Psychogenic Pseudosyncope and Pseudoseizure: Approach and Treatment

Abstract

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.