ASU News Examines Why Non-Epileptic Seizures Keep Getting Mislabeled

ASU News has published a feature under the headline "When seizures aren't epilepsy: Understanding a misdiagnosed condition," drawing attention to a category of paroxysmal events that continue to be misclassified as epilepsy in routine care. The piece centers on psychogenic non-epileptic seizures (PNES) — also called functional seizures or dissociative seizures — episodes that clinically resemble epileptic seizures but arise without the abnormal synchronized cortical discharges that define epilepsy.

What is PNES, in clinical neurophysiology terms?

PNES events are not driven by the ictal EEG patterns — rhythmic evolution, spike-wave runs, or high-frequency oscillations — that an epileptologist looks for on scalp EEG or, where indicated, on intracranial recordings. During a typical PNES episode captured in an epilepsy monitoring unit (EMU), the scalp EEG remains free of epileptiform activity, and the clinical semiology (movements, vocalization, eye deviation, posturing) does not map onto the cortical substrate an ictal pattern would predict. This mismatch — clinical seizure without electrical seizure — is the diagnostic cornerstone the ASU article references.

How often does the misdiagnosis happen?

Misclassification of PNES as epilepsy is among the most cited diagnostic errors in outpatient neurology and emergency settings. Patients frequently carry an epilepsy diagnosis for years before video-EEG monitoring, often over 24 hours and including sleep, captures a typical event and the clinical team confirms the absence of ictal EEG changes. The delay carries direct cost: exposure to antiseizure medications that cannot address the underlying disorder, lost driving privileges, and missed access to the cognitive-behavioral and psychiatric care that the evidence base supports for PNES.

What does the EEG actually show?

In a confirmed PNES event, the interictal background may be normal or show nonspecific findings, and the ictal recording lacks the spatiotemporal evolution of a true seizure. Movement and muscle artifact can dominate the trace, which is itself a useful clinical signal: technicians and readers learn to recognize that "dirty" ictal recordings without organized rhythmic activity often point away from epilepsy. EMG/EP correlates, where they have been studied, similarly do not show the recruitment patterns seen in epileptic myoclonus or tonic events.

Why does the confusion persist?

Three structural factors recur in the PNES literature and are likely to underpin the ASU reporting. First, the initial evaluation rarely includes prolonged video-EEG; brief routine EEGs have limited sensitivity and even lower specificity for excluding epilepsy. Second, the semiology of PNES overlaps with focal seizures, frontal-lobe seizures, and convulsive syncope, and many non-neurologists rely on history and witness description alone. Third, the patient population — disproportionately women, often with trauma histories, frequently with comorbid anxiety or mood disorder — overlaps demographically with the population labeled as having drug-resistant epilepsy, which compounds the error when escalation of medication follows failed therapy.

What does correct identification change?

Re-attribution of the diagnosis to PNES alters the treatment pathway. Antiseizure medications are tapered, the patient receives a clear explanation of the diagnosis, and referral is made to trauma-informed psychotherapy, cognitive behavioral therapy, or rehabilitation programs with a functional-seizures track. Outcome data from EMU-confirmed cohorts consistently show that earlier correct diagnosis predicts better engagement with the appropriate treatment and lower long-term healthcare utilization.

What to watch next

The ASU piece lands as professional societies continue to refine their position statements on PNES diagnosis and as EMU capacity expands in tertiary centers. The next practical gains will come from earlier referral to video-EEG monitoring in patients whose seizures do not respond to two appropriately chosen antiseizure medications, and from structured communication protocols that help clinicians deliver the re-attribution without losing the patient's trust.