Quirinal Syndrome (Psychogenic Non‑Epileptic Seizures)
Overview
Quirinal syndrome is another name for psychogenic non‑epileptic seizures (PNES)—episodes that look like epileptic seizures but are not caused by abnormal electrical activity in the brain. Instead, they arise from psychological factors such as stress, trauma, or underlying mental‑health conditions. The term “Quirinal” comes from the historic Quirinal Hospital in Rome, where early case series were described.
- Who it affects: PNES can occur at any age, but most reports show a peak in adolescence and early adulthood (15‑35 years). Women are diagnosed roughly twice as often as men (≈ 2:1 ratio).
- Prevalence: Studies estimate that PNES account for 10‑20 % of all patients evaluated in tertiary epilepsy centers. In the general population, the lifetime prevalence is estimated at 2‑5 per 1,000 people.[1][2]
- Impact: Up to 40 % of patients with PNES experience frequent episodes (≥ 1 per week), leading to missed school or work, injury, and high health‑care utilization.
Symptoms
Because PNES mimic epileptic seizures, the clinical picture is varied. The following list includes the most common presentations, with brief descriptions.
Motor symptoms
- Convulsive movements: Synchronous or asynchronous shaking of the arms, legs, or trunk; often longer than typical epileptic convulsions (≥ 2 minutes).
- Stiffening (atonic) episodes: Sudden loss of muscle tone leading to a “drop attack.”
- Focal motor activity: Jerking of a single limb without spread.
Non‑motor symptoms
- Altered responsiveness: Unresponsiveness to name or pain, but often retains eye opening or blinking.
- Breathing changes: Hyperventilation, sighing, or irregular breathing pattern.
- Sensory phenomena: Tingling, numbness, or a feeling of being “out of body.”
Autonomic signs
- Flushing, pallor, or sweating.
- Transient tachycardia (heart rate > 100 bpm).
- Gastrointestinal upset (nausea, abdominal pain) before or after the event.
Other distinguishing features
- Episodes often occur in the presence of a known stressor or emotional trigger.
- Timing may be related to the clinic schedule (e.g., more frequent during EEG monitoring).
- Patients retain some degree of voluntary control: they can often be “woken” by a loud voice, and post‑ictal confusion is usually brief or absent.
Causes and Risk Factors
PNES are “functional” seizures—no structural brain abnormality is needed. Instead, a complex interplay of psychological, neurobiological, and environmental factors is implicated.
Psychological triggers
- History of sexual, physical, or emotional abuse (reported in 30‑50 % of patients).
- Acute stressors (relationship loss, job change, legal issues).
- Underlying mood or anxiety disorders (depression, PTSD, panic disorder).
Neurobiological contributors
- Altered limbic system connectivity (functional MRI studies show hyper‑activation of the amygdala during stress).
- Abnormalities in autonomic regulation (elevated heart‑rate variability).
Social and demographic risk factors
- Female gender (≈ 2‑3 times higher risk).
- Low socioeconomic status and limited access to mental‑health resources.
- History of previous epileptic seizures or misdiagnosed epilepsy.
- Personality traits such as suggestibility or high ‘need for care.’
Diagnosis
Accurate diagnosis requires a systematic approach to separate PNES from true epileptic seizures.
Clinical assessment
- Detailed history: Onset, frequency, triggers, witnessed description, and psychosocial background.
- Physical exam: Neurologic exam is usually normal between events.
Investigations
- Video‑EEG monitoring (gold standard): Simultaneous video recording and electroencephalography for ≥ 24 hours. In PNES, the clinical seizure is not accompanied by ictal EEG changes.
- Standard EEG: May be normal or show non‑specific findings; not diagnostic alone.
- Neuroimaging (MRI): Performed to exclude structural lesions; often normal in PNES.
- Laboratory tests: Basic metabolic panel to rule out hypoglycemia, electrolyte disturbances, or drug toxicity that could provoke seizures.
- Psychiatric evaluation: Structured interviews (e.g., MINI, SCID) to identify comorbid mental‑health conditions.
Diagnostic criteria (adapted from the International League Against Epilepsy)
- Clinical events that resemble epileptic seizures.
- Absence of ictal EEG correlates during the events.
- Presence of a psychological precipitants or stressors.
- Exclusion of other neurologic or medical causes.
Treatment Options
Because PNES are rooted in psychological processes, treatment focuses on psychotherapy, education, and addressing comorbid conditions. Medications are used only for associated psychiatric diagnoses, not for the seizures themselves.
First‑line: Psychoeducation
- Explain the diagnosis in clear, non‑judgmental language.
- Provide written materials and reputable websites (e.g., Mayo Clinic).
Psychotherapy
- Cognitive‑behavioral therapy (CBT): The most evidence‑based approach; 60‑70 % of patients achieve ≥ 50 % reduction in seizure frequency after 12‑16 sessions.[3]
- Dialectical behavior therapy (DBT): Helpful for patients with borderline personality traits or self‑harm behaviors.
- Trauma‑focused therapies (EMDR, prolonged exposure): Recommended when a clear history of abuse or PTSD exists.
Medication
- Antidepressants (SSRIs, SNRIs) for comorbid depression or anxiety.
- Atypical antipsychotics (e.g., quetiapine) when mood instability is prominent.
- Anti‑seizure drugs are NOT indicated for PNES and may worsen side‑effects.
Adjunctive therapies
- Stress‑reduction programs: Mindfulness‑based stress reduction (MBSR), yoga, or tai‑chi.
- Physical therapy: For patients with injury from falls or prolonged immobility during episodes.
- Family therapy: Improves support and reduces “secondary gain” dynamics.
Multidisciplinary care model
Best outcomes are seen when neurologists, psychiatrists/psychologists, and primary‑care providers collaborate. A typical pathway includes:
- Neurologist confirms PNES via video‑EEG.
- Psychiatrist conducts diagnostic interview.
- Psychologist initiates CBT while the neurologist monitors seizure frequency.
- Primary‑care physician manages any medical comorbidities and medication monitoring.
Living with Quirinal Syndrome (Psychogenic Non‑Epileptic Seizures)
Long‑term management focuses on empowerment, self‑monitoring, and coping strategies.
Practical daily tips
- Maintain a seizure diary: Note date, time, triggers, duration, and mood before/after the event.
- Identify early warning signs: “Feeling detached,” rapid breathing, or rising anxiety often precede a seizure.
- Develop a “pause plan”: When a warning appears, practice grounding techniques (5‑4‑3‑2‑1 sensory exercise).
- Sleep hygiene: Aim for 7‑9 hours/night; sleep deprivation can increase episodes.
- Limit alcohol and recreational drugs: These substances can lower seizure threshold and interfere with therapy.
- Stay active: Moderate aerobic exercise (e.g., walking 30 min most days) reduces stress hormones.
- Engage support networks: Peer‑support groups (online or in‑person) decrease isolation.
Work and school considerations
- Provide a brief medical note explaining the condition without disclosing sensitive psychiatric details.
- Request reasonable accommodations: flexible break times, ability to step away to a quiet space, or a safety plan for seizures.
When to revisit the doctor
- Seizure frequency does not decline after 3 months of psychotherapy.
- New psychiatric symptoms arise (e.g., suicidal thoughts, severe depression).
- Injury occurs during a seizure (fracture, head trauma).
Prevention
Because PNES develop from psychological vulnerability, primary prevention aims at reducing risk factors and strengthening coping mechanisms.
- Early mental‑health screening: Adolescents with history of trauma, anxiety, or depression should receive timely counseling.
- Stress‑management education in schools and workplaces: Programs that teach relaxation, problem‑solving, and emotional regulation lower the likelihood of conversion into PNES.
- Avoid unnecessary diagnostic procedures: Over‑medicalization can reinforce a “seizure identity.” Ensure proper explanation when tests are negative.
- Promote healthy sleep and substance‑use habits: Both are protective against many functional neurological disorders.
Complications
If unrecognized or untreated, PNES can lead to significant morbidity.
- Physical injury: Falls, burns, or drowning during a seizure.
- Psychiatric comorbidity: Depression, anxiety, PTSD, or substance use disorder—often more disabling than the seizures themselves.
- Social and occupational consequences: Stigmatization, loss of employment, or academic failure.
- Healthcare overuse: Repeated emergency department visits and unnecessary antiseizure medication trials increase costs and side‑effects.
- Reduced quality of life: Studies show scores on the WHOQOL‑BREF are comparable to chronic pain syndromes.
When to Seek Emergency Care
Call 911 or go to the nearest emergency department if you observe any of the following during an event:
- Loss of consciousness lasting longer than 5 minutes.
- Severe injury (head trauma, broken bone, deep laceration).
- Difficulty breathing, bluish color around lips or nails.
- Seizure lasting > 10 minutes (status epilepticus‑like picture) or a series of seizures without regaining consciousness.
- Pregnancy complications (seizure with abdominal pain, vaginal bleeding).
- Any new neurological signs (speech difficulty, weakness on one side, vision loss).
If you have a known diagnosis of PNES but are unsure whether this episode fits the typical pattern, it is safer to seek urgent evaluation.
References
- World Health Organization. Neurological Disorders: Public Health Challenges. WHO Press, 2021.
- Reuber M, et al. “Epidemiology of Psychogenic Non‑Epileptic Seizures.” Epilepsia. 2020;61(5):1029‑1037.
- Goldstein LH, et al. “Cognitive‑Behavioral Therapy for Psychogenic Non‑Epileptic Seizures: A Randomized Controlled Trial.” JAMA Neurology. 2022;79(4):452‑460.