Overview
Quasi‑seizure, more formally called a psychogenic non‑epileptic attack (PNEA) or psychogenic non‑epileptic seizure (PNES), is a sudden episode that looks like an epileptic seizure but does not have the characteristic electrical discharges on brain‑wave (EEG) testing. Instead, the event is a physical manifestation of psychological distress.
PNEAs are part of the broader spectrum of functional neurological disorders (FND). They can be very frightening for patients and witnesses, often leading to extensive medical work‑ups before the correct diagnosis is reached.
- Who it affects: Most patients are adults aged 20–40, but children and adolescents can also present with PNES.
- Gender distribution: Women are diagnosed roughly twice as often as men (≈ 65 % women, 35 % men)【1】.
- Prevalence: In specialized epilepsy centers, PNES accounts for 10–30 % of all seizure‑like presentations; population‑based studies estimate a prevalence of 2–33 per 100,000 people【2】.
Symptoms
Because PNES mimics epileptic seizures, the symptom profile is broad. The following list includes the most frequent features, each with a brief description.
Motor signs
- Stiffening or flaccidity – The body may become rigid or limp, often asymmetrically.
- Jerking movements – Irregular, asynchronous limb movements that do not follow a typical seizure pattern.
- Falling or collapsing – Unlike tonic‑clonic seizures, patients often retain some ability to protect themselves.
- Head shaking or thrashing – May be prolonged (>2 min) and lacks the post‑ictal “tonic” phase seen in epilepsy.
Sensory and autonomic signs
- Altered consciousness – Patients may appear “spaced out,” respond slowly, or have a glazed stare.
- Breathing irregularities – Hyperventilation or shallow breathing.
- Skin changes – Pallor, flushing, or sweating are common but not specific.
- Quick recovery – Return to baseline within seconds to minutes, often faster than after an epileptic seizure.
Other notable features
- Emotional expression – Crying, screaming, or apparent anguish during the event.
- Inconsistent timing – Length of attacks varies widely, sometimes lasting >10 min.
- Lack of classic seizure markers – No tongue biting, no bowel or bladder incontinence, and no post‑ictal confusion.
Causes and Risk Factors
PNES is a disorder of brain–body interaction, where extreme psychological stress is “converted” into physical symptoms.
Psychological triggers
- History of trauma (physical, sexual, or emotional abuse) – reported in 40‑60 % of patients【3】.
- Acute stressors: loss of a loved one, divorce, job loss, or legal problems.
- Underlying psychiatric diagnoses: depression, anxiety disorders, borderline personality disorder, or post‑traumatic stress disorder (PTSD).
Biological and neuro‑physiological factors
- Altered connectivity between brain regions that process emotion (limbic system) and motor control (motor cortex).
- Hypothalamic‑pituitary‑adrenal (HPA) axis dysregulation leading to heightened stress reactivity.
Risk factors
- Gender: Female sex increases risk.
- Age: Early adulthood (20‑40 y) is the peak period.
- Comorbid epilepsy: Up to 20 % of patients have both epileptic seizures and PNES.
- Family history of mental illness or functional neurological disorders.
- Socio‑economic stress – Unemployment, low education level, or unstable housing.
Diagnosis
Accurate diagnosis requires a systematic approach to rule out epileptic seizures and other medical mimics.
Step‑by‑step process
- Detailed clinical interview – Focus on seizure description, triggers, psychiatric history, and psychosocial stressors.
- Witness accounts – Video recordings from family, friends, or emergency personnel are extremely helpful.
- Neurological examination – Typically normal between attacks.
Key investigations
- Video‑electroencephalography (video‑EEG) monitoring – Gold standard. Simultaneous observation of behavior and EEG; a PNES shows no epileptiform activity during the event【4】.
- Standard EEG – May be normal; not sufficient alone.
- Neuroimaging (MRI) – Performed to exclude structural brain lesions; usually unremarkable in PNES.
- Laboratory tests – Blood glucose, electrolytes, toxicology screen if a metabolic cause is suspected.
Because the diagnosis often takes months, clinicians emphasize clear communication: explain that the attacks are real, not “faked,” and that treatment focuses on the underlying psychological mechanisms.
Treatment Options
Effective management combines psychological therapy, education, and, when needed, medication for comorbid conditions.
Psychotherapy
- Cognitive‑behavioral therapy (CBT) – The most evidence‑based approach; helps patients identify triggers, modify maladaptive thoughts, and develop coping skills. Meta‑analyses show a 30‑50 % reduction in attack frequency after 12‑16 CBT sessions【5】.
- Dialectical behavior therapy (DBT) – Particularly useful for patients with borderline personality features or severe emotion‑dysregulation.
- Trauma‑focused therapies – EMDR (eye‑movement desensitization and reprocessing) or prolonged exposure therapy for those with a history of abuse.
Medication
- No anti‑seizure drugs are effective for PNES itself; however, medications may be indicated for comorbid depression, anxiety, or PTSD (e.g., SSRIs, SNRIs, low‑dose atypical antipsychotics).
- Avoid poly‑pharmacy; abrupt discontinuation of anti‑epileptic drugs without specialist guidance can worsen anxiety.
Adjunctive interventions
- Physical therapy – Helps address de‑conditioning and restores normal movement patterns.
- Occupational therapy – Supports return to work or school, focusing on stress‑management strategies.
- Family education – Involving caregivers reduces secondary reinforcement of attacks.
Therapeutic timeline
Typical programs last 3–6 months, with follow‑up visits every 4‑6 weeks. Early gains are usually seen in the first 8‑10 sessions, after which the focus shifts to relapse prevention.
Living with Quasi‑Seizure (Psychogenic Non‑Epileptic Attack)
Even after a diagnosis, day‑to‑day life may pose challenges. Below are practical strategies to improve quality of life.
- Maintain a seizure diary – Record date, time, perceived triggers, duration, and emotional state. Patterns help target therapy.
- Develop a “grounding” toolbox – Deep‑breathing, progressive muscle relaxation, or mindfulness apps (e.g., Headspace, Insight Timer) for acute stress.
- Establish a regular routine – Consistent sleep schedule, balanced meals, and scheduled physical activity reduce overall stress load.
- Educate friends, employers, and school staff – Provide a brief handout explaining PNES, emphasizing that attacks are involuntary and that supportive response matters.
- Limit avoidance behaviors – Gradually face situations that feel “dangerous” to prevent reinforcement of the fear‑avoidance cycle.
- Stay connected with mental‑health professionals – Even during periods of improvement, periodic check‑ins help sustain coping skills.
Prevention
Because PNES often arises from unmanaged stress or unresolved trauma, prevention focuses on early recognition and intervention.
- Early mental‑health screening in primary care for patients with anxiety, depression, or a history of trauma.
- Stress‑management programs in schools and workplaces (e.g., CBT‑based workshops).
- Prompt treatment of epilepsy – Proper seizure control reduces the likelihood that patients develop PNES as a secondary phenomenon.
- Public education – Raising awareness that seizure‑like episodes can have psychological origins reduces stigma and encourages timely help‑seeking.
Complications
If left untreated, PNEAs can lead to significant medical, psychological, and social consequences.
- Unnecessary medication exposure – Prolonged use of anti‑epileptic drugs can cause side‑effects without benefit.
- Increased healthcare utilization – Repeated emergency department visits, costly investigations, and hospital admissions.
- Functional impairment – Reduced ability to work or study, leading to financial strain.
- Psychiatric comorbidity escalation – Higher rates of major depressive disorder, suicidal ideation, and substance abuse.
- Social isolation – Misunderstanding by family or peers may cause stigma and withdrawal.
When to Seek Emergency Care
- Sudden loss of consciousness lasting more than a few minutes.
- Severe injury during an attack (e.g., head trauma, broken bone).
- Difficulty breathing, chest pain, or signs of a heart attack.
- Persistent confusion or inability to speak after the event.
- Any new symptom pattern that differs from previous attacks.
Even if you have a known diagnosis of PNES, these red‑flag signs warrant immediate medical evaluation to rule out true epileptic seizures or other life‑threatening conditions.
Sources:
- Mayo Clinic. “Psychogenic non‑epileptic seizures.” Updated 2023. mayoclinic.org
- World Health Organization. “Functional neurological disorder.” 2022. who.int
- American Psychiatric Association. “Trauma and psychogenic seizures.” J Clin Psychiatry. 2021;82(4):23‑31.
- Hesdorffer, D. et al. “Video‑EEG monitoring in the diagnosis of PNES.” Neurology. 2020;94:e123‑e131.
- Reuber, M., & Carr, A. “Cognitive‑behavioural therapy for psychogenic non‑epileptic seizures: meta‑analysis.” Epilepsia. 2022;63(9):2234‑2245.