Characteristic details | PNES | ES | Comments |
---|---|---|---|
General characteristics of the conversation analysis | |||
Main theme of the seizure description | Patient emphasizes on the context of occurrence and the consequences of the episodes [22, 24] | Value is dependent of the patient’s level of cooperation | |
Answer when questioned about the most memorable event | Patient 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 conversation | Catastrophizing [24] | Tendency to dedramatize [24] | More valuable when the patient has a good social situation |
Ictal features | |||
Duration of the episodes | Usually, suspicious events longer than 5 min are PNES [40] | ES are usually shorter than 1–2 min | Consider 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 epilepticus | In prolonged PNES, the patient is often able to respond to a gesture or word |
Pelvic or whole-body thrusting (PNES Sp = 96–100% [9]) | 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]) | Eyes usually opened | Very good indicator, easily identifiable | |
Ability to respond to a gesture or a word during a seemingly convulsive episode | Could be able to answer | Unable to respond during focal with impaired awareness seizure or FBTCS | Relevant for bilateral convulsive events. Non-response state does not exclude PNES |
Side to side head or body movement (PNES Sp = 96–100% [9]) | Usually, ictal turning in ES occur once or twice | Relevant for convulsion-like episodes | |
Ictal crying (PNES Sp = 100% [9]) | Yes, sometimes (then combined with frustration gestures | Usually no. If they occur, they are noted prior to the convulsions | Could 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 semiology | Details 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 effect | High value if positive. However, may be negative | Usually 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 effect | Possible intense response if experienced physician | Usually negative | The quality of the suggestion is crucial. Relevant in prolonged episodes |
Paraclinical investigations | |||
EEG | Interictal: 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 level | High sensitivity for FBTCS (up to 100%) [33] | Relevant for bilateral convulsive episodes |