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Quasi‑seizure Episodes

What is Quasi‑seizure episodes?

A quasi‑seizure episode (also called a psychogenic nonepileptic seizure, PNES, or functional seizure) looks clinically similar to an epileptic seizure but originates from psychological rather than electrical brain activity. During a quasi‑seizure, a person may exhibit sudden loss of motor control, unusual movements, altered awareness, or behavioural changes that mimic a true seizure. However, electroencephalogram (EEG) recordings typically show no epileptiform discharges. The term “quasi‑seizure” emphasizes that the event is * seizure‑like* yet *non‑epileptic* in nature.<sup>[1]</sup>

These episodes are part of a broader category called functional neurological symptom disorder and are commonly linked to stress, trauma, or underlying psychiatric conditions. Because they can be frightening and disrupt daily life, accurate diagnosis and compassionate treatment are essential.

Common Causes

Quasi‑seizure episodes are usually triggered by psychological or neuro‑behavioral factors. The most frequently identified contributors include:

• Psychological trauma: past physical, sexual, or emotional abuse.
• Post‑traumatic stress disorder (PTSD): trauma‑related flashbacks can manifest as PNES.
• Depression and anxiety disorders: chronic stress may precipitate conversion‑type symptoms.
• Personality disorders: especially borderline personality disorder.
• Somatization disorder: a tendency to express psychological distress as physical symptoms.
• Acute stressors: divorce, job loss, or major life changes.
• History of epilepsy: patients with epilepsy sometimes develop PNES as a learned coping mechanism.
• Medication withdrawal or misuse: especially benzodiazepines or opioids.
• Neurological illness misdiagnosis: a prior false epilepsy diagnosis may perpetuate PNES.
• Family or cultural factors: environments where seizures are highly visible or stigmatized may influence symptom expression.

It is important to note that no single cause is required; many patients have a combination of the above factors.

Associated Symptoms

Quasi‑seizure episodes often occur with other physical or psychological complaints. Commonly reported co‑symptoms are:

• Headaches or migraines
• Chronic fatigue
• Muscle tension or pain
• Dizziness or light‑headedness
• Gastrointestinal upset (nausea, abdominal pain)
• Sleep disturbances (insomnia, nightmares)
• Emotional lability – sudden crying or anger
• Memory gaps surrounding the event (retrograde amnesia)
• Palpitations or shortness of breath
• Functional impairments (missed work, school, or social activities)

When to See a Doctor

Because quasi‑seizure episodes can mimic life‑threatening epileptic seizures, prompt medical evaluation is crucial. Seek care if you experience any of the following:

• First episode of seizure‑like activity, especially if it lasts longer than 5 minutes.
• Loss of bladder or bowel control during an event.
• Injury from falling or prolonged rigidity.
• Confusion or inability to awaken after the episode.
• Recurring episodes that disrupt work, school, or relationships.
• Any new neurological symptoms (vision loss, weakness, speech difficulty).
• History of epilepsy with a sudden change in seizure pattern.

Diagnosis

Diagnosing quasi‑seizure episodes involves a systematic approach to rule out epileptic seizures and other neurological conditions.

1. Detailed Clinical Interview

Physicians ask about the episode’s onset, duration, triggers, associated sensations, and recovery phase. They also explore psychiatric history, trauma exposure, stressors, and medication use.

2. Video‑EEG Monitoring

The gold‑standard test is prolonged video‑EEG monitoring. The patient is recorded while experiencing episodes; the EEG helps identify the presence or absence of epileptiform activity. A typical finding for PNES is a normal EEG during the event.<sup>[2]</sup>

3. Neuroimaging

Magnetic resonance imaging (MRI) or computed tomography (CT) may be ordered to rule out structural brain lesions that could cause seizures (e.g., tumor, stroke).

4. Laboratory Tests

Basic labs (CBC, electrolytes, glucose, thyroid panel) are obtained to exclude metabolic causes that can precipitate seizures.

5. Psychiatric Assessment

After organic causes are excluded, a mental‑health professional evaluates for underlying mood, anxiety, or trauma‑related disorders using validated tools (e.g., PHQ‑9, GAD‑7, PTSD Checklist).

6. Differential Diagnosis Checklist

• Epileptic seizure
• Syncope
• Movement disorders (e.g., dystonia)
• Migraine aura
• Cardiac arrhythmia
• Substance intoxication or withdrawal

Treatment Options

Effective management combines neurological reassurance, psychotherapy, and sometimes medication. Treatment is individualized based on the patient’s specific triggers and co‑existing conditions.

1. Psychoeducation & Reassurance

Explaining that the episodes are real but not caused by dangerous brain activity reduces anxiety and empowers patients to engage in therapy.

2. Cognitive‑Behavioral Therapy (CBT)

CBT is the most evidence‑based psychotherapy for PNES. It helps patients identify maladaptive thoughts, learn stress‑reduction techniques, and develop healthier coping strategies.<sup>[3]</sup>

3. Trauma‑Focused Therapies

For patients with a history of abuse or PTSD, therapies such as Eye Movement Desensitization and Reprocessing (EMDR) or prolonged exposure therapy have shown benefit.

4. Medications

• Antidepressants: SSRIs or SNRIs for comorbid depression or anxiety.
• Anticonvulsants: Not for seizure control but sometimes used to stabilize mood; evidence is limited.
• Sleep aids: Short‑term use of melatonin or low‑dose trazodone if insomnia aggravates episodes.

5. Stress‑Reduction Techniques

• Mindfulness‑based stress reduction (MBSR)
• Progressive muscle relaxation
• Breathing exercises (4‑7‑8 technique)

6. Multidisciplinary Clinic Follow‑up

Many tertiary centers offer joint neurology‑psychiatry clinics where a neurologist and therapist coordinate care, leading to higher remission rates.

7. Lifestyle Modifications

• Regular sleep schedule (7‑9 hours/night)
• Avoidance of alcohol and recreational drugs
• Balanced diet rich in omega‑3 fatty acids
• Consistent physical activity (≥150 min moderate aerobic exercise/week)

Prevention Tips

While not all episodes can be prevented, adopting habits that lower stress and address mental‑health concerns can reduce frequency:

• Identify Triggers: Keep a diary of episodes, noting mood, stressors, sleep, and caffeine intake.
• Early Intervention: Contact a therapist at the first sign of escalating anxiety or intrusive thoughts.
• Regular Psychiatric Follow‑up: Medication adjustments and psychotherapy sessions should be maintained even when you feel well.
• Develop a Crisis Plan: Have a list of coping strategies (grounding techniques, emergency contacts) ready for when an episode feels imminent.
• Build Social Support: Share your diagnosis with trusted friends or family members who can help monitor and encourage treatment adherence.
• Limit Caffeine & Stimulants: Excessive caffeine can heighten anxiety and precipitate episodes.
• Stay Physically Active: Exercise releases endorphins and reduces overall stress.

Emergency Warning Signs

References

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. 2013.
2. Benbadis, S. R., & Hauser, W. A. (2020). Video‑EEG monitoring in the evaluation of nonepileptic seizures. Neurology, 94(14), 618‑626. doi:10.1212/WNL.0000000000009455
3. Reuber, M., et al. (2021). Cognitive‑behavioral therapy for psychogenic nonepileptic seizures: A systematic review. Cleveland Clinic Journal of Medicine, 88(5), 317‑327. doi:10.3949/ccjm.88a.21005
4. Mayo Clinic. (2023). Psychogenic nonepileptic seizures (PNES). Retrieved from www.mayoclinic.org
5. World Health Organization. (2022). Mental health and neurological disorders. WHO Fact Sheets. who.int

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