of the tongue, seizures lasting more than two minutes (easiest factor to distinguish), seizures having a gradual onset, a fluctuating course of disease severity, the eyes being closed during a seizure, and side to side head movements. Features that are uncommon in PNES include automatisms (automatic complex movements during the seizure), severe tongue biting, biting the inside of the mouth, and incontinence. If a person with suspected PNES has an episode during a clinical examination, there are a number of signs that can be elicited to help support or refute the diagnosis of PNES. Compared to people with epilepsy, people with PNES will tend to resist having their eyes forced open (if they are closed during the seizure), will stop their hands from hitting their own face if the hand is dropped over the head, and will fixate their eyes in a way suggesting an absence of neurological interference. Treatment Patient understanding of the new diagnosis is crucial for their treatment, which requires their active participation. There are a number of recommended steps to explain to people their diagnosis in a sensitive and open manner. A negative diagnosis experience may cause frustration and could cause a person to reject any further attempts at treatment. Eight points recommended to explain the diagnosis to the person and their caregivers are: Reasons for concluding they do not have epilepsy What they do have (describe FND) Emphasize they are not suspected of "putting on" the attacks, and the symptoms are not "all in their head" There may be no triggering "stresses" Maintaining factors May improve after correct diagnosis Caution that anticonvulsant drug withdrawal should be done in conjunction with their physician Describe treatment to help regain control of symptoms Psychotherapy is the most frequently used treatment, which might include cognitive behavioral therapy or therapy to retrain the physical symptoms and allow the individual to regain control of the attacks (ReACT). There is also some evidence supporting selective serotonin reuptake inhibitor antidepressants. Cognitive behavioral therapy Cognitive behavioral therapy (CBT) treatments for PNES typically target fear avoidance and work to reattribute patients' symptoms to psychosocial issues. Retraining and Control Therapy (ReACT) ReACT, while new and understudied, has shown extremely promising outcomes for reduction of PNES episodes in pediatric patients. This therapy focuses on the idea that PNES are caused by a learned physical reaction or habit the body develops, similar to a reflex. ReACT aims to