13th May 2022 | Dr Boon Lim & Melanie Dani
Psychogenic pseudosyncope, also known as psychogenic non-epileptic seizures (PNES), is a condition characterized by episodes that resemble syncope or seizures but are not caused by underlying neurological or cardiac issues. These episodes are believed to have a psychological origin and are often triggered by emotional or psychological stressors. This condition is often also seen with other conditions, and commonly, vasovagal syncope does also co-exist with psychogenic pseudosyncope, making it challenging to diagnose. Understanding psychogenic pseudosyncope, its diagnosis, and management strategies are crucial for individuals experiencing these episodes. This article provides an overview of psychogenic pseudosyncope, covering its definition, diagnosis, management options, including conservative strategies and drug interventions, and the overall outlook for patients.
What is Psychogenic Pseudosyncope?
Psychogenic pseudosyncope, or psychogenic non-epileptic seizures (PNES), refers to episodes that mimic syncope or seizures but have a psychological, rather than neurological or cardiac, cause. These episodes are typically triggered by emotional or psychological stressors and may be related to underlying psychological factors or psychiatric conditions.
Diagnosing Psychogenic Pseudosyncope
Diagnosing psychogenic pseudosyncope involves a comprehensive evaluation by healthcare professionals, including neurologists, psychiatrists, or psychologists. The diagnosis process may include:
– Detailed Medical History: The healthcare provider will inquire about your episodes, triggers, associated symptoms, and medical history to differentiate psychogenic pseudosyncope from other conditions. Factors in the history which may suggest this diagnosis include frequent episodes (daily episodes, typically more than 1 episode per day), previous trauma or significant stressors. However, the presence of other conditions, most notably, vasovagal syncope, can make it challenging to arrive at a diagnosis.
– Physical Examination: A physical examination will be conducted to assess general health and rule out any underrlying neurological or cardiac issues.
– Diagnostic Tests: Additional tests, such as video electroencephalogram (EEG) monitoring, tilt table testing, or psychiatric evaluations, may be recommended to aid in the diagnosis of psychogenic pseudosyncope. Often times, a clear video recording of the event (even from a smart phone camera) can be very useful in aiding your physician to make a diagnosis. During a psychogenic pseudosyncope episode, the blood pressure and heart rate, as well as electrical brain signals (EEG) are normal, in the face of the apparent loss of consciousness episode.
Management of Psychogenic Pseudosyncope
Psychotherapy and Counseling: Cognitive Behavioral Therapy (CBT): CBT techniques can help individuals identify and modify patterns of thoughts and behaviors that contribute to the episodes.
Education: Understanding the psychological nature of pseudosyncope and learning coping strategies can empower individuals to better manage their symptoms. In fact, in some patients, having a clear diagnosis and a narrative of the patient’s symptoms, explained in a sympathetic and understanding manner, can help improve symptoms, as the anxieties / stress triggers of the uncertainty of the events can be dissipated by education.
Medications: In rare cases, medications such as selective serotonin reuptake inhibitors (SSRIs) or other psychiatric medications may be prescribed if there are underlying psychiatric conditions that contribute to the pseudosyncope episodes.
– Stress Management Techniques: Implementing stress reduction techniques such as relaxation exercises, mindfulness, and engaging in activities that promote emotional well-being can be helpful in managing psychogenic pseudosyncope.
– Support Systems: Building a strong support network, including family, friends, and support groups, can provide emotional support and aid in coping with the condition.
Outlook for Patients
The outlook for individuals with psychogenic pseudosyncope can vary depending on various factors, including the underlying psychological factors and the individual’s willingness to engage in treatment. With appropriate management, including psychotherapy and lifestyle adjustments, many individuals can experience a reduction in the frequency and severity of episodes. However, it is important to note that management may require ongoing efforts and collaboration between the individuals, supportive friends and family, and healthcare professionals.
In the video below, see Dr Lim explain a diagnosis of psychogenic pseudosyncope to a patient
Making a diagnosis of psychogenic pseudosyncope, or psychogenic non-epileptic seizures (PNES), can often be challenging and time-consuming. There are several reasons why it may take time to reach a definitive diagnosis:
1. Symptom Similarity: The symptoms of psychogenic pseudosyncope closely resemble those of other medical conditions, including neurological disorders or cardiac abnormalities. This similarity can make it difficult to differentiate between the different causes and require a comprehensive evaluation to rule out other potential underlying conditions.
2. Lack of Objective Diagnostic Tests: Unlike some medical conditions that can be diagnosed through objective tests, such as blood tests or imaging studies, diagnosing psychogenic pseudosyncope relies heavily on clinical evaluation and the elimination of other potential causes. The absence of specific biomarkers or diagnostic tests specific to psychogenic pseudosyncope can contribute to the diagnostic challenge.
3. Complex Nature of Psychological Factors: Psychogenic pseudosyncope is believed to have a psychological origin, often related to underlying emotional or psychological distress. Identifying and understanding these psychological factors can require in-depth psychological evaluations, including psychiatric assessments and psychological testing, which may take time to conduct and interpret.
4. Co-occurring Conditions: Individuals with psychogenic pseudosyncope may have comorbid psychiatric conditions, such as anxiety or depression, which can further complicate the diagnostic process. Untangling the interplay between these conditions and determining the primary cause of the episodes can be a complex task.
5. Overlapping Symptoms: Psychogenic pseudosyncope can present with a wide range of symptoms that may overlap with other conditions. This overlap can make it challenging to pinpoint the exact cause and contribute to the need for thorough evaluation and elimination of alternative diagnoses.
6. Variability of Symptoms: Symptoms of psychogenic pseudosyncope can vary in frequency, severity, and presentation, which adds another layer of complexity to the diagnostic process. The episodic nature of the condition and the variability of symptoms can make it more challenging to capture and evaluate the episodes during diagnostic evaluations.
Given these factors, diagnosing psychogenic pseudosyncope requires a multidisciplinary approach, involving collaboration between neurologists, psychiatrists, psychologists, and other healthcare professionals. It often involves a comprehensive evaluation, including detailed medical history, physical examination, diagnostic tests, and psychological assessments. This thorough evaluation helps ensure an accurate diagnosis and the development of an appropriate management plan for individuals with psychogenic pseudosyncope.