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Quasi‑Seizure (Psychogenic Non‑Epileptic Seizure)

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

Quasi‑seizure, also called a psychogenic non‑epileptic seizure (PNES), is a sudden, involuntary episode that looks like an epileptic seizure but originates from psychological rather than electrical disturbances in the brain. During a PNES episode the person may lose consciousness, show convulsive movements, or experience altered sensations, yet electroencephalogram (EEG) recordings typically show no epileptiform activity.

PNES belongs to a broader group of disorders called functional neurological symptom disorders. It is not “faking” or “pretending”; the brain genuinely produces the observed signs, but the pathway is mediated by emotional stress, trauma, or other mental‑health factors rather than abnormal neuronal firing.

According to the National Institute of Neurological Disorders and Stroke (NINDS), PNES accounts for 10‑30 % of patients referred to epilepsy monitoring units, highlighting how common it can be in neurology clinics.

Common Causes

PNES rarely has a single cause. It usually results from an interplay of psychological, social, and neurobiological factors. The most frequently identified contributors include:

• Psychological trauma – physical, sexual, or emotional abuse; combat exposure; or severe accidents.
• Post‑traumatic stress disorder (PTSD) – intrusive memories can trigger dissociative episodes that mimic seizures.
• Depression and anxiety disorders – chronic stress can dysregulate the brain‑body connection.
• Conversion disorder – a somatic symptom disorder where psychological distress is expressed as neurological symptoms.
• Personality disorders – especially borderline personality disorder, which is linked with emotional dysregulation.
• History of epileptic seizures – prior epilepsy can condition the brain to produce “seizure‑like” responses even after epilepsy resolves.
• Substance misuse – alcohol, benzodiazepines, or recreational drugs can precipitate dissociative episodes.
• Medical comorbidities – chronic pain, migraines, or endocrine disorders can increase stress and predispose to PNES.
• Family or cultural factors – in some cultures, somatic expression of distress is more accepted than emotional expression.
• Secondary gain – unconscious benefits such as attention, relief from responsibilities, or financial compensation may reinforce the behavior.

Associated Symptoms

While each episode is unique, certain features frequently accompany PNES:

• Prolonged “post‑ictal” confusion that does not correspond with typical seizure recovery.
• Variable motor patterns – movements may be asynchronous, side‑to‑side, or too purposeful for an epileptic seizure.
• Preserved eye tracking and ability to follow commands during the event.
• Sudden onset or termination of the episode when the person is distracted.
• Accompanying psychosomatic complaints such as chronic headache, abdominal pain, or dizziness.
• Emotional symptoms before or after the event – intense anxiety, fear, anger, or feeling “out of control.”
• Fluctuating frequency – episodes may occur in clusters during stressful periods and disappear during relaxation.

When to See a Doctor

Because PNES can be mistaken for epileptic seizures—some of which are life‑threatening—it is essential to seek professional evaluation promptly if you notice:

• Any new seizure‑like activity, especially if you have no known epilepsy diagnosis.
• Seizure‑like spells that last longer than 2‑3 minutes, or that recur rapidly without full recovery.
• Persistent confusion, weakness, or injury after an episode.
• New onset of episodes after a traumatic event, major life change, or with increasing stress.
• Feelings of helplessness, anxiety, or depression that seem tied to the episodes.

Early evaluation reduces unnecessary anti‑seizure medication use and helps direct you to appropriate mental‑health support.

Diagnosis

Diagnosing PNES is a stepwise process that combines neurological assessment with psychiatric evaluation.

1. Detailed Clinical History

• Chronology of episodes, triggers, and recovery pattern.
• Past medical history, especially epilepsy, head injury, or psychiatric disorders.
• Medication list, substance use, and psychosocial stressors.

2. Physical & Neurological Examination

• Rule out focal neurological deficits that would suggest structural brain disease.
• Observe gait, coordination, and reflexes between episodes.

3. Video‑EEG Monitoring (Gold Standard)

Patients are admitted to an epilepsy monitoring unit where seizures are recorded on simultaneous video and EEG. In PNES, the video shows typical seizure behavior while the EEG remains normal (no ictal spikes).

Reference: American Academy of Neurology guidelines (2020) recommend video‑EEG for definitive diagnosis of PNES.

4. Additional Tests (as needed)

• Brain MRI to exclude structural lesions.
• Blood work for metabolic disturbances.
• Neuropsychological testing to assess cognitive function and identify dissociative traits.

5. Psychiatric Assessment

A mental‑health professional will evaluate for trauma history, mood disorders, conversion disorder, and other relevant conditions using standardized tools such as the DSM‑5 criteria, the Beck Depression Inventory, or the PTSD Checklist.

Treatment Options

Treatment is multidisciplinary, targeting both the seizure‑like behavior and the underlying psychosocial drivers.

1. Psychotherapy

• Cognitive‑Behavioral Therapy (CBT) – teaches coping skills, reduces avoidance, and restructures maladaptive thoughts. Randomized trials show a 30‑40 % reduction in episode frequency after 12‑16 weeks of CBT (Cleveland Clinic, 2021).
• Dialectical Behavior Therapy (DBT) – especially useful for patients with borderline personality disorder or severe emotional dysregulation.
• Trauma‑Focused Therapies – EMDR (Eye‑Movement Desensitization and Reprocessing) or trauma‑focused CBT for patients with a clear abuse history.

2. Psychiatric Medications

• Selective serotonin reuptake inhibitors (SSRIs) for comorbid depression or anxiety.
• Atypical antipsychotics (e.g., quetiapine) if psychotic features or severe agitation are present.
• Low‑dose benzodiazepines may be used short‑term for acute anxiety, but they are not a long‑term solution and can worsen dissociation.

3. Education & Counseling

• Explain the diagnosis in clear, non‑judgmental language; patients often feel “dismissed” when told the seizures are psychogenic.
• Provide written material and reputable online resources (e.g., Mayo Clinic, Epilepsy Foundation).
• Involve family members to create a supportive environment and avoid reinforcement of seizure behavior.

4. Physical Rehabilitation

• Physical therapy can help restore normal gait or balance if episodes have led to deconditioning.
• Occupational therapy assists with return to work or school.

5. Lifestyle & Self‑Help Strategies

• Regular sleep schedule (7‑9 hours) – sleep deprivation is a potent seizure trigger.
• Stress‑reduction techniques: mindfulness meditation, progressive muscle relaxation, or yoga.
• Avoidance of alcohol, recreational drugs, and excessive caffeine.

Prevention Tips

While PNES cannot always be prevented, the following strategies can lower the likelihood of new episodes:

• Identify Triggers – Keep a diary of episodes, noting stressors, time of day, and preceding emotions.
• Maintain a Routine – Predictable daily structure reduces anxiety spikes.
• Build a Stress‑Management Toolbox – Practice at least one relaxation technique daily.
• Seek Early Mental‑Health Support – Address trauma, depression, or anxiety before they become chronic.
• Engage in Regular Physical Activity – Exercise improves mood and neurological resilience.
• Limit “Secondary Gain” Reinforcement – Work with therapists and caregivers to ensure episodes are not unintentionally rewarded (e.g., excessive attention or avoidance of responsibilities).

Emergency Warning Signs

Key Take‑aways

Quasi‑seizure (PNES) is a real, treatable condition that sits at the crossroads of neurology and mental health. Accurate diagnosis—primarily via video‑EEG—prevents unnecessary anti‑seizure medication and opens the door to effective therapies such as CBT, trauma‑focused treatment, and lifestyle modification. Prompt medical evaluation is essential, especially when episodes are new, prolonged, or accompanied by injury.

For more detailed information, consult reputable sources:

• Mayo Clinic – Psychogenic non‑epileptic seizures
• CDC – Epilepsy and seizure disorders facts
• NIH – PNES information page
• World Health Organization – Mental health and neurology
• Cleveland Clinic – PNES treatment overview

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