Differentiating Epileptic from Psychogenic seizures

Behavior Psychological nonepileptic seizure Epileptic seizure
Eye movement Eyes closed at onset and during seizure; geotropic eye movement may be observed Eyes open during seizure onset; may close briefly
Post-ictal nose rubbing and cough Not present May be present
Weeping May be present Not present
Body movements Pelvic thrusting; out-of-phase or side-to-side oscillatory movements; chaotic and disorganized thrashing; ictal stuttering; post-ictal whispering Pelvic thrusting; quick, tonic posturing; vocalization
Self-injury May be present May be present
Tongue laceration May be present May be present
Incontinence May be present May be present

* Eyes open or closed? Using data from video-EEG monitoring, researchers found that:

* Ictal eye closure was 96% sensitive and 98% specific for diagnosing psychogenic nonepileptic seizures, the investigators found. link to article

* Serum prolactin drawn within 30 minutes of ictus onset is helpful for differentiating generalized tonic clonic seizures and partial complex seizures from PNES

* A pooled analysis of data from the literature shows that urinary incontinence has no value either in the differential diagnostic between ES and syncope/PNES.

Screening tool to assist in distinguishing between psychogenic nonepileptic seizures and epileptic seizures

A. Ictal Stage
   Head movements Fixed Side to side
     Eyelids Open Closed
     Light reflex Absent Present
     Corneal touch No response Guarding response
     Vocalizations No Yes
     Tongue injury May bite the side(s) May bite the tip
   Limb movements
     Synchronous Yes No
     Continuous Yes No (with pauses)
     Typical Yes (tonic, clonic, or both) No
   Duration 2–3 minutes More than 3 minutes
B. Post-ictal Stage
     Deep Yes No
     Regular Yes No
     Loud Yes (with snoring) No
     Duration 5 minutes 1 minute
   Recall of episode events No Yes
   Confusion Yes No
   Headache Yes No
   Fatigue Yes No