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Quasi‑Seizure (Psychogenic Non‑Epileptic Seizure)

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

A psychogenic non‑epileptic seizure (PNES), often called a “quasi‑seizure,” is an event that looks like an epileptic seizure but does not arise from abnormal electrical activity in the brain. Instead, the episode is a physical manifestation of psychological distress. The brain’s motor pathways are activated voluntarily—or semi‑voluntarily—through emotional or mental triggers, producing convulsions, loss of consciousness, or other seizure‑like behaviors without the electroencephalographic (EEG) changes seen in epilepsy.

PNES belongs to the broader category of functional neurological symptom disorder (FND). It is a legitimate medical condition, not “faking” or “staged,” and it can be as disabling as true epilepsy if left untreated.

Common Causes

PNES is usually multifactorial. Below are the most frequently identified contributors:

• Post‑traumatic stress disorder (PTSD) – exposure to physical or sexual abuse, combat, or serious accidents.
• Depression and anxiety disorders – chronic stress, generalized anxiety, or panic attacks.
• History of childhood adversity – neglect, emotional abuse, or early loss.
• Conversion disorder (functional neurological disorder) – psychological conflict expressed as physical symptoms.
• Somatoform disorders – persistent preoccupation with bodily symptoms without organic cause.
• Personality disorders – especially borderline personality disorder, where emotional dysregulation is common.
• Substance use or withdrawal – alcohol, benzodiazepines, or opiates can precipitate or mimic PNES.
• Sleep disturbances – chronic insomnia or fragmented sleep can lower the seizure threshold.
• Medical comorbidities – migraines, chronic pain, or autoimmune conditions that increase overall stress burden.
• Secondary gain – although rare, occasionally seizures may provide unconscious benefits such as avoidance of a stressful situation.

Associated Symptoms

Patients with PNES often experience a cluster of other physical or psychological signs:

• Rapid breathing or hyperventilation
• Chest tightness or “heart‑racing” sensation
• Palpitations
• Muscle weakness or flaccidity after the episode
• Headache, dizziness, or visual disturbances
• Emotional lability – sudden crying, screaming, or intense fear
• Memory gaps surrounding the event (retrograde amnesia)
• Fatigue or exhaustion after an episode
• History of other functional symptoms (e.g., functional gait disorder, chronic pain)

When to See a Doctor

Although PNES is non‑life‑threatening, prompt evaluation is essential to rule out true epilepsy or other neurological emergencies. Seek medical care if you notice any of the following:

• First‑time seizure‑like event, especially if it lasts longer than 5 minutes
• Loss of bladder or bowel control during an episode
• Injury from a fall or striking a hard surface
• Persistent confusion or prolonged post‑ictal state (more than 30 minutes)
• Any new neurological symptom (vision loss, speech difficulty, weakness)
• History of epilepsy with a sudden change in seizure pattern
• Episodes occurring more than once a week, affecting work or daily life

Even if you suspect PNES, a neurologist or epileptologist should first conduct a thorough work‑up to exclude epileptic seizures. Early referral to a mental‑health professional skilled in functional disorders can then be arranged.

Diagnosis

The diagnosis of PNES is a collaborative process that combines neurological, psychiatric, and sometimes neurophysiological assessments.

1. Detailed Clinical History

• Onset, frequency, and triggers of events
• Witness accounts (family, friends, EMS)
• Past medical, psychiatric, and trauma history
• Medication list, including over‑the‑counter and recreational drugs

2. Physical and Neurological Examination

Often normal between episodes; however, clinicians look for signs that differentiate PNES from epileptic seizures (e.g., asynchronous limb movements, side‑to‑side head shaking, prolonged duration).

3. Electroencephalography (EEG)

Video‑EEG monitoring is the gold standard. The patient is observed while a seizure‑like event is captured on video; the EEG is examined simultaneously. In PNES, the video shows convulsive activity without the characteristic epileptiform spikes or rhythmic discharges that define epilepsy.<sup>1</sup>

4. Neuroimaging

MRI of the brain is performed to rule out structural lesions (tumor, stroke, malformation) that could provoke seizures.

5. Psychological Assessment

Standardized tools such as the Patient Health Questionnaire‑9 (PHQ‑9), Generalized Anxiety Disorder‑7 (GAD‑7), and the Somatoform Dissociation Questionnaire (SDQ‑20) help identify underlying mood, anxiety, or dissociative disorders.

6. Differential Diagnosis

Clinicians must differentiate PNES from:

• Epileptic seizures (focal, generalized, status epilepticus)
• Syncope with convulsive activity
• Movement disorders (e.g., dystonia)
• Acute metabolic disturbances (hypoglycemia, electrolyte imbalance)

Treatment Options

Effective management blends neurological reassurance with evidence‑based psychotherapy, medication when appropriate, and lifestyle adjustments.

1. Education and Reassurance

• Explain the diagnosis in clear, non‑judgmental language. Emphasize that the episodes are real and involuntary, not “faked.”
• Provide written materials (e.g., handouts from the Mayo Clinic or Epilepsy Foundation) to reinforce understanding.

2. Psychotherapy

• Cognitive‑Behavioral Therapy (CBT) – the most studied approach; helps patients identify triggers, develop coping strategies, and gradually reduce seizure frequency.<sup>2</sup>
• Dialectical Behavior Therapy (DBT) – useful for patients with borderline personality disorder or severe emotion‑regulation problems.
• Trauma‑Focused Therapies (e.g., EMDR, prolonged exposure) – indicated when PTSD is a major driver.

3. Psychiatric Medication

Medications do not treat PNES directly but can address comorbid conditions:

• SSRIs (e.g., sertraline) for depression and anxiety
• SNRIs (e.g., duloxetine) when both pain and mood symptoms coexist
• Low‑dose antipsychotics (e.g., risperidone) for severe agitation or psychosis
• Avoidance of poly‑sedative regimens that can worsen dissociation.

4. Physical Rehabilitation

For patients who develop deconditioning or gait problems after repeated episodes, a tailored physiotherapy program can rebuild strength and confidence.

5. Community and Peer Support

• Support groups (online or in‑person) can reduce isolation and provide coping models.
• Organizations such as the International League Against Epilepsy (ILAE) – FND Chapter offer resources.

6. Lifestyle Interventions

• Regular sleep schedule (7‑9 hours) – poor sleep is a known trigger.
• Stress‑reduction techniques: mindfulness, progressive muscle relaxation, yoga.
• Avoidance of alcohol, recreational drugs, and excessive caffeine.
• Structured daily routines to reduce unpredictability.

Prevention Tips

While you cannot completely eliminate the risk of a PNES episode, the following strategies can markedly lower frequency and severity:

• Identify personal triggers (e.g., arguments, sleep loss) and plan early‑intervention coping steps.
• Maintain a symptom diary to spot patterns and discuss them with your therapist.
• Practice grounding techniques when feeling dissociated – 5‑4‑3‑2‑1 sensory exercise is a simple tool.
• Engage in regular physical activity (aerobic + strength) to improve mood and resilience.
• Adopt a balanced diet rich in omega‑3 fatty acids, B‑vitamins, and magnesium, which support neuronal stability.
• Schedule routine mental‑health check‑ins even when you feel stable; early adjustments prevent relapse.
• Limit exposure to **trauma‑related media** or stressful news cycles, especially before bedtime.

Emergency Warning Signs

Key Take‑aways

• PNES is a genuine, treatable condition that mimics epileptic seizures but originates from psychological processes.
• Thorough evaluation—including video‑EEG—ensures accurate diagnosis and rules out dangerous neurological causes.
• Multidisciplinary care—education, CBT, medication for comorbid mood disorders, and lifestyle changes—offers the best outcomes.
• Early professional help, especially when episodes are frequent or disabling, prevents chronic disability and improves quality of life.

References

1. World Health Organization. International Classification of Diseases (ICD‑11). 2022.
2. Martinez‑Montes E, et al. Cognitive‑behavioral therapy for psychogenic nonepileptic seizures: A systematic review. Epilepsia. 2021;62(4):921‑933.
3. Mayo Clinic. Psychogenic non‑epileptic seizures (PNES). Updated 2023. https://www.mayoclinic.org
4. American Academy of Neurology. Practice guideline: Evaluation of seizures in adults. 2020.
5. Cleveland Clinic. Psychogenic non‑epileptic seizures (PNES). 2022.

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