Two epileptologists spent five years giving the same lecture on functional seizures on three continents. Each time, they showed the same patient videos. Each time, an unannounced observer in the room counted how many people laughed.
At grand rounds in the United States, roughly 57% of the medical audience did. At an epilepsy symposium in Marburg, Germany, about 5%. At an epilepsy course in São Paulo, about 8%. At the Turkish Epilepsy Congress in Bodrum, about 13%, and about 17% across the remaining countries.
Among the non-medical audiences, graduate ethics students and undergraduate sociology students watching identical footage, the figure was zero.
Those observations, published in Frontiers in Neurology by Mohamad Koubeissi of George Washington University and Tanvir Syed of Access Telecare with colleagues including W. Curt LaFrance Jr. of Brown, are paired with a survey asking a blunt question: why do people laugh at this?
The Condition Being Laughed At
Functional seizures, previously called psychogenic nonepileptic seizures, are episodes that resemble epileptic seizures but lack the electrical signature on EEG. They are the most common functional neurological disorder, and they are not minor.
The standardized mortality ratio for functional seizures runs two to three times that of the general population, comparable to drug-resistant epilepsy. Patients face prolonged misdiagnosis, unnecessary antiseizure medication, and, in cases presenting as functional status, invasive interventions carrying real iatrogenic risk.
The mechanism is also not what many clinicians assume. Functional neurological disorders occur unconsciously. Patients are not producing symptoms for conscious gain, and imaging work has identified associated brain network abnormalities. The older term pseudoseizures was retired precisely because the prefix implies fake.
Doctors and Everyone Else Gave Different Answers
Of 221 respondents, 124 were physicians, and 97 were not. Free-text answers were sorted into 10 categories by two independent raters, one physician and one non-physician, and the split between the groups was statistically striking.
Physicians most often attributed the laughter to the belief that the patient was faking, at 29% versus 14% among non-physicians. They cited a sense of superiority, along the lines of the patient cannot fool me, at 14% versus 3%. They cited the event not being organic at 13% versus 1%.
Non-physicians read it almost the opposite way. They described nervous laughter as a defense mechanism at 23% versus 4% among doctors. They called the behavior immature, unprofessional or cruel at 21% versus 1%. They attributed it to ignorance at 14% versus 5%.
Among US physicians specifically, willingness to name discomfort, negative opinion or ignorance as reasons was far higher than among physicians elsewhere. Neurologists and internists did not differ significantly from each other on any category.
One reason that appeared on both sides was relief: the recognition that this event is not life-threatening and does not require emergency escalation.
The Part That Reaches Patients
The authors are direct about the consequence. When laughter and eye-rolling happen on rounds, trainees absorb it, and a dismissive posture toward a suffering group of patients gets transmitted as culture rather than taught as content.
They also offer an unusually generous reading of where some of it comes from. Physicians who have algorithms for status epilepticus and code stroke can find themselves confronting shaking they cannot stop, and the resulting powerlessness may surface as a coping response. Earlier work has characterized joking about these seizures as a defense that damages patients.
That explanation does not neutralize the effect. Research on stigma in functional neurological disorder links being dismissed or delegitimized by clinicians to poorer quality of life, and patients who sense their diagnosis is not taken seriously often keep seeking further testing, adding cost, confusion and distrust.
What the Survey Cannot Establish
The limitations are extensive, and the authors list them plainly.
Respondents were not necessarily the people who laughed, so the stated reasons may be projections rather than introspection. The question itself asked "Why do you or others laugh, giggle, or smile?", which invites participants to explain someone else's behavior while presenting themselves favorably. Laughter counts were made by observers but never formally documented, so no inter-rater reliability statistic could be calculated, and the percentages are explicit approximations. US respondents were overrepresented at 51%. And asking people to explain a spontaneous reflex may produce a tidy narrative rather than the actual cause.
The team's recommendation is education rather than reprimand: more curriculum time on functional neurological disorders, on the grounds that clinicians who understand the mechanism are less likely to treat it as a joke. Anyone experiencing seizure-like episodes, whatever the eventual diagnosis, should be evaluated by a neurologist.
Key Questions Answered
What are functional seizures?
Episodes resembling epileptic seizures that occur without the electrical abnormalities seen on EEG in epilepsy. They are the most common functional neurological disorder and occur unconsciously.
How many people laughed?
Approximately 57% of medical audiences at US grand rounds, between 5% and 17% at international meetings, and none of the non-medical student audiences.
Why did physicians say they laughed?
The most common reason physicians gave was a belief the patient was faking, at 29%. Non-physicians more often described nervous laughter or called the behavior unprofessional.
Are these seizures dangerous?
Yes. Mortality is two to three times higher than the general population, comparable to drug-resistant epilepsy, and misdiagnosis exposes patients to unnecessary medication and procedures.
Are patients faking?
No. Functional neurological disorders occur without conscious intent, and research has identified associated brain network abnormalities.
What did the researchers recommend?
More training on functional neurological disorders in medical education, on the reasoning that understanding the condition reduces dismissive responses to it.
