Psychogenic Nonepileptic Seizures Raise Risk for Suicide in Veterans

Photo taken in Romoos, Switzerland
Although the increased rate of suicide in people with epilepsy has been documented, this is the first study to report the rates of suicide and suicide-related behavior in those with psychogenic nonepileptic seizures.

Veterans with seizures are at increased risk of death by suicide and suicide related behavior (SRB), according to study results published in Neurology: Clinical Practice.

Cohort studies have shown that epilepsy increases the risk of suicide and SRB independent of antiseizure medications, even after successful epilepsy surgery. Patients with psychogenic nonepileptic seizures (PNES) face similar psychosocial challenges as people with epilepsy but do not share neuropathology, and no studies to date have reported the rates of suicide and SRB associated with PNES.

Study researchers drew the data of 801,734 veterans from a cohort study of veterans enrolled in Veterans Health Administration care from 2002 to 2017. They divided them by diagnosis of PNES (n=752), epilepsy (n=10,994) and neither (n=789,988), which they call the general group. Those with both PNES and epilepsy were excluded.

There were 1,870 total deaths from suicide: 0.80% of veterans with PNES, 0.65% of veterans with epilepsy, and 0.23% of veterans in the general group. SRB, as defined using ICD-9 and ICD-10 coding, was present in 29% of veterans with PNES, 24% with epilepsy, and 5.6% in the general group.

The standardized mortality rate (SMR) for PNES, epilepsy, and the general veteran group was 2.65 (95% CI, 1.95-5.52), 2.04 (95% CI, 1.60-2.55), and 0.7 (95% CI, 0.673-0.738), respectively. More than 80% of deaths by suicide among those with epilepsy occurred 1 year after diagnosis.

Veterans diagnosed with PNES (relative risk [RR], 1.75; 95% CI, 1.51-2.02) had a higher risk than veterans with epilepsy for dying by suicide and a 3.82 (95% CI, 3.32-4.39) times higher risk of suicide than the general group. Veterans with epilepsy had 2.19 times the risk of suicide (95% CI, 2.10-2.28) compared with the general group.

Veterans with PNES also had a higher risk of SRB compared with veterans with epilepsy (RR, 1.61, 95% CI, 1.51-1.73) and the general population (RR, 3.65; 95% CI, 3.42-3.90) whereas veterans with epilepsy were more than 2.26 times more likely (95% CI, 2.22-2.31) to engage in SRB than the general group (P <.0001 for all).

Female veterans with PNES were less likely than male veterans with PNES to die by suicide (RR, 0.48; 95% CI, 0.46-0.50; P<.0001) or engage in SRB (RR, 0.96; 95% CI, 0.95-0.98; P<.0001). Black veterans had a RR of 0.93 (95% CI, 0.92-0.94; P <.0001) for SRB compared with White veterans with PNES.

Anxiety and traumatic brain injury were significantly associated with SRB only (P<0.0001). Of comorbid covariates, veterans with PNES who were engaging in drug abuse had the greatest risk of suicide, with a RR of 1.92 (95% CI, 1.88-1.96; P<.0001). Veterans with PNES using psychotropic medication had the highest risk of engaging in SRB (RR, 8.38; 95% CI, 8.15-8.61; P<.0001).

Limitations of the study include limited generalizability because most of the population were men and aged between 30 and 49 years. In addition, the patients were not systematically evaluated, and confidence intervals are wide due to the limited sample size.

Based on their findings, study researchers concluded, “Veterans with PNES and veterans with epilepsy are both at significantly increased risk for suicide and SRB when compared to the general population.” They added, “Future research will look at whether PTSD therapy and PNES-driven psychotherapy is protective for suicide and whether delayed diagnosis of PNES plays a part in the increased suicidality.”

Disclosure: Some study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.


Bornovski Y, Jackson-Shaheed E, Argraves S, et al. Suicide and seizures: a national cohort study in veterans. Neurol Clin Pract. Published online March 12, 2021. doi:10.1212/CPJ.0000000000001070