Can PNES Be Fatal?
PNES itself does not directly cause death because these episodes lack the epileptogenic brain activity that produces life-threatening complications like status epilepticus, severe hypoxia, aspiration, or cardiac arrhythmias seen in true epileptic seizures. 1
Direct Mortality Risk from PNES
- PNES episodes do not involve abnormal electrical brain discharge that could cause the physiological sequelae leading to death 1
- Episodes typically last less than 30 seconds, significantly shorter than epileptic seizures (74-90 seconds), and do not produce prolonged cerebral dysfunction 1, 2
- There is no cerebral hypoperfusion during PNES attacks, unlike true syncope or seizures 3
Indirect Mortality Risk: Iatrogenic Complications from Misdiagnosis
The real danger lies in misdiagnosis and inappropriate treatment, which can be fatal. 1, 4
Harmful Interventions from Misdiagnosis:
- 8 out of 10 PNES patients are prescribed unnecessary anticonvulsants, and 6 receive anticonvulsants in emergency departments 1
- Aggressive treatment of presumed status epilepticus in PNES patients can cause respiratory depression from benzodiazepines or propofol, potentially requiring intubation and mechanical ventilation 1
- Inappropriate sedation can lead to respiratory failure, cardiac complications, and CNS adverse effects 1
- Deaths have been documented from iatrogenic complications when PNES is mistaken for epileptic status epilepticus and treated aggressively 4
Specific High-Risk Scenarios:
- Nonepileptic psychogenic status (NEPS) - prolonged PNES episodes mimicking status epilepticus - carries the highest risk of harmful medical interventions and death 4
- Patients with both true epilepsy and PNES (20-30% of epilepsy center patients) face complex management decisions where treating the wrong condition can be life-threatening 1, 2
- PNES during pregnancy may be misdiagnosed as eclampsia, leading to premature delivery and harmful fetal medication exposure 4
Critical Prevention Strategies
- Video-EEG monitoring is the gold standard for diagnosis and prevents dangerous misdiagnosis 5, 1
- Avoid anticonvulsants once PNES is diagnosed - pharmacotherapy has no demonstrated benefit for PNES and carries unnecessary risks 5, 1
- Early psychiatric referral is essential, as 72% of PNES patients show resolution after psychiatric treatment 5, 1
- Do not rely on biomarkers (prolactin, creatine kinase, neuron-specific enolase) to differentiate PNES from epilepsy 5, 2
Additional Morbidity Risks
- Increased risk of self-harm and suicide attempts associated with NEPS, indicating serious comorbid psychiatric illness 4
- Accidents and injuries during PNES episodes are an underrecognized source of morbidity 4
- PNES significantly affects quality of life and functional status, though these improve with appropriate psychiatric treatment 6, 5