MDM Templates

Psychogenic Nonepileptic Spells (PNES)

Patient presents with observed shaking/jerking movements. Multiple features on exam inconsistent with epileptic seizure activity: preserved responsiveness during movements, forceful eye closure, directed eye movements away from examiner, absence of postictal confusion, and absence of physical injury (tongue bite, incontinence).

Presentation most consistent with psychogenic nonepileptic spell. Not consistent with epileptic seizure (no postictal state, preserved awareness, semiology inconsistent with cortical activity), syncope with myoclonic jerks (no preceding lightheadedness, no rapid return to baseline), or movement disorder (episodic, contextual).

Plan: Discharge with PCP follow-up and referral to neurology for outpatient video EEG to confirm diagnosis. Return for loss of consciousness, postictal confusion, injury, or recurrent episodes.

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Clinical Education

Approach to Suspected PNES

PNES is a real diagnosis, not malingering. These are involuntary events driven by a dissociative mechanism. Patients are not faking. The distinction matters for how you communicate the diagnosis and for the patient’s willingness to engage with treatment. Calling them “pseudoseizures” to the patient’s face is counterproductive.^[1]

Up to 10–20% of patients with PNES also have epilepsy. A known PNES diagnosis does not rule out concurrent epileptic seizures. If the presentation looks different from their usual PNES semiology, take it seriously.^[2]

The ED role is to exclude dangerous causes, not to definitively diagnose PNES. Definitive diagnosis requires video EEG capturing a typical event. What you can do is document the semiology carefully and avoid unnecessary benzodiazepines, intubation, and ICU admissions.

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Distinguishing Features

Feature	Epileptic Seizure	PNES
Eyes	Open, deviated	Forcefully closed, resists opening
Duration	Usually <2 minutes	Often >2 minutes, may wax and wane
Postictal state	Present (confusion, fatigue)	Absent or rapid recovery
Movement pattern	Rhythmic, evolving frequency	Asynchronous, side-to-side, pelvic thrusting
Tongue bite	Lateral tongue (highly specific)	Tip of tongue (if present)
Incontinence	Common	Uncommon
Crying during event	Not seen	May be present

Forced eye closure is the most reliable bedside sign. Patients with epileptic seizures have their eyes open. Forceful eyelid closure during convulsive movements is strongly suggestive of PNES.^[1]

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Communicating the Diagnosis

Frame it as a real medical condition. “Your brain is having episodes that look like seizures but aren’t caused by abnormal electrical activity. This is called a nonepileptic spell. It’s common and treatable, usually with specialized therapy.” Avoid language that implies the patient is faking or that nothing is wrong.

Do not give benzodiazepines for suspected PNES. They don’t work, they sedate the patient unnecessarily, and they reinforce the patient’s belief (and the medical record) that they have seizures requiring emergency treatment. If you’re unsure whether it’s epileptic or nonepileptic, err on the side of treating the first time — but document your reasoning and arrange definitive evaluation.

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Disposition

Discharge with neurology referral for outpatient video EEG. The patient does not need admission for a suspected PNES event. Ensure they have follow-up with both neurology and psychiatry/psychology for treatment (usually cognitive behavioral therapy).

Admit if: Diagnostic uncertainty (can’t distinguish from epileptic seizure), concurrent medical issues, or the patient is unable to safely care for themselves at home.

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References

1. LaFrance WC Jr, Baker GA, Duncan R, et al. Minimum requirements for the diagnosis of psychogenic nonepileptic seizures: a staged approach. Epilepsia. 2013;54(11):2005-2018. PubMed
2. Benbadis SR, Allen Hauser W. An estimate of the prevalence of psychogenic non-epileptic seizures. Seizure. 2000;9(4):280-281. PubMed