Psychogenic Pseudosyncope and Pseudoseizure: Approach and Treatment
- 15 Downloads
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.
KeywordsSyncope 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
Examples of pseudosyncope attacks in an otherwise healthy young woman (MP4 253739 kb)
- 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
- 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
- 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.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