Improved outcomes for patients with autonomic movement disorders originally evaluated for psychogenic non-epileptiform spells, 2026, Khoo

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Frontiers | Improved outcomes for patients with autonomic movement disorders originally evaluated for psychogenic non-epileptiform spells

BackgroundPatients experiencing autonomic storms related to dysautonomia may present with abnormal movements, including convulsions, tremors, and myoclonus. ...
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ORIGINAL RESEARCH article​

Front. Neurol., 07 September 2026

Sec. Movement Disorders

Volume 17 - 2026 | https://doi.org/10.3389/fneur.2026.1839185

Improved outcomes for patients with autonomic movement disorders originally evaluated for psychogenic non-epileptiform spells​

  • 1. Boston Medical Center Brighton, Boston, MA, United States
  • 2. Tufts University School of Medicine, Boston, MA, United States


Abstract​

Background:

Patients experiencing autonomic storms related to dysautonomia may present with abnormal movements, including convulsions, tremors, and myoclonus. Due to these nonspecific symptoms, they are often misdiagnosed with functional neurological disorders, including psychogenic non-epileptic spells (PNES), resulting in delayed or inappropriate treatment.

Methods:

This cohort study included 17 adult patients who presented to St. Elizabeth’s Medical Center’s emergency department with abnormal seizure-like activity. Inclusion criteria required non-epileptiform movements, confirmed by negative rEEG or cEEG testing, followed by a misdiagnosis of a functional neurological disorder, and referral to Neurology. Demographic and clinical information was collected from the electronic health record to describe the clinical pattern and treatment responses in patients with AMD initially diagnosed with PNES.

Results:

Among the 17 patients (male [n = 6], female [n = 11]), with a mean baseline age of 52 and a median age of 64, the most common movement phenotypes were tremor (n = 6), and myoclonus (n = 6). Other neurological manifestations were obtundation (n = 10) and presyncope (n = 6). All participants showed features of orthostatic hypotension, indicating possible dysautonomia. 14 of 17 patients were started on at least one medication for symptom management, including fludrocortisone, pyridostigmine, midodrine, and propranolol, with 8 of 17 on combination therapy. 10 of 17 patients who underwent pharmacological interventions reported improvement, including a decrease or resolution of abnormal movements, reduction of autonomic dysfunction symptoms, and fewer readmissions.

Conclusion:

Patients presenting with abnormal seizure-like movements confirmed as non-epileptic after further evaluation should be assessed for autonomic dysfunction. Treatment targeting orthostatic hypotension may help alleviate these abnormal movements.
 
As much as I hope that these patients did experience real benefits from the medications, this is hardly 'a beautiful study'. We can't know that the medications helped. I imagine BPS proponents might suggest that the patients were given a reason to hope that they would get better, and, as a result, some did.

Even without BPS ideology, it is possible to think that there were some components of the placebo effect at play here e.g. natural recovery, politeness towards clinicians. 'Reduction of autonomic dysfunction symptoms' sounds quite vague with plenty of room for subjectivity in its interpretation. Without a more rigorous study, we can't know.
 
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