REFERENCE · DIAGNOSIS

Functional Seizures

Refers to:

episodes of shaking, jerking or stillness with altered responsiveness;
changes in awareness or memory during seizure-like events; and
functional seizures assessed through the whole event and its recovery.

Scope boundary: Isolated or persistent limb paralysis belongs on the paralysis page. A brief sudden fall without definite blackout and with rapid recovery may belong on the drop-attacks page. The diagnostic method below assesses the whole event, not one shared symptom such as shaking or immobility.

Quick Reference

Presentation: Seizure-like episodes assessed from onset through recovery, using the history and appropriate recordings.

Typical-event assessment and video-EEG — assess a usual event alongside its brain electrical recording.
Smartphone-video assessment — expert review of a safely recorded event.
Semiology and the whole event sequence — interpret signs from onset through recovery.

More techniques: See the full list below.

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You may have episodes of shaking or jerking, or become still and unable to move or answer. You might hear people around you, feel distant from what is happening, or find gaps in your memory afterward. This page covers assessment of these seizure-like episodes, including functional seizures. The symptoms can take different forms; you do not need to experience all of them. [1][22]

Also called: Dissociative seizures, functional/dissociative seizures or psychogenic nonepileptic seizures (PNES). The ILAE task force proposed “functional/dissociative seizures” in 2025; terminology in older papers varies. [22]

Functional seizures are involuntary. Epileptic seizures, fainting and other episodic conditions can share some of these experiences, so the clinician needs to assess the whole event. No single behaviour establishes its cause.

The most reliable assessment begins with a detailed account from you and anyone who witnessed the event. A clinician may review a safely obtained home video. When it is feasible, the diagnostic standard is to record a typical event using video-EEG, so the person’s behaviour and the brain’s electrical activity can be interpreted together. More than one type of event may need to be recorded. [1][2]

A normal routine EEG between events does not rule out epilepsy. Some people have both functional seizures and epilepsy, so the diagnosis should identify which event type was recorded and how certain the team is.

The seizure is episodic, but the surrounding symptoms may last longer

Functional seizures are episodic by definition, but their duration and recovery can vary. Some people have a recognizable warning; some have clusters; some take substantial time to recover. Other functional symptoms—such as jerking, gait change, weakness, speech difficulty or altered sensation—may appear before, during or after a seizure-like event and may last for a different amount of time. Those associated symptoms should be described separately rather than assuming the entire period is one seizure.

At a familiar warning or onset, follow the person’s established safety plan: move away from traffic, water, stairs, heat or other hazards; get into the safest practical position; and use a pre-agreed grounding, attention or breathing strategy only if the person remains able to use it. A first event, a substantially different event, serious injury, unusual breathing or colour change, or prolonged/repeated events outside the person’s plan need appropriate urgent assessment.

What you feel and what someone else sees

You may hear people but be unable to answer or move. You may remember only parts of an episode, or discover afterward that you responded without remembering it. The clinician needs both accounts: your experience and the witness’s observations. Neither account cancels out the other. Movement, awareness and later memory are related, but they are not the same function. [22]

Responsiveness: An observable reaction, such as answering or following an instruction. Awareness: What you experience or know about yourself and your surroundings at the time.

Tell the team about immobility or paralysis during events, alongside any jerks or other involuntary movement. Describe how long the immobility continues afterward. Also mention breath-holding or apparent pauses in breathing, unusual movements of the mouth, confused walking, and any episode that differs from your familiar pattern. These observations need assessment; they do not by themselves identify a functional or epileptic event. A video showing only recovery can be misleading. [1][21]

Breathing safety: Difficulty breathing, blue or grey colour, or failure to return to normal breathing needs urgent help. A functional-seizure diagnosis must not be used to dismiss a breathing emergency. Do not practise breath-holding to reproduce an event.

What is understood about the biology

Researchers study how networks involved in awareness, body sensations, automatic responses and movement control interact. These are working explanations, with differences between people. There is no established biological marker that explains every functional seizure or maps a universal before–during–after sequence. An EEG can help distinguish event types; it cannot read thoughts or establish why a particular functional seizure happened. [20][22]

Some people identify a warning or a context that makes episodes more likely; others cannot identify a trigger. You do not need to find a stressful thought or traumatic memory to make your symptoms understandable. A trigger is something associated with an episode starting; it is not necessarily the underlying cause. The diagnosis should rest on the clinical evidence for the events. [1][2]

Getting a useful explanation

Ask which of your event types has been assessed and what supports the conclusion. If one type has been recorded and another has not, the team should explain what is known about each. Functional seizures and epilepsy can coexist. A new label should lead to an agreed plan and follow-up, with medication decisions made by the prescribing team. [1]

Life between episodes matters too

Counting seizures does not capture the whole burden. Tell the team about recovery time, injuries, interrupted sleep, cancelled plans, difficulty bathing or cooking safely, travel, and help you need. An event-free appointment cannot establish how safely or reliably you manage those activities.

In a UK study of 368 adults entering the CODES trial, participants reported substantial functional impairment and reduced physical and mental quality of life. Mental-health difficulties were common, but these associations do not establish the cause of seizures or mean everyone has the same needs. The trial-selected sample did not represent all people with functional seizures. [23]

Ask for care that addresses your goals, wellbeing and practical support as well as event frequency. See assessment and everyday function and the separate functional-seizure recovery pages.

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During an event, follow the person’s safety plan, protect them from injury and seek urgent help when the situation calls for it. Recording is secondary to care. If a spontaneous event can be filmed safely, record the whole person and surrounding context, note the time, and do not restrain them, test their response in painful ways or try to make the episode continue.

Describe what you observed in ordinary language: what happened first, whether the person responded, how breathing and colour looked, how long the event lasted and what recovery was like. Do not decide the diagnosis from a video yourself.

Before, during and after an episode

The visible seizure-like event may be only one part of a longer period of symptoms. If the person develops their familiar speech, gait, jerking, weakness or sensory changes before or after events, follow the separate safety and recovery plan for those symptoms rather than repeatedly asking whether another seizure is starting. Reduce unnecessary crowding and instructions if that is part of the agreed plan.

Time the event when practical, but do not let timing or filming interfere with safety. Note whether the person returned to their usual baseline between repeated events; that information can be important to the emergency plan and clinical review.

Preparing for the appointment together

With permission, write a short description of each recurring event type. Start with what happens first, then describe changes in movement, response, breathing and recovery. Say when you did not see the beginning. A gap in someone’s memory is useful clinical information, not a reason to question their account.

Agree in advance whether recording would be welcome and how it would be shared privately with the team. There is no obligation to produce a video, and no one should provoke an event to supply evidence. Use the smartphone-video page for recording limits and clinical interpretation.

After the assessment, ask for a written plan that you and the person can understand: which events have been identified, how to respond, when to seek help, and who reviews a change. Mention your own practical support needs too. A plan that depends on help that is unavailable needs revising.

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Episodic pattern and longer surrounding flares

For each event type, document warning/prodrome, ictal sequence, duration, frequency, clustering, recovery and return to baseline. Also document motor, speech, cognitive, sensory or gait symptoms that occur around the event but have a different time course. Do not automatically label the entire symptomatic period as one prolonged functional seizure.

Provide a written onset and emergency plan with thresholds that account for the person’s established pattern, coexisting epilepsy and other medical risks. If the patient has a usable warning, adapt one or two treatment skills for that short window; if awareness is lost too quickly, the plan should rely on environmental safety and supporter response instead. A changed semiology or recovery pattern requires renewed differential assessment.

Differential and coexistence

Describe each event before assigning it a cause. Relevant alternatives include focal or generalized epileptic seizures, syncope and cardiac arrhythmia, sleep-related events, metabolic disturbance and other episodic neurological symptoms. Select investigations for the actual question. Syncope-like presentations may require ECG/rhythm and blood-pressure assessment; blood biomarkers do not independently establish functional seizures. [1]

Syncope: A brief loss of consciousness caused by reduced blood flow to the brain. Semiology: The sequence of symptoms and observable signs during an event.

Assess changes in breathing and colour clinically rather than assigning them to FND from appearance. Immobility, recall, automatisms or confused wandering require interpretation within the complete sequence. Consider whether a recording captures the seizure, recovery, or both. [20][21]

Automatisms: Movements such as lip-smacking or handling objects that can occur with reduced awareness. Their presence alone does not settle the diagnosis.

A functional diagnosis applies to the assessed event type; it does not exclude epilepsy or explain every future event. Mood symptoms, trauma history, suggestibility and response to medication are not substitutes for positive event-level evidence. [1][3]

Technique outline: typical-event assessment with video-EEG

The original seven-step outline is retained in the detailed video-EEG page. Companion pages cover smartphone video and whole-event semiology.

From assessment to an actionable care plan

Record the event descriptions, evidence, certainty, remaining differential and whether each habitual type was captured. Discuss the positive reasoning in language the person understands. Arrange continuing care rather than treating diagnostic explanation as discharge from all support. The AAN guideline supports assessment of coexisting epilepsy and mental-health needs and individualized communication and follow-up. [1]

Include baseline function and recovery burden: mobility and transfers after events, communication, personal care, travel, supervision and supporter availability. Nursing, primary care, occupational therapy and psychological care may each answer a different practical question. Mental-health assessment should identify care needs without presuming a cause. The CODES baseline cohort measured quality of life and function, not the causal origin of seizures. [23]

Antiseizure medication decisions require a prescriber-led review of epilepsy and other indications. Do not infer from one captured functional event that all such medication can be stopped. See the recovery collection for treatment rather than duplicating it here. [1]

Media contributor brief

The original process-diagram brief is preserved on the video-EEG page. No seizure footage or attributed patient quotation has been added.

Diagnostic techniques at a glance

The inventory explains the role of each observation, investigation and diagnostic framework.

For the Person With FND
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Research and Sources

Evidence notes

Start with the 2026 AAN guideline for assessment, coexisting epilepsy and continuing care, then the semiology meta-analysis for evidence about observed signs. The 2025 ILAE paper proposes terminology and a definition; it does not establish one mechanism for everyone’s seizures. [1][6][22]

Functional seizures are involuntary. Clinical assessment brings together the person’s account, witnessed events and appropriate recordings, using respectful, safe observation. Earlier examination descriptions are retained as references within this current approach, rather than instructions to provoke responses or infer conscious control. [1][15][20]

The newer smartphone review concerns identifying epileptic seizures, so its pooled accuracy should not be relabelled as functional-seizure accuracy. The CODES baseline study describes wellbeing and participation in a selected adult treatment-trial cohort; these associations do not identify the cause of an individual’s seizures. [23][24]

Citation table

Citation	Figure	Full citation
[1]	—	Tolchin B, Goldstein LH, Reuber M, et al. Management of functional seizures practice guideline executive summary: report of the AAN Guidelines Subcommittee. Neurology. 2026;106(1):e214466. FND-CIT-0010. https://doi.org/10.1212/WNL.0000000000214466 AAN clinician summary.
[2]	—	Bennett K, Diamond C, Hoeritzauer I, Gardiner P, McWhirter L, Carson A, Stone J. A practical review of functional neurological disorder (FND) for the general physician. Clinical Medicine. 2021;21(1):28–36. FND-CIT-0001. https://doi.org/10.7861/clinmed.2020-0987
[3]	—	LaFrance WC, Baker GA, Duncan R, et al. Minimum requirements for the diagnosis of psychogenic nonepileptic seizures: a staged approach: a report from the International League Against Epilepsy Nonepileptic Seizures Task Force. Epilepsia. 2013;54(11):2005-2018. DOI. PMID: 24111933. FND-CIT-0146.
[4]	—	Tatum WO, Hirsch LJ, Gelfand MA, et al. Assessment of the Predictive Value of Outpatient Smartphone Videos for Diagnosis of Epileptic Seizures. JAMA neurology. 2020;77(5):593-600. DOI. PMID: 31961382. FND-CIT-0168.
[5]	—	Chung SS, Gerber P, Kirlin KA. Ictal eye closure is a reliable indicator for psychogenic nonepileptic seizures. Neurology. 2006;66(11):1730-1731. DOI. PMID: 16769949. FND-CIT-0139.
[6]	—	Muthusamy S, Seneviratne U, Ding C, Phan TG. Using Semiology to Classify Epileptic Seizures vs Psychogenic Nonepileptic Seizures: A Meta-analysis. Neurology. Clinical practice. 2022;12(3):234-247. DOI. PMID: 35747545. FND-CIT-0165.
[7]	—	Gates JR, Ramani V, Whalen S, Loewenson R. Ictal characteristics of pseudoseizures. Archives of neurology. 1985;42(12):1183-1187. DOI. PMID: 3933461. FND-CIT-0144.
[8]	—	Duncan AJ, Peric I, Boston R, Seneviratne U. Predictive semiology of psychogenic non-epileptic seizures in an epilepsy monitoring unit. Journal of neurology. 2022;269(4):2172-2178. DOI. PMID: 34550469. FND-CIT-0161.
[9]	—	Seneviratne U, Minato E, Paul E. How reliable is ictal duration to differentiate psychogenic nonepileptic seizures from epileptic seizures? Epilepsy & behavior : E&B. 2017;66:127-131. DOI. PMID: 28039841. FND-CIT-0133.
[10]	—	Geyer JD, Payne TA, Drury I. The value of pelvic thrusting in the diagnosis of seizures and pseudoseizures. Neurology. 2000;54(1):227-229. DOI. PMID: 10636155. FND-CIT-0157.
[11]	—	Wardrope A, Wong S, McLaughlan J, et al. Peri-ictal responsiveness to the social environment is greater in psychogenic nonepileptic than epileptic seizures. Epilepsia. 2020;61(4):758-765. DOI. PMID: 32154929. FND-CIT-0163.
[12]	—	Azar NJ, Tayah TF, Wang L, et al. Postictal breathing pattern distinguishes epileptic from nonepileptic convulsive seizures. Epilepsia. 2008;49(1):132-137. DOI. PMID: 17651411. FND-CIT-0159.
[13]	—	Walczak TS, Bogolioubov A. Weeping during psychogenic nonepileptic seizures. Epilepsia. 1996;37(2):208-210. DOI. PMID: 8635432. FND-CIT-0184.
[14]	—	De Paola L, Terra VC, Silvado CE, et al. Improving first responders’ psychogenic nonepileptic seizures diagnosis accuracy: Development and validation of a 6-item bedside diagnostic tool. Epilepsy & behavior : E&B. 2016;54:40-46. DOI. PMID: 26645799. FND-CIT-0167.
[15]	—	Marcus H, Aldam P, Lennox G, Laing R. Medically unexplained neurological symptoms. JRSM short reports. 2010;1(3):25. FND-CIT-0153.
[16]	—	Bacchi S, Slee M. Physical examination in functional unresponsiveness. Practical neurology. 2023;23(1):54-56. DOI. PMID: 36717206. FND-CIT-0119.
[17]	—	Popkirov S, Grönheit W, Wellmer J. A systematic review of suggestive seizure induction for the diagnosis of psychogenic nonepileptic seizures. Seizure. 2015;31:124-132. DOI. PMID: 26362389. FND-CIT-0148.
[18]	—	Chen DK, So YT, Fisher RS, Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Use of serum prolactin in diagnosing epileptic seizures: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2005;65(5):668-675. DOI. PMID: 16157897. FND-CIT-0123.
[19]	—	Tannemaat MR, van Niekerk J, Reijntjes RH, et al. The semiology of tilt-induced psychogenic pseudosyncope. Neurology. 2013;81(8):752-758. DOI. PMID: 23873974. FND-CIT-0174.
[20]	—	Whitehead K, Kane N, Wardrope A, Kandler R, Reuber M. Proposal for best practice in the use of video-EEG when psychogenic non-epileptic seizures are a possible diagnosis. Clinical Neurophysiology Practice. 2017;2:130–139. FND-CIT-0233.
[21]	—	Freund B, Tatum WO. Pitfalls using smartphones videos in diagnosing functional seizures. Epilepsy & Behavior Reports. 2021;16:100497. DOI. Full text. FND-CIT-0234.
[22]	—	Hingray C, Popkirov S, Kozlowska K, et al. Functional/dissociative seizures: Proposal for a new diagnostic label and definition by the ILAE task force. Epilepsia. 2025;66(11):4162–4182. DOI. Full text. FND-CIT-0235.
[23]	—	Goldstein LH, Robinson EJ, Mellers JDC, et al. Psychological and demographic characteristics of 368 patients with dissociative seizures: data from the CODES cohort. Psychological Medicine. 2021;51(14):2433–2445. Published online May 11, 2020. DOI. Full text. FND-CIT-0236.
[24]	—	Alva-Diaz C, Nieto-Gutierrez W, Rodriguez-López E, et al. Smartphone-based interventions for the diagnosis of epileptic seizures: A systematic review and meta-analysis. Epilepsia. 2025;66:3138–3152. DOI. FND-CIT-0266.

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