What are the patient's psychogenic models for seated syncope (fainting)?

From the Guidelines

Psychogenic models for seated syncope primarily involve psychological factors triggering fainting episodes while in a seated position, and the most effective approach combines cognitive behavioral therapy (CBT) with applied tension techniques, as recommended by recent guidelines 1.

Key Components of Psychogenic Models for Seated Syncope

• Psychological factors play a significant role in triggering fainting episodes
• Cognitive behavioral therapy (CBT) is a crucial component of treatment
• Applied tension techniques, such as tensing leg and abdominal muscles, help maintain blood pressure

Treatment Approach

• Combine CBT with applied tension techniques
• Patients should practice tensing their leg and abdominal muscles for 10-15 seconds when feeling lightheaded
• 5-10 sessions of CBT focusing on identifying triggers and managing anxiety responses
• Lifestyle modifications, including adequate hydration, regular meals, and avoidance of prolonged sitting

Rationale

• Counteracting the vasovagal response that causes blood pressure drops during psychological stress
• Increasing peripheral vascular resistance through muscle tension techniques
• Addressing underlying psychological triggers through CBT

Outcomes

• Significant reduction in syncope episodes within 3-6 months of consistent practice
• Improved quality of life and reduced morbidity and mortality associated with syncope According to the 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope 1, psychogenic pseudosyncope is a syndrome of apparent but not true loss of consciousness that may occur in the absence of identifiable cardiac, reflex, neurological, or metabolic causes. The guideline recommends psychiatric evaluation when symptoms suggest psychogenic pseudo-syncope or if true syncope is due to psychiatric medication, which may need to be altered 1.

From the Research

Psychogenic Models for Seated Syncope

The psychogenic models for seated syncope, also known as fainting, can be understood through various studies that have investigated the relationship between psychiatric disorders and syncope.

• A study published in 2004 2 suggests that a well-defined relationship between transient loss of consciousness and a psychiatric disorder has not yet been established, but some clinical features can suggest the diagnosis.
• The same study 2 defines pseudosyncope as a phenomenon that resembles syncope but occurs with normal blood pressure and heart rate values, and may be related to a psychiatric disorder.
• Another study published in 2009 3 cautions against labeling syncope as psychogenic without thorough evaluation, as some cases may be due to cardiac rhythm-related etiologies.
• A study published in 2013 4 highlights the importance of considering the patient's perspective and not dismissing symptoms, as misdiagnosis or nondiagnosis can have a negative impact on patient well-being and quality of life.
• Studies published in 2015 5 and 2021 6 focus on the clinical assessment and management of syncope, including the identification of cardiac, orthostatic, and reflex mechanisms, but do not specifically address psychogenic models.

Seated Syncope and Psychiatric Disorders

• The relationship between seated syncope and psychiatric disorders is complex and not fully understood, with some studies suggesting a higher incidence of psychiatric origin than previously thought 2.
• The diagnosis of psychogenic syncope can be challenging, and may require direct observation of the clinical event or the use of diagnostic tests such as the Tilting test (HUTT) 2.
• It is essential to approach the diagnosis of syncope with a structured approach, considering various potential causes, including cardiac, orthostatic, and reflex mechanisms, as well as psychogenic factors 5, 6.