Informative Articles

found article – Psychogenic Non-Epileptic Attack

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Found this article on Facebook in a PNES group, figured I should share it here, since it applies.

Psychogenic Non-Epileptic Attacks (PNEA)


If you’ve been around the Emergency Department for a while, then you’re likely to have seen your fair share of pseudoseizures. This infamous condition can be frustrating for a busy ED doc (this post from GomerBlog captures the feeling for many). Additionally, it can be challenging at times to tell a pseudoseizure from an epileptic seizure. All in all, they are a bit of a strange entity – Neurological? Psychological?… Faking?

Most of us have much to learn about pseudoseizures. Even the name is wrong: what used to be called pseudoseizures was re-defined as PNES (psychogenic non-epileptic seizures) at the turn of the century, and even this has now changed to PNEA (psychogenic non-epileptic attacks).

I offer the following two papers to help us understand PNEA. The first is a recent opinion piece, co-authored by a neurologist and a psychiatrist. The second is a systematic review and meta-analysis looking at which clinical signs can distinguish PNEA from epileptic seizures.

Paper 1 – overview of PNEA

Tolchin B, Martino S, Hirsch LJ. Treatment of patients with psychogenic nonepileptic attacks. JAMA. 2019 Apr;321(20):1967-1968​[1]​

This is a succinct and sensible presentation of what PNEA is and what it is not. In summary…

Defining and diagnosing

  • PNEA is a type of ‘conversion disorder’, listed in DSM-5​[2]​ under somatic symptom disorders – i.e. it is a psychiatric rather than medical diagnosis
  • It is often the result of past trauma, psychological or physical
  • It is not the same as malingering or drug-seeking (although these can co-exist)
  • The symptoms of PNEA are not consciously produced by the patient (i.e. they are not ‘faking it’)
  • The standard criteria for diagnosis require the capture of an episode on video EEG, demonstrating normal brain activity before, during and after the event, with clinical features consistent with PNEA as determined by an experienced epileptologist​[3]​

Management advice

  • The treatment of choice is cognitive behavioral therapy (CBT) or another type of psychotherapy. Treatment options do not generally include anticonvulsants or benzodiazepines
  • It is common for patients suffering from PNEA to be disparaged or ignored in the ED. We should bear in mind that they can usually hear everything we say during an episode. The following are real quotes from the recollections of patients: “Get up… Stop faking… You are wasting my time… Why do I have to put up with patients like you?… Everyone has left, so the drama can stop now… Pull yourself together and go home…” ​[4]​
  • There are reports of physical abuse by clinicians, in an effort to “snap [them] out of it” or assess the GCS. Patients have reported being slapped, having to inhale noxious chemicals, having multiple needle-pricks and even IO injections… Don’t do this. ​[4]​
  • The most appropriate ED management of PNEA is primarily reassurance. You can tell patients that they’re in a safe place, that you’re going to take care of them, that you’re not going to do anything painful or distressing.
  • It’s worth remembering that even tonic-clonic seizures don’t need to be terminated urgently within the first 2 minutes, so you have some time to observe and make a decision about what you’re looking at.

Paper 2 – how can you be sure it’s PNEA?

Avbersek A, Sisodiya S. Does the primary literature provide support for clinical signs used to distinguish psychogenic nonepileptic seizures from epileptic seizures? J Neurol Neurosurg Psychiatry. 2010;81:719-725​[5]​

This is a systematic review of studies investigating the semiology (signs) of PNEA, especially papers comparing epileptic seizures (ES) to PNEA. They considered a specific sign to be “well supported by the primary literature” if there were at least two controlled studies demonstrating its usefulness and if the data from other studies were not contradictory. Only those studies using video-EEG as a reference standard were included.

Signs that favour PNEA

  • Long duration: it is rare for ES to last longer than 2 minutes, whereas PNEA can last anywhere from 1 to 150 minutes
  • Fluctuating course: brief pauses in rhythmic movement are strongly suggestive of PNEA
  • Asynchronous movements: tonic clonic seizures tend to produce bilateral, synchronous movements
  • Pelvic thrusting: this sign was never observed in ES, but found in up to 30% of cases of PNEA
  • Side-to-side head or body movement: generally not found in ES, but present in 25% of PNEA
  • Closed eyes during episode: this happened 3% of ES and 96% of PNEA
  • Ictal crying (i.e. during the episode): present in no ES but 14% of PNEA
  • Memory recall: present in 6% of ES and 85% of PNEA

Signs that favour epileptic seizure

  • Occurrance during sleep: 30-60% of ES occur during sleep, but PNEA never does (note that the ‘diagnosis’ of sleep may require an EEG, which limits the usefulness of this sign in the ED)
  • Postictal confusion: present in up to 100% of ES, but only 16% of PNEA
  • Postictal stertorous breathing: present in up to 91% of ES and no episodes of PNEA
  • Serum lactate: if drawn within 2 hours of the episode, a level >2.45mmol/L suggests ES rather than PNEA (sensitivity and specificity 64% and 85% respectively). A level drawn within 1 hour increases the sensitivity and specificity considerably.​[6,7]​
  • Serum prolactin: a level more than double the baseline suggests ES rather than PNEA, but this must be drawn 10-20 minutes after the episode​[8]​

Signs with inconclusive evidence

  • Tongue biting: can be found in both entities (no significant difference found)
  • Urinary incontinence: present in around 20% of ES and 10% of PNEA, but this difference was not statistically significant

The bottom line

Patients with PNEA are not consciously in control of their ‘seizure’. Therefore they should not be subjected to painful stimuli to ‘test’ them. An episode of PNEA is not associated with the same risks as an epileptic seizure. Therefore we should not give benzodiazepines to terminate it.

Podcast discussion of the papers

Expert commentary

“This is something I think we all need to think about – and move away from the idea that “they’re putting it on”. These patients are often frequent attenders who ultimately need proper care plans.”
(Dr Dwynwen Roberts, ED consultant)

More FOAMed on this…

FOAMcast: Psychogenic Non-Epileptic Attacks (PNEA)


  1. 1.
    Tolchin B, Martino S, Hirsch LJ. Treatment of Patients With Psychogenic Nonepileptic Attacks. JAMA [Internet] 2019;1967. Available from:
  2. 2.
    American Psychiatric Association . Diagnostic and statistical manual of mental disorders. 5th ed. Washington D.C.; 2013.
  3. 3.
    LaFrance WC Jr, Baker GA, Duncan R, Goldstein LH, Reuber M. Minimum requirements for the diagnosis of psychogenic nonepileptic seizures: A staged approach. Epilepsia [Internet] 2013;2005–18. Available from:
  4. 4.
    Robson C, Lian OS. “Blaming, shaming, humiliation”: Stigmatising medical interactions among people with non-epileptic seizures. Wellcome Open Res [Internet] 2017;55. Available from:
  5. 5.
    Avbersek A, Sisodiya S. Does the primary literature provide support for clinical signs used to distinguish psychogenic nonepileptic seizures from epileptic seizures? Journal of Neurology, Neurosurgery & Psychiatry [Internet] 2010;719–25. Available from:
  6. 6.
    Matz O, Heckelmann J, Zechbauer S, Litmathe J, Brokmann JC, Willmes K, et al. Early postictal serum lactate concentrations are superior to serum creatine kinase concentrations in distinguishing generalized tonic–clonic seizures from syncopes. Intern Emerg Med [Internet] 2017;749–55. Available from:
  7. 7.
    Doğan EA, Ünal A, Ünal A, Erdoğan Ç. Clinical utility of serum lactate levels for differential diagnosis of generalized tonic–clonic seizures from psychogenic nonepileptic seizures and syncope. Epilepsy & Behavior [Internet] 2017;13–7. Available from:
  8. 8.
    Chen DK, So YT, Fisher RS. Use of serum prolactin in diagnosing epileptic seizures: Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology [Internet] 2005;668–75. Available from:
Featured Posts

Seizure Streamed to YouTube Live

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I managed to start a YouTube Live Stream as I was between seizures. I thought about doing it as I felt the seizures starting, but didn’t quite get all the way loaded, as I also took the time to clear my computer off my bed. So, when I came to and recognized that I wasn’t done seizing yet, I finished getting the Live Stream activated and then fell back into the seizure, which lasted another hour-and-a-half.

I felt ok after, a bit loopy, but back to functioning enough to finish getting ready for bed and try to get to sleep again. Yeah, wake up just so I can go to sleep. It was around 10 PM when I woke up from the seizure. Something happening outside woke me up around 1 AM, and I didn’t get much sleep after that.

Next day I woke up feeling more ok than I usually am after a long seizure spell, but too exhausted to go out during the day. Which was very unfortunate, because it was one of the nicest weather days we’ve had so far this year, and I was really looking forward to a warm Saturday on the beach. Even if my car was currently working, I don’t think I was stable enough to drive and definitely not enough to walk the mile each way through the ups and downs of the coastal trail.


Also, it’s been two months now, and I’m still waiting to hear back on Disability, I’ve checked the SSA website and that still lists as Processing. Not unexpected to me.

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May 3 – Disability Hearing

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After two years since moving to Humboldt, I finally had the hearing for my Disability claim that I’ve been working on since 2014 on this round, and since 2006 in total.

It’s taken so long, in part, because I did not have doctors who understood what was going on. And also the constant changing of doctors. I didn’t have a set diagnosis, but this time we do: Conversion Disorder and Psychogenic Non-Epileptic Seizures.

With my not being physically able to remain on task due to anxiety and my body reacting in myoclonic seizure-like convulsions, the vocational specialist flat stated that there would be no jobs within the US that I could perform. So this gives me some hope that it may finally get approved after these 12 years of fighting.


I know when briefly browsing this site, my other websites, perhaps even my YouTube, it looks like I can do stuff, but when you look closer at the dates of posts, or if you could watch my trying to type this, having had three episodes of being spasmed flat to my bed for a few minutes each time, so far this post, it starts to make sense why I can’t actually do this professionally, for someone else. I can put stuff together for me, but a client or employer requires deadlines and reliability that I am not able to meet. And it’s taken me 11 days to post this.


Ritalin causing Seizures

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Found this article relating Ritalin use to seizures, which is one of the things we believe may be the cause of mine. In Summer of 2001, the Nation Guard Recruiter turned me away after he asked if I’d ever been on Ritalin, a few months later I had my first seizure.

This article is from

Research Shows Ritalin Causes Long-Term Brain Injury

By John Lavitt 04/14/14

Though still in the research phase, a new study showed that the ADHD drug can potentially cause clinical depression and damage to the frontal lobes.

According to a study reported by the American College Of Neuropsychopharmacology, long-term use of the popular ADHD drug Ritalin can potentially result in serious brain injury.

Chemically similar to cocaine, the short-term side effects of Ritalin include “nervousness, agitation, anxiety, insomnia, loss of appetite, nausea, vomiting, dizziness, palpitations, headache, increased heart rate, increased blood pressure, and psychosis.” It was thought that Ritalin had limited long-term effects, but a past study recorded in the Journal of the American Medical Association showed this not to be the case.

Lead researcher, Prof. Joan Baizer of the University of Buffalo explained how “clinicians consider Ritalin to be short-acting. When the active dose has worked its way through the system, they consider it all gone.” What proved problematic to Baizer was that the research conducted “suggests that [Ritalin] has the potential for causing long-lasting changes in brain cell structure and function.”

Another study funded by the National Institute on Drug Abuse revealed that Ritalin causes physical changes in neurons in reward regions of mouse brains and these effects were similar to the long-term side effects of cocaine. When placed together, the three studies implied that the long-term side effects of Ritalin include both the onset of clinical depression and potential brain injury to the frontal lobes.

As reported in The New York Timesthree million children in this country take drugs for ADHD. In the past 30 years, there has been a 2,000 percent increase in the consumption of drugs for attention-deficit disorder. Among many children, the abuse of Ritalin has become commonplace. When their peers are prescribed these drugs, peer pressure leads to abuse.

The result of the damage done by Ritalin in the brain is similar to frontal lobe syndrome. Over time, frontal lobe syndrome can render a person increasingly incapable of inhibiting impulsive behaviors. In addition, such damage contributes to the onset of clinical depression.

Young people are more vulnerable than adults to the negative side effects of Ritalin because their brains are still actively forming and are becoming delineated. It would seem that any battle against drugs needs to begin by eliminating the all-too-common thread of prescribing ADHD drugs like Ritalin to children in the United States.

Live Updates

Local Therapist

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I was able to be put in touch with a local therapist so as to make me more likely to be able to make my appointments, and that if I can’t, she can potentially come to my house.

It was a typical first appointment, discussing the overview of my life history: ADD, Depression, Anxiety, and the “Seizures.” We discussed plans for going forward with Disability, and what we can do in the one month left before my hearing.

We’re going to be focusing more on the triggers (the anxiety sensitivity) and looking at “Conversion Disorder” as the main focus rather than the seizures, since my “seizures” are not epileptic.

I’m feeling hopeful for the help she is willing to give.


I had a couple small spasm episodes, and when a siren went down the highway (1/3 mile away?), my body locked up and I went into some convulsions, but mostly my muscles locked in a weird pose, and it hurt a lot. I give the episode a 5/10 on my scale (cover photo episode was a 9/10, really bad, but not the worst).

Medical Personnel

Community Health Center

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The Nightmare.

Doesn’t even begin to describe it.

Doctors constantly changing.

They wouldn’t try to figure out what why I was having seizures. They actually accused me of faking it, or over-exaggerating. Doctors who had never seen me before, who knew nothing of my condition, telling me the thing they didn’t know about or understand must be fake.

And it was many years of this. With many doctors, because they kept coming and going.

At one point, I had 5 appointments with 4 different doctors.

This was before the “Affordable Care Act” and after I was too old to be on my parents’ insurance, despite still being 100% dependent on them. And so I did not have insurance due to “pre-existing conditions.” My lack of insurance is possibly one reason why the CHC doctors didn’t care to try to help, along with knowing they likely wouldn’t be there long.

A few times I went in to try to get paperwork filled out to get EBT Cash Aid, but the doctors, who had never seen me before and didn’t know my condition, looked at me as said they wouldn’t sign that I was disabled. Which angered me, because I’ve lost every job I’ve undertaken since the seizures started as a result of the seizures preventing me from being able to work, and so I’d end up in seizures. They’d panic and call 911, take away my driver’s license, but still refuse to sign for me to get Assistance. After watching me convulsing on the floor for half an hour.

One of these doctors was so bad (Raj), that when he left, the rest of the staff actually threw a party in relief of him leaving.

When I would finally get a doctor that would listen, and did stick around for more than one or two appointments, they completely agreed that I was disabled. Although, at those times, I had financial support from my parents and grandmother, and so I had too much money to qualify for Cash Aid, which was less than what I needed at the time in order to attend school, eat, etc, and so I could not qualify for Cash Aid.

I did have two or three doctors at the CHC over the years that did listen and were supportive of my seizures being a hindrance to my ability to work.

Live Updates

Cancelled 2nd Appointment with New Therapist

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Last week I started seeing a new psychologist, finally got one after nearly two years in Humboldt County, and now I’m already done seeing her.

I could not get stable enough to drive. There’s just no way. I’m barely standing.

I had to cancel less than one hour before the appointment. Doctors, etc, usually like to be notified 24-hours beforehand for a cancelation, but I can’t do that.

My health is so variable that I can never guarantee that I will be able to make an appointment, arrive at a gig (with my photography), be able to stay for the whole gig, and definitely not for a steady, regular 40-hour job.


It’s also a long drive to do every week, 40ish mile round trip.

She’s going to help me find someone in my town that can be more flexible in meeting location.


Gist: my health prevented me from being able to make a doctor’s appointment in the last few hours prior. My health is too unpredictable to schedule activities.


(This was actually not written Live at the event, but over two weeks later, on the 31st of March)

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Depakote, Tegratol, and Keppra

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After the failure of Lamictol, we began trying other anti-epilepsy medications….remember, my neurologist said I that I didn’t have epilepsy, but couldn’t come up with an alternative diagnosis.

I don’t remember the exact order of these three, but they did overlap, and it was nasty.

My knees got weak, I fell asleep in classes, I was angry (though still controlled, didn’t quite have the full Keppra Rage).

I started using a cane just to keep myself off the ground.

After a few years of these, and one or two others I can’t recall by name, I gave up on pharmaceuticals as a treatment for my seizures sometime between 2006 and 2009, I don’t remember when exactly. I started feeling much better once I was off the pills.

Featured Posts

First Neurologist, Medication, and Italy

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In March of 2002, I started with my first Neurologist, Dr. Mary Amir (San Luis Obispo, CA).
She gave me an EEG, and told me I didn’t have Epilepsy, she nearly referred me to Cardiology, until we told her that Cardiology sent us to her. So, she gave me an anti-epileptic drug, Lamictal…

Yup, she tells me I don’t have epilepsy, and then gives me medication for epilepsy….

So we take a family vacation to Italy, right as I’m starting the new medication. And at first, things were ok, then they weren’t.

Turns out, I’m allergic to Lamictal, and my legs broke out in rashes while we were walking around Rome, Florence, Brindisi, and Mesagna. By the time we got to Venice, I stopped taking it and the rash has subsided. But that didn’t mean Venice was uneventful.

The details that lead up to this are unnecessary, so, to the point: I was having to walk very quickly through the streets of Venice, in the hot summer of early July, and I don’t do well in heat or with physical exertion. Finally, I felt the seizure coming on, I couldn’t keep walking, got my sister’s attention, and I collapsed. She got some help and an ambulance boat was called to take me to the public hospital.

At the hospital, no one spoke English, and our Italian wasn’t quite good enough to explain my health issues. They found one nurse who spoke French, and so my sister and I spoke the French we knew to her, and she translated to Italian, and then back; it was challenging. They gave me some sort of medication, I don’t know what, looking back, realizing as I’m writing this, it could have been morphine… And so I vomited in the waiting room as my sister left to try to find our parents, and somehow managed to find her way across the city and the bay to the hotel and find our parents, and then get back to the hospital. It took four hours, and the vomit was still on the floor when they arrived.

My dad, who does speak Italian, got me out of the hospital.

I don’t really remember much of the next few days besides puking in the back of the tour bus.

Medical Personnel

Cardiology, Early 2002

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A few of the key features of my episodes were very high heart rate and low blood pressure, and since I had not lost consciousness since the first episode, the hospital and my doctor recommended I see a cardiologist, Dr. Tway, in San Luis Obispo.

I changed jobs, leaving the movie theater and then finding a job at McDonald’s.

Tway gave me a heart monitor to wear for a few days, during which I had classes and work.

We were really noticing the state of my heart during episodes, and so we did a stationary bicycle test at home. I rode for a few minutes, fairly hard, but no harder than I’d ridden a bike as a kid, and my pulse reached 200bpm.

I slowed down and tried for a cooldown instead of stopping quickly, typical recommendation for any exercise, but my pulse barely went down. After several minutes, I was still over 170, and so I got off the bike to lay down. Ten minutes later, my body went haywire, after a “sudden” drop from 160 to 100bpm.

I know I had one or two during classes at that time, but I don’t really remember them enough to write about them.

In March, Dr. Tway had me do a treadmill test in his office. Once again, my heart rate reached 200bpm. He had me slow and then stop once it got that high. And then I sat, and we waited for ten or more. Deciding that nothing was going to happen, the assistant began disconnecting the leads from the computer, and then I felt it coming.

I yelled out, reached out, grabbed the doctor, and collapsed off the patient bed and Tway helped me to the ground, the assistant frantic to put the leads back in.

After this event, Dr. Tway referred me to a neurologist, saying that it was not my heart that was the cause, but that I was having a type of seizure.

The owner of the McDonald’s that I was working at, found out that I was seeing a cardiologist, and although I actually never had a single episode while working very long hours due to the high turn-over rate, and he took me off the work schedule until I got a doctor’s note saying that I was safe to work. I did that, and he still did not put me back on the schedule, so I had to quit that job.