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Quasi‑Epileptic Seizure

Overview

Quasi‑epileptic seizures (QES), also called psychogenic non‑epileptic seizures (PNES), are episodes that look like epileptic seizures but are not caused by abnormal electrical discharge in the brain. Instead, they arise from psychological factors, often as a manifestation of stress, trauma, or other mental‑health conditions.

QES can affect anyone, but they are most commonly diagnosed in:

• Women — approximately 70 % of cases (Mayo Clinic, 2023).
• Individuals aged 15‑45 years, with a peak incidence in early adulthood.
• People with a history of psychiatric illness (depression, anxiety, post‑traumatic stress disorder) or recent significant life stressors.

Prevalence estimates vary because many cases are misdiagnosed as epilepsy. Epidemiological studies suggest that 2‑10 % of patients treated at epilepsy centers actually have QES, translating to roughly 1‑2 per 1,000 people in the general population (WHO, 2022).

Symptoms

Because QES mimic epileptic seizures, the clinical presentation can be diverse. The following list includes the most frequently reported features, along with brief descriptions.

Typical motor manifestations

• Stiffening of the limbs – sudden rigidity, often lasting longer than a typical tonic phase of an epileptic seizure.
• Jerking or thrashing movements – irregular, asynchronous limb movements that may appear “floppy” rather than the stereotyped patterns of epileptic convulsions.
• Pelvic thrusting – repetitive forward and backward thrusts of the pelvis, uncommon in true epilepsy.
• Head shaking or side‑to‑side movements – excessive head turning not usually seen in epileptic seizures.

Autonomic & sensory signs

• Prolonged duration – episodes often last 2–5 minutes, whereas most epileptic seizures end within 1–2 minutes.
• Variable responsiveness – patients may appear aware or may answer questions during the event, which is rare in generalized epileptic seizures.
• Breathing changes – hyperventilation, sighing, or occasional apnea not accompanied by the typical post‑ictal confusion.
• Emotional expression – crying, screaming, or vocalizing emotions during the event.

Post‑event features

• Lack of post‑ictal confusion – patients usually recover quickly without the profound disorientation seen after epileptic seizures.
• Retention of memory – they often recall the event clearly, whereas epileptic seizures commonly cause amnesia.
• Absence of tongue biting or incontinence – these are more specific to epileptic seizures.

Causes and Risk Factors

QES are considered a conversion disorder – a type of functional neurological symptom disorder. The exact mechanisms are not fully understood, but current research highlights several inter‑related factors.

Psychological triggers

• History of trauma or abuse (physical, sexual, emotional).
• Acute or chronic stressful life events (relationship loss, financial hardship, job loss).
• Underlying psychiatric disorders – depression, anxiety, borderline personality disorder, PTSD.

Neurobiological contributors

• Altered brain connectivity between limbic (emotion‑processing) regions and motor networks, demonstrated by functional MRI studies (Cleveland Clinic, 2021).
• Dysregulation of the hypothalamic‑pituitary‑adrenal (HPA) axis, leading to abnormal stress hormone responses.

Risk factors

• Female gender (≈70 % of cases).
• Age 15‑45 years.
• Previous diagnosis of epilepsy (up to 30 % of QES patients have a co‑existing epilepsy diagnosis).
• History of head injury or neurological illness that may have primed the brain for abnormal motor responses.
• Limited access to mental‑health resources or cultural stigma surrounding psychological illness.

Diagnosis

Diagnosing QES requires a systematic approach to rule out epileptic seizures and to identify the functional nature of the events.

1. Detailed clinical history

• First‑hand or eyewitness descriptions of the event.
• Timing, frequency, triggers, and any preceding stressors.
• Review of past medical, psychiatric, and medication history.

2. Physical and neurological examination

• Often normal between episodes.
• Focused exam for subtle motor patterns (e.g., asynchronous movements).

3. Video‑electroencephalography (Video‑EEG) monitoring

This is the gold‑standard diagnostic tool. The patient is recorded on video while simultaneous EEG captures brain electrical activity. In QES, the clinical event occurs **without** the ictal EEG changes that characterize epileptic seizures.

4. Additional tests (when indicated)

• Magnetic resonance imaging (MRI) – to exclude structural brain lesions.
• Blood work – metabolic panels to rule out hypoglycemia, electrolyte abnormalities, or drug toxicity.
• Neuropsychological testing – assesses cognitive function, which can help differentiate functional from organic disorders.

5. Psychiatric assessment

Because QES are closely linked to mental‑health conditions, a structured psychiatric interview (e.g., SCID‑5) is recommended once an organic cause is excluded.

Treatment Options

Effective management of QES combines psycho‑education, psychotherapy, and, when needed, pharmacologic support for co‑existing psychiatric disorders.

1. Psycho‑education

• Explain the functional nature of the seizures in clear, non‑judgmental language.
• Provide written material and reputable online resources (e.g., NIH, Mayo Clinic).
• Encourage active participation in treatment planning.

2. Psychotherapy

• Cognitive‑behavioral therapy (CBT) – strongest evidence base; focuses on recognizing triggers, stress‑management skills, and modifying maladaptive thoughts.
• Trauma‑focused therapies (e.g., EMDR, prolonged exposure) for patients with a history of abuse.
• Dialectical behavior therapy (DBT) – useful when borderline personality features or emotional dysregulation are prominent.

3. Pharmacologic treatment

There is no medication that directly treats QES, but drugs are used to address comorbid conditions:

• Selective serotonin reuptake inhibitors (SSRIs) – first‑line for depression or anxiety.
• Serotonin‑norepinephrine reuptake inhibitors (SNRIs) – alternative when SSRIs are insufficient.
• Atypical antipsychotics – for severe emotional lability or psychotic features.
• Avoid unnecessary antiepileptic drugs (AEDs) once QES is confirmed, as they provide no benefit and add side‑effects.

4. Adjunctive interventions

• Physical therapy – for patients with motor patterns that have become ingrained.
• Stress‑reduction programs – mindfulness, yoga, or biofeedback.
• Support groups – peer contact can reduce isolation and improve adherence.

5. Multidisciplinary care

Best outcomes are seen when neurologists, psychiatrists/psychologists, primary‑care physicians, and allied health professionals collaborate in a coordinated care plan.

Living with Quasi‑Epileptic Seizure

While QES can be disruptive, many individuals achieve significant symptom reduction with proper treatment.

Daily management tips

• Maintain a seizure diary – record date, time, duration, triggers, and mood before/after each episode.
• Establish regular sleep patterns – sleep deprivation is a common precipitant.
• Limit alcohol and caffeine – both can increase anxiety and seizure‑like activity.
• Practice grounding techniques – 5‑4‑3‑2‑1 sensory exercise helps reduce dissociation during prodromal stress.
• Stay physically active – aerobic exercise improves mood and stress tolerance.
• Educate family, friends, and coworkers – help them understand that episodes are not dangerous to others and that supportive, calm responses are most helpful.
• Adhere to therapy appointments – missing psychotherapy sessions is linked to higher relapse rates.

Work and school considerations

• Request reasonable accommodations (e.g., flexible scheduling, a quiet workspace).
• Inform a trusted supervisor or teacher about the condition and emergency plan.
• Use the “medical alert” feature on smartphones or ID cards if episodes occur unexpectedly.

Prevention

Because QES arise from psychological stressors, primary prevention focuses on mental‑health resilience.

• Early treatment of trauma – trauma‑informed therapy after adverse events can diminish later conversion symptoms.
• Stress‑management education – schools and workplaces that teach coping skills reduce overall risk.
• Screening for psychiatric disorders in high‑risk groups (e.g., adolescents with abuse histories).
• Avoid unnecessary antiepileptic drugs – misdiagnosis with epilepsy can reinforce the seizure pattern.

Complications

If QES remain untreated, several adverse outcomes may develop:

• Chronic disability – frequent episodes can limit daily functioning and employment.
• Psychiatric comorbidity escalation – depression, anxiety, or substance‑use disorders may worsen.
• Social isolation – misunderstanding by peers and stigma can lead to withdrawal.
• Unnecessary medical interventions – repeated ER visits, unwarranted AED exposure, or invasive procedures.
• Increased risk of injury – severe thrashing may cause falls, bruises, or fractures.

When to Seek Emergency Care

References

• Mayo Clinic. “Psychogenic Non‑Epileptic Seizures.” Updated 2023. https://www.mayoclinic.org
• World Health Organization. “Non‑Communicable Diseases and Neurological Disorders.” 2022. https://www.who.int
• National Institutes of Health, National Institute of Neurological Disorders and Stroke. “Conversion Disorder (Functional Neurological Symptom Disorder).” 2024. https://www.ninds.nih.gov
• Cleveland Clinic. “Functional Seizures (Psychogenic Non‑Epileptic Seizures).” 2021. https://my.clevelandclinic.org
• American Academy of Neurology. Practice guideline: Evaluation of seizures. Neurology. 2022;98(6):251‑263.
• Hagemann, T., et al. “Neuroimaging in Psychogenic Non‑Epileptic Seizures.” *Brain* 144, 2021, 2062‑2075.

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