Psychodynamic interpretation of linguistic findings in patients with epileptic and psychogenic non-epileptic seizures:  the role of metaphors

Interpretazione psicodinamica dei contenuti linguistici in pazienti con crisi epilettiche e pazienti con crisi psicogene non epilettiche: il ruolo delle metafore



1School of Medicine and Surgery, University of Milano Bicocca, Milan, Italy

2Cognitive Neuro-Rehabilitation Unit, “Zucchi” Clinical Institutes, San Donato Group, Carate Brianza (MB), Italy

3School of Physical and Occupational Therapy, McGill University, Montréal, Canada

4Institute of Pharmacological Researches “Mario Negri”, Milan, Italy

5Epilepsy Centre, Neurological Department, University of Messina, Italy

6Department of Neurology, University of Rochester, USA

7Department of Mental Health, AUSL Romagna, Cesena, Italy

SUMMARY. This work points out the main differences in the semantic expressions used by patients with psychogenic non-epileptic seizures (PNES) and epileptic seizures (ES). In reference to the body as a phenomenological entity, in ES the concept of the body-object prevails while in PNES the body, with all its life attributes, predominates. In description of seizures and in similitudes and metaphors used, ES patients focus on the description of the attack, trying to close the “gap” with a big effort, while patients with PNES concentrate on the context and on the presence of bystanders. Patients with PNES are unable to describe their own attack, since this it is not at the core of their distress, but rather the manifestation of something else, which is hiding the extreme anguish associated with experiences of the past that cannot be revealed (expressed). In the case of ES, instead, the ability to talk and the willingness to elaborate on the emotions become useful tools for facing the disease, an entity perhaps unsurmountable but at least manageable, to the benefit of everyone. In general, we can say that the experience of a disease (real or symbolic) deserves constant attention because it gives us the opportunity not only to probe the depth of the emotional experiences but also the psychic structure of the individual in front of us. A cure would not be a cure without considering such fundamental elements. It would become a sterile exercise of prescribing medications without paying attention to the person, which is the best way of preserving dignity in a state of illness.

KEY WORDS: pseudoseizures, epilepsy, semantics, differential diagnosis, metaphors.

RIASSUNTO. Questo lavoro sottolinea le principali differenze nelle espressioni semantiche usate dai pazienti con crisi psicogene non epilettiche (CPNE) e crisi epilettiche (CE). Per quanto concerne il corpo inteso come un’entità fenomenologica, nelle CE prevale il concetto di corpo-oggetto mentre nelle CPNE predomina il corpo con tutti i suoi attributi di vita. Nella descrizione delle crisi e nelle similitudini e metafore utilizzate, i pazienti con CE focalizzano la loro descrizione sull’attacco, cercando di chiudere il “gap” con un grande sforzo, mentre i pazienti con CPNE si concentrano sul contesto delle crisi e sulla presenza di spettatori. I pazienti con CPNE non sono in grado di descrivere il loro attacco, dal momento che non è il core del loro disagio, ma piuttosto la manifestazione di qualcosa d’altro, che sta nascondendo l’estrema angoscia associata con le esperienze del passato, che non possono essere rivelate (espresse). Nel caso delle CE, al contrario, l’abilità di parlare e la volontà di elaborare le emozioni diventano strumenti utili per fronteggiare la malattia, un’entità forse insormontabile ma almeno affrontabile, per il bene di tutti. In generale, possiamo affermare che l’esperienza di malattia (reale o simbolica) merita costante attenzione poiché ci dà l’opportunità non solo di provare la profondità delle esperienze emozionali, ma anche la struttura psichica dell’individuo davanti a noi. Una cura non sarebbe infatti una cura senza considerare elementi così fondamentali. Il nostro diventerebbe uno sterile esercizio di prescrizione di farmaci se non prestassimo la giusta attenzione alla persona, che è il miglior modo di preservare la dignità in una condizione di malattia.

PAROLE CHIAVE: pseudocrisi, epilessia, semantica, diagnosi differenziale, metafore.


Psychogenic non-epileptic seizures (PNES) are paroxysmal episodes of compromised self-control with a wide range of motor, sensory, and psychological manifestations that resemble those of epileptic seizures (ES), but are not associated with paroxysmal discharges at EEG1. Recently, the International League Against Epilepsy (ILAE) has proposed a stepwise approach for the diagnosis of PNES2, with four categories of certainty (possible, probable, clinically established and documented), based on common scenarios and the combination of the data, reflective of clinical practice. These two types of experiences, despite the same phenotype, are the expression of two completely different phenomena, from an etiopathogenetic perspective. In particular, PNES, like other physical manifestations of psychogenic origin, are related to one of the most typical manifestations of hysterical disorders3, which can manifest themselves within a framework of conversion or disassociation. The essence of an hysteric symptom is the fact that it is something always referred to as something else (from the Greek simpipto: to occur together), in the sense that “unconscious conflicts” are not verbalized, but rather “transferred” to the body, as they are unspeakable or cannot be elaborated by the individual. For this reason, the physical symptom is the symbol of the “unspoken” trauma and it is expressed through metaphors4,5.

On the other hand, as we can speak of “psychological trauma” distinct from “physical trauma”, we can refer to a “representative (symbolic) body”, otherwise defined as “sexual body”6, as opposed to the “physical body”.

The physical body, as it occurs in ES, responds to the homunculus or to whatever brain area is involved, while the representative body, as it occurs in PNES, does not correspond anatomically to any part of the brain structure, homunculus or other, but rather to an unconscious linguistic expression (the trauma). It is not by chance that Lacan talked about sinthome7, that has a structure similar to aletheia (described by Heidegger as the place where our own’s true essence is concealed).

This was masterfully represented in Raffaello Sanzio’s last painting (“The Transfiguration”, 1520), already correlated by Janz to the “Passion of Christ”8. By a different interpretation, nowadays we could suggest that the “epileptic” boy in reality “plays” for the crowd in the lower part of the painting the unspeakable truth, namely the Transfiguration of Christ (Figure 1).

Essentially, the child draws upon himself what cannot be spoken, transforming his body into word. The child, through the attack occurring in his body, makes visible the transfiguration, which, through him, can be recognized and revealed.

Precisely because the phenomenon derives from two different types of traumas, one a physical scar, the other a psychological wound, and affects two different worlds or “bodies”, although the phenomenological expression, represented the dissociative experience, is identical (Erba, personal communication), patients with ES and PNES express themselves through different semantics9. Recent studies have used linguistic analysis10-13 to investigate the verbal expressions that individuals with ES or PNES choose in describing the critical episodes.

Subjects with ES principally concentrate on the direct description of the critical episodes, including the surrounding context only as a corollary to a very painful experience14. They describe the attacks in appropriate terms15, although they conceptualize them as extraneous entities16 (from the original meaning of the Greek term epilambanein for epilepsy: to be seized), making in that way an effort to prevent or avoid the attack. Their account starts with the direct description of the attack17.

Conversely, individuals with PNES concentrate mainly on the context within which the attacks occur, enriching the description with details, as well as on the consequences of such experiences. They report the attacks as expression of their own state of mind15 revealing a marked tendency to “dramatize” the experience; often they start talking about the attacks moving the attention on the pharmacological treatment17.

Finally, the different focus of attention noticed in the two groups when describing how they experienced the attacks becomes evident also in the linguistic style they adopt: while individuals with ES employ a language that tends to reproduce the attacks in an almost concrete/aseptic form, individuals with PNES tend to use a language rich of metaphors or similitudes related mostly to attributes of space and place16.

The objective of the present work is to analyze the psychological meaning of the two different semantics. Since the description of the underlying mechanisms is still lacking in the literature, we hope that a better knowledge of the phenomenon may contribute to a greater understanding of these two different clinical conditions.


The linguistic studies available so far10-12,15 are all concordant indicating a number of findings, only briefly mentioned before, that characterize the two semantics. They are summarized in Table 1.

The purpose of this study is to analyze from a psychiatric point of view the specific clusters of signs and symptoms observed in the two groups. We will provide examples derived from the transcript of 55 interviews obtained from patients with either ES or PNES whose diagnosis was documented by monitoring the attacks on video-EEG in the following centers: Milan, Messina and Rochester. The characteristics of the patients’ sample are described in previous works from our group5, 9-11.

Focusing the attention on the context vs. the attack

As previously mentioned, an individual with ES tends not to elaborate on the context, unless to mention it simply as a descriptive or accidental element, whereas the individual with PNES concentrates on the context and on the presence of bystanders.

In describing the attack, individuals with ES perceive the context as hostile, because it undetermines their own image and because it leads to a representation of self as “another different than self”. Thus, it becomes an attack on one’s own self-esteem. The attack is, therefore, described hastily and as an accident. This comes naturally, since the loss of consciousness could be interpreted as a dissociative phenomenon (the paroxysmal discharge of the neurons) that interrupts the existential continuum and, consequently, represents a traumatic event.

For individuals with PNES, the attack is perceived in function of the context and of the inner emotional world of the individual involved. Semantically, the context is part of the attack itself and is integrated within it. This is no surprise considering the mimetic nature of the hysteric symptomology, which tends to be intertwined with the context and to display signs that relate to the moment in history18. While in Charcot’s times, the predominant phenotype was the hysterical fainting, typical of the female subject, viewed as fragile and weak, and all male hysterical manifestations were absent, nowadays, even if still more prevalent in the female gender, symptoms are reported in both sexes, displaying a modality of communication that utilizes the body as a theatrical presence in the context of a society that otherwise would not come to a halt if confronted with other manifestations.

Therefore, a first major difference between patients with ES and PNES is the way in which they use the surrounding environment. For those with ES, the purpose is to escape from the context in order to conceal their illness. For those with PNES, the context becomes the theatre in which they show their own inexpressible distress. Since a PNES represents a form of language (and all patients with PNES have their own story to tell), its narrative must reach out to the “audience”, in this case represented by the bystanders.

The context represents, in Freudian terms, the secret theatre where the unconscious can manifest itself publicly, albeit disguised, just like in a dream.

The examples presented in Table 2 clearly show that in people with ES the narrative is extremely concise, whereas in patients with PNES attack and context are integrated.

A body that is the victim vs. a body that becomes  the protagonist of the attack

In reference to the body as a phenomenological entity, in ES the concept of the body-object seems to prevail (Koeper), while in PNES the body, with all its life attributes, predominates (Leib).

In ES the body is a passive entity while in PNES the body is alive, precisely because it has a language on its own. While in the body-object that characterizes ES meaning and signifier coincide, in the living body typical of PNES meaning and signifier are distinct. Just like in the famous painting by Magritte (“Ceci n’est pas une pipe”/ “This is not a pipe”), a PNES is a representation of a meaning though it is not the meaning itself, it is simply its signifier, that is, the metaphor.

The defense mechanisms in a patient with ES are aimed to the protection of one’s own body and are mostly concentrated on the dissociative phenomena. Since epilepsy is a trauma, there can be amnesia, avoidance to mention where the attack occurred, to verbalize or recount (describe) the attack.

There is a greater tendency to shift toward metonymy rather than the use of metaphors. This is because ES is the trauma and not the representation of the trauma. The dissociative phenomenon is apparent in the broad lines of the “description” of the attack. Individuals with organic pathology cannot have full access to self-expression because they are under the constant threat of losing control of their own body, which is exactly what happens in epilepsy. This is also apparent in the Rorschach test19 because subjects with ES do not have access to their personal phantasy world, defined as unconscious desire processing, and their attitude when confronting an ambiguous stimulus such as the one presented in the test leads them to being defensive, without revealing anything about themselves. The interpretation of the tables is hard because the content is in itself evocative of something else, which is very likely to give that person great difficulties. As Piotrovsky claims20, there are specific signals that characterize the Rorschach of a person with an organic illness and one of these is not being able to integrate the element of color, proposed in the tables, in the elaboration of one’s answers.

Patients with PNES do not experience the “deception of the body”, in that, paradoxically, the body is their ally since it allows for the expression of a conflict. Therefore, the body is visible and treatable. PNES are not a trauma per se, but are a representation of a trauma, at a deeper level. This, of course, does not eliminate the pain caused by the trauma.

The differences in semantics are clearly shown in the examples reported in Table 3 and are particularly evident in the conciseness of the reports from patents with ES.

To maintain vs. to alter the narrative of the attack  with respect to normal conversation

Through an analysis of how patients describe the attacks, compared to their usual every day conversation, it is possible to evaluate the presence or absence of changes in the narration velocity, fluidity and quantity. When describing an attack, patients with ES have great difficulties explaining what they went through. When asked to describe what they do in their spare time, there is a marked change in their speech; it becomes faster, more fluid, more captivating, without pauses to reflect upon what to say. Moreover, there is more expressiveness and harmony in both facial and linguistic expression.

The linguistic component and its variations may also vary depending on the way they are used. The fundamental difference is that, when facing the attack, individuals with ES find themselves “short of words”, because just speaking about their trauma is in itself sufficient to inhibit their own narrative.

By contrast, patients with PNES find that speaking about their trauma is a way to compensate for their distress, and, therefore, they set up a dramatized form of communication, replete with details, precisely to impress the others and get their attention through the description of their own symptoms.

To close vs. to keep open the gap

Patients with PNES are unable to describe their own attack, since this it is not at the core of their distress, but rather they give a representation of it. That, albeit bothersome and painful, represents the best possible compromise in order to avoid a psychic breakdown.

The use of language in patients with PNES reflects the same barrier that blocks the acknowledgment of their discomfort. They do not know how to speak about themselves and are unable to access a more symbolic language since the solution to their problem is to focus entirely on the body. It is as if the body were the nest where the trauma and the ensuing anguish are kept hidden and neither can be expressed because inaccessible to any attempt of elaboration

Patients with ES, in this respect, are more “free” because for them the problem is the illness and they concentrate also on the many modalities to resolve it, since the illness represents an impediment to their personal fulfillment. Examples of semantics are presented in Table 4.

To explain vs. to impress

In describing their own attack, patients with ES try to explain what happened to them so that they can share something that they find frightening.

In patients with PNES, the description is rather impressionistic, in line with the old hysterical semiology of the belle indifference (Freud). In reality, the subject employs a dramatized form of speech to avoid speaking about their pain and to impress others. The symptom is used to provide the illusory belief of being at the center of the audience attention. They perceive no other way to obtain such attention (which is also a cause of pain).

The communication is lengthy and full of details precisely to impress the others who must feel literally struck by what they hear, even if further probing reveals all the emptiness behind it. The listening space is the beginning of a journey toward self-awareness.

Patients with ES on the contrary need to explain their distress because it is the only way they can try to find a solution to their problem. They cannot miss the opportunity to be heard, even if this generates further discomfort, since the moment the illness is unveiled is also the moment one may be able to find a space for healing.

It is essential in both cases to maintain an inquisitive attitude and ask questions that can help these subjects to further explore their condition. For patients with PNES, the purpose is to find new reassuring words that may help them to separate themselves from the symptom and look at the real issue. For patients with ES, is to encourage them to explore new roles, other than the sick role. Table 5 depicts the narrative differences between individuals with ES and PNES.

The use of metaphors and similitudes

Out of the similitudes observed in the 55 interviews analyzed, we tried to extrapolate the image or theme they were referring to, in an effort to bring such verbalizations as close as possible to a symbolic content.

Patients with PNES mostly use similarities that can be grouped under the common theme of “uncertainty”, (“It’s like having the flu… and I start sweating” “My legs were like a jelly” or “kind of like going through a tunnel. It’s like an airplane… you’re going down the runway and it’s pretty rough…”). The focus is on their own internal state rather than the attack itself. There are also similarities that refer to the theme of “judgement” and of “control” (“I hear these noises in my head… my body is in control, it controls itself”). This underlines what mentioned before, that the symptoms, as they are expressed, tend to be externalized more as moments of discomfort, rather than capturing their internal significance, as if this were a mental state.

Additionally, we see the use of very dramatic images: “face on fire”, “bloodshot eyes”, “speech block”, without however providing a precise explanation of the state described (“I feel like a blister on this side that tickles my throat. At this point I develop a violent cough with a feeling like vomiting that prevents me from breathing… it’s like a little bubble that pops…”).

On the contrary, patients with ES use mostly terms that focus on the description of the attack and their language is calm and more technical (“my voice could not come out”, “I felt something rising up”, “something was preventing me from speaking”. The similarities they use refer mostly to the broad themes of “protection” or “impediment”, projecting in this way the image of a sick individual who badly needs a cure and requires a lot of attention. “I think it’s coming because my body and my hands are starting to feel strange and I am starting to open and close my fists” or “the bed started shaking…”).

Another element is the correlation with what is happening in the environment. In patients with PNES the attacks are much more likely to arise when they are in the presence of other people. The contexts of reference are: in church, in a garden, at work, at the doctor’s office, at the restaurant, at a lounge, at school, or “since my father passed away” (which indicates a very strong emotional involvement). Even in patients with ES, there is a correlation with the surrounding context and the presence of bystanders, but without the need to be observed, as in the case of subjects with PNES.

The environmental element seems to be more of a determinant factor in patients with PNES as if the verbalization of the attacks were a mean to modify a situation experienced as negative.

According to our observations, patients with ES experience what is defined as the “betrayal of the body”. Namely, their own body begins to do things that cannot be controlled nor predicted (“I was gathered up like a candle… like a hedgehog that gathers…”). However, it is significant that, presumably after acquiring more knowledge of the illness and its pharmacological treatment, the patient may use metaphors that focus on “change” and on the “acceptance” of the current or previously experienced illness (“I feel like another person” or “I feel like I just came down from the clouds”). From a semantic point of view the only real metaphor we encountered appeared in the report of a subject with ES: “I was a dead body”; but even in this case, one can notice how it is centered on the body, making a direct reference to the part most likely to be affected by an epileptic manifestation.

The defense mechanism commonly used is the repression. Namely, unacceptable contents are relegated to the unconscious and could not be recalled. However, the contents persist and manifest themselves in a series of escalating symptoms of which the attack could be one. The broad theme that emerges mostly in patients with PNES is that of “uncertainty”, easily linked to one of the principal characteristics of the hysteric personality, which is to maintain an attitude of “not knowing, not seeing, and not recognizing” reality. The symptom represents the “disappearance of the idea (the trauma) but the affect persists (which is expressed through the symptom)”.

The emotions

The following are some reflections on the presence, or absence, of emotional connotations during the reported “attack”.Patients with PNES do not report emotions related to the context or to the attack itself. All the attention is projected on a reference figure, who functions as observer and also as rescuer in such moments of peril.

The accounts reported by patients with PNES reflect the urgency to immediately translate the problem in medical terms without a chance to reflect on the intermediate determinants, considering that the attack, in most cases, occurs during stressful situations such undergoing an exam, doing homework, having a rift with a friend, etc.

Subjects with ES, on the contrary, show greater “competency” in talking about their seizures, describing the state of fear and agony associated with them. The same when talking about the pharmacological therapy they are following. These subjects speak openly of their distress and, above all, they ask themselves about the illness, harbouring the fear that it may be something very serious.

Conversely, subjects with PNES describe the “attack” as a reaction (to something) and in their accounts they consider such manifestations as part of a behavioural response. It is interesting to note that they do not use similarities while in subjects with ES we found at least two, that appeared quite significant with respect to what those subjects have experienced.

A recurrent emotion in subjects with ES is “fear” that in one case was identified with the anguish evoked by “the wild wolves” (as described by an eight-year-old child). Subjects with PNES describe their state as “strange” and it is remarkable how the caregiver becomes the key figure, who also «serves» as an explanation for what they are going through.

Emotionality represents a fundamental feature when trauma comes under discussion. If subjects are able to identify and name their emotions it means that the traumatic attack can be looked at and, as such, it can be confronted.


The current work outlines the main elements derived from the analysis of semantics in subjects with ES and PNES and demonstrates the profound differences that characterize the two groups. This is the basic difference between patients with PNES and ES. Subjects in the former group are unable to identify or acknowledge their emotions because their symptoms result from an agonizing fear of past experiences that cannot be expressed.

Subjects with ES, instead, are willing to discuss and even try to elaborate on their emotions. For them this is a useful mean to confront the disease, a condition that may be unsurmountable but at least can be faced (up front), to everyone’s benefit.

In general, experiencing a disease (real or symbolic) is an attack that deserves constant and in-depth probing because it offers the opportunity to explore the emotional world and the psychic structure of the individual in front of us.

The treatment cannot ignore all those elements because, otherwise, it would become a sterile exercise of prescribing medications. Paying proper attention to the person is the only way to preserve the dignity due to any state of illness.

Conflict of interests: the authors have no conflict of interests to declare.


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