Functional Seizures and Epilepsy: How Do Doctors Tell Them Apart?

What are functional seizures?

In recent literature, these events are called functional seizures. The term “psychogenic nonepileptic seizures” (PNES), or “dissociative seizures,” has also been widely used. The newer name aims to describe a functional disorder without implying that the experience is fabricated or that its cause is “only psychological” in an oversimplified sense.

In functional neurological disorder, genuine neurological symptoms arise from a disruption in how neural networks function and are regulated, rather than from structural damage that explains the symptom in the usual way. One cautious analogy is a device whose main components are intact but whose operating system is not carrying out a command as expected. The analogy does not mean that the brain is a computer; it only illustrates that “functional” does not mean “imaginary.”

A functional seizure may include shaking, stiffening, falling, unresponsiveness, changes in breathing or voice, or varied movements. The experience can be frightening, painful, injurious and socially disabling. The person does not choose it in the way someone chooses a deliberate movement, even if stress, attention or learned neural patterns influence it.

What is an epileptic seizure?

An epileptic seizure results from abnormal, excessive and synchronized electrical activity in networks of the brain. Its appearance depends on where the activity begins and how it spreads: it may involve a brief stare, an unusual sensation, movement in one limb, or loss of consciousness with generalized stiffening and shaking. The popular image of epilepsy as only falling and convulsing therefore does not represent every seizure type.

One seizure also does not always mean that a person has epilepsy. Diagnosis requires assessment of the context, recurrence risk and acute causes. An EEG between seizures can be normal in a person who has epilepsy, and nonspecific changes may appear in someone who does not. EEG therefore cannot be read apart from the clinical story.

Why is “they’re faking it” medically and ethically wrong?

Some seizures may look variable or be influenced by people around the person, and some movements may stop in a way that does not resemble the usual epileptic pattern. But variability does not prove voluntary control. Many symptoms—including pain, tremor, panic attacks and muscle spasm—can be influenced by attention, fear and environment without being fabricated.

Deliberate feigning is a different diagnosis that requires independent evidence, and it should not be assumed simply because an EEG did not show an epileptic discharge. A sound diagnostic message is: “We believe these seizures are happening and that you are not causing them deliberately; the evidence points to a functional mechanism, so we need treatment that fits that mechanism.” The American Academy of Neurology guideline issued in 2025 emphasized clear, respectful and supportive communication of the diagnosis.^[1][2]

Is there one sign that tells them apart?

There is no single movement that is safe to use for self-diagnosis. Some features may increase the likelihood of a functional seizure, such as a long event, waxing and waning intensity, asynchronous movements, or forceful eye closure in some contexts. Other features may favor particular epileptic seizures, such as a brief stereotyped onset, changes that fit a specific neural network, or an appropriate postictal confusion pattern. But every sign has exceptions, epilepsy has many forms, and medication effects, injury or fainting can produce other appearances.

A common mistake is to take an internet checklist and turn it into a test: “the eyes were closed, so it was psychological,” or “the tongue was bitten, so it was epilepsy.” Professional diagnosis does not work as a binary checklist. It weighs a group of features, the quality of observation, the circumstances before, during and after the event, and then connects them with testing.

How does a doctor build the diagnosis?

The recent AAN guideline recommends gathering detailed historical and semiological information from the patient and witnesses, requesting smartphone video when available, and obtaining video-EEG of typical events where feasible. It also recommends evaluating for coexisting epilepsy and coexisting psychiatric conditions rather than assuming one diagnosis explains everything.^[1]

1. What happened before the seizure?

A clinician asks about sleep deprivation, illness, pain, prolonged standing, stress, preceding memories or sensations, medications and substances, injuries, and a history of epilepsy or fainting. The aim is not to find a quick “psychological cause,” but to map a context that can distinguish among several possible pathways.

2. What did the witness see?

A witness may describe an onset the patient did not see: did the person fall suddenly? Did they respond to a voice? Did their color change? Did movement begin on one side? How long did it last? What happened to breathing? How did it end? A witness who saw the beginning and the end is therefore more informative than a general statement such as “they were convulsing.”

3. What happened after the seizure?

Recovery time, confusion, sleepiness, pain, memory, and the ability to speak and move are all parts of the pattern. But none is a single diagnostic key; some epileptic seizures are not followed by prolonged confusion, and some functional seizures leave severe exhaustion.

4. Are there events of more than one type?

A person may say: “Some seizures begin with a sensation and then brief loss of consciousness, while others last longer and involve different movements.” This detail matters because recording one event does not necessarily explain every event. Each usual pattern should be defined and, when needed, recorded.

What is the role of video-EEG?

The test combines a video of the patient with recording of the brain’s electrical activity. If the person’s typical seizure occurs without a corresponding epileptic pattern, and the appearance and context fit, this can support a functional-seizure diagnosis with a high degree of confidence. If a corresponding epileptic discharge appears, that establishes the epileptic nature of the captured event.

Even this test requires interpretation. Some deep or limited epileptic seizures may not be clearly detected by scalp electrodes, and movement can obscure the recording. Failure to capture the person’s typical seizure in the monitoring unit also does not provide a final answer. The International League Against Epilepsy therefore developed a staged approach to diagnostic certainty when video-EEG is unavailable or inconclusive.^[3]

Is a smartphone video useful?

Yes, provided recording is safe and does not delay first aid. In a multicenter study, epilepsy specialists using smartphone videos predicted the final diagnosis with high accuracy: 89% for epileptic seizures and 86% for psychogenic nonepileptic seizures in the study sample. The video was used as an addition to the history and examination, not as a replacement for them.^[4]

Those numbers do not mean that every person or app can diagnose seizures with the same accuracy. The participants interpreting the videos were experts, the cases came from specialist centers, and accuracy was not 100%. A useful video shows as much of the whole body as possible, the beginning if feasible, and the response to voice, while the witness notes the time. Safety—removing hazards and protecting the patient—always comes before filming.

Can epilepsy and functional seizures coexist?

Yes. This fact prevents two opposite errors: not every event in a person with epilepsy should automatically be assumed epileptic, and a functional-seizure diagnosis does not erase all possibility of epilepsy. In one epilepsy-monitoring-unit study, 14.8% of patients diagnosed with psychogenic nonepileptic seizures had coexisting epilepsy under the study definition; the proportion fell to 7.4% when a stricter standard of epilepsy evidence was applied.^[7] These are context-specific figures from a referral center, not global prevalence estimates, but they establish that coexistence is possible and that each event pattern matters.

In practice, a patient may need two plans: medication for confirmed epileptic seizures and functional, psychological or rehabilitative treatment for functional seizures. Stopping medication because “some seizures are functional” can be dangerous if coexisting epilepsy remains.

Why is explaining the diagnosis part of treatment?

When a patient hears “your EEG is normal, there is nothing wrong,” they may understand that they are being accused of lying or dismissed from neurology. That can leave them trapped between fear and stigma and delay treatment. A better explanation makes three points clear: the event is real; the evidence does not show that the captured event was caused by epileptic discharge; and treatment exists for the functional mechanism.

The clinician should explain how the diagnosis was reached, the level of certainty, whether all event types were captured, what coexisting conditions are present, and who will follow the treatment. Involving family or a care partner can help when the patient agrees, because their response to an event can either improve safety or increase fear and disability.

What treatment is supported by evidence?

There is no single prescription for every person. A plan usually begins with a clear and acceptable explanation of the diagnosis, then identifies factors that may trigger or perpetuate seizures: sleep disturbance, anxiety or depression, trauma, chronic pain, hyperventilation, avoidance, fear of symptoms, or other neurological problems. Care may include psychotherapy designed for functional seizures, physical or occupational therapy when motor symptoms are present, training to recognize early signals and regulate responses, and treatment of coexisting conditions.

The AAN guideline reviewed intervention studies and concluded that psychological interventions may be effective in increasing the likelihood of seizure freedom, reducing seizure frequency and anxiety, and improving quality of life and psychosocial functioning, while the quality of evidence remains limited in several areas.^[2] The word “may” matters: there is no promise of cure and no single treatment that fits everyone.

The CODES trial also shows why results must be read in full. It compared specialized cognitive behavioral therapy plus standardized medical care with standardized medical care alone in 368 adults. At 12 months, the difference in the primary outcome—monthly seizure frequency—was not statistically significant, while several secondary outcomes improved, including longer seizure-free periods, distress, and some measures of quality of life and functioning.^[5][6] The study therefore cannot accurately be summarized as “CBT cures the seizures,” nor as “CBT has no benefit”; the pattern of effects was mixed.

What about antiseizure medications?

Antiseizure medications treat epileptic activity, and there is no evidence that they benefit functional seizures alone. The AAN guideline recommends against prescribing antiseizure medications—including benzodiazepines—for functional seizures alone when there is no coexisting epilepsy or another indication, and recommends explaining the risks and lack of evidence of benefit in this setting.^[1]

But this recommendation is not permission to stop medication on your own. A drug may have been prescribed for coexisting epilepsy or another reason, and abrupt withdrawal can lead to dangerous seizures. Tapering is a clinical decision led by the doctor who has reviewed the diagnosis and the full medication list. The NHS likewise advises not to change the dose or stop epilepsy medicine without speaking to a specialist.^[9]

What should we do during an undiagnosed seizure?

Until the medical team knows what type of seizure is occurring, put safety first:

• Stay calm and start timing the seizure.
• Move sharp or hot objects away, and place something soft under the person’s head if they are on the ground.
• Do not restrain the limbs or try to stop the movements by force.
• Do not put fingers, a spoon or anything else in the mouth.
• Do not give food or drink until the person is fully alert again.
• Turn the person onto their side after the convulsions stop when it is safe to do so, and monitor breathing.
• Seek emergency help for a first seizure, if it lasts more than five minutes, if another occurs without recovery, if there is injury or breathing difficulty, or if it happens in water.

These rules are consistent with seizure first-aid guidance from the U.S. Centers for Disease Control and Prevention and the NHS.^[8][10] If the person has a written seizure action plan, follow it as instructed by the treating team.

How can family help instead of making seizures worse?

Families do not need to choose between a “physical illness” camp and a “psychological illness” camp. They need accurate language and a consistent response:

1. Believe the person’s suffering without locking in an untested explanation.
2. Record timing and description calmly instead of shouting or accusing.
3. Do not label every disagreement or emotional reaction as “the cause of the seizure” in front of the patient.
4. Do not turn the home into a permanent monitoring unit that strips the person of independence.
5. Help the person keep appointments and follow the safety, sleep and treatment plan.
6. Ask the clinical team what response is appropriate for each event type, especially when epilepsy and functional seizures coexist.

Family fear is understandable, but it can become a system that increases disability: constant monitoring, banning every activity, fighting over interpretations, or turning to people who exploit uncertainty. Good treatment gradually restores boundaries and responsibility instead of building an entire identity around the seizure.

Can AI diagnose a seizure from a video?

It should not be used for that purpose outside an approved medical system. Models may eventually learn useful patterns, and the AAN guideline itself notes that artificial intelligence and wearable devices are areas of research that require better technologies.^[1] But a smartphone clip may miss the beginning, hide the limbs, or lack sound and context, and the patient may have two conditions at the same time.

Even an epilepsy specialist uses video as part of a case file, not as an isolated verdict. An app or language model saying “this is a psychogenic seizure with 95% probability” can therefore create false confidence and delay treatment of epilepsy, cardiac syncope or another emergency. A safer role for a tool is to organize questions, timing and description—not to issue the diagnosis.

Common questions and mistakes

Does a functional seizure mean the person is “mentally ill”?

Functional seizures fall within functional neurological disorders. Anxiety, depression or trauma-related disorders may coexist, but a single psychiatric diagnosis does not necessarily explain the seizures. Each case should be assessed rather than having a psychological biography imposed on it.

Does a normal EEG rule out epilepsy?

No. A routine interictal EEG can be normal. The strongest value comes when the person’s typical seizure is recorded and the video is compared with electrical activity and context.

Does a seizure stopping when someone talks to the person prove they are faking it?

No. Attention can change functional symptoms, and some people with certain types of seizures or syncope may also respond partially. Behavior alone does not prove intent.

Is psychological stress always present before a seizure?

Not necessarily at the same moment, and not everyone can identify a stressor. Neural networks may learn a pattern that becomes automatic. Looking for a psychological factor should not delay excluding important neurological, cardiac or metabolic causes.

Can people recover?

Functional seizures can improve or stop in some people, especially with a clear diagnosis and appropriate treatment, but the course varies. Guaranteed promises are unscientific, just as absolute pessimism is unjustified.

Conclusion

The difference between functional seizures and epilepsy is not the difference between “real” and “imaginary,” but between two real mechanisms that require different treatment. A strong diagnosis does not come from one movement, one routine EEG or one family impression; it comes from a careful history, witnesses, video when available, examination, and recording of the person’s typical seizure when needed, while also checking whether both conditions coexist.

The best protection for the patient is a combination of compassion and diagnostic rigor: believe the experience, do not call it faking, do not give epilepsy medication for a functional seizure without an indication, do not withdraw medication from someone who may have epilepsy, and do not let artificial intelligence or family fear replace a specialist team.

This report connects to a question raised by the novel «أم عباس»

Ahmed Alhafiz’s forthcoming novel explores the ambiguity of illness, fear and interpretation within a family. This report, however, is medically independent: it does not diagnose a fictional character or the reader, and it does not reveal the plot.

Novel page — forthcoming

References

1. American Academy of Neurology, “AAN issues new guideline for the management of functional seizures” (2025). Official summary of diagnostic, treatment, medication and communication recommendations.
2. Tolchin B, et al. Management of Functional Seizures Practice Guideline Executive Summary. Neurology. 2026;106(1):e214466. Executive summary of the guideline based on a systematic review.
3. LaFrance WC Jr, et al. Minimum requirements for the diagnosis of psychogenic nonepileptic seizures: a staged approach. Epilepsia. 2013. Levels of diagnostic certainty and the role of video-EEG.
4. Tatum WO, et al. Assessment of the Predictive Value of Outpatient Smartphone Videos. JAMA Neurology. 2020. Evaluation of smartphone videos as an adjunctive tool used by experts.
5. Goldstein LH, et al. Cognitive behavioural therapy for adults with dissociative seizures (CODES). Lancet Psychiatry. 2020;7:491–505. The primary randomized trial.
6. Open full text of the CODES trial. Details of primary and secondary outcomes and the analysis method.
7. Vanderbilt EMU cohort: coexisting epilepsy and PNES. Epilepsy & Behavior. 2016;62:62–65. A context-specific study of coexisting epilepsy and functional seizures.
8. U.S. CDC, First Aid for Seizures. Safety rules, seizure timing and when to seek emergency help.
9. NHS, Epilepsy. Information about diagnosis and treatment, including the warning not to change epilepsy medication without specialist advice.
10. NHS, What to do if someone has a seizure. First-aid steps and actions to avoid.

This material was reviewed against the most recent available guideline, specialist sources and original research. It must not be used to diagnose a person or alter treatment.