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PNES · 5 min read

Psychogenic Non-Epileptic Seizures (Functional Seizures)

Functional seizures are a brain-network disorder, not faking — and they respond to specific therapy.

Originator: W. Curt LaFrance Jr. (Cognitive Behavioral Therapy informed by Mindfulness for PNES, 2014)Best for: PNES / functional seizures · Co-occurring PTSD and dissociation · Mixed epileptic + functional seizures · Adolescents with functional seizures

Core idea

Psychogenic non-epileptic seizures (also called functional or dissociative seizures) are involuntary episodes that resemble epileptic seizures but are not caused by abnormal cortical electrical activity. Current models view PNES as a functional neurological disorder rooted in dysregulated processing of emotion, attention, and threat — often with a trauma history. The best-evidenced treatment is the 12-session CBT-informed protocol developed by LaFrance and colleagues (Taking Control of Your Seizures workbook).

Key concepts

Functional, not factitious
Symptoms are genuine and involuntary — the brain produces the event without conscious intent.
Diagnostic certainty
Gold standard is video-EEG capturing a typical event without ictal EEG changes.
Warning signs / aura
Most PNES are preceded by identifiable internal cues — the entry point for intervention.
Avoidance and accommodation
Family and social systems often reorganize around seizures, reinforcing the cycle.
Dissociation as a mechanism
PNES often functions as a nervous-system circuit-breaker for overwhelming affect or memory.

What a session looks like

  1. 1
    Diagnostic handoff
    Deliver the diagnosis collaboratively with neurology — language matters: 'real, treatable, not epilepsy.'
  2. 2
    Psychoeducation
    Explain the brain-network model; validate seizures as involuntary; introduce the role of triggers and warning signs.
  3. 3
    Trigger and warning sign mapping
    Identify the prodrome — the 30–120 sec window before an event where intervention is possible.
  4. 4
    Skills training
    Grounding, breathing, somatic anchoring, cognitive reappraisal — practiced in session and at warning signs.
  5. 5
    Trauma and avoidance work
    Phase-based trauma processing where indicated; exposure to avoided emotions, memories, and situations.

Signature techniques

LaFrance CBT-ip protocol (12 sessions)
Workbook-driven: seizure log, triggers, communications, healthy lifestyle, internal awareness, relaxation, trauma chapter.
Warning sign interruption
Trained response to aura — grounding script, paced breath, postural change — to abort the event.
Grounding and dual awareness
5-4-3-2-1, cold water, weighted touch — anchors attention during prodrome and post-event.
Family psychoeducation
Coach family on calm, non-rewarding response during events; reduce accommodation that maintains the cycle.
Phase-based trauma processing
Where trauma is a driver, integrate with stabilization-first trauma therapy (not unprocessed exposure).

Evidence base

LaFrance et al. (JAMA Psychiatry, 2014): 12-session CBT-ip reduced seizures by 51% with significant improvements in depression, quality of life. ILAE Task Force consensus (2021) endorses psychological treatment as first-line. CODES trial (Goldstein et al., 2020): CBT did not beat standardized medical care on monthly seizure count but improved most secondary outcomes — interpretation debated.

Common pitfalls

  • ▸Diagnostic ambivalence — hedging the diagnosis sabotages treatment; clarity is itself therapeutic.
  • ▸Using the term 'pseudoseizures' — stigmatizing and clinically obsolete.
  • ▸Diving into trauma processing before stabilization, grounding, and warning-sign work are in place.
  • ▸Missing the ~10–20% of patients with co-occurring epilepsy who need both treatments.

Where to go next

Taking Control of Your Seizures: Workbook
LaFrance, Wincze, Reiter
The 12-session protocol manual + client workbook.
Treatment of Functional Neurological Symptoms (the FND textbook)
Stone, Carson, Hallett (eds.)
Comprehensive clinician reference.
FND Society & FND Hope
fndsociety.org / fndhope.org
Professional and patient resources, clinician training listings.