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Quasi‑Seizure (Psychogenic Non‑Epileptic Attack)

What is Quasi‑Seizure (Psychogenic Non‑Epileptic Attack)?

A quasi‑seizure, more formally called a psychogenic non‑epileptic attack (PNEA) or psychogenic non‑epileptic seizure (PNES), is an event that looks like an epileptic seizure but does not have the characteristic electrical discharges in the brain that define epilepsy. Instead, the episode is produced by psychological factors—often as a manifestation of stress, trauma, or underlying mental‑health conditions.

People experiencing PNEA may have shaking, loss of consciousness, drooling, or urinary incontinence, similar to an epileptic seizure. However, the underlying mechanism is functional rather than structural: the brain’s wiring is intact, but emotional or cognitive triggers generate the abnormal motor and sensory response.

Recognizing PNEA is crucial because the treatment pathway differs from that of epilepsy; antiepileptic drugs (AEDs) are generally ineffective and may expose patients to unnecessary side‑effects.

Sources: Mayo Clinic, National Institute of Neurological Disorders and Stroke (NINDS), 2023.

Common Causes

Psychogenic non‑epileptic attacks arise from a complex interplay of psychological, social, and biological factors. Below are the most frequently identified contributors:

• Stressful life events – bereavement, divorce, job loss, or academic pressure.
• History of trauma – physical, sexual, or emotional abuse, especially when untreated.
• Underlying psychiatric disorders – borderline personality disorder, depression, anxiety disorders, or post‑traumatic stress disorder (PTSD).
• Somatic symptom disorder – excessive focus on physical symptoms without a medical cause.
• Conversion disorder (functional neurological symptom disorder) – neurological symptoms that arise unconsciously in response to psychological conflict.
• Substance use or withdrawal – alcohol, benzodiazepines, or stimulants can precipitate episodes.
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• Medication side‑effects – certain psychotropic drugs may lower seizure threshold or cause motor manifestations.
• Family or cultural influences – observing seizures in a family member can create a learned response.
• Sleep deprivation – chronic poor sleep worsens emotional regulation.
• Chronic pain or medical illness – ongoing physical discomfort can amplify stress and trigger functional seizures.

Associated Symptoms

While the hallmark of PNEA is the seizure‑like event, many patients report additional symptoms that can help distinguish it from epilepsy:

• Prolonged “aura” feeling of anxiety or dread before the event.
• Fluctuating intensity; the same person may have mild shaking one day and a full‑body convulsion another.
• Preserved awareness or rapid recovery (often within seconds to a few minutes).
• Non‑stereotyped movements—e.g., asynchronous limb jerking, side‑to‑side head turning.
• Pelvic thrusting or vocalizations that are uncommon in epileptic seizures.
• Absence of post‑ictal confusion or deep fatigue.
• Emotional lability—crying, screaming, or pleading during the episode.
• History of psychiatric symptoms such as depression, anxiety, or dissociation.

When to See a Doctor

Because PNEA mimics epilepsy, any new or unexplained seizure‑like activity warrants prompt medical evaluation. Seek professional care if you notice:

• First‑time seizure‑like episode, regardless of severity.
• Seizure that lasts longer than 5 minutes or clusters (multiple episodes close together).
• Injury during an episode (e.g., head trauma, broken bone).
• Persistent confusion, weakness, or speech difficulty after the event.
• New onset of uncontrolled “seizures” despite being on antiepileptic medication.
• Any seizure accompanied by chest pain, shortness of breath, or palpitations (possible cardiac cause).
• Worsening mental‑health symptoms (depression, suicidal thoughts) alongside the attacks.

Early evaluation can prevent unnecessary medication, reduce stigma, and open the door to appropriate therapy.

Diagnosis

Diagnosing PNEA is a stepwise process that combines clinical assessment, neurophysiological testing, and exclusion of other causes.

1. Detailed History & Physical Examination

• Chronology of events (frequency, triggers, duration).
• Psychosocial background – recent stressors, trauma, psychiatric history.
• Medication review, substance use, sleep patterns.

2. Video‑Electroencephalography (Video‑EEG) Monitoring

This is the gold‑standard test. The patient is recorded with simultaneous EEG and video for several hours (or days in an epilepsy monitoring unit). Key findings for PNEA:

• Absence of ictal EEG changes during the clinically observed event.
• Normal background EEG inter‑ictally.

3. Neuroimaging

CT or MRI is performed to rule out structural brain lesions that could cause seizures.

4. Laboratory Tests

• Basic metabolic panel, glucose, calcium, magnesium.
• Toxicology screen if substance use is suspected.

5. Psychiatric Evaluation

A mental‑health professional assesses for mood, anxiety, trauma, and somatic‑symptom disorders. Standardized tools such as the PHQ‑9 (depression) or GAD‑7 (anxiety) may be used.

6. Differential Diagnosis

Clinicians must rule out true epileptic seizures, cardiac arrhythmias, syncope, sleep disorders, and movement disorders.

Treatment Options

Management of PNEA requires a multidisciplinary approach that addresses both the physical manifestations and the underlying psychological drivers.

1. Education & Reassurance

Explaining the diagnosis in clear, non‑blaming language is therapeutic. Emphasize that the brain is not “damaged” and that symptoms are treatable.

2. Psychotherapy

• Cognitive‑Behavioral Therapy (CBT) – helps patients identify triggers, develop coping skills, and reduce seizure frequency.
• Dialectical Behavior Therapy (DBT) – useful when emotional dysregulation or borderline personality features are present.
• Trauma‑Focused therapies (e.g., EMDR, prolonged exposure) for individuals with a history of abuse.

3. Psychiatric Medication

While AEDs are ineffective, appropriate psychotropic drugs can treat comorbid mood or anxiety disorders:

• Selective serotonin reuptake inhibitors (SSRIs) for depression/anxiety.
• Serotonin‑norepinephrine reuptake inhibitors (SNRIs) when pain is a component.
• Atypical antipsychotics for severe dysregulation or psychosis.

Medication should be titrated by a psychiatrist familiar with functional neurological disorders.

4. Stress‑Management & Lifestyle Strategies

• Regular aerobic exercise (30 min, 3‑5 times/week) improves mood and neuroplasticity.
• Sleep hygiene – aim for 7‑9 hours, consistent bedtime.
• Mind‑body practices: meditation, yoga, progressive muscle relaxation.
• Limit caffeine and alcohol, which can exacerbate anxiety.

5. Multidisciplinary Clinics

Many academic centers now offer dedicated functional seizure clinics that bring together neurology, psychiatry, psychology, and social work. Referral to such a program improves outcomes (reported remission rates up to 50 % in 2 years) — see Cleveland Clinic’s functional seizure program.

6. Family & Social Support

Educating caregivers helps prevent reinforcement of the behavior and encourages supportive coping.

Prevention Tips

While a single “trigger” may not be identifiable, the following strategies lower the risk of recurrent attacks:

• Identify personal triggers – keep a diary of events, stressors, sleep, and diet preceding attacks.
• Maintain regular mental‑health follow‑up – attend therapy appointments and take prescribed meds consistently.
• Develop a crisis plan – know who to call, grounding techniques, and safe space strategies.
• Engage in structured daily routine – reduces unpredictability that fuels anxiety.
• Limit exposure to seizure‑like media – excessive viewing of seizure videos can act as a visual trigger.
• Practice relaxation before high‑stress situations – 5‑minute deep‑breathing or box‑breathing.
• Seek early help for new stressors – proactive counseling after major life changes.

Emergency Warning Signs

Key Take‑aways

• Quasi‑seizures are real, disabling events driven by psychological factors, not abnormal brain electricity.
• A thorough evaluation—including video‑EEG—distinguishes PNEA from epilepsy.
• Effective treatment combines patient education, psychotherapy, appropriate psychiatric medication, and lifestyle modifications.
• Early specialist involvement and a supportive environment dramatically improve long‑term outcomes.

For personalized guidance, please consult a neurologist or a mental‑health professional experienced in functional neurological disorders.

References:

1. Mayo Clinic. Psychogenic non‑epileptic seizures (PNES). 2023.
2. National Institute of Neurological Disorders and Stroke. “Psychogenic Non‑Epileptic Seizures Fact Sheet.” 2022.
3. Cleveland Clinic. Functional Seizure Program. Accessed July 2024.
4. World Health Organization. International Classification of Diseases (ICD‑11) – Dissociative (Conversion) Disorders. 2023.
5. American Academy of Neurology. Practice Guidelines for Video‑EEG Monitoring. 2021.

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