Quasi‑Seizure (Non‑Epileptic Attack)

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

A quasi‑seizure, also called a non‑epileptic attack (NEA) or psychogenic nonepileptic seizure (PNES), is an episode that looks like an epileptic seizure but does not arise from abnormal electrical activity in the brain. Instead, these events are usually driven by psychological, physiological, or metabolic factors that cause the brain to produce seizure‑like movements, loss of consciousness, or autonomic changes.

Unlike epileptic seizures, quasi‑seizures do not show the characteristic spike‑and‑wave patterns on an electroencephalogram (EEG). They are often, but not always, linked to stress, trauma, or other mental‑health conditions. Recognizing the difference is crucial because the management strategies differ markedly from those used for epilepsy.

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

Common Causes

Quasi‑seizures are not caused by a single factor. Below are the most frequently identified contributors:

• Psychological stress or trauma: PTSD, childhood abuse, or recent life crises.
• Conversion disorder: A somatic symptom disorder where emotional distress is expressed as neurological symptoms.
• Depression and anxiety disorders: Chronic anxiety can trigger dissociative episodes.
• Personality disorders: Especially borderline personality disorder, where emotional dysregulation is common.
• Acute medical illnesses: Severe infection, hypoglycemia, or metabolic imbalance can mimic seizures.
• Medication withdrawal or misuse: Sudden cessation of benzodiazepines, barbiturates, or alcohol.
• Sleep deprivation: Can lower the seizure threshold for both epileptic and nonepileptic events.
• Functional neurological disorder (FND): A broader category that includes PNES.
• Migraine aura or hemiplegic migraine: May produce motor phenomena that resemble seizures.
• Cardiovascular events: Arrhythmias or orthostatic hypotension can cause transient loss of consciousness that is mistaken for a seizure.

Associated Symptoms

Because the underlying mechanisms differ, many patients experience additional signs alongside the seizure‑like episode:

• Emotional lability – sudden crying or screaming.
• Preserved awareness or memory of the event (unlike many epileptic seizures).
• Variable duration – episodes may last from a few seconds to several minutes.
• Resistance to physical restraints (the person may move despite being held).
• Absence of tongue‑biting, urinary incontinence, or post‑ictal confusion.
• Rapid recovery – the individual often returns to baseline quickly.
• Fatigue or emotional exhaustion after the episode.
• Co‑existing psychosomatic complaints – headaches, abdominal pain, or chronic fatigue.

When to See a Doctor

Although quasi‑seizures are not life‑threatening in the same way as some epileptic events, prompt evaluation is essential to rule out other conditions and to start appropriate therapy. Seek professional help if you notice any of the following:

• First‑time seizure‑like episode, especially if it follows a head injury or a new medication.
• Episodes lasting longer than 5 minutes or occurring in clusters.
• Any loss of consciousness, difficulty breathing, or injury during an event.
• Persistent confusion or weakness after the episode.
• Signs of depression, anxiety, or suicidal thoughts.
• New or worsening headaches, vision changes, or speech difficulties.
• Any history of epilepsy that suddenly changes in pattern.

Early assessment helps prevent unnecessary anti‑epileptic drug (AED) use and directs patients to mental‑health resources.

Diagnosis

Diagnosing a quasi‑seizure involves a systematic approach to exclude epileptic seizures and identify the underlying cause.

1. Detailed Clinical History

• Describe the onset, duration, and triggers of the episodes.
• Ask about recent stressors, trauma, mood changes, substance use, and sleep patterns.
• Review past medical and psychiatric history.

2. Physical & Neurological Examination

Provides baseline data and looks for focal deficits that would suggest an organic brain disorder.

3. Video‑EEG Monitoring

The gold‑standard test. By recording brain activity while the patient experiences an event, clinicians can see whether the EEG remains normal during the attack – confirming a non‑epileptic nature.

4. Laboratory Tests

• Blood glucose, electrolytes, and toxicology screens to rule out metabolic causes.
• Thyroid function tests if hypothyroidism is suspected.

5. Neuroimaging

MRI or CT scans are performed when structural brain disease (tumor, stroke, malformation) is a concern.

6. Psychiatric Evaluation

Psychologists or psychiatrists assess for conversion disorder, PTSD, mood disorders, or personality disorders.

References: Cleveland Clinic, Cleveland Clinic; WHO, WHO.

Treatment Options

Successful management typically requires a multidisciplinary approach.

1. Psychoeducation

Explain that the episodes are real but not caused by dangerous brain activity. Understanding reduces fear and improves cooperation.

2. Cognitive‑Behavioral Therapy (CBT)

• Focuses on identifying triggers, stress‑management techniques, and modifying maladaptive thoughts.
• CBT has the strongest evidence for reducing frequency and severity of PNES.

3. Psychodynamic or Trauma‑Focused Therapy

For patients with a history of abuse or severe trauma, therapies such as EMDR (Eye Movement Desensitization and Reprocessing) can be beneficial.

4. Psychiatric Medication

• Selective serotonin reuptake inhibitors (SSRIs) for co‑existing depression or anxiety.
• Atypical antipsychotics if severe agitation or mood instability is present.
• Medication is adjunctive; it does not “cure” the PNES itself.

5. Physical Rehabilitation

Occupational or physiotherapy may help restore confidence in motor abilities, especially if patients have avoided activity due to fear of attacks.

6. Lifestyle & Stress‑Reduction Strategies

• Regular sleep schedule (7‑9 hours/night).
• Mindfulness meditation, yoga, or breathing exercises.
• Limiting caffeine, alcohol, and recreational drug use.

7. Family Involvement

Educating family members reduces inadvertent reinforcement of the behavior and improves support for therapy.

8. When AEDs Are Prescribed In Error

If anti‑epileptic drugs have been started, a careful taper under physician supervision is recommended to avoid withdrawal seizures.

Prevention Tips

Although not all episodes can be prevented, the following steps lower the risk of recurrent attacks:

• Identify and manage stressors: Keep a diary of triggers (e.g., arguments, work deadlines) and develop coping plans.
• Maintain mental‑health care: Regular therapy sessions, medication adherence, and support groups.
• Adopt a healthy sleep routine: Consistent bedtime, low‑light environment, and limiting screen time.
• Practice relaxation techniques daily: 10‑minute guided breathing or progressive muscle relaxation.
• Stay physically active: Moderate aerobic exercise improves mood and reduces anxiety.
• Limit stimulant use: Reduce caffeine and avoid nicotine or illicit substances.
• Educate close contacts: Friends and family should know how to respond (stay calm, ensure safety, avoid restraints).
• Promptly address psychiatric symptoms: Early treatment of depression or anxiety prevents escalation.

Emergency Warning Signs

If any of the following occur, call emergency services (911 in the U.S.) or go to the nearest emergency department immediately:

• Sudden loss of consciousness lasting more than 5 minutes.
• Severe chest pain, shortness of breath, or palpitations during an episode.
• Difficulty speaking, sudden weakness on one side of the body, or visual changes.
• Falling and sustaining a head injury or other trauma.
• Seizure‑like activity that does not stop despite gentle restraints and lasts >3 minutes (possible status epilepticus).
• Signs of overdose or withdrawal (e.g., extreme agitation, tremors, seizures).
• Any new symptom suggestive of stroke or heart attack.

Early emergency care can rule out life‑threatening causes and provide appropriate stabilization.

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