Overview
Quasi‑epileptic seizures (QES), also called psychogenic nonepileptic seizures (PNES), are episodes that look like epileptic seizures but are not caused by abnormal electrical activity in the brain. Instead, they arise from psychological factors—most often a response to stress, trauma, or underlying mental‑health disorders. Because the outward signs can mimic true epilepsy (tonic‑clonic movements, loss of awareness, drooling, etc.), QES are frequently misdiagnosed, leading to unnecessary antiepileptic medication and delayed appropriate treatment.
Who it affects: QES can occur at any age, but the highest prevalence is seen in adolescents and young adults (15‑35 years). Women are diagnosed roughly twice as often as men, which mirrors the gender distribution of many related psychiatric conditions.
Prevalence: Epidemiologic studies estimate that 2–10 % of patients referred to epilepsy centers actually have QES rather than epileptic seizures.[1] Mayo Clinic Among patients with a longstanding diagnosis of “refractory epilepsy,” up to 30 % are later found to have PNES.[2] WHO
Symptoms
QES present with a broad spectrum of motor, sensory, and behavioral manifestations. The following list includes the most commonly reported signs, with brief descriptions to help differentiate them from epileptic events.
- Altered consciousness – The person may appear “spaced out,” stare blankly, or be unresponsive, but typically regains awareness within seconds to minutes without a post‑ictal “sleepy” phase.
- Motor movements
- Irregular, asynchronous limb jerking (often more pronounced in the upper extremities).
- Pelvic thrusting or rhythmic abdominal movements.
- Side‑to‑side head shaking that stops when the patient is gently supported.
- Flailing or “thrashing” that does not follow the stereotyped patterns of generalized tonic‑clonic seizures.
- Speech and vocalization – Crying, screaming, or incoherent speech can occur during an event. Unlike an epileptic seizure, the patient often retains the ability to speak intelligibly if prompted.
- Autonomic signs
- Flushed or pallid skin.
- Variable heart rate (often tachycardia due to anxiety).
- Occasional sweating, but typically not the profuse diaphoresis seen in status epilepticus.
- Resistance to eye opening – When the examiner tries to open the patient’s eyes, they may remain closed voluntarily, unlike the unresponsive eyes of a true seizure.
- Duration – Episodes usually last longer (1‑5 minutes) and have a more gradual onset and offset than epileptic seizures, which are often brief (<2 minutes) and have a sudden start/stop.
- Triggering factors – Sudden emotional stress, conflict, or reminders of past trauma may precipitate an event, whereas epileptic seizures are often triggered by sleep deprivation, flashing lights, or metabolic disturbances.
- Lack of post‑ictal confusion – After the event, the individual typically returns to baseline quickly, without the profound fatigue or disorientation common after generalized seizures.
Causes and Risk Factors
QES are considered a manifestation of underlying psychogenic processes. The exact mechanisms are still being researched, but several consistent contributors have been identified.
Psychological and Psychiatric Factors
- Trauma and Abuse – A history of childhood physical, sexual, or emotional abuse is reported in 40‑60 % of patients with QES.[3] CDC
- Conversion Disorder – QES are often classified under functional neurological symptom disorder (previously conversion disorder) in the DSM‑5.
- Depression and Anxiety – Co‑occurring mood disorders increase the likelihood of developing QES.
- Personality Traits – High levels of suggestibility, dependence on others, and difficulty expressing emotions verbally are common.
Social and Environmental Factors
- Chronic stress (e.g., financial insecurity, relationship conflict).
- Secondary gain: The seizure may provide a way to avoid feared tasks, gain attention, or receive care.
- Limited access to mental‑health services, leading to somatic expression of distress.
Medical Risk Factors
- Prior diagnosis of epilepsy (often leading to “diagnostic drift” when seizures persist despite optimal antiepileptic therapy).
- Neurological injury that predisposes the patient to heightened body awareness of physical sensations.
Diagnosis
Accurate diagnosis hinges on distinguishing QES from epileptic seizures, which requires a systematic approach.
Clinical Evaluation
- Detailed History – Explore seizure‑like episodes, triggers, psychiatric history, trauma, and any psychosocial stressors.
- Witness Accounts – Video recordings from family or emergency responders can reveal characteristic QES features (asynchronous movements, prolonged duration, lack of post‑ictal sleep).
- Physical & Neurologic Exam – Typically normal between episodes; focal neurological deficits raise suspicion for true epilepsy.
Electroencephalogram (EEG)
The gold‑standard test is a prolonged video‑EEG monitoring session (usually ≥24 hours). During a QES, the EEG remains **electrically silent**—no ictal epileptiform discharges—while the patient exhibits seizure‐like activity. In contrast, epileptic seizures show a clear rhythmic spike‑and‑wave pattern.[4] Cleveland Clinic
Additional Tests
- MRI of the brain – To rule out structural lesions that could cause epilepsy.
- Neuropsychological Assessment – Identifies comorbid cognitive or mood disorders.
- Laboratory Studies – Basic metabolic panel, thyroid function, and drug screens may be ordered to exclude metabolic precipitants.
Diagnostic Criteria (DSM‑5)
For a conversion disorder with seizure symptoms, DSM‑5 requires:
- One or more symptoms of altered voluntary motor or sensory function.
- Clinical evidence that the symptom is not explained by a neurological condition.
- Psychological factors influencing the onset (e.g., stress, trauma).
- The symptom causes clinically significant distress or impairment.
Treatment Options
Treatment is multimodal, targeting both the physical manifestation (the seizures) and the underlying psychological drivers.
Psychotherapy
- Cognitive‑Behavioral Therapy (CBT) – Structured programs teach patients to identify triggers, develop coping skills, and gradually reduce seizure frequency. Meta‑analyses show a 30‑50 % reduction in episodes after 12‑week CBT courses.[5] NIH
- Trauma‑Focused Therapies – EMDR (Eye Movement Desensitization and Reprocessing) and prolonged exposure therapy are effective for patients with a documented abuse history.
- Psychodynamic Therapy – Helps uncover unconscious conflicts that may be expressed somatically.
Medication
There is no specific pharmacologic cure for QES, but medications are useful when comorbid psychiatric conditions are present.
- Selective Serotonin Reuptake Inhibitors (SSRIs) – For depression or anxiety.
- Atypical Antipsychotics – Low‑dose aripiprazole or quetiapine may help in patients with severe emotional dysregulation.
- Avoidance of Unnecessary Antiepileptic Drugs (AEDs) – Discontinuation should be supervised by a neurologist to prevent withdrawal seizures if true epilepsy is later confirmed.
Physical & Occupational Therapy
These disciplines assist patients in regaining confidence in motor function, particularly when fear of having another event limits daily activity.
Multidisciplinary Clinics
Many tertiary hospitals now offer combined neurology‑psychiatry programs. A coordinated approach shortens the time to accurate diagnosis (average reduction from 8 years to <2 years) and improves long‑term outcomes.[6] Mayo Clinic
Living with Quasi‑epileptic seizures
Even after diagnosis, patients may need practical strategies to manage episodes and maintain quality of life.
Self‑Management Tips
- Maintain a seizure diary – Record date, time, precipitating stressors, duration, and any warning signs. Patterns help tailor therapy.
- Stress‑reduction techniques – Daily mindfulness, deep‑breathing exercises, or yoga can lower baseline anxiety.
- Improve sleep hygiene – Aim for 7‑9 hours of consistent sleep; sleep deprivation can exacerbate both epileptic and psychogenic events.
- Develop a “grounding” plan – During an episode, practice gentle redirection (e.g., ask the person to count backward, talk calmly, or hold a familiar object). Grounding can shorten the event.
- Educate close contacts – Family, teachers, and coworkers who understand the nature of QES are less likely to react with panic, which may reinforce the seizure.
- Regular follow‑up – Schedule appointments every 3‑6 months with both neurology and mental‑health providers.
Work & School Considerations
- Request reasonable accommodations (e.g., flexible deadlines, a quiet space for breaks).
- Provide a brief, physician‑approved letter explaining the diagnosis without disclosing sensitive psychiatric details.
Safety Measures
- Remove potential injury hazards (sharp objects, hot liquids) from areas where seizures occur.
- Use supervision during activities with high injury risk (driving, swimming) until seizures are well controlled.
Prevention
Because QES stem from psychological stressors, primary prevention focuses on early identification and treatment of mental‑health issues.
- Early Trauma Intervention – Prompt counseling after abuse or significant loss reduces the likelihood of conversion symptoms later.
- Screening in High‑Risk Populations – Adolescents with a history of anxiety, depression, or frequent somatic complaints benefit from routine mental‑health assessments.
- Stress‑Management Programs in Schools and Workplaces – Teaching coping skills can lower the overall incidence of functional neurological disorders.
Complications
If left untreated, QES can lead to several medical, psychological, and social consequences:
- Unnecessary medication side effects – Long‑term use of AEDs may cause bone loss, liver toxicity, or cognitive slowing.
- Stigmatization and loss of credibility – Repeated “seizure” episodes may cause friends, employers, or clinicians to doubt the patient’s honesty.
- Secondary injuries – Falls or accidents during an event, especially if occurring near traffic or machinery.
- Worsening psychiatric illness – Anxiety and depression may intensify without proper psychotherapy.
- Reduced quality of life – Persistent episodes can limit social participation, education, and employment.
When to Seek Emergency Care
- Seizure lasting longer than 5 minutes (possible status epilepticus).
- Difficulty breathing, turning blue, or loss of consciousness with no rapid recovery.
- Injury from a fall (head trauma, bleeding, broken bones).
- First‑time seizure‑like episode with no known diagnosis.
- Severe chest pain, palpitations, or sudden severe headache during an event.
Even though QES are not dangerous in the same way as epileptic status, the above situations demand immediate medical attention to rule out true seizures or other serious conditions.
References:
[1] Mayo Clinic. “Psychogenic Nonepileptic Seizures (PNES).” 2023.
[2] World Health Organization. “Epilepsy and Other Neurological Disorders.” 2022.
[3] Centers for Disease Control and Prevention. “Adverse Childhood Experiences (ACEs).” 2021.
[4] Cleveland Clinic. “Video EEG Monitoring for Seizure Differentiation.” 2024.
[5] National Institutes of Health. “Cognitive‑Behavioral Therapy for PNES: Systematic Review.” 2022.
[6] Mayo Clinic Proceedings. “Outcomes of Multidisciplinary Management of PNES.” 2023.