Does psychogenic non-epileptic seizures (PNES) reduce lifespan?

Does PNES Reduce Lifespan?

Yes, PNES significantly increases mortality risk, with patients having a 5.5-fold higher risk of death compared to the general population, driven by both natural causes (8.1-fold increased risk) and non-natural causes including suicide (15.3-fold increased risk). 1

Direct Mortality Impact

PNES itself does not cause death through the seizure mechanism, as these episodes lack epileptogenic brain activity and do not produce the life-threatening physiological complications of true epileptic seizures such as status epilepticus, severe hypoxia, or cardiac arrhythmias. 2 Episodes typically last less than 30 seconds without the prolonged cerebral dysfunction that could directly lead to death. 2

However, the condition carries substantial mortality risk through indirect mechanisms:

Natural Causes of Death

• Patients with PNES have an 8.1-fold increased risk of death from natural causes compared to controls. 1
• This elevated risk stems from psychiatric comorbidities, socioeconomic factors, and the chronic nature of the condition affecting overall health. 1

Non-Natural Causes and Suicide

• Non-natural causes of death are 15.3 times more common in PNES patients, with suicide representing 18.8% of deaths in this population. 1
• This extraordinarily high suicide rate demands aggressive psychiatric intervention and long-term monitoring. 1

Iatrogenic Mortality Risks

Misdiagnosis creates life-threatening situations through inappropriate treatment:

• 8 out of 10 PNES patients receive unnecessary anticonvulsants, and nearly all undergo invasive procedures. 2
• Aggressive treatment of presumed status epilepticus with benzodiazepines or propofol causes respiratory depression, cardiac complications, and CNS adverse effects potentially requiring intubation. 2
• These iatrogenic complications from treating non-existent epilepsy can be fatal, particularly when respiratory failure occurs. 2

Age-Related Mortality Patterns

The mortality risk varies significantly with age and time since diagnosis:

• Patients with older age at PNES onset (mean 32.9 years vs 22.3 years in those who achieve seizure freedom) have worse outcomes and higher mortality risk. 3, 1
• The association between PNES diagnosis and mortality changes over time, emphasizing the need for long-term follow-up. 1

Comparison to Epilepsy

For context, patients with epilepsy have a 6.7-fold increased mortality risk compared to controls, making PNES mortality risk (5.5-fold) nearly comparable to true epilepsy despite the absence of epileptogenic activity. 1

Critical Interventions to Reduce Mortality

To minimize mortality risk, implement these evidence-based strategies:

• Accurate diagnosis via video-EEG monitoring prevents harmful treatments and identifies the psychiatric nature requiring appropriate intervention. 2
• Immediate psychiatric referral is essential, as 72% of PNES patients showed resolution after psychiatric treatment. 4, 2
• Cognitive behavioral therapy as first-line treatment addresses the underlying conversion disorder. 4
• Discontinue unnecessary anticonvulsants once PNES is confirmed, as these carry risks without benefit. 2
• Aggressive suicide risk assessment and monitoring given the 18.8% suicide rate in this population. 1

Common Pitfalls

• Do not rely on biomarkers (prolactin, creatine kinase, neuron-specific enolase) to differentiate PNES from epilepsy, as these are unreliable. 5, 4
• Avoid treating presumed status epilepticus without video-EEG confirmation when clinical features suggest PNES (asynchronous movements, closed eyes, duration <30 seconds). 5, 2
• Recognize that 20-30% of patients in epilepsy centers actually have PNES, making misdiagnosis common. 5