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Quasi‑epileptic Seizure

What is Quasi‑epileptic Seizure?

A quasi‑epileptic seizure (also called a psychogenic non‑epileptic seizure or PNES) is an episode that looks like an epileptic seizure but is not caused by abnormal electrical activity in the brain. Instead, the event originates from psychological or functional disturbances. Because the outward signs can mimic true epilepsy—loss of consciousness, rhythmic shaking, staring, or automatisms—PNES is often misdiagnosed, leading to unnecessary antiepileptic medication and delayed treatment of the underlying condition.

PNES belongs to a broader group of functional neurological disorders (FND). The International League Against Epilepsy (ILAE) defines PNES as “a seizure‑like event that is not associated with the electrophysiological changes that characterize epileptic seizures.” The distinction is critical: while the physical manifestations are real, the brain’s electrical pattern is normal.

Common Causes

Quasi‑epileptic seizures are multifactorial. The following conditions and risk factors are most frequently implicated (source: Mayo Clinic, NIH, Cleveland Clinic):

• Psychological trauma – past physical, sexual, or emotional abuse.
• Conversion disorder – neurologic symptoms that arise as an unconscious response to stress.
• Post‑traumatic stress disorder (PTSD) – hyperarousal and dissociation can trigger PNES.
• Depression and anxiety disorders – chronic stress lowers the threshold for functional seizures.
• Personality disorders – particularly borderline personality disorder.
• History of genuine epileptic seizures – up to 30 % of patients with epilepsy develop PNES.
• Somatic symptom disorder – excessive focus on physical symptoms without a clear medical cause.
• Substance misuse – alcohol, benzodiazepines, or recreational drugs can precipitate episodes.
• Sleep deprivation – disrupts emotional regulation and can lead to functional seizures.
• Family or cultural factors – modeling of illness behavior or expectations about illness.

Associated Symptoms

While the seizure‑like event itself is the hallmark, patients with PNES often report additional features:

• Emotional lability – sudden crying, screaming, or intense fear before or after the episode.
• Fatigue or “post‑ictal” exhaustion that is less severe than after epileptic seizures.
• Headache or muscle soreness from thrashing movements.
• Memory gaps (retrograde amnesia) limited to the event.
• Symptoms of underlying psychiatric illness (e.g., persistent anxiety, depressive mood).
• Physical complaints such as chronic pain, gastrointestinal upset, or dizziness.
• Frequent doctor visits and extensive medication lists without clear benefit.

When to See a Doctor

Because PNES can coexist with true epilepsy, any new or worsening seizure‑like activity warrants medical evaluation. Seek professional help promptly if you notice:

• First‑time seizure‑like event, especially if it lasts longer than 5 minutes.
• Loss of consciousness accompanied by tongue biting, urinary incontinence, or injury.
• Seizure that occurs during sleep or awakens you from deep sleep.
• Recurring episodes that interfere with work, school, or daily activities.
• History of mental health conditions that have recently worsened.
• New medication or dosage change preceding the episodes.
• Any “red‑flag” signs listed below.

Early evaluation can prevent unnecessary antiepileptic drugs (AEDs) and open the door to appropriate psychotherapy.

Diagnosis

Diagnosing PNES requires a systematic approach to rule out epileptic seizures and identify functional contributors.

1. Detailed Clinical History

• Onset, frequency, duration, and triggers of episodes.
• Witnessed descriptions (e.g., flailing vs. rhythmic jerking).
• Past neurological or psychiatric diagnoses.
• Medication list, substance use, sleep patterns.

2. Physical & Neurological Examination

Typically normal between events. However, a focused exam may reveal signs of other neurological disorders that need separate attention.

3. Video‑EEG Monitoring (Gold Standard)

Patients are continuously recorded on video and electroencephalography for several days. A PNES is diagnosed when the clinical event occurs **without** the ictal EEG pattern that defines epileptic seizures. This test also helps to capture genuine epilepsy if present.

4. Additional Tests (as needed)

• Magnetic Resonance Imaging (MRI) – rules out structural brain lesions.
• Blood work – electrolyte abnormalities, infection, or toxicology.
• Neuropsychological testing – assesses cognitive function and may identify conversion disorder patterns.

5. Psychiatric Assessment

Involvement of a mental‑health professional is essential. Structured interviews (e.g., SCID‑5) can diagnose comorbid mood, anxiety, or trauma‑related disorders.

Treatment Options

Treatment is multimodal, aiming at both seizure control and the underlying psychological drivers.

1. Psychoeducation

Understanding that the episodes are real but not caused by brain “electrical storms” reduces stigma and improves engagement. Providing written material and reputable websites (e.g., Epilepsy Foundation, NHS) can reinforce learning.

2. Cognitive‑Behavioral Therapy (CBT)

CBT is the most evidence‑based psychotherapy for PNES. It focuses on:

• Identifying maladaptive thoughts that precipitate episodes.
• Developing coping skills (relaxation, grounding techniques).
• Gradual exposure to feared triggers.

Randomized trials have shown a 40‑60 % reduction in seizure frequency after 12–20 CBT sessions (source: JAMA Neurology, 2021).

3. Trauma‑Focused Therapies

If a history of abuse or PTSD is present, therapies such as EMDR (Eye Movement Desensitization and Reprocessing) or trauma‑focused CBT are recommended.

4. Medications

There is no specific drug for PNES, but medications may treat comorbid conditions:

• Selective serotonin reuptake inhibitors (SSRIs) for depression/anxiety.
• Atypical antipsychotics for severe emotional dysregulation.
• Low‑dose benzodiazepines only for short‑term anxiety control; long‑term use can worsen PNES.

Any antiepileptic drug (AED) should be discontinued only after a confirmed PNES diagnosis and in collaboration with a neurologist.

5. Physical & Occupational Therapy

Addressing deconditioning, improving balance, and teaching safety strategies can reduce injury risk during episodes.

6. Supportive Interventions

• Peer‑support groups (online or in‑person).
• Family counseling – educates relatives on how to respond during an event without reinforcing the behavior.
• Stress‑management programs (mindfulness, yoga, biofeedback).

Prevention Tips

Although PNES often correlates with underlying stress, certain practical steps can lower the likelihood of an episode:

• Maintain regular sleep hygiene – aim for 7–9 hours, consistent bedtime.
• Limit caffeine and alcohol – both can increase anxiety and disrupt sleep.
• Practice daily relaxation – deep‑breathing, progressive muscle relaxation, or guided meditation.
• Identify personal triggers – keep a brief journal of mood, stressors, and seizure timing.
• Adhere to psychotherapy appointments – consistency improves coping skills.
• Engage in regular physical activity – at least 150 minutes of moderate exercise per week.
• Build a supportive network – friends, family, or support groups who understand PNES.
• Limit exposure to “dangerous” situations – e.g., operating heavy machinery when feeling unusually stressed.

Emergency Warning Signs

Key Take‑aways

• Quasi‑epileptic (psychogenic non‑epileptic) seizures are real events driven by psychological factors, not abnormal brain electricity.
• Accurate diagnosis relies on video‑EEG monitoring and a thorough psychiatric assessment.
• Effective treatment combines psychoeducation, CBT (or trauma‑focused therapy), management of comorbid mental health conditions, and lifestyle modifications.
• Early medical evaluation prevents unnecessary AEDs and reduces the risk of injury.
• Red‑flag symptoms require immediate emergency care.

For further reading, consult reputable sources such as the Mayo Clinic, the CDC, the National Institutes of Health, and the World Health Organization.

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