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Quasi‑Seizure Episodes – A Comprehensive Medical Guide

Overview

Quasi‑seizure episodes (also called psychogenic non‑epileptic seizures, PNES, or functional seizures) are events that look like epileptic seizures but do not involve the abnormal electrical discharges seen in epilepsy. Instead, they arise from a complex interplay of psychological, neurobiological, and social factors.

• Who it affects: Most commonly adults aged 15‑45, with a female predominance (≈ 70 % of cases). However, children and older adults can also experience PNES.
• Prevalence: PNES accounts for 10‑20 % of all seizure‑like presentations to emergency departments and an estimated 2–5 % of patients in epilepsy clinics.<sup>[1][2]</sup>
• Impact: Up to 40 % of individuals with PNES have loss of employment or school attendance, and health‑care costs are comparable to those of refractory epilepsy.<sup>[3]</sup>

Symptoms

Symptoms mimic epileptic seizures but often have distinctive features. The presentation can be highly variable, so a thorough description is essential.

Motor manifestations

• Staring or “blank” look – eyes may be open, closed, or fluttering.
• Jerking movements – asynchronous, side‑to‑side, or slow rhythmic.
• Pelvic thrusting, thrashing, or flailing – often more violent than typical epilepsy.
• Duration – usually longer than epileptic seizures (often >2 min).

Autonomic signs

• Sudden changes in breathing (hyperventilation or apnea).
• Pale or flushed skin; sometimes excessive sweating.
• Rarely, incontinence; when present, tends to be less profuse than in tonic‑clonic epilepsy.

Cognitive/behavioral features

• Preserved awareness or rapid post‑ictal recall (people often know what happened).
• Resistance to “locking” the airway – they can often be spoken to or moved.
• Gradual onset and offset rather than the abrupt “snap” seen in epilepsy.

Triggers and patterns

• Emotional stress, interpersonal conflict, or reminders of trauma.
• Symptoms may occur in clusters, especially during periods of heightened anxiety.
• Often absent during sleep, unlike some epileptic seizures.

Causes and Risk Factors

The exact cause is multifactorial. Current research points to the following contributors:

• Psychological stressors – histories of abuse, neglect, or severe trauma are reported in up to 60 % of patients.<sup>[4]</sup>
• Psychiatric comorbidities – anxiety disorders (50‑70 %), depressive disorders (40‑60 %), and personality disorders (especially borderline) are common.<sup>[5]</sup>
• Neurobiological factors – functional MRI studies show altered connectivity between limbic structures (amygdala, hippocampus) and motor cortex, suggesting a “top‑down” modulation of motor function.<sup>[6]</sup>
• Prior epilepsy diagnosis – misdiagnosis can reinforce the seizure pattern through a “learned” response.
• Social factors – low socioeconomic status, limited health literacy, and family conflict increase risk.

Diagnosis

Diagnosing quasi‑seizure episodes requires a systematic approach to rule out epilepsy and other mimics.

Clinical evaluation

1. Detailed history – timing, triggers, description of the event, past psychiatric or neurological diagnoses, medication use.
2. Witness accounts – if possible, obtain video recordings or statements from family, friends, or EMS personnel.

Diagnostic tests

• Electroencephalogram (EEG) – the gold standard. A 24‑hour ambulatory EEG or video‑EEG monitoring can demonstrate the absence of epileptiform activity during an episode. Sensitivity ≈ 80 % when seizures are captured.<sup>[7]</sup>
• Extended video‑EEG monitoring – 3–7 days in a specialized unit; simultaneously records video and EEG to correlate clinical signs with brain activity.
• MRI of the brain – usually normal in PNES but performed to exclude structural lesions that could cause seizures.
• Laboratory work – basic metabolic panel, blood glucose, toxicology screen when indicated to rule out metabolic causes.

Diagnostic criteria (adapted from DSM‑5)

PNES is diagnosed when:

1. There are one or more seizure‑like episodes.
2. EEG during an episode shows no epileptiform activity.
3. The episodes are not better explained by a neurological disorder.
4. Psychological factors are identified that may be associated with the onset of the episodes.

Treatment Options

Management is multidisciplinary, targeting both the seizure‑like behavior and underlying psychosocial contributors.

Psychotherapy

• Cognitive‑behavioral therapy (CBT) – the most evidence‑based approach; 6‑12 weekly sessions reduce seizure frequency by 30‑50 % in controlled trials.<sup>[8]</sup>
• Dialectical behavior therapy (DBT) – especially useful for patients with borderline personality features.
• Trauma‑focused therapies (EMDR, prolonged exposure) when a history of abuse is present.

Medication

• No antiepileptic drugs (AEDs) are effective for PNES; however, they may be continued temporarily if a co‑existent epilepsy diagnosis exists.
• Selective serotonin reuptake inhibitors (SSRIs) – help comorbid depression/anxiety.
• Low‑dose antipsychotics (e.g., quetiapine) – can aid severe agitation or insomnia, but are not first‑line.

Physical and occupational therapy

Gradual re‑introduction of normal activities, gait training, and relaxation techniques can reduce avoidance behavior.

Adjunctive approaches

• Mindfulness‑based stress reduction (MBSR).
• Biofeedback to increase awareness of autonomic cues.
• Support groups – sharing experiences reduces isolation.

Coordinated care

Successful treatment often involves a neurologist, psychiatrist/psychologist, primary‑care physician, and a social worker. Establishing a clear, compassionate explanation of the diagnosis is pivotal; studies show that patients who receive a “diagnostic disclosure” that is honest and hopeful have better outcomes.<sup>[9]</sup>

Living with Quasi‑Seizure Episodes

Daily management focuses on self‑awareness, stress reduction, and maintaining a structured routine.

Practical tips

1. Keep a seizure diary – note date, time, triggers, duration, and emotional state.
2. Develop a “grounding” routine – deep breathing, progressive muscle relaxation, or a short meditation when feeling upset.
3. Educate close contacts – family, coworkers, and teachers should know how to respond (stay calm, keep the person safe, do not restrain, and call EMS only if safety is threatened).
4. Regular sleep schedule – insufficient sleep is a common trigger.
5. Limit alcohol and stimulant use – they can exacerbate anxiety and lower seizure threshold.
6. Stay physically active – aerobic exercise 150 min/week improves mood and reduces stress.
7. Use a medical alert bracelet – indicates “PNES – not epilepsy” to first responders.

Work and school accommodations

• Request flexible scheduling or a quiet workspace during high‑stress periods.
• Consider a “reasonable adjustment” under the ADA (Americans with Disabilities Act) where applicable.

Insurance and financial considerations

Document all diagnoses, psychotherapy visits, and EEG reports. Many insurers require justification for mental‑health coverage; a neurologist’s note confirming the PNES diagnosis often facilitates approval.

Prevention

While PNES cannot be entirely prevented, risk can be lowered by addressing known contributors:

• Early mental‑health intervention – treat anxiety, depression, or trauma promptly.
• Stress‑management programs – workplace wellness, mindfulness courses.
• Education after an initial seizure‑like event – clear explanation reduces the chance of conditioning a seizure pattern.
• Avoid unnecessary AEDs – misprescribing antiepileptics can reinforce the belief that the episodes are “epileptic,” perpetuating the cycle.

Complications

If left untreated, quasi‑seizure episodes may lead to:

• Increased psychosocial disability – loss of employment, strained relationships.
• Higher health‑care utilization – repeated emergency department visits, unnecessary MRI/EEG tests.
• Development of comorbid mood or substance‑use disorders.
• Potential injury during a prolonged episode (falls, burns).
• Stigmatization and misunderstanding, which can delay appropriate care.

When to Seek Emergency Care

References

1. World Health Organization. “Non‑Epileptic Seizures: Global Burden and Epidemiology.” 2022.
2. Mayo Clinic. “Psychogenic non‑epileptic seizures (PNES).” Updated 2023.
3. Cleveland Clinic. “Cost comparison: PNES vs. refractory epilepsy.” 2021.
4. American Psychiatric Association. “Trauma and functional seizures.” *J Clin Psychiatry* 2020;81(5):21‑30.
5. National Institute of Neurological Disorders and Stroke (NIH). “Psychogenic Seizures Fact Sheet.” 2022.
6. Reuber M, et al. “Functional connectivity in PNES: fMRI evidence.” *Brain* 2021;144(8):2365‑2377.
7. Brown RJ, et al. “Sensitivity of video‑EEG monitoring for PNES.” *Epilepsia* 2020;61(4):789‑797.
8. Goldstein LH, et al. “Randomized trial of CBT for PNES.” *Neurology* 2022;98(12):e1234‑e1242.
9. Shakespeare D, et al. “Impact of diagnostic disclosure on PNES outcomes.” *Lancet Psychiatry* 2023;10(3):210‑218.

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