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Quasi‑seizure Activity

What is Quasi‑seizure activity?

Quasi‑seizure activity, also called psychogenic nonepileptic seizures (PNES) or functional seizures, refers to episodes that look like epileptic seizures but are not caused by abnormal electrical discharges in the brain. Instead, they arise from a complex interaction of psychological, neurological, and social factors. Because the outward signs (shaking, loss of consciousness, abnormal movements) can mimic true epilepsy, the condition is often misdiagnosed initially.

People experiencing quasi‑seizures may feel a loss of control, sudden “blank outs,” or involuntary movements that can last from a few seconds to several minutes. While the episodes are real and distressing, they do not cause the same brain injury risk as epileptic seizures. Nevertheless, they can lead to reduced quality of life, injury during a fall, and unnecessary medication use if not correctly identified.

Common Causes

Quasi‑seizure activity is usually rooted in emotional or psychological stressors rather than a single disease. The most frequently reported underlying conditions include:

• Post‑traumatic stress disorder (PTSD): Exposure to traumatic events can trigger dissociative episodes that manifest as seizures.
• Depression and anxiety disorders: Chronic stress, panic attacks, and severe depressive states are strong contributors.
• Conversion disorder (functional neurological symptom disorder): The brain “converts” emotional distress into physical symptoms.
• Borderline personality disorder: Emotional dysregulation may precipitate brief seizure‑like events.
• History of childhood abuse or neglect: Early life trauma is a well‑documented risk factor for PNES.
• Somatic symptom disorder: Excessive focus on physical symptoms without a medical cause can evolve into seizure‑like activity.
• Substance use or withdrawal: Alcohol, benzodiazepines, or recreational drugs can precipitate dissociative episodes that resemble seizures.
• Medical “brain‑injury” mimics: Conditions such as mild traumatic brain injury, migraines, or sleep deprivation may exacerbate PNES.
• Family or social modeling: Observing seizures in a close family member can unconsciously influence symptom development.
• Psychosocial stressors: Relationship problems, financial hardship, or major life changes can act as triggers.

It is important to note that many patients have more than one of these risk factors, and the exact cause often remains a combination of several influences.

Associated Symptoms

Quasi‑seizure episodes frequently occur together with other physical or psychological signs. Commonly reported co‑symptoms include:

• Headaches or migraine‑like pain
• Palpitations or feeling “light‑headed”
• Chest tightness or shortness of breath
• Muscle tension or unexplained aches
• Dissociation (feeling detached from self or surroundings)
• Memory gaps surrounding the event
• Emotional lability – sudden crying, anger, or fear
• Sleep disturbances (insomnia, night terrors)
• Fatigue and reduced concentration after an episode
• Injury from falls during the event (abrasions, bruises)

When to See a Doctor

Because quasi‑seizure activity can be mistaken for epilepsy, any new or unexplained seizure‑like episode warrants professional evaluation. Seek medical attention promptly if you notice:

• First‑time seizure‑like activity, especially after a head injury.
• Loss of consciousness lasting longer than 5 minutes.
• Injury during the episode (e.g., head wound, broken bone).
• Repeated episodes that interfere with work, school, or daily responsibilities.
• Signs of depression, anxiety, or suicidal thoughts accompanying the events.
• Recent major stressors (bereavement, divorce, job loss) that precede the episodes.
• Any new medication that could lower seizure threshold.

When in doubt, schedule a visit with a primary‑care physician or neurologist. Early assessment can prevent unnecessary antiepileptic drug use and guide you to appropriate mental‑health support.

Diagnosis

Diagnosing quasi‑seizure activity is a stepwise process that combines neurological evaluation with psychiatric assessment.

1. Detailed Clinical History

The physician will ask about the onset, duration, triggers, and description of the events, as well as any past psychiatric or medical diagnoses. Witness accounts (family, friends) are especially valuable.

2. Physical & Neurological Examination

A thorough neurologic exam helps rule out focal deficits, weakness, or sensory changes that would suggest true epilepsy.

3. Electroencephalogram (EEG)

Standard scalp EEG is the cornerstone test. In true epileptic seizures, the EEG shows abnormal, synchronized electrical discharges. In PNES, the EEG remains normal during the event, though a video‑EEG monitoring (simultaneous video and EEG) is the gold standard because it captures the episode while correlating clinical signs with electrical activity.

4. Neuroimaging

MRI of the brain is often performed to exclude structural lesions (tumors, cortical dysplasia) that could cause seizures.

5. Psychiatric Evaluation

A mental‑health professional assesses for trauma history, mood disorders, and dissociative features. Standardized questionnaires (e.g., PHQ‑9, GAD‑7, Dissociative Experiences Scale) are useful.

6. Laboratory Tests (if indicated)

Blood work may be ordered to rule out metabolic causes (electrolyte imbalance, thyroid dysfunction) that can mimic seizures.

Diagnostic Criteria

According to the International League Against Epilepsy (ILAE) and the American Psychiatric Association, a diagnosis of PNES is made when:

• Clinical episodes resemble epilepsy, and
• EEG during the episode is normal, or
• Video‑EEG shows no epileptiform activity during the event.

Treatment Options

Treatment is multidisciplinary, focusing on both the seizure‑like manifestations and the underlying psychological drivers.

1. Psychotherapy

• Cognitive‑Behavioral Therapy (CBT): The most evidence‑based approach for PNES. CBT helps patients identify triggers, develop coping skills, and reduce episode frequency.
• Dialectical Behavior Therapy (DBT): Effective for patients with borderline personality features or severe emotional dysregulation.
• Trauma‑Focused Therapies (e.g., EMDR, TF‑CBT): Recommended when PTSD or childhood abuse is a major factor.

2. Medication

• Antidepressants (SSRIs, SNRIs): Helpful for comorbid depression or anxiety.
• Anticonvulsants: Generally NOT indicated for PNES unless the patient also has true epilepsy.
• Low‑dose benzodiazepines: May be used short‑term for acute anxiety but carry dependence risk.

3. Education & Reassurance

Providing a clear explanation that the episodes are real, not “faked,” and that they stem from brain‑body stress pathways reduces stigma and encourages engagement in therapy.

4. Physical & Occupational Therapy

When episodes lead to deconditioning or fear of movement, gradual graded exercise programs can restore confidence and improve overall health.

5. Stress‑Management Techniques

• Mindfulness meditation
• Progressive muscle relaxation
• Breathing exercises (4‑7‑8 technique, box breathing)

6. Support Groups

Connecting with others who experience PNES can reduce isolation and provide practical coping strategies.

Prevention Tips

While not all triggers are avoidable, the following strategies can lower the likelihood of an episode:

• Identify personal triggers: Keep a diary of episodes, stressors, sleep patterns, and caffeine/alcohol intake.
• Maintain regular sleep hygiene: Aim for 7‑9 hours/night; avoid screens before bed.
• Limit stimulant and alcohol use: Both can heighten anxiety and increase dissociative episodes.
• Practice daily stress‑reduction: Incorporate at least 10 minutes of mindfulness or deep‑breathing.
• Stay physically active: Moderate aerobic exercise 3‑5 times per week improves mood and neuro‑regulation.
• Seek early mental‑health support: Address trauma, depression, or anxiety before they become entrenched.
• Build a crisis plan: Have a trusted person and an action plan for when an episode begins (e.g., lay down safely, note time, call a support line).

Emergency Warning Signs

If any of the following occur, call 911 or go to the nearest emergency department immediately:

• First‑time seizure‑like episode with loss of consciousness.
• Severe injury during an episode (head trauma, uncontrolled bleeding).
• Episode lasting longer than 5 minutes or does not resolve with normal breathing.
• Breathing difficulty, chest pain, or signs of a heart attack during or after an event.
• Persistent confusion or inability to awaken after the episode.
• Any signs of suicidal thoughts or self‑harm urges.

References

• Mayo Clinic. “Psychogenic non‑epileptic seizures (PNES).” Link. Accessed May 2026.
• American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM‑5). 2022.
• World Health Organization. “International Classification of Diseases (ICD‑11).” 2022.
• National Institute of Neurological Disorders and Stroke. “Seizures.” Link. 2023.
• Cleveland Clinic. “Psychogenic Non‑Epileptic Seizures (PNES).” Link. 2024.
• Reuber M, et al. “Psychogenic Non‑epileptic Seizures: Pathophysiology and Treatment.” *Lancet Neurology*. 2021;20(8):648‑658.

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