Which feature best differentiates psychogenic non-epileptic seizures (PNES) from epileptic seizures?

• A. PNES often have longer duration, wax-and-wane movements, preserved or regained consciousness inconsistently, and EEG does not show epileptiform activity during events.
• B. Epileptic seizures always have a short duration and complete immediate recovery.
• C. PNES show epileptiform discharges on EEG during events.
• D. Epileptic seizures never involve loss of consciousness.

Answer: (A)

When telling the difference between PNES and epileptic seizures, the key clue is what the brain is doing during the event and how the event presents clinically. In PNES, the movements can appear dramatic but are often not tightly stereotyped and may wax and wane. The person’s level of consciousness can be preserved, or change inconsistently during the event, rather than following a predictable postictal pattern. Crucially, video-EEG monitoring shows no epileptiform discharges during PNES, meaning the brain isn’t producing the abnormal electrical activity that drives epileptic seizures.

By contrast, epileptic seizures are tied to abnormal electrical activity in the brain, so the EEG during the event typically reveals epileptiform discharges. The clinical course tends to be more stereotyped, and many seizures involve a clear loss of consciousness with a defined postictal state as the brain recovers.

That combination—longer duration with waxing/waning movements and consciousness that isn’t consistently altered, plus no epileptiform EEG activity during the event—best differentiates PNES from epileptic seizures.