Diagnosis and Management of Pseudoseizures

Clinical Characteristics

Pseudoseizures are characterized by open eyes during the episode, duration of loss of consciousness generally between 30 seconds and 2 minutes (average 74-90 seconds), symmetrical and synchronous movements that begin at the onset of loss of consciousness, oral automatism, cyanotic face, tongue biting, and stertorous breathing, as noted by the European Society of Cardiology 1
High frequency of episodes (even daily) and increased heart rate and blood pressure during the episode are also characteristic of pseudoseizures, according to the American Heart Association 2
Pseudoseizures can also be distinguished by closed eyes during unconsciousness, prolonged duration (>5 minutes), asymmetrical and asynchronous movements, pelvic thrusting, fluctuating intensity, and changes in the nature of the movement, as reported by the European Society of Cardiology 1
Apparent loss of consciousness lasting 10-30 minutes, eyes closed during unconsciousness, eye fluttering, pelvic thrusting movements, asymmetrical and asynchronous movements, repeated waxing and waning in intensity, and absence of post-ictal confusion are characteristic of PNES, as noted by the European Heart Journal and supported by the American Academy of Pediatrics 1, 3

The American College of Cardiology recommends tilt-table testing as a reasonable method for establishing a diagnosis of pseudosyncope, with normal blood pressure and heart rate (and a normal EEG if obtained) during the test indicating pseudoseizure 2
Video-EEG monitoring is considered the gold standard for diagnosis, with a normal EEG during a typical episode being diagnostic for pseudoseizure 1, 3
Normal EEG during a typical seizure event is a gold standard diagnostic criterion for PNES, as reported by the European Heart Journal and supported by the American Academy of Pediatrics 1, 3

The American Academy of Pediatrics recommends that PNES should be treated primarily with psychological interventions, particularly cognitive behavioral therapy (CBT), as part of a multidisciplinary approach that includes clear diagnosis communication and supervised withdrawal of antiepileptic medications when appropriate, with 72% of patients' PNES resolving after psychiatric treatment 3
A multidisciplinary approach with psychological interventions, such as Cognitive Behavioral Therapy (CBT), is essential for reducing seizure frequency, improving psychiatric symptoms, and enhancing psychosocial functioning and quality of life, as reported by the American Academy of Pediatrics 3
Treatment should target specific underlying factors identified in the individual, including trauma processing, anxiety management techniques, family therapy, and stress reduction strategies, to reduce seizure frequency, improve psychiatric symptoms, and enhance overall quality of life and psychosocial functioning 3

Accurate differentiation between true epileptic seizures and pseudoseizures is crucial to avoid unnecessary and potentially harmful treatments, as well as to provide appropriate treatment that improves the patient's quality of life, as noted by the European Heart Journal and supported by the American Academy of Pediatrics 1, 3
Misdiagnosis of PNES as epilepsy can lead to unnecessary anticonvulsant treatment for an average of 7 years before correct diagnosis, and some patients have both PNES and epilepsy, making diagnosis and treatment more complex, as reported by Pediatrics 3
Assuming all seizure-like events in psychiatric patients are psychogenic and missing the dual diagnosis of epilepsy and PNES are common pitfalls in diagnosis and treatment, according to the American Academy of Pediatrics 3
Approximately 1/3 to 1/4 of patients develop chronic PNES despite treatment, and even after seizure reduction, many patients continue to experience psychiatric symptoms and impaired functioning, as reported by the American Academy of Pediatrics 3