Quasi‑seizure (Psychogenic Non‑Epileptic Seizure)
Overview
Quasi‑seizure, more formally called a psychogenic non‑epileptic seizure (PNES), is a seizure‑like event that looks like an epileptic seizure but originates from psychological rather than electrical disturbances in the brain. The episodes are genuine, involuntary, and often distressing, but they do not show the abnormal neuronal firing patterns seen on an electro‑encephalogram (EEG) during true epilepsy.
Who it affects
- Predominantly women (≈ 70‑80 % of cases)[1]
- Typically begins in late adolescence or early adulthood (average onset 20–30 years)[2]
- People with a history of trauma, anxiety, depression, or other psychiatric disorders are at higher risk[3]
Prevalence
- PNES accounts for 10‑30 % of patients referred to epilepsy centers[4].
- Population‑based studies suggest a prevalence of about 2–5 per 100,000 people[5].
- Up to 30 % of individuals diagnosed with “refractory epilepsy” actually have PNES[6].
Symptoms
PNES can mimic many types of epileptic seizures. The key is that the clinical picture is not accompanied by the characteristic EEG changes. Common symptom clusters include:
Motor Features
- Staring or unresponsiveness – lasting seconds to several minutes.
- Irregular limb movements – flailing, stiffening, or asynchronous jerking.
- Pelvic thrusting or head shaking – more typical of PNES than epilepsy.
- Resistance to eye opening – the patient may keep eyes tightly shut.
- Longer duration – seizures often last > 2 minutes, whereas epileptic seizures usually end within 2 minutes.
Autonomic and Sensory Features
- Flushing, pallor, or cold sweats.
- Breathing changes (hyperventilation or apnea).
- Feelings of unreality, déjà vu, or intense fear.
Behavioral / Psychological Features
- Clustering of episodes around stressful events.
- Pre‑ictal “warning” sensations (e.g., rising anxiety, urge to cry).
- Subjective memory loss for the event (often amnesia is partial, not total).
- Variable symptoms between episodes, unlike the stereotyped pattern of epileptic seizures.
Red‑Flag Features Suggestive of PNES
- Seizure occurring only during daytime, especially in public places.
- Resistance to typical antiepileptic drugs (AEDs) with no improvement.
- History of psychiatric illness, trauma, or abuse.
- Gradual onset and resolution of the episode, rather than an abrupt start/stop.
Causes and Risk Factors
PNES is a complex neuro‑psychological condition. No single cause has been identified; instead, a combination of biological, psychological, and social factors interact.
Psychological Triggers
- Trauma and abuse – physical, sexual, or emotional trauma in childhood or adulthood is the most consistently reported risk factor[7].
- Acute stress – loss, divorce, legal problems, or medical procedures can precipitate episodes.
- Conversion disorder – PNES is classified under “Functional Neurological Symptom Disorder” in DSM‑5, reflecting a subconscious conversion of emotional distress into physical symptoms.
Psychiatric Comorbidities
- Depression (30‑50 % of cases)[8]
- Anxiety disorders, especially panic disorder and PTSD[9]
- Personality disorders, particularly borderline personality disorder[10]
Neurological and Medical Factors
- Co‑existing epilepsy – up to 20 % of patients have both conditions, complicating diagnosis[11].
- Chronic pain, migraines, or other somatic illnesses that increase distress.
Social and Demographic Risk Factors
- Female gender (as noted above).
- Lower socioeconomic status and limited access to mental‑health services.
- History of frequent medical visits or “doctor shopping.”
Diagnosis
Because PNES mimics epilepsy, a careful, stepwise evaluation is essential. The goal is to differentiate PNES from epileptic seizures and to identify any comorbid conditions.
Clinical Evaluation
- Detailed history – onset, frequency, triggers, description of the event, previous diagnoses, medication history, trauma exposure.
- Witness accounts – collateral information from family, friends, or emergency personnel is often decisive.
- Physical & neurological exam – usually normal between episodes; any focal deficits may suggest epilepsy.
Electro‑encephalography (EEG)
- Routine interictal EEG – may be normal; low sensitivity for PNES.
- Video‑EEG monitoring (VEM) – gold standard. Simultaneous video and EEG capture the event; lack of ictal EEG changes confirms PNES.
- Typical VEM duration: 3–7 days, with a diagnostic yield of 70‑90 %[12].
Neuroimaging
- MRI brain is performed to rule out structural lesions (tumors, vascular malformations) that could cause seizures.
- Findings are usually normal in pure PNES, but incidental abnormalities are possible.
Psychiatric Assessment
- Standardized questionnaires: PHQ‑9 (depression), GAD‑7 (anxiety), PTSD Checklist, and the Somatoform Dissociation Questionnaire.
- Structured clinical interview (SCID‑5) for DSM‑5 disorders.
Differential Diagnosis
Important conditions to rule out include:
- Epileptic seizures (focal, generalized, status epilepticus)
- Syncope, cardiac arrhythmias
- Movement disorders (e.g., dystonia)
- Sleep-related events (e.g., REM behavior disorder)
- Migraine with aura
Treatment Options
Effective management requires a biopsychosocial approach: education, psychotherapy, medication for comorbidities, and supportive lifestyle changes.
1. Education & Diagnosis Disclosure
- Provide a clear, empathetic explanation that the episodes are real but not caused by abnormal brain electricity.
- Use visual aids (e.g., video of a captured seizure) to illustrate the difference.
- Reassure patients that the prognosis improves dramatically when they engage in treatment.
2. Psychotherapy
- Cognitive‑Behavioral Therapy (CBT) – the most evidence‑based modality. Techniques include stress‑management, exposure to feared situations, and restructuring maladaptive thoughts. Randomized trials show a 30‑50 % reduction in seizure frequency[13].
- Psychodynamic/Trauma‑focused therapy – useful when a history of abuse is present (e.g., EMDR, narrative exposure therapy).
- Dialectical Behavior Therapy (DBT) – helpful for borderline personality traits and emotion‑regulation difficulties.
3. Pharmacotherapy
There is no medication that directly stops PNES, but drugs can treat underlying psychiatric conditions:
- Antidepressants (SSRIs, SNRIs) – for depression and anxiety.
- Anticonvulsants are NOT indicated for PNES alone, but may be continued if the patient also has epilepsy.
- Low‑dose benzodiazepines – short‑term use for acute anxiety, not recommended for chronic management due to dependence risk.
4. Rehabilitation & Supportive Therapies
- Occupational therapy – strategies for returning to work or school.
- Physical therapy – if deconditioning from frequent seizures has occurred.
- Family counseling – improves understanding, reduces secondary gains, and promotes a supportive environment.
5. Multidisciplinary Care Teams
Best outcomes are achieved when neurologists, psychiatrists/psychologists, epilepsy nurses, and social workers collaborate. Many large epilepsy centers now have dedicated PNES clinics.
Living with Quasi‑seizure (psychogenic non‑epileptic seizure)
Adapting daily life is essential for reducing seizure frequency and improving quality of life.
Practical Tips
- Maintain a seizure diary – note date, time, triggers, mood, sleep, and duration. Patterns often emerge.
- Prioritize sleep hygiene – aim for 7–9 hours; sleep deprivation is a common trigger.
- Stress‑management toolbox – mindfulness meditation, progressive muscle relaxation, or breathing exercises practiced daily.
- Limit alcohol and recreational drugs – they can lower seizure threshold and worsen anxiety.
- Exercise regularly – moderate aerobic activity (30 min most days) reduces anxiety and improves mood.
- Educate close contacts – let family, friends, and coworkers know how to respond (e.g., stay calm, prevent injury, time the episode, and do not administer rescue medications unless prescribed).
- Workplace accommodations – discuss flexible scheduling or a quiet space to practice calming techniques.
- Plan for emergencies – carry a card or medical alert bracelet stating “PNES – not epilepsy; call emergency services if seizure lasts > 5 minutes or injury occurs.”
Self‑Advocacy
Because PNES is often misunderstood, patients may encounter skepticism. Having written summaries of diagnoses, videos of captured events, and a list of supportive clinicians can help navigate healthcare encounters.
Prevention
While PNES cannot be entirely prevented, risk can be reduced by addressing underlying factors.
- Early treatment of trauma – trauma‑focused psychotherapy after adverse events.
- Screen for anxiety/depression in primary care and treat promptly.
- Educate patients with epilepsy about PNES to avoid misdiagnosis and unnecessary medication escalations.
- Develop healthy coping skills – problem‑solving training, assertiveness, and emotion regulation.
- Maintain regular medical follow‑up – especially after a new seizure‑like event.
Complications
If left untreated, PNES can lead to significant physical, psychological, and socioeconomic consequences.
- Injury – falls, fractures, or head trauma during prolonged episodes.
- Medical over‑utilization – repeated ER visits, unnecessary AEDs, and costly investigations.
- Mental health decline – worsening depression, anxiety, or development of substance‑use disorders.
- Functional impairment – loss of employment, school dropout, or reliance on disability benefits.
- Social stigma – misunderstanding can lead to isolation, marital strain, or legal issues (e.g., driving restrictions).
When to Seek Emergency Care
Call 911 or go to the nearest emergency department if:
- The episode lasts longer than 5 minutes (possible status epilepticus or true seizure).
- The individual sustains a head injury, bleeds, or shows signs of fracture.
- Breathing becomes labored, lips turn blue, or there is loss of consciousness with no return within a few minutes.
- The person is pregnant, has a known cardiac condition, or is diabetic with altered mental status.
- There is any doubt whether the event is a seizure versus a medical emergency (e.g., chest pain, severe abdominal pain, sudden weakness).
Even after emergency care, follow up promptly with a neurologist or epilepsy center for definitive diagnosis.
References
- World Health Organization. “Epilepsy Fact Sheet.” 2022.
- Reuber M, et al. “Psychogenic non‑epileptic seizures: a review of the literature.” *Neurology* 2020;94:e726‑e738.
- American Psychiatric Association. DSM‑5. 2013.
- Benbadis SR, et al. “Epilepsy misdiagnosis and the frequency of psychogenic nonepileptic seizures.” *Epilepsia* 2011;52(3):495‑502.
- LaFrance WC Jr, et al. “Incidence and prevalence of psychogenic nonepileptic seizures.” *Epilepsy Behav* 2019;93:10‑14.
- Gilliam FG, et al. “Psychogenic nonepileptic seizures in a tertiary epilepsy center.” *Neurology* 2010;75:208‑214.
- Goldstein LH, et al. “The relationship of trauma to psychogenic nonepileptic seizures.” *Lancet Psychiatry* 2015;2:362‑371.
- Cleveland Clinic. “Depression and Anxiety in PNES.” 2023.
- Centers for Disease Control and Prevention. “Post‑Traumatic Stress Disorder.” 2022.
- Stuart BB, et al. “ Personality disorders in patients with PNES.” *Psychosomatics* 2021;62(4):411‑418.
- Devinsky O, et al. “Co‑occurrence of epilepsy and psychogenic nonepileptic seizures.” *Lancet Neurology* 2018;17:869‑878.
- Rivkind A, et al. “Video‑EEG monitoring for diagnosis of PNES: a systematic review.” *Epilepsia* 2014;55(10):1677‑1684.
- Kramer LA, et al. “Cognitive‑behavioral therapy for psychogenic nonepileptic seizures.” *JAMA Psychiatry* 2020;77(5):480‑488.