The semiology of tilt-induced psychogenic pseudosyncope
Open accessAbstract
OBJECTIVES: To provide a detailed semiology to aid the clinical recognition of psychogenic pseudosyncope (PPS), which concerns episodes of apparent transient loss of consciousness (TLOC) that mimic syncope. METHODS: We analyzed all consecutive tilt-table tests from 2006 to 2012 showing proven PPS, i.e., apparent TLOC had occurred without EEG changes or a decrease in heart rate (HR) or blood pressure (BP). We analyzed baseline characteristics, video data, EEG, ECG, and continuous BP measurements on a 1-second time scale. Data were compared with those of 69 cases of tilt-induced vasovagal syncope (VVS). RESULTS: Of 800 tilt-table tests, 43 (5.4%) resulted in PPS. The majority (74%) were women. The median duration of apparent TLOC was longer in PPS (44 seconds) than in VVS (20 seconds, p < 0.05). During the event, the eyes were closed in 97% in PPS but in only 7% in VVS (p < 0.0001). A sudden head drop or moving down the tilt table was more common in PPS than in VVS (p < 0.01), but jerking movements occurred more frequently in VVS (p < 0.0001). In PPS, both HR and BP increased before and during apparent TLOC (p < 0.0001). CONCLUSIONS: PPS is clinically distinct from VVS and can be diagnosed accurately with tilt-table testing and simultaneous EEG monitoring. Compared with VVS, eye closure during the event, long periods of apparent TLOC, and high HR and BP are highly specific for PPS. Improved understanding of the semiology of PPS as a clinical entity is vital to ensure accurate diagnosis.
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Tilt testing may be helpful in separating syncope from psychogenic pseudosyncope.
“Tilt testing may be helpful in separating syncope from PPS.”
From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [116]
A normal EEG helps to confirm the diagnosis of psychogenic pseudosyncope.
“a normal EEG helps to confirm the diagnosis. 116,117”
From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [116]
Video recording of tilt-induced PPS ensures that apparent TLOC occurs while BP and HR are not low; adding an EEG increases the diagnostic probability of PPS even further.
“Video recording of tiltinduced PPS 116 ensures that apparent TLOC occurs while BP and HR are not low; adding an EEG increases the diagnostic probability of PPS even further.”
From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [116]
The eyes are usually open in epileptic seizures and syncope but are usually closed in psychogenic TLOC.
“The eyes are usually open in epileptic seizures and syncope but are usually closed in psychogenic TLOC.”
From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [116]
PPS and PNES differ pathophysiologically from the TLOC forms that they resemble: in PPS, BP and HR are normal or high rather than low, and the EEG is normal instead of showing the slowing or flattening typical of syncope; in contrast to epileptic seizures, the EEG in PNES shows no epileptiform brain activity during an attack.
“PPS and PNES differ pathophysiologically from the TLOC forms that they resemble: in PPS, BP and HR are normal or high rather than low, and the EEG is normal instead of showing the slowing or flattening typical of syncope; in contrast to epileptic seizures, the EEG in PNES shows no epileptiform brain activity during an attack.”
From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [116]
There are two types of psychogenic TLOC: PPS and PNES.
“There are two types: PPS and PNES.”
From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [116]
In most cases, the duration of PPS is as short as in syncope, but a much longer duration is a useful diagnostic finding: patients may lie immobile on the floor for 15-30 min.
“In most cases, the duration of PPS is as short as in syncope, but a much longer duration is a useful diagnostic finding: patients may lie immobile on the floor for 15-30 min.”
From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [116]
There is usually no recognisable trigger, and no sweating, pallor, or nausea beforehand in PPS.
“There is usually no recognisable trigger, and no sweating, pallor, or nausea beforehand.”
From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [116]
In PPS movements are absent, so PPS resembles syncope or longer-lasting LOC, whereas in PNES impressive limb movements mean the attacks resemble epileptic seizures.
“In PPS movements are absent, so PPS resembles syncope or longer-lasting LOC, whereas in PNES impressive limb movements mean the attacks resemble epileptic seizures.”
From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [116]
The attack frequency in PPS is high, with several attacks occurring over a week or in a day.
“The attack frequency is high, with several attacks occurring over a week or in a day.”
From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [116]
In psychogenic TLOC there is no gross somatic brain dysfunction, but the attacks fulfil the criteria for TLOC.
“In psychogenic TLOC there is no gross somatic brain dysfunction, but the attacks fulfil the criteria for TLOC (see section 3.1).”
From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [116]
The rate of PPS varies from 1% of patients referred to general syncope clinics to 8% of patients referred to specialist neurological clinics.
“The rate of PPS varies from 1% of patients referred to general syncope clinics 94 to 8% of patients referred to specialist neurological clinics, 116”
From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [116]
The diagnosis of PPS rests on positive clues taken from the patient's history and from documenting normal EEG results, HR, or BP during an attack.
“The diagnosis of PPS rests on positive clues taken from the patient's history and from documenting normal EEG results, HR, or BP during an attack.”
From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [116]
Injury does not exclude PNES or PPS.
“Injury does not exclude PNES or PPS.”
From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [116]
The gold standard for PPS is documenting an attack with a home video recorder or with a tilt testing during which BP, HR, and EEG are normal.
“The gold standard for PPS is documenting an attack with a home video recorder or with a tilt testing during which BP, HR, and EEG are normal.”
From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [116]
Patients with psychogenic pseudosyncope are often young females.
“Patients with psychogenic pseudosyncope are often young females with a higher prevalence of preexisting VVS or a history of physical and/or sexual abuse (229,525).”
From 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope (2017) · cites this paper as [229]
A normal pulse, blood pressure, or EEG during a psychogenic pseudosyncope episode can be documented.
“A normal pulse, blood pressure, or EEG during a psychogenic pseudosyncope episode can be documented (229).”
From 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope (2017) · cites this paper as [229]
In the absence of associated jerky movements, patients with apparent loss of consciousness are likely to be referred for evaluation of syncope.
“In the absence of associated jerky movements, the patient is likely to be referred for evaluation of syncope (30,229,524).”
From 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope (2017) · cites this paper as [229]
Patients with psychogenic pseudosyncope have a higher prevalence of preexisting VVS or a history of physical and/or sexual abuse.
“Patients with psychogenic pseudosyncope are often young females with a higher prevalence of preexisting VVS or a history of physical and/or sexual abuse (229,525).”
From 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope (2017) · cites this paper as [229]
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- Authors
- Tannemaat, M. R., van Niekerk, J., Reijntjes, R. H., Thijs, R. D., Sutton, R., & van Dijk, J. G.
- Affiliations
- Leiden University (NL)
- From the Department of Neurology and Clinical Neurophysiology (M.R.T., R.H.R., R.D.T., J.G.v.D.), Leiden University Medical Centre; Laboratory for Neuroregeneration (M.R.T.), Netherlands Institute for Neuroscience, Royal Academy of Arts and Sciences, Amsterdam; Faculty of Medicine (J.v.N.), Leiden University; SEIN–Epilepsy Institute in the Netherlands Foundation (R.D.T.), Heemstede, the Netherlands; UCL (R.D.T.), Department of Clinical and Experimental Epilepsy, London; Imperial College London (R.S....
- Venue
- Neurology
- Published
- 2013-08-20
- Volume
- 81
- Issue
- 8
- Pages
- 752-758
- ISSN
- 0028-3878 (ISSN-L)
- 1526-632X
- PMC
- PMC3776458
- OpenAlex
- W2149786680
- Cited by
- 99
- References
- 25
- Citations by year
- 2026: 3 · 2025: 2 · 2024: 7 · 2023: 4 · 2022: 8 · 2021: 10 · 2020: 12 · 2019: 5 · 2018: 11 · 2017: 15 · 2016: 8 · 2015: 4 · 2014: 10
- FWCI
- 7.22
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Neurology (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- KNAW Research Portal (The Royal Netherlands Academy of Arts and Sciences) (publishedVersion)
- Data Archiving and Networked Services (DANS) (submittedVersion)
- Leiden Repository (Leiden University) (submittedVersion)
- Topics
- Health Sciences › Medicine › Surgery › Cardiovascular Syncope and Autonomic Disorders
- Health Sciences › Medicine › Psychiatry and Mental health › Psychosomatic Disorders and Their Treatments
- Life Sciences › Neuroscience › Neurology › Vestibular and auditory disorders
- Keywords
- transient loss of consciousness, vasovagal syncope, tilt table test, semiology, eyelid closure, heart rate, blood pressure, EEG monitoring, differential diagnosis
- MeSH terms
- Adolescent, Adult, Blood Pressure, Blood Pressure Determination, Diagnosis, Differential, Electrocardiography, Female, Heart Rate, Humans, Male, Middle Aged, Netherlands, Sensitivity and Specificity, Unconsciousness, Reproducibility of Results, Tilt-Table Test, Syncope, Vasovagal, Young Adult, Symptom Assessment
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