Managing psychogenic pseudosyncope: Facts and experiences

Abstract

Psychogenic pseudosyncope (PPS) is a common cause of apparent transient loss of consciousness (TLOC) with a dramatic impact on the quality of life. This review aims to give an overview of the definition, incidence, etiology, diagnosis, treatment, and prognosis of PPS based on a combination of literature data and personal experience. The limited literature on the subject suggests that PPS is relatively common but insufficiently recognized. PPS is probably similar to psychogenic nonepiteptic seizures (PNES), in which a long delay to diagnosis worsens the prognosis. A detailed history is of paramount importance for the diagnosis. The key feature in the history of patients with PPS is the occurrence of frequent, long attacks of apparent TLOC with closed eyes. The diagnosis is certain when a typical event is recorded during a tilt- (Cardiol J 2014; 21, 6: 658-664)

Tilt-induced vasovagal syncope and psychogenic pseudosyncope

“…Indeed, history taking of people with VVS/PPS often suggests separate features for VVS and PPS, which can be disentangled based on knowledge of semiology of VVS 7 and PPS. 2,11 Our study may give the impression that VVS/PPS is a rare condition, as it only occurred in 2% of all tilt-table tests in 2 tertiary referral centers. We only selected cases, however, where both conditions were documented during a single tilt-table test.…”

“…Our clinical impression is that when PPS attacks dominate the clinical picture, this should be the main focus of attention. 11,17,18 When VVS is the dominant issue, however, it may be sufficient to give instructions on physical countermaneuvers and lifestyle advice. [19][20][21] This advice provides individuals with control over the situation, reducing anxiety, and might therefore be beneficial for both vasovagal and psychogenic episodes.…”

“…Those with VVS had also been referred to tertiary care, presumably because of perceived complexity. 11 In PNESs it has been well-established that a timely and accurate diagnosis may help to reduce the burden for individuals and the health care system. [12][13][14][15][16] The double nature of VVS/PPS may warrant multiple therapeutic approaches.…”

Long-term follow-up of psychogenic pseudosyncope

“…The diagnosis rested on history taking of patients and eyewitnesses and on event documentation with tilt table testing, home video recording or, rarely, home blood pressure recording. The explanation of the nature of PPS conformed to PNES procedures, 8,9 stressing that attacks happen involuntarily, that patients were taken seriously and were not "mad," and that the attacks signaled an underlying psychological problem. Terms such as psychological were used and not avoided.…”

“…The history had to contain positive features of PPS such as closed eyes during attacks, a long duration, and high frequency. 7 Attack documentation required recording an event recognized as typical by patients or relatives during a tilt table test, comprising continuous blood pressure, ECG, EEG, and video, 8,9,19 or ictal home video or blood pressure recording. Patients with a positive history and attack documentation were classified as definite; those with a positive history without documentation were classified as probable.…”