Syncope pp 135-147 | Cite as

Psychogenic Pseudosyncope and Pseudoseizure: Approach and Treatment

  • Raffaello FurlanEmail author
  • Alessandra Alciati


Psychogenic pseudosyncope (PPS) is the appearance of apparent transient loss of consciousness (TLOC) in which movements are absent, resembling syncope but without true loss of consciousness. Psychogenic non-epileptic seizure (PNES) involves apparent TLOC and pronounced movements of limbs, head, and trunk, resembling epilepsy. PPS and PNES differ in their pathophysiology from true transient loss of consciousness (TLOC), as in PPS the hemodynamic and electroencephalographic changes characterizing syncope are absent and in PNES the epileptiform brain activity during the attack is absent.

A detailed history is of paramount importance for the diagnosis. Clinical clues that should raise the suspicion for psychogenic spells are similar for PPS and PNES and include the high frequency of attacks, prolonged duration of the loss of consciousness, eye closure during the episode, unusual triggers, and no recognizable prodromes. The presence of an established diagnosis of syncope or epilepsy should not deter from the concomitant diagnosis of PPS.

The gold standard for diagnosis of PPS is documenting an attack with video or with tilt testing during which hemodynamic and electroencephalographic parameters are normal. The gold standard for PNES is documenting an attack with video-EEG monitoring showing no epileptiform brain activity during an attack.

For both PPS and PNES, treatment is based on the clear and empathetic communication of the diagnosis which can often be followed by an immediate reduction of attack frequency and emergency service use. Psychological interventions may be beneficial in patients with PPS/PNES and among these, Cognitive Behavioral Therapy holds the most reliable evidence of efficacy.


Syncope Pseudosyncope Pseudoseizure TLOC Conversion disorders Cognitive behavioral therapy Psychotherapy Hypnosis Psychogenic EEG Nonepileptic Tilt-testing 



We would like to thank A.C. for providing us with the video recordings of the pseudosyncope attacks that were obtained by her friends and relatives.

We have also to acknowledge the work done by Dr. Roberto Menè, Dr. Dana Shiffer, and the Humanitas University IT Director Dr. Antonino Marsala and the IT staff Dr. Federico Sabolla in building up the final video-audio recording. We are thankful to Sachin Paranjape for having edited and revised the manuscript.

Conflict of Interest/Disclosure


Supplementary material

Video 11.1

Examples of pseudosyncope attacks in an otherwise healthy young woman (MP4 253739 kb)


  1. 1.
    Brignole M, Moya A, de Lange FJ, Deharo JC, Elliott PM, Fanciulli A, Fedorowski A, Furlan R, Kenny RA, Martín A, Probst V, Reed MJ, Rice CP, Sutton R, Ungar A, van Dijk JG, ESC Scientific Document Group. 2018 ESC Guidelines for the diagnosis and management of syncope. Eur Heart J. 2018;39:1883–948.CrossRefGoogle Scholar
  2. 2.
    Tannemaat MR, van Niekerk J, Reijntjes RH, Thijs RD, Sutton R, van Dijk JG. The semiology of tilt-induced psychogenic pseudosyncope. Neurology. 2013;81:752–8.CrossRefGoogle Scholar
  3. 3.
    Walsh KE, Baneck T, Page RL, Brignole M, Hamdan MH. Psychogenic pseudosyncope: not always a diagnosis of exclusion. Pacing Clin Electrophysiol. 2018;41:480–6.CrossRefGoogle Scholar
  4. 4.
    Saal DP, Overdijk MJ, Thijs RD, van Vliet IM, van Dijk JG. Long-term follow-up of psychogenic pseudosyncope. Neurology. 2016;87:2214–9.CrossRefGoogle Scholar
  5. 5.
    Blad H, Lamberts RJ, van Dijk GJ, Thijs RD. Tilt-induced vasovagal syncope and psychogenic pseudosyncope: overlapping clinical entities. Neurology. 2015;85:2006–10.CrossRefGoogle Scholar
  6. 6.
    Shen WK, Sheldon RS, Benditt DG, Cohen MI, Forman DE, Goldberger ZD, Grubb BP, Hamdan MH, Krahn AD, Link MS, Olshansky B, Raj SR, Sandhu RK, Sorajja D, Sun BC, Yancy CW. ACC/AHA/HRS guideline for the evaluation and management of patients with syncope: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2017;70:620–63.CrossRefGoogle Scholar
  7. 7.
    Avbersek A, Sisodiya S. Does the primary literature provide support for clinical signs used to distinguish psychogenic nonepileptic seizures from epileptic seizures? J Neurol Neurosurg Psychiatry. 2010;81:719–25.CrossRefGoogle Scholar
  8. 8.
    LaFrance WC Jr, Baker GA, Duncan R, Goldstein LH, Reuber M. Minimum requirements for the diagnosis of psychogenic nonepileptic seizures: a staged approach: a report from the International League Against Epilepsy Nonepileptic Seizures Task Force. Epilepsia. 2013;54:2005–18.CrossRefGoogle Scholar
  9. 9.
    LaFrance WC Jr, Reuber M, Goldstein LH. Management of psychogenic nonepileptic seizures. Epilepsia. 2013;54:53–67.CrossRefGoogle Scholar
  10. 10.
    Diprose W, Sundram F, Menkes DB. Psychiatric comorbidity in psychogenic nonepileptic seizures compared with epilepsy. Epilepsy Behav. 2016;56:123–30.CrossRefGoogle Scholar
  11. 11.
    McKenzie P, Oto M, Russell A, Pelosi A, Duncan R. Early outcomes and predictors in 260 patients with psychogenic nonepileptic attacks. Neurology. 2010;74:64–9.CrossRefGoogle Scholar
  12. 12.
    Goldstein LH, Chalder T, Chigwedere C, Khondoker MR, Moriarty J, Toone BK, Mellers JD. Cognitive-behavioral therapy for psychogenic nonepileptic seizures: a pilot RCT. Neurology. 2010;74:1986–94.CrossRefGoogle Scholar
  13. 13.
    LaFrance WC Jr, Baird GL, Barry JJ, Blum AS, Frank Webb A, Keitner GI, Machan JT, Miller I, Szaflarski JP, NES Treatment Trial (NEST-T) Consortium. Multicenter pilot treatment trial for psychogenic nonepileptic seizures: a randomized clinical trial: NES Treatment Trial (NEST-T) consortium. JAMA Psychiat. 2014;71:997–1005.CrossRefGoogle Scholar
  14. 14.
    Martlew J, Pulman J, Marson AG. Psychological and behavioural treatments for adults with non-epileptic attack disorder. Cochrane Database Syst Rev. 2014;2:CD006370.Google Scholar
  15. 15.
    Carlson P, Nicholson PK. Psychological interventions for psychogenic non-epileptic seizures: a meta-analysis. Seizure. 2017;45:142–50.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Internal MedicineHumanitas Clinical and Research Center-IRCCSMilanItaly
  2. 2.Department of Biomedical SciencesHumanitas UniversityMilanItaly
  3. 3.Department of Clinical NeurosciencesHermanas Hospitalarias, Villa S. Benedetto Menni HospitalAlbese con CassanoItaly

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