Pseudoseizures: Causes, Symptoms, Treatment, Prognosis, Diagnosis

What are Pseudoseizures?

Seizure, which is also known as convulsions, is a condition in which an individual has involuntary and uncontrollable shaking of the body. The seizure disorder is observed in a medical condition called epilepsy. Epilepsy is associated with abnormal electrical activity in the brain cells that are trigger by dysfunctional cortical (brain) cells.

Sometimes, individuals with no prior history of epilepsy for no rhyme or reason starts to have convulsions or rapid shaking of the body. In few such cases, an individual also develops symptoms of fainting episodes. Most of these cases are taken to the emergency room and evaluated for convulsion disorder. Pseudoseizures will mimic the symptoms of an actual seizure but will not show any abnormal electrical activities in brain cells during an electroencephalogram (EEG) studies.

Such a condition indicating normal electrical brain activities resulting in a seizure-like disorder is diagnosed as Pseudoseizures. The brain’s electrical activities are evaluated by the brain EEG (Electroencephalogram) study. Pseudoseizure like conditions is also known as hysterical seizures or psychogenic seizures. Recently published papers described the condition as psychogenic nonepileptic spells (PNES) or psychogenic nonepileptic episodes (PNEE).1

The literature suggests Pseudoseizure is either caused by psychological cerebral (brain) imbalance (PNEE) as well as emotional distress and occasionally associated with malingering. Every case of seizure disorder related to normal brain electrical activity is not caused by malingering. The most individual suffering from PNEE is not consciously aware of their seizure disorder behavior. Such non-malingering PNEE is observed in individuals who were physically or sexually abuse and seen mostly in females.2 Malingering or fictitious pseudoseizure disorder is associated with secondary gain.3

Thus, pseudoseizure is classified as follows-

Psychogenic nonepileptic episodes- Normal EEG, no secondary gain and individual is not aware of epileptic seizure

Fictitious (Malingering) pseudoseizure- Normal EEG, secondary gain and individual, is aware of epileptic seizure.3

What are Pseudoseizures?

What is the Difference between Epileptic Seizures and a Pseudoseizure?

The main difference between an actual epileptic seizure and pseudoseizure is that in epilepsy, there are clear electrical abnormalities observed on EEG in the brain. In contrast, in pseudoseizures, no such abnormal activities are visible on the EEG. Another difference between a true seizure and a Pseudoseizure is that a true seizure episode lasts for a few seconds to 2 minute. If the seizure lasts for 5 minutes or longer and repeated every few minutes, then the condition is known as status epilepticus.4 Non-fictitious Pseudoseizures may last longer than 2 minutes. The fictitious or malingering pseudoseizures often last longer and repeated depending on the situation and surrounding observer.

What are the Causes of Pseudoseizures?

As stated, there is no medical cause for Pseudoseizures associated with healthy brain electrical activities. The non-fictitious pseudoepilepsy or pseudoseizure tends to occur in individuals suffering from psychological issues at work or home associated with stress at work, a disturbing environment at home, and emotional trauma. Pseudoseizures are psychological reactions induced in a patient suffering from anxiety and mental trauma of the brain that influences several muscles to contract simultaneously that mimics seizure-like conditions. Pseudoseizures are mostly seen in people who have been victims of child abuse. Some people also use it as a means of escaping from work or get financial aid and hence Pseudoseizures can also be said to be a form of a behavioral disorder. Pseudoseizures are more common in adolescents and teenagers and tend to be seen more in females than in males.

What are the Symptoms of Pseudoseizures?

The symptoms of Pseudoseizures may mimic some of the symptoms of epilepsy or true seizure. The rapid shaking of the body, fainting episodes, change in behavior, or confusion is observed in both conditions. Some observations differ in epilepsy and pseudoseizures. The main difference observed in a neuromotor outburst that results in entire body muscle contraction is the time seizure may last. The muscle contractions in seizure disorder last for 2 minutes or less, whereas pseudoseizure may last for a more extended period. Individuals having Pseudoseizures will tend to have convulsions and act as if they are losing consciousness. They may also complain of extreme anxiety and fear.

How are Pseudoseizures Treated?

Following diagnosis, neurologists often refer a patient to a psychiatrist for psychotherapy and psychopharmacological medication. During initial psychotherapy sessions, the physician must disclose the diagnosis of pseudoseizures to individuals who have seizure disorder with normal brain electrical function. The discussion involves the disclosure of condition that suggests he or she does not have epilepsy, and electrical brain activities are normal. Such discussion often causes severe anxiety in a patient as well as close relatives. In most cases, patients and relatives feel the symptoms may have caused by a serious condition. Hence, the physician needs to be very sensitive when telling the patient that what he or she is experiencing is not epilepsy but a form of a psychological disorder.

In most cases, patients and relatives accept the diagnosis following a brief explanation that includes the presence of brain electrical activities in epilepsy, and such activities are absent in pseudoepilepsy or pseudoseizure. The physician should also describe in detail, the true condition of the patient, without actually offending the patient and creating anxiety. The physician should reassure the patient that the disease is entirely treatable with proper psychological counseling and medications. The physician should also tell the patient about different ways to get rid of stress.

  • Medication such as SSRIs has shown promise in the treatment of Pseudoseizure
  • The antianxiety and antidepressants have been prescribed to treat underlying anxiety or depression.
  • In case of child abuse as being a contributing factor for pseudoseizure, then referral to a psychiatrist for psychotherapy has shown to be quite effective.
  • Cognitive-behavioral therapy has also been used for the treatment of Pseudoseizures. Antidepressants have also been used in some cases for treating Pseudoseizures.

The treatment for Pseudoepilepsy is classified into following groups.5

  • Psychotherapy
  • Medications- Psychopharmacological treatments
  • Short-term treatment
  • Long term treatment
  • Functional recovery assistance

What is the Prognosis of Pseudoseizures?

The prognosis of Pseudoseizures is not that good as a relatively few percentages of people undergo full treatment as most of them are lost to followups or do not attend therapy sessions. Hence, they continue to have attacks of Pseudoseizures. However, the prognosis is good in people who are stronger willed, well educated, young, and have a will to get better and come out of the situation so that they suffer no more attacks and have fewer physical complaints due to Pseudoseizures.

References:

      1. Pseudoseizures J. Stephen Huff; Najib Murr., Last Update: February 28, 2019. https://www.ncbi.nlm.nih.gov/books/NBK441871/
        Seizures Medline Plus
        https://medlineplus.gov/seizures.html
      2. Nonepileptic seizures and childhood sexual and physical abuse.
        Alper K1Devinsky OPerrine KVazquez BLuciano D., Neurology. 1993 Oct;43(10):1950-3.
      3. Malingering and factitious disorder.
        Bass C1Wade DT2., Pract Neurol. 2019 Apr;19(2):96-105. doi: 10.1136/practneurol-2018-001950. Epub 2018 Nov 13.
      4. How long do most seizures last? A systematic comparison of seizures recorded in the epilepsy monitoring unit.
        Jenssen S1Gracely EJSperling MR., Epilepsia.. 2006 Sep;47(9):1499-503.
      5. Treatment of Psychogenic Nonepileptic Seizures: Updated Review and Findings From a Mindfulness-Based Intervention Case Series

        Gaston Baslet,1,2 Barbara Dworetzky,2,3 David L. Perez1,1,2,4,5 and Megan Oser2,5

        Clin EEG Neurosci. 2015 Jan; 46(1): 54–64.
        Published online 2014 Dec 2. doi: 10.1177/1550059414557025

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