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. 2026 Apr 8;28(4):1095–1105. doi: 10.1002/epd2.70242

Psychological and trauma‐related differences in psychogenic nonepileptic seizures: An exploratory severity‐based comparison

Mehmet Murat Kırpınar 1,✉, Memet Şakir Delil 2, Halil İbrahim Deniz 3, Gülsüm Hançer 4, Öznur Demirel 1, Nesibe Boyraz 1, Bengi Gül Türk 2, Şenol Turan 1, Seher Naz Yeni 2
PMCID: PMC13499259  PMID: 41948840

Abstract

Objective

This study examined psychological and trauma‐related characteristics of patients with psychogenic nonepileptic seizures (PNES) and explored whether a clinically informed severity grouping distinguished distinct psychosocial patterns. PNES patients were compared with individuals with epilepsy and healthy controls.

Methods

Participants included mild PNES (n = 20), severe PNES (n = 28), epilepsy (n = 48), and healthy controls (n = 50). Assessments measured anxiety, depression, childhood trauma, dissociation, somatization, and alexithymia. PNES severity was defined using clinical indicators such as acute healthcare utilization and ictal motor intensity.

Results

Both mild and severe PNES groups showed significantly higher anxiety scores than epilepsy patients and healthy controls (p < .01). Depression scores were highest in the mild PNES group and differed significantly from severe PNES, epilepsy, and healthy control groups (p < .05). Trauma profiles varied by severity: sexual abuse was more frequently reported in mild PNES, whereas physical abuse and emotional neglect were significantly higher in severe PNES (p < .05). Mild PNES patients also exhibited higher dissociation, somatization, and total alexithymia scores compared with severe PNES and healthy controls (all p < .05).

Significance

Severity‐linked clinical characteristics in PNES were associated with distinct trauma profiles and psychological symptom patterns. These exploratory findings highlighted the relevance of individualized psychological assessment and support the need for further research to validate severity‐based distinctions.

Keywords: alexithymia, dissociation, epilepsy, PNES, somatization, trauma

Key points.

  • Mild and severe PNES groups exhibited distinct psychosocial profiles.

  • Mild PNES was associated with higher depression, somatization, and dissociation.

  • Severe PNES was linked to higher rates of physical abuse and emotional neglect.

  • Findings support the relevance of severity‐based approaches in PNES assessment.

1. INTRODUCTION

Psychogenic nonepileptic seizures (PNES), increasingly referred to within the broader framework of functional or dissociative seizures, present with paroxysmal episodes that resemble epileptic seizures but occur in the absence of ictal epileptiform activity. Advances in video‐EEG monitoring have substantially improved diagnostic accuracy; however, misdiagnosis remains common, and many patients without coexisting epilepsy continue to receive unnecessary anti‐seizure treatment. 1 , 2 , 3 , 4 Contemporary models conceptualize PNES as arising from complex interactions among neurobiological vulnerability, psychological processes, and social context, rather than from a purely psychological or purely neurological mechanism. 5 , 6 Based on accumulating evidence, recent expert consensus has proposed adopting the term “functional/dissociative seizures” in future research and clinical practice. 7

PNES is a heterogeneous condition, and its clinical diversity is reflected in the wide range of associated psychiatric and psychosocial features, including depression, anxiety, dissociative symptoms, somatization, post‐traumatic stress disorder, and personality‐related vulnerabilities. 1 , 2 , 8 While some patients exhibit substantial psychiatric comorbidity and functional impairment, others display few or no accompanying disorders, highlighting the broad clinical spectrum encompassed by PNES. 9 Traumatic experiences are more prevalent among individuals with PNES compared with other clinical populations, although reported rates vary substantially across studies. 3 , 10 , 11 , 12 Alexithymia—difficulties in identifying and describing emotions—has been associated with both somatization and trauma exposure and appears to be elevated in PNES samples. 10 , 13 , 14 Dissociation has likewise been proposed as a central mechanism in PNES, supported by evidence of elevated dissociation scores compared with healthy individuals or epilepsy patients; however, some studies report similarly high dissociation levels in epilepsy cohorts, suggesting overlapping vulnerability patterns. 15 , 16

In recent years, increasing attention has been directed toward the heterogeneity of functional neurological disorders, including PNES. Multidimensional approaches have identified distinct patient profiles based on psychological symptoms, trauma history, and functional impairment rather than diagnostic category alone. 17 , 18 For example, recent work has described multiple psychosocial profiles among patients with functional or dissociative seizures, highlighting meaningful within‐group variability and challenging one‐size‐fits‐all models of PNES. 19 Despite these advances, relatively few studies have examined whether clinically observable severity‐related characteristics, such as seizure‐related risk markers or healthcare utilization, are associated with distinct psychological or trauma‐related patterns within PNES.

Severity distinctions have been discussed in relation to clinical course, seizure burden, or semiology, yet they have rarely been operationalized in a manner that reflects routine clinical decision‐making in centers. 19 Existing seizure severity scales were primarily developed for epileptic seizures and may not adequately capture dimensions relevant to PNES, such as acute care utilization, ictal injury risk, or disruptive motor behaviors. From a clinical perspective, patients presenting with frequent emergency admissions, intensive care requirements, or high‐risk ictal features may represent a subgroup with distinct needs and vulnerabilities compared with those experiencing less acute or disruptive presentations. Clarifying whether such severity‐linked clinical features correspond with specific psychological profiles may offer practical value for individualized assessment and management.

The present study compared patients with PNES, epilepsy patients, and healthy individuals across domains central to PNES psychopathology, including depression, anxiety, childhood trauma, dissociation, somatization, and alexithymia. We further examined PNES subgroups defined according to a clinically informed two‐tier severity framework based on observable seizure‐related characteristics and healthcare utilization markers. We hypothesized that PNES patients would differ significantly from epilepsy patients and healthy controls and explored whether severity‐related distinctions within PNES would be reflected in differential trauma exposure and psychological symptom patterns.

2. METHODS

2.1. Study design, setting, and participants

This study was conducted at the Departments of Psychiatry and Neurology in a tertiary university hospital, between October 2020 and June 2024. Patients were consecutively recruited from the Consultation‐Liaison Psychiatry outpatient clinic and the Epilepsy outpatient clinic. The PNES group consisted of individuals diagnosed with ICD‐10 F44.5 “Conversion disorder with seizures or convulsions,” confirmed through clinical evaluation by a psychiatrist and a neurologist, and supported by spontaneous or suggestion‐induced video‐EEG (vEEG) recordings. Inclusion criteria were: (a) a definitive diagnosis of PNES based on vEEG capture of typical events, and (b) age between 18 and 65 years. The epilepsy group included adults (18–65 years) diagnosed with epileptic seizures based on neurological examination, clinical history, and confirmation of epileptic activity on vEEG monitoring. Exclusion criteria for both clinical groups were: (a) evidence of structural brain lesions on neuroimaging, (b) major psychiatric disorders such as psychosis or dementia, (c) severe systemic medical illness (e.g., advanced organ failure, malignancy), (d) intellectual disability, (e) illiteracy, and (f) coexistence of epilepsy and PNES. Healthy controls were adults (18–65 years) with no current or past neurological or psychiatric disorders, evaluated during routine occupational health assessments.

2.2. Severity classification of PNES

PNES patients were categorized into mild and severe subgroups using a clinically informed severity framework based on markers of seizure burden, acute healthcare utilization, and ictal behavioral intensity. Criteria for severe PNES included one or more of the following: history of intubation or intensive care due to PNES episodes, cluster or status‐like PNES events, prominent positive motor phenomena (e.g., rigidity or convulsive‐appearing movements), incontinence and tongue biting during episodes. Patients meeting any of these criteria were classified as severe PNES; the remaining patients were categorized as mild PNES.

2.3. Measures

2.3.1. Sociodemographic and clinical data form

A structured form assessed demographic characteristics, employment status, substance use, seizure type, seizure‐related clinical features (onset age, duration, frequency, time since last seizure, nocturnal episodes), ictal risk markers (intubation, Intensive Care Unit admission, tongue biting, incontinence), stressor before seizure, self‐harm behavior, history of psychiatric disorder, family history of seizure or psychiatric disorder, suicide history, trauma history, and recent psychosocial stressors.

2.3.2. Beck Anxiety Inventory (BAI

The 21‐item scale assesses anxiety symptoms on a 0–3 Likert scale. 20 The validity and reliability studies of the Turkish version were carried out by Ulusoy. 21

2.3.3. Beck Depression Inventory (BDI)

A 21‐item self‐report measure of depressive symptoms scored 0–3. 22 The validity and reliability study for Turkish society was conducted by Hisli. 23

2.3.4. Childhood Trauma Questionnaire (CTQ)

A 28‐item scale assessing emotional, physical, sexual abuse and physical, emotional neglect. 24 Turkish validity established by Şar et al. 25

2.3.5. Toronto Alexithymia Scale‐20 (TAS‐20)

A 20‐item measure with three subscales: difficulty identifying emotions, difficulty describing emotions, and externally oriented thinking. 26 Turkish validation by Sayar et al. 27

2.3.6. Somatoform Dissociation Questionnaire (SDQ‐20)

A 20‐item instrument assessing somatoform dissociative symptoms, developed by Nijenhuis et al. and validity and reliability studies of the Turkish version were conducted by Şar et al. 28 , 29 Scores ≥40 suggest probable dissociative disorder. 30

2.3.7. Dissociation Questionnaire (DIS‐Q)

A 63‐item scale assessing general dissociative experiences. 31 The validity and reliability study of the questionnaire in Turkiye was conducted by Sar et al. Turkish norms indicate a cutoff of 2.5 for probable dissociative disorder. 32

2.4. Statistical analysis

Statistical analyses were conducted using IBM SPSS Statistics 24.0. While evaluating the study data, descriptive statistical methods (mean, standard deviation, median, frequency, ratio, minimum, maximum) as well as the suitability of quantitative data to normal distribution were tested with the cut‐off points of kurtosis and skewness values. One‐way ANOVA test was used for comparisons of three or more groups, and in cases where there were differences between groups, the Bonferroni correction test was used. Pearson chi‐square test was used to evaluate qualitative data. Significance was evaluated at p < .01 and p < .05 levels.

3. RESULTS

3.1. Sociodemographic and clinical characteristics

The study included 48 PNES patients (20 mild, 28 severe), 48 epilepsy patients, and 50 healthy controls. Gender distribution and mean age did not differ significantly between groups (p > .05). Education level, marital status, and employment status showed significant group differences (p < .01; Table 1).

TABLE 1.

Sociodemographic features of the participants.

Mild PNES Severe PNES Epilepsy Healthy control p a
Mean ± SD (median) Mean ± SD (median) Mean ± SD (median) Mean ± SD (median)
Age 29.1 ± 8.7 (28) 34.86 ± 13.8 (31) 29.4 ± 8.48 (27) 32.84 ± 8.5 (30) .057
Mild PNES Severe PNES Epilepsy Healthy Group p b
n % n % n % n %
Gender
Female 17 85.0 19 67.9 28 58.3 26 52.0 .064
Male 3 15.0 9 32.1 20 41.7 24 48.0
Education level
Literate (no formal education) 1 5.0 1 3.6 1 2.1 0 0.0 .001**
Elementary 8 40.0 12 42.9 9 19.1 4 8.0
High school 9 45.0 7 25.0 19 40.4 13 26.0
University 2 10.0 8 28.6 18 38.3 33 66.0
Marital status
Single 7 35.0 14 50.0 33 68.8 20 40.0 .018*
Married 13 65.0 14 50.0 12 25.0 28 56.0
Divorced 0 0.0 0 0.0 3 6.3 2 4.0
Employment
Employed 6 30.0 12 42.9 24 51.1 43 86.0 .001**
Unemployed 10 50.0 11 39.3 17 36.2 7 14.0
Never employed 4 20.0 5 17.9 6 12.8 0 0.0
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a

One way ANOVA test.

b

Pearson chi‐squared tests.

*

p < .05.

**

p < .01.

Group differences were also observed in comorbid medical conditions (p = .042). No participants in any of the study groups reported current or past substance use. No significant differences emerged regarding history of suicide and psychiatric disorder, or family history of seizure or psychiatric disorder (all p > .05). The frequency of psychosocial stressors differed significantly across groups (p < .01). Childhood trauma history also showed significant group differences (p < .01; Table 2).

TABLE 2.

Clinical characteristics of the participants.

Mild PNES Severe PNES Epilepsy Healthy group p a
n % n % n % n %
Comorbid disease
Yes 0 0.0 4 15.4 2 4.2 1 2.0 .042*
No 20 100.0 22 84.6 46 95.8 49 98.0
Head trauma or CNS infection history
Yes 0 0.0 0 0.0 2 4.3 0 0.0 .229
No 20 100.0 28 100.0 44 95.7 50 100.0
History of psychiatric disorder
Yes 2 10.0 2 7.1 6 12.5 1 2.0 .253
No 18 90.0 26 92.9 42 87.5 49 98.0
Suicide history
Yes 2 10.0 1 3.6 2 4.2 0 0.0 .215
No 18 90.0 27 96.4 46 95.8 50 100.0
Self‐harm behavior
Yes 1 5.0 1 3.6 3 6.3 0 0.0 .557
No 19 95.0 27 96.4 45 93.8 32 100.0
Family history of psychiatric disorder
Yes 5 25.0 8 28.6 8 16.7 10 20.0 .634
No 15 75.0 20 71.4 40 83.3 40 80.0
Childhood trauma history
Yes 6 30.0 7 25.0 9 18.8 1 2.0 .006**
No 14 70.0 21 75.0 39 81.3 49 98.0
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a

Pearson chi‐squared tests.

*

p < .05.

**

p < .01.

Seizure‐related ictal characteristics differed significantly across patient groups. Seizure type distribution showed a strong association with diagnostic group (χ 2 test, p < .001), with a moderate‐to‐large effect size (Cramér's V = 0.42). Indicators of ictal severity, including the need for intubation, tongue biting, urinary incontinence, and nocturnal seizure occurrence, also differed significantly across groups (all p < .05), with effect sizes ranging from small‐to‐moderate to moderate (Cramér's V = 0.29–0.41). These findings suggest clinically meaningful heterogeneity in seizure presentation and severity among patient groups (Table 3).

TABLE 3.

Seizure‐related clinical characteristics of PNES and epilepsy groups.

Mild PNES Severe PNES Epilepsy p a
Mean ± SD (median) Mean ± SD (median) Mean ± SD (median)
Age at seizure onset (years) 24.6 ± 8.29 (23.5) 26.54 ± 11.55 (25) 17.6 ± 8.52 (17) .001**
Mean seizure duration 11.35 ± 7.94 (10) 25.96 ± 55.75 (10) 3.49 ± 5.23 (1.5) .011*
Annual seizure frequency 109.7 ± 197.67 (24) 94.54 ± 169.41 (24.5) 49.63 ± 187.11 (12) .388
Time since last seizure (weeks) 3.45 ± 3.79 (2) 6.89 ± 10.86 (1) 21.91 ± 53.82 (3) .115
n % n % n % p b
Seizure type
Non‐motor seizure 18 90.0 6 21.4 9 21.4
Motor seizure 1 5.0 11 39.3 17 40.5
Mixed seizure 1 5.0 11 39.3 16 38.1
Stressor before seizure
Yes 9 45.0 16 57.1 16 33.3 .035*
No 11 55.0 12 42.9 32 66.7
Intubation, intensive care unit admission
Yes 0 0.0 7 25.0 3 6.4 .019*
No 20 100.0 21 75.0 44 93.6
Tongue biting
Yes 0 0.0 11 39.3 20 41.7 <.001**
No 20 100.0 17 60.7 28 58.3
Incontinence
Yes 1 5.0 11 39.3 19 39.6 .006**
No 19 95.0 17 60.7 29 60.4
Nocturnal episodes
Yes 6 30.0 13 46.4 31 64.6 .011*
No 14 70.0 15 53.6 17 35.4
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Note: Continuous variables are presented as mean ± standard deviation (median). Categorical variables are presented as n (%).

a

Group comparisons for continuous variables were performed using one‐way ANOVA or Kruskal–Wallis tests, as appropriate.

b

Categorical variables were analyzed using Pearson's chi‐squared test or Fisher–Freeman–Halton exact test when expected cell counts were small.

*

p < .05.

**

p < .01.

3.2. Anxiety and depression

Anxiety scores differed significantly across groups (one‐way ANOVA, F(3, 142) = 22.73, p < .001, η 2 = .32), indicating a large effect size. Depression scores also showed significant group differences (F(3, 142) = 11.07, p < .001, η 2 = .19), reflecting a moderate‐to‐large effect. Post‐hoc analyses showed that both mild and severe PNES groups had significantly higher anxiety scores than epilepsy patients and healthy controls. Depression scores were highest in the mild PNES group, which scored significantly higher than the severe PNES (p = .024), epilepsy (p = .034), and healthy groups (p < .001). The epilepsy group also demonstrated higher depression scores compared with healthy controls (p = .003; Table 4).

TABLE 4.

Comparison of psychopathology scores across groups.

Mild PNES Severe PNES Epilepsy Healthy control p a
Mean ± SD (median) Mean ± SD (median) Mean ± SD (median) Mean ± SD (median)
Beck Anxiety Inventory 31.1 ± 15.1 (32.5) 22.04 ± 16.39 (19.5) 15.08 ± 14.72 (10) 5.6 ± 4.68 (5) <.001**
Beck Depression Inventory 21.2 ± 10.83 (18) 13.46 ± 7.88 (12) 14.44 ± 11.31 (10) 7.98 ± 5.83 (8) <.001**
Emotional Abuse 6.9 ± 3.24 (5) 7.18 ± 3.35 (5) 6.98 ± 3.5 (6) 6.4 ± 1.84 (6) .667
Physical abuse 5.1 ± 0.45 (5) 6.21 ± 2.66 (5) 5.83 ± 2.21 (5) 5.14 ± 0.5 (5) .028*
Sexual abuse 6.45 ± 2.95 (5) 5.39 ± 0.92 (5) 5.5 ± 1.46 (5) 5.14 ± 0.76 (5) .013*
Physical Neglect 6.95 ± 2.48 (6) 7.46 ± 2.57 (7) 6.73 ± 2.36 (5) 6.52 ± 2.17 (6) .389
Emotional Neglect 12.95 ± 4.54 (11.5) 13.18 ± 5.3 (13) 9.9 ± 4.9 (8.5) 10.2 ± 3.38 (10) .003**
CTQ Total Score 38.25 ± 9.6 (35.5) 38.96 ± 10.81 (35) 35.02 ± 10.7 (31) 33.56 ± 6.13 (33) .051
Somatoform Score Sdq‐20 36.25 ± 13.1 (36.5) 32.54 ± 11.69 (28.5) 31.79 ± 11.44 (26) 23.12 ± 3.63 (22) <.001**
Dıs‐Q 2.36 ± 0.87 (2.38) 1.83 ± 0.65 (1.71) 1.94 ± 0.8 (1.7) 1.4 ± 0.28 (1.36) <.001**
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Note: Beck Anxiety Inventory: Mild PNES; vs Epilepsy p = .001, vs Healthy controls p = .001, Severe PNES; versus Epilepsy p = .024, versus Healthy controls p = .042. Beck Depression Inventory: Mild PNES; versus Severe PNES p = .024, versus Epilepsy p = .034, vs Healthy controls p = .001, Epilepsy versus Healthy controls p = .003. The physical abuse; severe PNES; vs mild PNES p = .044, vs Healthy controls p = .042 The sexual abuse; mild PNES versus Healthy controls p = .007, The emotional neglect; severe PNES; versus Epilepsy p = .015, vs Healthy controls p = .033. The SDQ: Healthy controls; versus Mild PNES p = .001, versus Severe PNES p = .014; versus Epilepsy p = .033. The DIS‐Q: Mild PNES; versus Severe PNES p = .035, versus Healthy controls p = .001. Healthy controls; versus Severe PNES p = .033, vs Epilepsy p = .001.

Abbreviations: CTQ, Childhood Trauma Questionnaire, DIS‐Q, Dissociation Questionnaire; SDQ, Somatoform Dissociation Questionnaire.

a

One Way ANOVA Test.

*

p < .05.

**

p < .01.

3.3. Childhood trauma

Total CTQ scores did not differ significantly across groups (F(3, 142) = 2.65, p = .051, η 2 = .05), although the effect size was small. Emotional abuse and physical neglect scores did not differ significantly across groups (p > .05). However, specific trauma dimensions displayed distinct patterns; physical abuse was higher in severe PNES compared with both mild PNES (p = .044) and healthy individuals (p = .042). Sexual abuse scores were significantly higher in mild PNES compared with healthy controls (p = .007). Emotional neglect was greater in severe PNES compared with epilepsy (p = .015) and healthy groups (p = .033; Table 4).

3.4. Somatoform and dissociative symptoms

Somatoform dissociation scores (SDQ‐20) were lower in healthy controls than in mild PNES (p = .001), severe PNES (p = .014), and epilepsy patients (p = .033). Dissociation scores (DIS‐Q) also demonstrated significant group differences (F(3, 142) = 12.14, p < .001, η 2 = .20), indicating a moderate‐to‐large effect. Dissociation scores were as follows: higher in mild PNES compared with severe PNES (p = .035) and healthy controls (p = .001), higher in severe PNES compared with healthy controls (p = .033), and higher in epilepsy compared with healthy controls (p = .001; Table 4).

3.5. Alexithymia and emotional processing

Significant group differences were observed in TAS‐20 subscales. Difficulty identifying emotions was elevated in mild PNES compared with epilepsy (p = .014) and healthy controls (p = .001); severe PNES also scored higher than healthy controls (p = .001). Difficulty describing emotions was higher in mild PNES compared with severe PNES (p = .013) and healthy individuals (p = .002). Externally oriented thinking did not differ significantly between groups (p > .05). Total alexithymia scores differed significantly between groups (F(3, 142) = 8.45, p < .001, η 2 = .15), suggesting a moderate effect size. Total alexithymia scores were significantly higher in the mild PNES group than in the severe PNES (p = .033), epilepsy (p = .014), and healthy groups (p = .001). No other between‐group differences were statistically significant (Table 5).

TABLE 5.

Comparison of Alexithymia Scores Between Groups.

Mild PNES Severe PNES Epilepsy Healthy control p a
Mean ± SD (median) Mean ± SD (median) Mean ± SD (median) Mean ± SD (median)
Difficulty in identifying emotions 20.4 ± 7.6 (19.5) 16.86 ± 6.75 (17.5) 15.44 ± 6.59 (13.5) 12.5 ± 4.03 (12) <.001**
Difficulty in describing emotions 16.4 ± 5.2 (17) 12.32 ± 4.38 (12) 13.71 ± 4.95 (14) 11.98 ± 3.61 (13) .002**
Externally oriented thinking 22.05 ± 4.67 (20) 20.82 ± 3.7 (20.5) 20.9 ± 3.9 (20) 20.12 ± 3.63 (20) .310
Toronto Total Score 59.1 ± 14.68 (57) 50 ± 12.27 (50) 50.04 ± 10.77 (49) 44.58 ± 8.57 (45) <.001**
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Note: Difficulty in identifying emotions: Mild PNES; versus Epilepsy p = .014, vs Healthy controls p = .001, Severe PNES versus Healthy controls p = .001. Difficulty in describing emotions: Mild PNES; versus Severe PNES p = .013, versus Healthy controls p = .002. Toronto Total Score: Mild PNES; versus Severe PNES p = .033, versus Epilepsy p = .014, versus Healthy controls p = .001.

a

One Way ANOVA Test.

**

p < .01.

4. DISCUSSION

This study examined psychological and trauma‐related correlates of PNES by comparing patients with epilepsy and healthy individuals, and by exploring differences within PNES across a clinically informed severity framework. Although severity classifications for PNES have been suggested previously, 33 , 34 , 35 , 36 , 37 empirical examinations remain limited. Our approach should therefore be regarded as exploratory, aiming to clarify whether certain clinical features associated with greater healthcare utilization and ictal behavioral intensity correspond with distinct psychological profiles. Notably, our analyses identified several psychological differences between the mild and severe PNES subgroups, suggesting that severity‐linked clinical characteristics may reflect distinct underlying psychosocial patterns.

Consistent with earlier findings, both mild and severe PNES groups exhibited higher anxiety levels than the epilepsy and healthy control groups, supporting the role of heightened arousal and emotional distress in PNES symptomatology. 38 , 39 Depression scores were highest in the mild PNES subgroup, suggesting that individuals without prominent ictal motor features or acute presentations may internalize distress more intensely or report affective symptoms more readily. Similar observations in prior studies have linked higher depressive symptoms to maladaptive emotion regulation, catastrophizing, and difficulties tolerating internal affective states among individuals with PNES. 40 , 41 , 42

Childhood trauma findings further differentiated PNES subgroups. Mild PNES patients reported higher rates of sexual abuse, whereas severe PNES patients showed higher levels of physical abuse and emotional neglect. These patterns align with literature indicating that various trauma subtypes are disproportionately represented in PNES patients. 43 The differing trauma profiles between mild and severe PNES may reflect distinct developmental pathways or coping responses: emotional neglect and physical abuse may contribute to more externally dysregulated, motorically intense seizure expressions, whereas sexual trauma has frequently been associated with internalized distress and dissociative tendencies. Although certain trauma subscales did not differ across groups, prior research also emphasizes that cumulative trauma burden—rather than specific trauma types—may heighten vulnerability to PNES, which may partly explain variability across studies. 44

Somatoform and dissociative symptoms also distinguished the groups. Mild PNES patients demonstrated higher dissociation and somatization scores than severe PNES and healthy individuals. While counterintuitive, this pattern may indicate that individuals with milder ictal presentations retain greater awareness of internal psychological distress, resulting in higher endorsement of subjective dissociative or somatic symptoms. As previous literature shows, both PNES and epilepsy patients can exhibit elevated dissociation, highlighting that dissociation is not exclusive to PNES but may instead reflect shared vulnerability factors across paroxysmal disorders. 16 , 45 The consistently low SDQ‐20 and DIS‐Q scores in healthy controls support the clinical utility of these constructs in differentiating pathological from non‐pathological experiences.

Alexithymia findings likewise revealed distinct patterns. Both PNES groups exhibited greater difficulty identifying emotions compared with healthy controls, and mild PNES patients also showed greater difficulty describing emotions than severe PNES patients and healthy individuals. This suggests that emotion processing deficits may manifest differently depending on seizure presentation. Prior studies have reported mixed results when comparing PNES, epilepsy, and healthy controls, possibly because alexithymia varies with trauma exposure and affective symptoms rather than diagnostic category alone. 2 , 13 , 46 The elevated alexithymia scores in mild PNES patients may reflect greater reliance on somatic or dissociative mechanisms to regulate affect, which is consistent with models positing that insufficient emotional awareness contributes to the emergence of psychogenic symptoms.

Overall, the severity framework used in this study revealed meaningful differences in trauma exposure, dissociation, somatization, and emotion processing within the PNES cohort. While these findings require replication in larger samples, they suggest that PNES presentations characterized by more dramatic ictal behaviors and greater healthcare utilization may differ psychologically from those with less overt manifestations. Identifying such subgroups may contribute to more targeted case formulations and treatment planning, highlighting the relevance of trauma assessment, emotion regulation interventions, and personalized psychotherapy approaches.

5. LIMITATIONS

This study has several limitations. First, the sample was hospital‐based and drawn from tertiary epilepsy and psychiatry clinics, where patients with more complex or treatment‐resistant presentations are typically seen. As a result, the findings may not generalize to community or primary care populations. Second, psychological and trauma‐related variables were assessed using self‐report instruments, which may be affected by recall bias or differences in emotional awareness across groups. Third, although the severity‐based PNES subgrouping revealed distinct psychological patterns, the sample size limited the ability to examine this categorization with more granular clinical or statistical approaches. Larger, multi‐center studies will be needed to validate the applicability and stability of this exploratory classification. Finally, the cross‐sectional design restricts causal interpretations regarding the relationships between trauma, affective symptoms, dissociation, and PNES severity.

6. CONCLUSION

This study compared psychological, dissociative, somatic, and trauma‐related features in patients with PNES, epilepsy, and healthy controls, while also exploring differences within PNES based on a clinically informed severity framework. The findings indicate that PNES subgroups characterized by differing clinical features may also diverge in trauma exposure, emotion processing, and dissociative and somatic symptom profiles. These results support the relevance of considering severity‐related clinical characteristics when formulating individualized psychological assessments for PNES. Although the proposed severity grouping is preliminary, it may provide a useful starting point for understanding clinical heterogeneity within PNES and for guiding tailored therapeutic approaches. Future studies with larger and more diverse samples are needed to validate this framework, clarify its prognostic implications, and determine whether severity‐based distinctions can inform treatment selection or predict clinical outcomes.

AUTHOR CONTRIBUTIONS

Mehmet Murat Kırpınar: formal analysis, investigation, supervision, visualization, writing original draft, writing, review and editing. Memet Şakir Delil: conceptualization, data curation, methodology, supervision, validation, visualization. Halil İbrahim Deniz: data curation, investigation, writing and original draft. Gülsüm Hançer, Öznur Demirel, and Nesibe Boyraz: data curation, investigation. Bengi Gül Türk: data curation, formal analysis, investigation and validation. Şenol Turan and Seher Naz Yeni: conceptualization, methodology, project administration, supervision, visualization, writing and review and editing.

FUNDING INFORMATION

This research did not receive any specific grant from funding agencies in the public, commercial, or not‐for‐profit sectors.

CONFLICT OF INTEREST STATEMENT

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

PATIENT CONSENT

Informed consent was obtained from all individual participants included in the study.

Test yourself.

  1. What is the main implication of this study?
    1. PNES is a homogeneous condition
    2. Trauma is unrelated to PNES
    3. Severity‐based clinical features may reflect distinct psychosocial profiles
    4. Only neurological factors are relevant
    5. PNES severity is unrelated to psychological characteristics
  2. Which psychological features were most elevated in patients with mild PNES?
    1. Anxiety only
    2. Depression, somatization, and dissociation
    3. Alexithymia only
    4. No significant differences compared with other groups
    5. Only trauma‐related variables
  3. Which trauma profile was more strongly associated with severe PNES?
    1. Sexual abuse
    2. Emotional abuse only
    3. Physical abuse and emotional neglect
    4. No trauma differences between groups
    5. Physical neglect only

Answers may be found in the supporting information .

Supporting information

Data S1

EPD2-28-1095-s001.docx (14.1KB, docx)

ACKNOWLEDGMENTS

The authors have nothing to report.

DATA AVAILABILITY STATEMENT

The data supporting the findings of this study are available from the corresponding author upon reasonable request.

REFERENCES

  • 1. Reuber M, Elger CE. Psychogenic nonepileptic seizures: review and update. Epilepsy Behav. 2003;4:205–216. [DOI] [PubMed] [Google Scholar]
  • 2. Bewley J, Murphy PN, Mallows J, Baker GA. Does alexithymia differentiate between patients with nonepileptic seizures, patients with epilepsy, and nonpatient controls? Epilepsy Behav. 2005;7:430–437. [DOI] [PubMed] [Google Scholar]
  • 3. Brown RJ, Reuber M. Psychological and psychiatric aspects of psychogenic non‐epileptic seizures (PNES): a systematic review. Clin Psychol Rev. 2016;45:157–182. [DOI] [PubMed] [Google Scholar]
  • 4. Keskin AO, Altintas E, Yerdelen VD, Demir B, Colak MY. Effects of attachment styles, childhood traumas, and alexithymia in Turkish patients with epilepsy and functional seizures. Epilepsy Behav. 2023;148:109458. [DOI] [PubMed] [Google Scholar]
  • 5. Popkirov S, Asadi‐Pooya AA, Duncan R, Gigineishvili D, Hingray C, Miguel Kanner A, et al. The aetiology of psychogenic non‐epileptic seizures: risk factors and comorbidities. Epileptic Disord. 2019;21(6):529–547. [DOI] [PubMed] [Google Scholar]
  • 6. Stone J, Hoeritzauer I, McWhirter L, Carson A. Functional neurological disorder: defying dualism. World Psychiatry. 2024;23(1):53–54. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7. Hingray C, Popkirov S, Kozlowska K, Pretorius C, Sarudiansky M, El‐Hage W, 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] [PMC free article] [PubMed] [Google Scholar]
  • 8. Diprose W, Sundram F, Menkes DB. Psychiatric comorbidity in psychogenic nonepileptic seizures compared with epilepsy/. Epilepsy Behav. 2016;56:123–130. [DOI] [PubMed] [Google Scholar]
  • 9. Brown RJ, Bouska JF, Frow A, Kirkby A, Baker GA, Kemp S, et al. Emotional dysregulation, alexithymia, and attachment in psychogenic nonepileptic seizures/. Epilepsy Behav. 2013;29:178–183. [DOI] [PubMed] [Google Scholar]
  • 10. Kaplan MJ, Dwivedi AK, Privitera MD, Isaacs K, Hughes C, Bowman M. Comparisons of childhood trauma, alexithymia, and defensive styles in patients with psychogenic non‐epileptic seizures vs. epilepsy: implications for the etiology of conversion disorder. J Psychosom Res. 2013;75:142–146. [DOI] [PubMed] [Google Scholar]
  • 11. Labudda K, Frauenheim M, Illies D, Miller I, Schrecke M, Vietmeier N, et al. Psychiatric disorders and trauma history in patients with pure PNES and patients with PNES and coexisting epilepsy. Epilepsy Behav. 2018;88:41–48. [DOI] [PubMed] [Google Scholar]
  • 12. Beghi M, Cornaggia I, Magaudda A, Perin C, Peroni F, Cornaggia CM. Childhood trauma and psychogenic nonepileptic seizures: a review of findings with speculations on the underlying mechanisms. Epilepsy Behav. 2015;52:169–173. [DOI] [PubMed] [Google Scholar]
  • 13. Sequeira A, Silva B. A comparison among the prevalence of alexithymia in patients with psychogenic nonepileptic seizures, epilepsy, and the healthy population: a systematic review of the literature. Psychosomatics. 2019;60:238–245. [DOI] [PubMed] [Google Scholar]
  • 14. Myers L, Matzner B, Lancman M, Perrine K, Lancman M. Prevalence of alexithymia in patients with psychogenic non‐epileptic seizures and epileptic seizures and predictors in psychogenic non‐epileptic seizures /. Epilepsy Behav. 2013;26:153–157. [DOI] [PubMed] [Google Scholar]
  • 15. Reuber M, House AO, Pukrop R, Bauer J, Elger CE. Somatization, dissociation and general psychopathology in patients with psychogenic non‐epileptic seizures. Epilepsy Res. 2003;57:159–167. [DOI] [PubMed] [Google Scholar]
  • 16. Myers L, Trobliger R, Bortnik K, Zeng R, Saal E, Lancman M. Psychological trauma, somatization, dissociation, and psychiatric comorbidities in patients with psychogenic nonepileptic seizures compared with those in patients with intractable partial epilepsy. Epilepsy Behav. 2019;92:108–113. [DOI] [PubMed] [Google Scholar]
  • 17. Wolf LD, Hentz JG, Ziemba KS, Kirlin KA, Noe KH, Hoerth MT, et al. Quality of life in psychogenic nonepileptic seizures and epilepsy: the role of somatization and alexithymia/. Epilepsy Behav. 2015;43:81–88. [DOI] [PubMed] [Google Scholar]
  • 18. Ertan D, Aybek S, LaFrance WC Jr, Kanemoto K, Tarrada A, Maillard L, et al. Functional (psychogenic non‐epileptic/dissociative) seizures: why and how? J Neurol Neurosurg Psychiatry. 2022;93(2):144–157. [DOI] [PubMed] [Google Scholar]
  • 19. Hingray C, Ertan D, Reuber M, Lother AS, Chrusciel J, Tarrada A, et al. Heterogeneity of patients with functional/dissociative seizures: three multidimensional profiles. Epilepsia. 2022;63(6):1500–1515. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20. Beck AT, Epstein N, Brown G, Steer RA. An inventory for measuring clinical anxiety: psychometric properties. J Consult Clin Psychol. 1988;56(6):893–897. [DOI] [PubMed] [Google Scholar]
  • 21. Ulusoy M, Sahin NH, Erkmen H. Turkish version of the Beck anxiety inventory: psychometric properties. J Cogn Psychother. 1998;12(2):163. [Google Scholar]
  • 22. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry. 1961;4(6):561–571. [DOI] [PubMed] [Google Scholar]
  • 23. Hisli N. Beck depresyon envanterinin universite ogrencileri icin gecerliligi, guvenilirligi. (A reliability and validity study of Beck depression inventory in a university student sample). J Psychol. 1989;7:3–13. [Google Scholar]
  • 24. Bernstein DP, Fink L, Handelsman L, Foote J, Lovejoy M, Wenzel K, et al. Initial reliability and validity of a new retrospective measure of child abuse and neglect’: reply. Am J Psychiatry. 1995;152(10):1535–1537. [DOI] [PubMed] [Google Scholar]
  • 25. Sar V, Öztürk E, Ikikardes E. Cocukluk Cagi Ruhsal Travma Ölceginin Türkce Uyarlamasinin Gecerlilik ve Güvenilirligi/validity and reliability of the Turkish version of childhood trauma questionnaire. Türkiye Klin Tip Bilim Derg. 2012;32(4):1054. [Google Scholar]
  • 26. Bagby RM, Taylor GJ, Parker JD. The twenty‐item Toronto alexithymia scale‐II. Convergent, discriminant, and concurrent validity. J Psychosom Res. 1994;38:33–40. [DOI] [PubMed] [Google Scholar]
  • 27. Sayar K, Güleç H, Ak I. Yirmi Soruluk Toronto Aleksitimi Ölçeğinin geçerlik ve güvenirliği. 37. Ulusal Psikiyatri Kongresi Kitabı 2001;02–06 Ekim 2001, İstanbul, s. 130.
  • 28. Nijenhuis ER, Spinhoven P, Van Dyck R, Van Der Hart O, Vanderlinden J. The development and psychometric characteristics of the somatoform dissociation questionnaire (SDQ‐20). J Nerv Ment Dis. 1996;184(11):688–694. [DOI] [PubMed] [Google Scholar]
  • 29. Sar V, Kundakci T, Kiziltan E, Bahadir B, Aydiner O. Reliability and validity of the Turkish version of the somatoform dissociation questionnaire (SDQ‐20). Proceeding of the International Society of Dissociation 15th international fall conference Seattle 1998.
  • 30. Aydemir Ö, Köroğlu E. Psikiyatride Kullanılan Klinik Ölçekler, 4.Baskı. İstanbul: HYB Yayıncılık; 2009. p. 319–338. [Google Scholar]
  • 31. Vanderlinden J, Van Dyck R, Vandereycken W, Vertommen H, Jan Verkes R. The dissociation questionnaire (DIS‐Q): development and characteristics of a new self‐report questionnaire. Clin Psychol Psychother. 1993;1:21–27. [Google Scholar]
  • 32. Sar V, Kızıltan E, Kundakcı T, Bakım B, Yargıc¸ LI. (Dissosiyasyon Olceginin Gecerlilik Ve Guvenilirligi, 33. Ulusal Psikiyatri Kongresi Tam Metin Kitabi, Antalya Turkiye) Validity and Safety of Dissociation Questionnaire, 33rd National Psychiatry Congress FullText Booklet: Antalya‐Turkey; 1997.
  • 33. Dhiman V, Sinha S, Rawat VS, Harish T, Chaturvedi SK, Satishchandra P. Semiological characteristics of adults with psychogenic nonepileptic seizures (PNESs): an attempt towards a new classification. Epilepsy Behav. 2013;27(3):427–432. [DOI] [PubMed] [Google Scholar]
  • 34. Vilyte G, Butler J, Ives‐Deliperi V, Pretorius C. Functional seizure semiology and classification in a public and private hospital. Seizure. 2024;122:71–79. [DOI] [PubMed] [Google Scholar]
  • 35. Gröppel G, Kapitany T, Baumgartner C. Cluster analysis of clinical seizure semiology of psychogenic nonepileptic seizures. Epilepsia. 2000;41(5):610–614. [DOI] [PubMed] [Google Scholar]
  • 36. Jones SG, O' Brien TJ, Adams SJ, Mocellin R, Kilpatrick CJ, Yerra R, et al. Clinical characteristics and outcome in patients with psychogenic nonepileptic seizures. Psychosom Med. 2010;72(5):487–497. [DOI] [PubMed] [Google Scholar]
  • 37. Reuber M, Pukrop R, Bauer J, Helmstaedter C, Tessendorf N, Elger CE. Outcome in psychogenic nonepileptic seizures: 1 to 10‐year follow‐up in 164 patients. Ann Neurol. 2003;53:305–311. [DOI] [PubMed] [Google Scholar]
  • 38. Vilyte G, Pretorius C. Personality traits, illness behaviors, and psychiatric comorbidity in individuals with psychogenic nonepileptic seizures (PNES), epilepsy, and other nonepileptic seizures (oNES): differentiating between the conditions. Epilepsy Behav. 2019;98(Pt A):210–219. [DOI] [PubMed] [Google Scholar]
  • 39. Scévola L, Teitelbaum J, Oddo S, Centurión E, Loidl CF, Kochen S, et al. Psychiatric disorders in patients with psychogenic nonepileptic seizures and drug‐resistant epilepsy: a study of an Argentine population. Epilepsy Behav. 2013;29(1):155–160. [DOI] [PubMed] [Google Scholar]
  • 40. Gupta R, Garg D, Kumar N, Singh MB, Shukla G, Goyal V, et al. Psychiatric co‐morbidities and factors associated with psychogenic non‐epileptic seizures: a case‐control study. Seizure. 2020;81:325–331. [DOI] [PubMed] [Google Scholar]
  • 41. Walsh S, Levita L, Reuber M. Comorbid depression and associated factors in PNES versus epilepsy: systematic review and meta‐analysis. Seizure. 2018;60:44–56. [DOI] [PubMed] [Google Scholar]
  • 42. Rawlings GH, Brown I, Reuber M. Predictors of health‐related quality of life in patients with epilepsy and psychogenic nonepileptic seizures. Epilepsy Behav. 2017;68:153–158. [DOI] [PubMed] [Google Scholar]
  • 43. Johnstone B, Velakoulis D, Yuan CY, Ang A, Steward C, Desmond P, et al. Early childhood trauma and hippocampal volumes in patients with epileptic and psychogenic seizures. Epilepsy Behav. 2016;64(Pt A):180–185. [DOI] [PubMed] [Google Scholar]
  • 44. Yang T, Roberts C, Winton‐Brown T, Lloyd M, Kwan P, O'Brien TJ, et al. Childhood trauma in patients with epileptic vs nonepileptic seizures. Epilepsia. 2023;64(1):184–195. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 45. van der Kruijs SJM, Bodde NMG, Vaessen MJ, Lazeron RH, Vonck K, Boon P, et al. Functional connectivity of dissociation in patients with psychogenic non‐epileptic seizures. J Neurol Neurosurg Psychiatry. 2012;83:239–247. [DOI] [PubMed] [Google Scholar]
  • 46. Trobliger R, Myers L, Simpson T, Krámská L. A comparison of patients with epileptic seizures (ES) versus those with psychogenic non‐epileptic seizures (PNES) on measures of alexithymia, mood, and anxiety. Seizure. 2024;120:33–40. [DOI] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Data S1

EPD2-28-1095-s001.docx (14.1KB, docx)

Data Availability Statement

The data supporting the findings of this study are available from the corresponding author upon reasonable request.

Articles from Epileptic Disorders are provided here courtesy of Wiley

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