All Stress, No Static: PNES
Each school day brings the steady rhythm of caregiving—minor injuries, medication administration, and the many small moments of connection that define student health services. Occasionally, that rhythm is interrupted by a student in visible distress. When the physical signs resemble a seizure, but the cause lies in psychological rather than neurological origins, the school nurse’s insight becomes critical. These are Psychogenic Non-Epileptic Seizures (PNES), and for the school-aged population, they present a unique challenge with real symptoms requiring clinical expertise and understanding support.
PNES as a Functional Brain Response
While an epileptic seizure is defined by a temporary "short circuit" of abnormal electrical activity in the brain, PNES is a functional neurological disorder. The brain’s hardware is intact, but the software is experiencing a critical error. These events are paroxysmal attacks involving sudden changes in behavior, sensation, or motor control that mimic epilepsy but stem from psychological distress.
Despite the lack of abnormal EEG discharges, the biology of PNES is undeniably real. Research suggests that students with PNES may have a stress-response system that’s working in overdrive. Their bodies often produce higher levels of cortisol—the main stress hormone—throughout the day, and the brain’s “alarm system,” known as the hypothalamic-pituitary-adrenal (HPA) axis, can stay highly activated. Brain imaging studies also show that the areas of the brain involved in emotions (like the amygdala and insula) communicate differently with regions that control movement. In simple terms, strong emotional stress can sometimes override the brain’s normal control systems, leading to physical symptoms that happen automatically rather than by choice.
Student Experience of PNES
In school settings, the triggers for PNES often look different from those seen in adults. While a history of trauma, such as physical or sexual abuse, can increase risk, many pediatric cases are connected to everyday stressors in the student’s environment. Academic pressure, learning challenges, bullying, and family conflict are among the most common contributing factors. PNES is also more frequently seen in female students, who make up roughly 70% to 80% of identified cases. Recognizing these patterns helps school nurses understand the emotional and social context behind each episode and support students more effectively.
School nurses may identify certain clinical “red flags” that help distinguish PNES from epileptic seizures. PNES episodes tend to last longer and often show waxing and waning movements rather than a consistent pattern. Common signs include broad or “thrashing” limb movements, side-to-side head shaking, and tightly closed eyes. Unlike most epileptic seizures—where the eyes are typically open—students experiencing PNES often keep their eyes shut and may even resist attempts to open them. Recognizing these patterns can guide more accurate assessment and promote a calm, supportive response.
PNES School Supports
The management of these types of seizures in the school setting differs from traditional seizure protocols and should always follow the guidance outlined in the student’s individualized care plan. Because PNES episodes are not caused by abnormal electrical activity, anti‑seizure rescue medications are usually ineffective and may lead to unnecessary or even harmful interventions.
In most cases, the school nurse’s role is to maintain safety, reduce environmental stress, and support the student’s recovery with calm, confident actions that reflect clinical understanding. Key management strategies may include:
- Creating a “quiet zone.” Reduce audience and activity by clearing unnecessary personnel and students. This preserves the student’s dignity and helps de-escalate the situation.
- Using a minimal‑intervention approach. Position the student safely on their side and remove nearby hazards, but avoid restraint or attempts to place objects in the mouth.
- Encouraging a brief rest and return. After about 10–15 minutes, and if the care plan allows, help the student re‑enter class. A prompt, supportive return prevents the episode from becoming a learned or avoidant behavior.
Deeper Understanding of PNES
Above all, each PNES management plan should be part of a coordinated 504 or individualized healthcare plan developed with input from the student’s neurologist, mental health provider, family, and the school nurse. One of the most painful barriers to recovery for students with PNES is being labeled as “faking it.” Accusations like this increase shame and isolation and can worsen symptoms over time. It is essential for school staff to understand that these episodes are not deliberate; they are involuntary responses to stress and can be distressing for the student. A consistent, team‑based approach helps reduce stigma, promote recovery, and keep the student engaged in learning.
PNES reveals the profound connection between emotional well-being and physical symptoms. By recognizing these episodes as legitimate signals of distress—rather than faking or emergencies—school nurses can create moments of safety and understanding that empower students to regain control. With the right support, most students not only recover from PNES and outgrow its episodes, but reclaim their classroom rhythm, stepping confidently back into learning and life.