms Lancet Neurol, 2022.PMID 35430029
7. [7]Patel H; Blake H; Dunn D Psychogenic Nonepileptic Seizures in Children and Adolescents Indian Pediatr, 2021.PMID 33713062
8. [8]Albert DVF; Voeller K; et al Psychogenic Nonepileptic Seizures in Children and Adolescents Semin Pediatr Neurol, 2022.PMID 35450667
9. [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. [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. [11]Spiegel D; Lewis-Fernandez R; Lanius R; et al Dissociative disorders in DSM-5 Annu Rev Clin Psychol, 2013.PMID 23394228
12. [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