PNES Itself Does Not Directly Cause Death
PNES (Psychogenic Non-Epileptic Seizures) are not inherently fatal and do not directly cause death, as they lack epileptogenic activity and do not produce the physiological consequences of true epileptic seizures. However, mortality risk arises indirectly through misdiagnosis, inappropriate treatment, and associated psychiatric comorbidities.
Why PNES Is Not Directly Fatal
PNES episodes involve motor, sensory, mental, or autonomic manifestations that mimic epileptic seizures but lack epileptogenic brain activity, meaning there is no abnormal electrical discharge that could cause life-threatening complications like status epilepticus 1, 2.
Episodes typically last less than 30 seconds, which is significantly shorter than true epileptic seizures (74-90 seconds), and patients do not experience the prolonged cerebral dysfunction that could lead to death 1, 3.
PNES does not cause the physiological sequelae of true seizures, such as severe hypoxia, aspiration, or cardiac arrhythmias that can occur during prolonged epileptic activity 3.
Indirect Mortality Risks from Misdiagnosis and Mistreatment
The real danger lies in diagnostic confusion and inappropriate management:
Misdiagnosis leads to unnecessary and potentially harmful interventions: Studies show that 8 of 10 PNES patients were prescribed anticonvulsants, 6 received anticonvulsants in the emergency department, and nearly all underwent invasive procedures and testing 4.
Inappropriate treatment with anticonvulsants and sedatives can cause respiratory depression, cardiac complications, and CNS adverse effects, potentially requiring intubation and mechanical ventilation 4.
Aggressive treatment of presumed status epilepticus in PNES patients can lead to iatrogenic complications, including respiratory failure from benzodiazepines or propofol, which are standard treatments for true seizures but unnecessary and dangerous in PNES 3.
The challenge is compounded when patients have both true epilepsy and PNES, making airway management and anticonvulsant decisions complex and potentially life-threatening if the wrong condition is treated 4.
Mortality Risk from Psychiatric Comorbidities
PNES patients have extremely high rates of psychiatric comorbidity (53-100%), including depression, PTSD, anxiety disorders, and personality disorders, which carry their own mortality risks through suicide 5, 6.
Depression is particularly prevalent and negatively impacts quality of life, and untreated depression is a known risk factor for suicide 5, 7.
The psychiatric burden is significantly higher in PNES compared to epilepsy (RR: 1.30,95% CI: 1.14-1.48), suggesting greater overall health vulnerability 5.
Clinical Implications for Preventing Mortality
Accurate diagnosis through video-EEG monitoring is critical to prevent harmful treatments and identify the true psychiatric nature of the condition 3.
Early psychiatric referral is essential, as 72% of PNES patients showed resolution after psychiatric treatment in follow-up studies 4.
Avoid unnecessary anticonvulsants and invasive procedures once PNES is diagnosed, as these interventions carry risks without providing benefit 4.
Screen for and aggressively treat comorbid psychiatric conditions, particularly depression and PTSD, which are the actual sources of mortality risk in this population 5, 6.