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Table 1 Main semiological details distinguishing PNES from ES

From: The first-line management of psychogenic non-epileptic seizures (PNES) in adults in the emergency: a practical approach

Characteristic detailsPNESESComments
General characteristics of the conversation analysis
Main theme of the seizure descriptionPatient emphasizes on the context of occurrence and the consequences of the episodes [22, 24]Patient emphasizes on the description of the signs [22, 24]Value is dependent of the patient’s level of cooperation
Answer when questioned about the most memorable eventPatient skipping the question or providing evasive answers [22]Usually 2–3 memorable episodes are reported [22]Value is dependent of patient’s level of cooperation
Emotional component of the conversationCatastrophizing [24]Tendency to dedramatize [24]More valuable when the patient has a good social situation
Ictal features
Duration of the episodesUsually, suspicious events longer than 5 min are PNES [40]ES are usually shorter than 1–2 minConsider the usual length of seizures thoroughly
Sleep occurrence (ES Sp = 100% [9])No [9]Episodes occurring during sleep are usually ES (or sleep disorders)Low reliability of details based on history. V-EEG proof is important
Fluctuating intensity of the manifestations during a seizure (PNES Sp = 96% [9])Usual for prolonged episodes (i.e. lasting more than 2 min) [9, 27]Not usual, except in some cases of status epilepticusIn prolonged PNES, the patient is often able to respond to a gesture or word
Pelvic or whole-body thrusting (PNES Sp = 96–100% [9])Yes, for episodes mimicking FBTCS [9, 10]No for FBTCS. Could be seen in hyperkinetic ES (often frontal or anterior insular).Here, the occurrence during sleep could help to eliminate PNES if this detail is reliable
Eye closure (PNES Sp = 74–100% [9])If yes, most likely PNES [9, 10]Eyes usually openedVery good indicator, easily identifiable
Ability to respond to a gesture or a word during a seemingly convulsive episodeCould be able to answerUnable to respond during focal with impaired awareness seizure or FBTCSRelevant for bilateral convulsive events. Non-response state does not exclude PNES
Side to side head or body movement (PNES Sp = 96–100% [9])Highly suggestive of PNES [9, 26, 40]Usually, ictal turning in ES occur once or twiceRelevant for convulsion-like episodes
Ictal crying (PNES Sp = 100% [9])Yes, sometimes (then combined with frustration gesturesUsually no. If they occur, they are noted prior to the convulsionsCould very rarely occur during ES but not during the convulsive phase
Post-ictal characteristics
Memory recall after a FBTCS-like episode (PNES Sp = 96% [9])Typically preserved [21]Usually, total amnesia of the episode or transient confusion [43]Relevant for FBTCS and focal seizures with impaired awareness
Post-ictal confusion (ES Sp = 84–88% [9])No (post-PNES fatigue may be confuse with confusion)If yes, likely ES. May be surprisingly absent in frontal seizures with hypermotor semiologyDetails often difficult to evaluate based on history
Breathing (ES Sp = 100% [9])Tachypnea or apnea [44]Bradypnea [44]
Stertorous breathing [44]
Relevant semiological value for bilateral convulsive episodes
Physical examination details
Induction test by nocebo effectHigh value if positive. However, may be negativeUsually negative. May be positive by induction of PNES. However, true reflex ES may be triggered! [28]A good suggestion is required. Rarely, the induction test may trigger PNES or ES in patients previously presenting only spontaneous ES [28]
Inhibition test by placebo effectPossible intense response if experienced physicianUsually negativeThe quality of the suggestion is crucial. Relevant in prolonged episodes
Paraclinical investigations
EEGInterictal: normal
Ictal: normal
Inter-ictal: normal or epileptiform activity
Ictal: abnormal
Physiologic spikes can be wrongly interpreted and thus lead to a wrong diagnosis. Epileptiform spikes do not exclude PNES (mixed PNES/ES patients)
Prolactin levelUsually normal [32, 33]High sensitivity for FBTCS (up to 100%) [33]Relevant for bilateral convulsive episodes
  1. ES epileptic seizure, PNES psychogenic non-epileptic seizure, SE status epilepticus, FBTCS focal to bilateral tonic-clonic seizure, Sp specificity (%) for PNES or ES