17 Patients Diagnosed With Psychogenic Seizures. All 17 Had Evidence of Autonomic Dysfunction

FND Nope Moderator

24 Oct 2026 0 comments

Seventeen patients arrived at an emergency department with seizure-like movements. Their EEG investigations showed no corresponding epileptic seizures, and they were diagnosed with psychogenic non-epileptic seizures (PNES). Further neurological investigation subsequently identified evidence of autonomic dysfunction in every patient. When doctors treated the autonomic abnormalities, 10 of the 14 patients receiving medication improved, with some experiencing complete resolution of their abnormal movements. This is what researchers documented in a September 2026 study published in Frontiers in Neurology.

The study, titled Improved outcomes for patients with autonomic movement disorders originally evaluated for psychogenic non-epileptiform spells, examined patients treated at St. Elizabeth's Medical Center between January 2022 and April 2025. All 17 had experienced seizure-like movements without corresponding epileptic activity on EEG and had subsequently received a clinical PNES diagnosis from an epileptologist. They were later referred for further neurological evaluation, where a different explanation emerged.

PNES is generally classified as a subtype of Functional Neurological Disorder (FND), also called functional or dissociative seizures. That makes these cases directly relevant to FND diagnosis and misdiagnosis. But non-epileptic does not automatically mean psychogenic: convulsive syncope, autonomic dysfunction and other physiological disturbances can produce seizure-like events without epileptic activity on EEG. The researchers state that epileptologists diagnosed these patients with PNES, but do not provide patient-by-patient documentation of the positive clinical signs used to justify those diagnoses. We therefore cannot determine exactly how each original diagnosis was established. What is documented is that further evaluation identified abnormal orthostatic findings in all 17 patients.

The central problem is straightforward. An EEG showing that a recorded event is not epileptic does not establish that the event is psychogenic. There are other physiological explanations for seizure-like movements, including disturbances of blood pressure, heart rate and cerebral blood flow. In these 17 patients, autonomic abnormalities were identified after the PNES diagnosis had already been made.

What the doctors actually found

The patients presented with a wide range of symptoms, including convulsions, tremors, myoclonus, involuntary muscle contractions, altered consciousness and episodes of near-fainting. Eleven experienced convulsive movements, ten had reduced levels of consciousness, six experienced tremors, six had myoclonus and six experienced presyncope. Some had movements resembling tonic-clonic seizures, while others experienced facial twitching, limb shaking, eyelid fluttering or episodes of unresponsiveness.

Every patient had abnormal orthostatic findings during bedside assessment, involving blood pressure or heart-rate changes associated with standing. The researchers report subsequent tilt-table confirmation of orthostatic hypotension and describe findings consistent with autonomic dysfunction. A movement disorder specialist subsequently diagnosed autonomic movement disorder (AMD), a proposed diagnostic category describing abnormal movements or altered responsiveness associated with impaired autonomic cardiovascular regulation.

The researchers proposed that transient reductions in cerebral blood flow could explain some of these events. When blood pressure regulation fails, the brain may temporarily receive insufficient blood flow, potentially producing involuntary movements, altered awareness and convulsive activity. Such events can resemble epileptic seizures without being caused by epilepsy. This is a physiological mechanism, not evidence that the patient is producing symptoms through a psychological process.

"Patients experiencing autonomic storms related to dysautonomia may present with abnormal movements, including convulsions, tremors, and myoclonus."

The proposed mechanism is plausible and supported by earlier research into convulsive syncope, although this small study did not directly demonstrate cerebral hypoperfusion during every recorded event. What it did document was a consistent pattern of orthostatic abnormalities in patients whose seizure-like movements had previously been labelled psychogenic.

Seventeen patients, seventeen clinical presentations

The study includes a case-by-case table showing the events that initially raised concerns about epilepsy, the subsequent investigations and the reported treatment outcomes. These are not hypothetical examples. They are clinical records of patients whose presentations were initially classified as PNES before autonomic abnormalities were identified.

All 17 patients had abnormal orthostatic findings, and none had epileptic activity corresponding to their recorded events. The first 11 cases in the published table showed improvements in motor symptoms and orthostatic measurements following medication, although the authors' overall results and outcome figure report improvement in 10 of the 14 medicated patients. That discrepancy between the case table and aggregate results is not explained in the paper. The remaining patients had incomplete follow-up, so their eventual outcomes cannot be established.

What happened when doctors treated the autonomic dysfunction?

All patients received conservative management, including fluids, electrolytes and compression stockings. Fourteen were also prescribed medication, including fludrocortisone, midodrine, pyridostigmine or beta-blockers, with eight receiving combinations of medications. These treatments target physiological abnormalities such as orthostatic hypotension and abnormal cardiovascular regulation rather than treating the events as psychogenic.

According to the researchers' aggregate results, 10 of the 14 patients receiving medication improved. Improvements included fewer or completely resolved abnormal movements, better orthostatic measurements and fewer hospital readmissions. Outcomes were assessed using patient reports and clinical evaluations by a movement disorder specialist, including follow-up at three and six months. The authors also reported that no improvement was recorded in their comparison categories receiving no intervention or conservative measures alone, although the groups were too small and non-randomized to establish comparative treatment effectiveness.

One patient described receiving appropriate treatment and experiencing improvement as feeling like a weight had been lifted. That reaction is understandable. These patients had experienced frightening neurological events, received a psychogenic diagnosis and subsequently underwent evaluation that identified measurable autonomic abnormalities. For those who improved, treatment directed at those abnormalities made a difference.

But there is an important distinction: the study was retrospective, involved only 17 selected patients and had no randomized control group. It cannot establish that the medications would produce the same outcomes in a broader population. It does, however, provide clinical evidence that further investigation identified potentially treatable physiological problems in patients previously diagnosed with PNES.

Some patients visited emergency departments seven times

One of the more disturbing findings concerns how long some patients remained without appropriate autonomic evaluation. The researchers reported that several patients repeatedly attended emergency departments before being referred for neurological assessment, with some presenting as many as seven times. These were people experiencing recurrent episodes severe enough to require emergency medical attention, yet the physiological abnormalities later identified had not been adequately investigated.

The authors explicitly acknowledge the consequences of this diagnostic delay. Patients can accumulate medical expenses, experience repeated hospital admissions and continue suffering from symptoms that might respond to treatment. They also note that an FND diagnosis can make subsequent investigations more difficult because new symptoms may be attributed to the existing diagnosis.

"Misdiagnosis prevents patients from receiving the proper treatment that they need to mitigate their symptoms."

This is the danger of diagnostic closure. Once a patient's movements have been labelled psychogenic, subsequent episodes can be interpreted through that label rather than prompting reconsideration of the original conclusion. In this study, the researchers identified autonomic abnormalities through assessments that should be considered when patients present with unexplained seizure-like movements, particularly when episodes involve fainting, lightheadedness or positional symptoms.

A negative EEG is not proof of a psychogenic seizure

The distinction between a non-epileptic event and a psychogenic event is fundamental. EEG testing can help establish whether a recorded episode is associated with epileptic brain activity. It does not, by itself, determine why a non-epileptic episode occurred. Syncope, cardiovascular disturbances, autonomic disorders and other physiological conditions can produce events that resemble seizures. A negative EEG therefore cannot serve as standalone proof of PNES.

The researchers recommend checking orthostatic blood pressure and heart rate and considering tilt-table testing when seizure-like events occur without corresponding epileptic activity. Orthostatic hypotension is generally identified by a significant fall in blood pressure on standing or during head-up tilt, while POTS involves an excessive increase in heart rate without the blood-pressure drop required for orthostatic hypotension. These are measurable physiological findings that can guide further investigation.

The paper does not establish that every patient diagnosed with PNES has autonomic dysfunction, nor does it determine how often these diagnoses are incorrect. The sample was deliberately selected from patients who received PNES diagnoses and were subsequently referred for further neurological evaluation. There was no population-wide screening, and no statistical hypothesis testing was performed. The proposed autonomic movement disorder category also requires further validation. Those limitations matter, but they do not erase the clinical findings.

What the study demonstrates is that patients diagnosed with PNES can have clinically important autonomic abnormalities that warrant investigation and treatment. The fact that a seizure-like event is not epileptic should be the beginning of an appropriate differential diagnosis, not the end of it.

Seventeen patients were given a psychogenic seizure diagnosis. Seventeen were subsequently found to have abnormal orthostatic findings. Most of those receiving medication improved. Some had already visited emergency departments repeatedly before receiving further assessment. The question is not whether every PNES diagnosis is wrong. It is why potentially treatable physiological explanations were not adequately investigated before these patients received a psychogenic label.

References

• Khoo A, Paul M, Rady N, et al. (2026). Improved outcomes for patients with autonomic movement disorders originally evaluated for psychogenic non-epileptiform spells. Frontiers in Neurology, 17, 1839185. Primary study.
• Khoo A, Brik J, Hohler AD. (2025). Autonomic storms and autonomic movement disorder associated with postural orthostatic tachycardia syndrome misdiagnosed as functional neurological disorder. Advances in Neurology, 4, 123–127.
• Blitshteyn S, Treisman GJ, Ruhoy IS, et al. (2024). Postural orthostatic tachycardia syndrome and other common autonomic disorders are not functional neurologic disorders. Frontiers in Neurology, 15, 1490744.
• Lempert T, Bauer M, Schmidt D. (1994). Syncope: A videometric analysis of 56 episodes of transient cerebral hypoxia. Annals of Neurology, 36, 233–237.
• Freeman R, Wieling W, Axelrod FB, et al. (2011). Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome. Clinical Autonomic Research, 21, 69–72.