Why PNES Does Not Directly Affect Lifespan
PNES episodes lack epileptogenic brain activity, meaning there is no abnormal electrical discharge that could cause life-threatening complications like status epilepticus, severe hypoxia, aspiration, or cardiac arrhythmias that occur during true epileptic seizures 1.
Pathophysiological Basis for Lack of Direct Mortality
The fundamental reason PNES does not directly threaten lifespan relates to its underlying mechanism:
PNES episodes are psychogenic manifestations without epileptogenic activity, distinguishing them from true seizures that involve dangerous electrical brain dysfunction 2, 1.
Episodes are typically brief (less than 30 seconds), significantly shorter than epileptic seizures (74-90 seconds), preventing the prolonged cerebral dysfunction that could lead to death 2, 1.
PNES does not cause the physiological sequelae of true seizures such as severe hypoxia, aspiration pneumonia, or life-threatening cardiac arrhythmias that can occur during prolonged epileptic activity 1.
There is no risk of true status epilepticus, which is a medical emergency with significant mortality risk in epilepsy but cannot occur in PNES due to the absence of epileptogenic activity 1.
Important Caveat: Indirect Mortality Risks Exist
While PNES itself does not directly affect lifespan, recent population-based research reveals that PNES patients have a 5.5 times higher risk of death compared to controls, with both natural (HR 8.1) and non-natural causes (HR 15.3) contributing 3.
Sources of Indirect Mortality:
Iatrogenic complications from misdiagnosis:
- 8 of 10 PNES patients receive unnecessary anticonvulsants, and nearly all undergo invasive procedures when misdiagnosed 1.
- Aggressive treatment of presumed status epilepticus in PNES patients causes respiratory depression from benzodiazepines or propofol, potentially requiring intubation 1.
- Inappropriate sedatives and anticonvulsants carry risks of respiratory failure, cardiac complications, and CNS adverse effects without providing any benefit 1.
Psychiatric comorbidities:
- Suicide ranks disproportionately high in PNES patients (18.8% of deaths), reflecting the severe psychiatric burden of this condition 3.
- Depression, anxiety, and trauma-related disorders are highly prevalent and contribute to both natural and non-natural causes of death 4, 5, 3.
Clinical Implications
Accurate diagnosis through video-EEG monitoring is critical to prevent harmful treatments and identify the psychiatric nature of the condition 1.
Once PNES is diagnosed, avoid unnecessary anticonvulsants and invasive procedures, as these interventions carry mortality risks without providing benefit 1.
Early psychiatric referral is essential, as 72% of PNES patients showed resolution after psychiatric treatment, and cognitive behavioral therapy is the first-line treatment 6, 1.
The challenge intensifies when patients have both epilepsy and PNES (occurring in 20-30% of cases), making treatment decisions complex and potentially life-threatening if the wrong condition is treated 1, 4.