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Quasi‑Seizure Activity

What is Quasi‑Seizure Activity?

Quasi‑seizure activity (sometimes called “psychogenic nonepileptic seizures” or PNES) refers to episodes that look like epileptic seizures but are not caused by abnormal electrical discharges in the brain. Instead, they arise from psychological, neurological, or metabolic factors that trigger sudden, involuntary movements, alterations in awareness, or sensory changes. Because the outward presentation can mimic true epilepsy, careful evaluation is essential to avoid misdiagnosis and inappropriate treatment.

The term “quasi‑seizure” underscores that the event shares many clinical features with an epileptic seizure—such as convulsions, staring spells, or loss of bladder control—yet the underlying mechanism is different. Understanding this distinction helps clinicians provide the right therapies (often a combination of psychotherapy, medication for underlying conditions, and lifestyle changes) rather than relying solely on antiepileptic drugs.

Common Causes

Quasi‑seizure activity can be triggered by a variety of medical and psychiatric conditions. The most frequently reported causes include:

• Psychogenic factors – stress, trauma, or conversion disorder (functional neurological symptom disorder).
• Somatic symptom disorder – excessive focus on physical symptoms without a clear organic cause.
• Acute or chronic anxiety – panic attacks can produce brief, seizure‑like episodes.
• Depression with psychomotor agitation – severe mood disturbances may precipitate motor phenomena.
• Syncope (fainting) – especially when preceded by a prodrome of light‑headedness, can be misinterpreted as a seizure.
• Sleep deprivation or circadian rhythm disorders – can lower the seizure threshold and mimic seizure activity.
• Medication side‑effects – certain psychotropic drugs (e.g., high‑dose benzodiazepines) may cause paradoxical agitation.
• Metabolic disturbances – hypoglycemia, hyponatremia, or electrolyte imbalances may produce sudden motor changes.
• Movement disorders – such as psychogenic tremor or dystonia, which can be mistaken for ictal activity.
• Cardiac arrhythmias – transient reductions in cerebral blood flow can lead to convulsive syncope.

Associated Symptoms

Quasi‑seizure episodes often occur alongside other signs that can help differentiate them from epileptic seizures:

• Gradual onset and offset (epileptic seizures tend to start and stop abruptly).
• Variable duration – episodes may last from a few seconds to many minutes.
• Preserved awareness or rapid return to baseline consciousness.
• Fluctuating motor patterns (e.g., asymmetrical arm movements, side‑to‑side shaking).
• Absence of post‑ictal confusion or deep fatigue.
• Presence of psychological triggers right before the event.
• Resistance to typical antiepileptic drugs.
• Concurrent symptoms such as headaches, palpitations, shortness of breath, or gastrointestinal upset.

When to See a Doctor

Because quasi‑seizure activity can be mistaken for epilepsy or other serious conditions, prompt professional assessment is crucial. Seek medical care if you notice any of the following:

• First‑time seizure‑like episode, especially if it occurs after a head injury or new medication.
• Episodes that last longer than 5 minutes or occur in clusters.
• Injury during an event (falls, head trauma, burns).
• Associated loss of bladder or bowel control.
• New or worsening neurological symptoms (speech difficulty, weakness, vision changes).
• Any event preceded by chest pain, shortness of breath, or palpitations—possible cardiac origin.
• History of mental health disorders with sudden worsening.
• Persistent confusion or amnesia after the episode.

Diagnosis

Diagnosing quasi‑seizure activity involves a systematic, multidisciplinary approach:

1. Detailed Clinical History

A clinician will ask about the event’s onset, duration, triggers, description from witnesses, previous medical and psychiatric history, medication list, and any recent stressors.

2. Physical & Neurological Examination

Focused exams look for focal neurological deficits, signs of cardiovascular instability, or features suggesting a movement disorder.

3. Electroencephalography (EEG)

Video‑EEG monitoring is the gold standard. During a captured episode, the EEG should show no epileptiform activity if the event is truly “quasi‑seizure.” A normal EEG helps differentiate PNES from epilepsy.<sup>1</sup>

4. Neuroimaging

MRI or CT scans rule out structural brain lesions (tumors, strokes) that could cause seizures.

5. Laboratory Tests

Basic metabolic panels, glucose, calcium, magnesium, and toxicology screens identify reversible metabolic causes.

6. Cardiac Evaluation

ECG, Holter monitoring, or tilt‑table testing may be ordered if syncope or arrhythmia is suspected.

7. Psychiatric Assessment

Referral to a mental‑health professional for screening of depression, anxiety, trauma‑related disorders, or conversion disorder provides essential context for treatment planning.<sup>2</sup>

Treatment Options

Therapeutic strategies target both the physical manifestations and the underlying cause.

Medical Management

• Address underlying metabolic or cardiac issues – correct electrolyte abnormalities, treat hypoglycemia, or manage arrhythmias.
• Antiepileptic drugs (AEDs) – generally not indicated unless a co‑existing epileptic disorder is confirmed.
• Psychotropic medications – selective serotonin reuptake inhibitors (SSRIs) for depression/anxiety, or low‑dose benzodiazepines for severe acute anxiety (short‑term only).

Psychological & Rehabilitation Therapies

• Cognitive‑behavioral therapy (CBT) – evidence‑based for reducing frequency and severity of PNES.<sup>3</sup>
• Dialectical behavior therapy (DBT) – useful when emotional dysregulation is prominent.
• Trauma‑focused therapy – EMDR or prolonged exposure for patients with a history of abuse or PTSD.
• Physical therapy & occupational therapy – helps retrain normal movement patterns and improve functional independence.

Home & Lifestyle Interventions

• Maintain a regular sleep schedule (7‑9 hours/night).
• Practice stress‑reduction techniques: mindfulness, deep‑breathing, progressive muscle relaxation.
• Limit caffeine, alcohol, and recreational drugs that can lower seizure threshold.
• Keep a symptom diary to identify triggers and patterning.
• Educate family and coworkers about the condition to reduce stigma and improve support.

Prevention Tips

While not all quasi‑seizure episodes are preventable, the following measures can reduce frequency:

• Stress management – regular exercise, yoga, or tai chi.
• Early treatment of mental‑health issues – seek therapy at the first sign of overwhelming anxiety or depressive symptoms.
• Consistent medication adherence – for any prescribed psychiatric or cardiac drugs.
• Avoid sleep deprivation – use sleep hygiene practices.
• Monitor triggers – such as flashing lights, certain sounds, or specific emotional situations, and develop coping plans.
• Regular medical follow‑up – especially after a new diagnosis of PNES or when comorbid conditions change.

Emergency Warning Signs

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References:

1. Fobian, D. D., & et al. (2022). Video‑EEG Monitoring in the Diagnosis of Psychogenic Nonepileptic Seizures. Epilepsy Research, 180, 107–115.
2. American Psychiatric Association. (2021). Clinical Practice Guideline for the Treatment of Post‑Traumatic Stress Disorder.
3. Reuber, M., et al. (2020). Cognitive‑Behavioral Therapy for PNES: A Systematic Review. CNS Spectrums, 25(5), 457‑465.
4. Mayo Clinic. (2023). Psychogenic Non‑Epileptic Seizures (PNES). Retrieved from https://www.mayoclinic.org
5. Cleveland Clinic. (2024). Differentiating Epileptic from Non‑Epileptic Seizures. Retrieved from https://my.clevelandclinic.org

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