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Quasi‑Seizure (Nonepileptic Attack)

What is Quasi‑Seizure (Nonepileptic Attack)?

A quasi‑seizure, also called a psychogenic nonepileptic attack (PNEA) or functional seizure, is an event that looks like an epileptic seizure but does not involve the abnormal electrical discharges in the brain that define epilepsy. Instead, the episode is produced by psychological or physiologic mechanisms such as stress, trauma, or certain medical conditions. Because the outward signs (staring, convulsions, loss of tone, etc.) can be indistinguishable from true epileptic seizures, a careful evaluation is essential.

Quasi‑seizures are classified under the broader category of functional neurological symptom disorders in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM‑5). They are not “faked” or “voluntary” – the person is typically unaware that the episode is driven by non‑epileptic mechanisms and may experience real distress and disability.

Sources: Mayo Clinic, Mayo Clinic – Psychogenic non‑epileptic seizures; CDC, CDC – PNEA.

Common Causes

Quasi‑seizures can arise from a variety of underlying factors. The most frequent contributors include:

• Psychological stress or trauma: History of physical, sexual, or emotional abuse, sudden loss, or chronic stress.
• Conversion disorder: A type of somatic symptom disorder where emotional conflicts are expressed as neurological symptoms.
• Borderline personality disorder: Emotional dysregulation can trigger dissociative episodes that mimic seizures.
• Post‑traumatic stress disorder (PTSD): Flashbacks or dissociative states may present as nonepileptic attacks.
• Depression and anxiety disorders: Severe anxiety or panic can precipitate brief loss of consciousness or motor symptoms.
• Somatic symptom disorder: Persistent preoccupation with health can lead to functional neurological manifestations.
• Substance use or withdrawal: Alcohol, benzodiazepines, or illicit drugs can provoke episodes that resemble seizures.
• Sleep deprivation or circadian rhythm disruption: Extreme fatigue can lower the threshold for dissociative events.
• Medical conditions that affect the brain's circuitry: Head injury, cerebrovascular disease, or neurodegenerative disorders may coexist and complicate the picture.
• Medication side‑effects: Certain antipsychotics or antidepressants can cause movement disorders that look like seizures.

Associated Symptoms

While the core event resembles a seizure, patients often report additional features that suggest a nonepileptic origin:

• Gradual onset and offset (epileptic seizures usually begin and end abruptly).
• Preserved awareness or rapid return to baseline after the event.
• Asynchronous or side‑to‑side limb movements, or “flopping” rather than rhythmic jerking.
• Eye closure during the episode (people with true seizures typically keep eyes open).
• Resistance to eye‑opening or “flaccidity” when gently lifted.
• Provocation by emotional triggers (e.g., arguments, stressful situations).
• Absence of post‑ictal confusion, severe fatigue, or tongue biting.
• Unusual or prolonged crying, screaming, or vocalizations during the episode.
• History of other functional symptoms such as non‑dermatomal numbness, gait disturbances, or vision changes.

When to See a Doctor

Because quasi‑seizure and epileptic seizure are difficult to differentiate without testing, any new or unexplained seizure‑like event warrants prompt medical attention. Seek professional help if you notice:

• First‑time seizure‑like activity, especially if it lasts longer than 5 minutes.
• Injury during the episode (falls, head trauma, cuts).
• Repeated episodes that are worsening in frequency or severity.
• Signs of breathing difficulty, chest pain, or loss of consciousness that lasts >2 minutes.
• Associated fever, severe headache, stiff neck, or rash (possible meningitis or encephalitis).
• Any known neurological condition (stroke, brain tumor) that could explain the event.
• Sudden change in mental status, confusion, or difficulty speaking after the event.

If you have a known diagnosis of epilepsy and notice a change in seizure pattern, contact your neurologist promptly.

Diagnosis

Diagnosing a quasi‑seizure requires a systematic approach to rule out epilepsy and identify functional contributors.

1. Detailed Clinical History

• Witness accounts of the event (eye‑witnesses are valuable).
• Timeline of symptoms, triggers, and any preceding stressors.
• Medication list, substance use, and past psychiatric history.

2. Physical & Neurological Examination

• Assess for focal neurological deficits that would suggest a structural brain problem.
• Examine gait, coordination, and sensory function.

3. Electroencephalogram (EEG)

• A standard EEG can capture abnormal electrical activity during a seizure.
• When possible, a video‑EEG monitoring—continuous EEG recorded with video—allows clinicians to compare observed movements with brain wave patterns.
• Typical finding in PNEA: normal EEG during the event.

4. Neuroimaging

• MRI of the brain (with or without contrast) to exclude structural lesions (tumor, scar tissue, vascular malformation).
• CT is reserved for emergent settings (e.g., after head trauma).

5. Psychological Evaluation

• Screening tools such as the Patient Health Questionnaire‑9 (PHQ‑9), Generalized Anxiety Disorder‑7 (GAD‑7), and the Somatoform Dissociation Questionnaire (SDQ‑20).
• Referral to a psychiatrist or psychologist experienced in functional neurological disorders.

6. Laboratory Tests (as indicated)

• Basic metabolic panel, thyroid function, and toxicology screen if substance use is suspected.

Diagnostic Summary

When the EEG is normal during an event, imaging is unrevealing, and a psychosocial stressor is identified, clinicians usually label the episode as a quasi‑seizure. A multidisciplinary diagnosis (neurology + psychiatry) improves outcomes.

Treatment Options

Treatment is individualized and often involves both medical and psychosocial strategies.

1. Education & Re‑framing

• Provide the patient and family with a clear explanation that the episodes are real but not caused by dangerous brain electrical activity.
• Use visual aids (e.g., videos of normal vs. epileptic seizures) to help differentiate.

2. Psychotherapy

• Cognitive‑behavioral therapy (CBT): Addresses maladaptive thoughts, stress coping, and avoidance behaviors.
• Dialectical behavior therapy (DBT): Particularly useful for patients with borderline personality features or severe emotional dysregulation.
• Trauma‑focused therapies: EMDR (Eye Movement Desensitization and Reprocessing) or prolonged exposure for those with a history of abuse.

3. Psychiatric Medication (when indicated)

• Selective serotonin reuptake inhibitors (SSRIs) for comorbid depression or anxiety.
• Atypical antipsychotics for severe mood instability.
• Low‑dose benzodiazepines are rarely used and only for short‑term anxiety control, as they can worsen dissociative symptoms.

4. Physical & Occupational Therapy

• Re‑training of motor patterns and balance to reduce injury risk.
• Gradual exposure to feared activities (e.g., walking in crowded places) to rebuild confidence.

5. Stress‑Reduction Techniques

• Mindfulness‑based stress reduction (MBSR), yoga, progressive muscle relaxation, or breathing exercises.
• Regular sleep hygiene and exercise routines.

6. Medication Review

• Discontinue anti‑epileptic drugs (AEDs) only after a confirmed diagnosis, as unnecessary AEDs can cause side effects.
• Collaborate with the prescribing neurologist for a safe taper if AEDs are no longer needed.

7. Supportive Measures

• Peer‑support groups for functional neurological disorders.
• Family counseling to improve communication and reduce secondary gain (e.g., inadvertently encouraging episodes).

Prevention Tips

Although quasi‑seizures are often linked to stressful or emotional triggers, several practical steps can lower the likelihood of an episode:

• Identify personal triggers: Keep a diary of events, mood, sleep, and diet to spot patterns.
• Maintain a regular sleep schedule: Aim for 7‑9 hours of quality sleep each night.
• Practice daily stress‑reduction: A 10‑minute mindfulness or breathing routine can modulate autonomic arousal.
• Avoid substance misuse: Limit alcohol, caffeine, and recreational drugs.
• Stay physically active: Moderate aerobic exercise improves mood and reduces anxiety.
• Seek early mental‑health care: Address depression, anxiety, or trauma before they become chronic.
• Use safety measures: Wear protective helmets when engaging in high‑risk activities if you have frequent falls.
• Educate close contacts: Friends, coworkers, and family members who understand the condition can help de‑escalate episodes.

Emergency Warning Signs

Bottom Line

Quasi‑seizures (nonepileptic attacks) are real, often distressing events that stem from psychological or functional neurological mechanisms rather than abnormal brain electrical activity. Accurate diagnosis usually requires video‑EEG monitoring, neuroimaging, and a thorough psychosocial assessment. Treatment focuses on education, psychotherapy, stress management, and, when needed, targeted psychiatric medication. Early involvement of a multidisciplinary team dramatically improves prognosis and helps patients regain control over their lives.

References:

• Mayo Clinic. Psychogenic non‑epileptic seizures. https://www.mayoclinic.org
• Centers for Disease Control and Prevention. Psychogenic Nonepileptic Seizures (PNES). https://www.cdc.gov
• National Institute of Neurological Disorders and Stroke. Functional Neurological Symptom Disorder. https://www.ninds.nih.gov
• World Health Organization. Mental health and neurological disorders. https://www.who.int
• Cleveland Clinic. Psychogenic seizures: Diagnosis and treatment. https://my.clevelandclinic.org
• Goldstein, L. H., et al. (2022). “Management of psychogenic nonepileptic seizures.” Neurology, 98(12), 567‑575.

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