What is Psychogenic Shock (Psychogenic Pseudosyncope)?
"Psychogenic shock" is a misnomer—the correct term is psychogenic pseudosyncope (PPS), which is a syndrome of apparent loss of consciousness that occurs without actual impairment of cerebral perfusion or brain function. 1
Definition and Pathophysiology
Psychogenic pseudosyncope is a conversion disorder—an involuntary external somatic manifestation in response to internal psychological stresses. 1 This is fundamentally different from true syncope, where loss of consciousness results from inadequate cerebral blood flow. 1
Key distinguishing features:
- During PPS episodes, there is no cerebral hypoperfusion, making the term "psychogenic syncope" pathophysiologically incorrect. 1
- The attacks are completely involuntary and should never be confused with malingering or Munchausen syndrome. 1, 2
- Patients do not pretend to have attacks—the episodes happen to them beyond their control, and they should not be blamed. 1
Clinical Presentation
The typical patient profile includes young females with higher prevalence of preexisting vasovagal syncope or history of physical and/or sexual abuse. 1, 2
Characteristic features that distinguish PPS from true syncope:
- Prolonged apparent duration of unconsciousness (5-20 minutes) with frequent episodes 1, 2
- Closed eyes during episodes 1, 2
- Lack of pallor and diaphoresis 1, 2
- Usually little physical harm despite frequent falls 1, 2
- Normal pulse, blood pressure, and EEG documented during episodes 1, 2
- Patients often appear as if asleep but cannot be woken 1
Diagnostic Approach
Tilt-table testing with simultaneous blood pressure, heart rate, video monitoring, and EEG is the gold standard for confirming psychogenic pseudosyncope. 2 Normal hemodynamic parameters and maintained cerebral perfusion during apparent loss of consciousness confirm the diagnosis. 2
A critical pitfall: Never assume psychiatric patients automatically have psychogenic pseudosyncope—always exclude organic cardiovascular and neurological causes first with appropriate evaluation. 2
Management Strategy
The American College of Cardiology recommends providing a candid, clear, and empathetic discussion with the patient about the diagnosis, explicitly acknowledging the involuntary nature of the attacks. 1, 2
Immediate Management During Episodes
- The attacks are not a medical emergency—calling an ambulance is unnecessary 1
- The attacks will pass by themselves, though patience is required 1
- Patients may be moved during an attack if necessary 1
- Relatives or colleagues should be educated beforehand about what typical attacks look like and what to do 1
Long-term Treatment
Cognitive behavioral therapy is the primary treatment for psychogenic pseudosyncope, with evidence of benefit in conversion disorders. 1, 2 Uncontrolled studies suggest psychotherapy, particularly cognitive behavioral therapy, may be beneficial. 1
There are no data supporting significant benefit from pharmacotherapy for this condition. 1
Impact on Quality of Life
Patients with PPS can suffer greatly from these spells—school, work, and social life are affected, with some becoming distressed and depressed. 1 The problem must be taken seriously and addressed appropriately. 1
Understanding what the attacks are represents the first step toward recovery. 1