Neuroimaging Findings in Idiopathic Generalized Epilepsy and Psychogenic Non-epileptic Seizures: A Narrative Review

Background: Psychogenic non-epileptic seizures (PNES) and idiopathic generalized epilepsy (IGE) are two clinical entities that may resemble each other in presentation but differ considerably in their mechanisms, outcomes, and therapeutic approaches. The differential diagnosis between PNES and IGE can be particularly difficult in cases resistant to medical therapy. Objectives: This review aimed to compare and contrast the neuroimaging findings associated with PNES and IGE to better understand their neurobiological underpinnings and to highlight potential imaging-based differentiators that may assist in clinical diagnosis and treatment planning. Materials & Methods: We reviewed published reports employing structural and functional neuroimaging modalities—including magnetic resonance imaging (MRI), morphometric studies, diffusion tensor imaging (DTI), positron emission tomography (PET), single-photon emission computed tomography (SPECT), magnetic resonance spectroscopy (MRS), and functional MRI (fMRI)—in patients with PNES and IGE. The data were synthesized to identify common patterns, divergent findings, and clinical correlations. Results: While IGE is characterized by thalamocortical dysfunction and white matter disorganization, PNES is more frequently associated with multifocal structural abnormalities and disrupted emotion-motor-executive connectivity. Functional imaging demonstrated distinct connectivity and metabolic profiles, with PNES patients showing greater alterations in the insular, cingulate, and prefrontal regions. MRS studies indicated differences in neurochemical profiles, supporting the theory of divergent network-level dysfunctions. Conclusion: Neuroimaging reveals considerable pathophysiological differences between PNES and IGE. These differences can support more accurate differential diagnosis and help guide personalized treatment strategies. Importantly, neuroimaging findings challenge the historical view of PNES as purely psychogenic, highlighting its organic basis.