A person may suddenly feel weak, lose sensation in part of the body, faint, shake uncontrollably, or experience an episode that looks very much like an epileptic seizure. Medical tests may fail to reveal the neurological disease that was initially suspected.

That can be confusing for the person experiencing the symptoms, frightening for the family, and sometimes difficult even for clinicians to explain.

For many years, medicine used broad terms such as hysteria or psychogenic symptoms for conditions like these. Those labels often mixed together very different problems and sometimes carried the unfair implication that a person was exaggerating or consciously producing symptoms.

Modern medicine approaches these conditions differently.

When the Symptoms Are Real

One diagnosis used in the United States is functional neurological disorder (FND), also called functional neurological symptom disorder or, historically, conversion disorder.

FND can affect movement, sensation, speech, awareness, or seizure-like activity. A person may experience weakness, tremor, difficulty walking, numbness, abnormal movements, episodes of unresponsiveness, or functional seizures.

The important point is that these symptoms are genuinely experienced. They are not automatically considered deliberate, imaginary, or fabricated.

Another important change in modern diagnosis is that doctors do not have to discover a psychological trauma or stressful event before diagnosing FND. Stress may be relevant for some people, but it is not required. Diagnosis should instead be based on recognizable clinical features and neurological examination findings that positively support FND.

This distinction matters. Telling someone, “Your tests are normal, so nothing is wrong,” can leave that person feeling dismissed. The absence of structural disease does not mean the absence of a genuine disorder.

Stress Can Still Matter

Although psychological stress is not required for diagnosis, emotional strain can sometimes influence symptoms.

Conflict at home, overwhelming responsibilities, fear, loss, trauma, or prolonged tension may increase nervous-system arousal. In some people, symptoms may appear or become stronger during these periods and lessen when the situation changes.

But the relationship is rarely as simple as “stress caused the symptom.”

FND is increasingly understood as a problem involving how brain networks responsible for attention, movement, sensation, emotion, and the sense of control over the body function together. That is very different from consciously deciding to produce a symptom.

For families, this difference can completely change the conversation. Accusing someone of pretending usually increases conflict and distress. Taking the symptoms seriously while still pursuing an accurate diagnosis is far more useful.

When an Episode Looks Like Epilepsy

One of the most dramatic forms of FND is a functional seizure, traditionally called a psychogenic nonepileptic seizure.

The person may fall, shake, become unresponsive, or appear to lose awareness. From the outside, the episode can look remarkably similar to epilepsy.

Yet functional seizures and epileptic seizures arise through different mechanisms, which is why careful neurological evaluation is essential. Simply looking at an episode is not always enough to determine what is happening.

And receiving a diagnosis of functional seizures does not mean that the person was “putting on a show.” Research has shown that targeted psychotherapy, particularly cognitive behavioral approaches, can reduce functional seizure frequency and improve associated symptoms and daily functioning for some patients.

Where Dissociation Fits In

Some people experiencing functional symptoms also describe dissociation.

Dissociation can involve feeling detached from oneself, feeling that the surroundings are unreal, experiencing changes in awareness, or having gaps in memory. Depersonalization and derealization are examples of dissociative experiences.

However, dissociative disorders and FND should not simply be treated as interchangeable diagnoses. In current U.S. classification, dissociative disorders form their own diagnostic group, including dissociative amnesia, depersonalization/derealization disorder, and dissociative identity disorder.

That is another reason why unusual symptoms require proper assessment. Fainting, altered awareness, unusual perceptions, memory problems, weakness, or seizure-like episodes can have many possible explanations. Neurological, psychiatric, medical, medication-related, and substance-related causes may all need to be considered.

The Problem With Calling Behavior “Demonstrative”

Older psychiatric descriptions sometimes interpreted intense symptoms or self-harming behavior mainly as attempts to attract attention, influence relatives, or escape an uncomfortable situation.

Modern clinical language is more cautious.

A person can certainly communicate distress through behavior. People may also have complicated or conflicting motives. But clinicians are discouraged from reducing suicidal behavior to a “gesture” simply because the person appears ambivalent about dying or because interpersonal conflict is involved.

The term can minimize a potentially dangerous situation. Suicidal behavior may involve mixed motives, and intent can change rapidly. Even an act that was not initially intended to be fatal can produce serious injury or death. Research literature has specifically recommended replacing dismissive terminology with more precise descriptions of the behavior and its intent.

This is especially important in people with functional seizures. Studies have found elevated mortality and significant suicide-related risk in this population, showing why suicidal statements or self-harming actions should always be taken seriously rather than interpreted simply as attempts to gain attention.

Treatment Is About Understanding, Not Accusing

Treatment begins with a clear explanation of what is happening.

For some people, simply hearing that the clinician believes the symptoms are real — and that there is a recognized condition that can explain them — can reduce fear and confusion.

Depending on the symptoms, treatment may involve a neurologist, psychiatrist, psychologist or licensed therapist, physical therapist, occupational therapist, or other specialists. Psychotherapy can be particularly useful when functional seizures, emotional stress, trauma, anxiety, or depression are present. Physical rehabilitation may be important when movement or mobility is affected.

The goal is not to prove that symptoms are “psychological.” It is to understand what keeps them going and help the nervous system regain more normal patterns of functioning.

Some people improve substantially, while others need longer-term care. Earlier recognition, a respectful explanation of the diagnosis, and appropriate treatment can make recovery more achievable.

Perhaps the most important lesson is simple: unusual symptoms deserve curiosity rather than accusation.

A body can produce very real distress even when standard medical tests do not reveal the explanation that one might expect to find.

References

• American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). American Psychiatric Association Publishing. doi:10.1176/appi.books.9780890425787.
  This is the principal diagnostic classification used in U.S. mental health practice. It provides the current framework for functional neurological symptom disorder, dissociative disorders, somatic symptom and related disorders, and their differential diagnosis. Page numbers are not specified here because pagination differs across print and electronic formats.
• Espay, A. J., Aybek, S., Carson, A., et al. (2018). Current Concepts in Diagnosis and Treatment of Functional Neurological Disorders. JAMA Neurology, 75(9), 1132–1141. doi:10.1001/jamaneurol.2018.1264.
  A major clinical review explaining modern FND diagnosis, including the shift away from requiring psychological stress as proof of the disorder and the use of positive neurological findings. Relevant pages: 1132–1141.
• LaFrance, W. C. Jr., Baird, G. L., Barry, J. J., et al. (2014). Multicenter Pilot Treatment Trial for Psychogenic Nonepileptic Seizures: A Randomized Clinical Trial. JAMA Psychiatry, 71(9), 997–1005. doi:10.1001/jamapsychiatry.2014.817.
  This randomized clinical trial examined treatment for functional seizures and found meaningful reductions in seizure frequency and improvements in several psychological and functional outcomes with CBT-informed psychotherapy. Relevant pages: 997–1005.
• Nightscales, R., McCartney, L., Auvrez, C., et al. (2020). Mortality in Patients With Psychogenic Nonepileptic Seizures. Neurology, 95(6), e643–e652. doi:10.1212/WNL.0000000000009855.
  This cohort study documents increased mortality among people diagnosed with functional seizures and highlights the importance of recognizing psychiatric comorbidity and suicide risk. Relevant pages: e643–e652.
• Heilbron, N., Compton, J. S., Daniel, S. S., & Goldston, D. B. (2010). The Problematic Label of Suicide Gesture: Alternatives for Clinical Research and Practice. Professional Psychology: Research and Practice, 41(3), 221–227. doi:10.1037/a0018712.
  The authors explain why describing potentially suicidal behavior as a “gesture” can be misleading and dismissive and recommend more precise assessment of behavior, intent, and function. Relevant pages: 221–227.