Seizures are commonly portrayed in popular media as dramatic, convulsive episodes that are impossible to miss: a person collapses, shakes violently, and is immediately rushed to the hospital. But the reality of epilepsy and seizure disorders is far more nuanced and, in many cases, far more elusive. Non-motor seizures—those without convulsions—often manifest as brief lapses in awareness, confusion, staring spells, or sudden emotional changes. These subtle expressions are frequently misread as psychiatric disturbances, behavioral issues, or even personality traits, leading to years of misdiagnosis and ineffective treatment.
Dr. Basem Hamid has extensively studied the complexity of non-motor and psychogenic seizures and how easily they can be overlooked.
Patients with non-motor seizures often find themselves on a diagnostic odyssey. They may see psychiatrists, primary care physicians, and even cardiologists before ever being referred to a neurologist. Along the way, they accumulate misdiagnoses: panic disorder, dissociative identity disorder, depression, attention deficit disorder. The failure to recognize these episodes as seizures is not just a clinical oversight; it is a failure of the medical system to truly listen to and observe patients. And for many, this oversight can delay appropriate treatment by years, sometimes decades.
The Spectrum of Seizure Manifestations
Seizures are electrical storms in the brain, but not all storms look the same. While tonic-clonic seizures (the dramatic full-body convulsions) are easy to recognize, focal aware seizures and focal impaired awareness seizures can be nearly invisible to the untrained eye. These may present as brief moments of blank staring, repetitive hand movements, a sudden sense of fear or euphoria, or nonsensical speech. The patient may retain awareness or have complete amnesia for the episode. Because these signs are subtle and transient, they are frequently dismissed as idiosyncratic or attention-seeking behavior.
Even more complex is the diagnosis of psychogenic non-epileptic seizures (PNES), which are seizure-like episodes that have a psychological origin rather than a neurological one. These episodes often occur in individuals with histories of trauma or chronic psychological stress. Although PNES are not caused by abnormal electrical activity in the brain, they are no less real and no less disruptive. Yet, because they defy the typical electroencephalogram (EEG) patterns of epileptic seizures, patients with PNES are often stigmatized or accused of faking their symptoms. This not only exacerbates psychological distress but also widens the diagnostic and therapeutic gap.
The Consequences of Diagnostic Error
When non-motor or psychogenic seizures are not correctly diagnosed, the implications are far-reaching. Patients may be prescribed medications that do nothing to control their episodes and instead introduce harmful side effects. Anti-seizure medications come with a host of potential complications, including cognitive dulling, mood changes, and organ toxicity. For patients with PNES, these medications are not only ineffective but may reinforce a sense of medical abandonment.
Misdiagnosis also strains patient-provider relationships. When treatments fail, trust erodes. Patients may begin to feel that their symptoms are being minimized or dismissed, leading them to disengage from care altogether. Families, too, can become frustrated and confused, unsure whether to seek psychiatric or neurological help. Children are especially vulnerable, often labeled as misbehaving or developmentally delayed when they are in fact experiencing non-convulsive seizures.
Educational and occupational setbacks are another consequence. Students with undiagnosed seizures may struggle in school due to missed material, disciplinary actions, or cognitive fatigue. Adults may lose jobs or be denied opportunities due to unexplained behaviors or absences. The lack of a clear diagnosis prevents accommodations and reinforces cycles of misunderstanding and marginalization.
Improving Diagnostic Confidence Through Clinical Insight
Advancing outcomes for individuals experiencing non-motor and psychogenic seizures relies on strengthening diagnostic awareness and refining approaches through continued education and collaboration. Physicians across specialties benefit from being equipped with up-to-date knowledge of the full clinical spectrum of seizure activity. Understanding the nuances of seizure presentation—and the limitations of tools like routine EEGs—can aid in identifying patterns that otherwise remain undetected during brief clinical visits. A normal EEG does not exclude epilepsy, and careful clinical correlation remains essential.
Gathering comprehensive patient histories and incorporating observations from close contacts can provide critical insight. Family members, caregivers, and coworkers often witness behaviors that patients themselves may not remember. Creating space in clinical conversations for these perspectives—through open-ended, empathetic questioning—enhances diagnostic clarity. Updating screening tools and intake forms to better reflect the subtleties of non-convulsive events can further support early recognition.
Multidisciplinary collaboration is also pivotal. Neurologists, psychiatrists, and primary care providers bring complementary perspectives that are necessary for distinguishing complex seizure types and guiding effective care plans. Psychogenic non-epileptic seizures, in particular, benefit from integrated care that combines cognitive behavioral strategies with a trauma-informed approach. Recognizing the legitimacy of patient symptoms and fostering trust within the clinical relationship helps build the foundation for recovery and improved quality of life.
A Call to Advance Care
As the field of neurology continues to evolve, so too must the methods used to identify and manage seizure disorders. Recognition of non-motor and psychogenic seizures is improving, but ongoing investment in research, education, and care coordination is necessary to ensure that all patients receive timely and appropriate support.
The future of seizure care rests not just in better diagnostics, but in an enhanced model of medicine—one that values complex patient stories, leverages multidisciplinary insights, and strengthens provider-patient relationships. By addressing the subtleties of seizure disorders with openness and precision, the medical community can foster earlier interventions, minimize suffering, and promote equity in care. In doing so, we continue the essential work of illuminating neurology’s more nuanced dimensions and expanding its reach to those who need it most.