Article Text

Does the primary literature provide support for clinical signs used to distinguish psychogenic nonepileptic seizures from epileptic seizures?
  1. Andreja Avbersek1,2,4,
  2. Sanjay Sisodiya1,2,3
  1. 1Department of Clinical and Experimental Epilepsy, Institute of Neurology, London, UK
  2. 2National Hospital for Neurology and Neurosurgery, London, UK
  3. 3National Society for Epilepsy, Chalfont St Peter, UK
  4. 4Department of Neurology, University Medical Centre Maribor, Maribor, Slovenia
  1. Correspondence to Dr S M Sisodiya, Department of Clinical and Experimental Epilepsy, Box 29, The National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK; s.sisodiya{at}


Psychogenic non-epileptic seizures (PNES) represent a diagnostic challenge. When trying to distinguish between PNES and epileptic seizures (ES), clinicians rely on the presence or absence of several clinical signs. The purpose of this review is to establish the extent to which these signs are supported by primary data from the literature. A Medline search was used to identify primary studies that used video-EEG to define the presence or absence of different clinical signs in PNES and ES. The methodological quality of the studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool. 34 studies matched the inclusion criteria. A specific sign was considered well supported by the data from the primary literature if we were able to identify at least two controlled studies demonstrating its usefulness and if the data from other studies were supportive. There is good evidence from the literature that long duration, occurrence from apparent sleep with EEG-verified wakefulness, fluctuating course, asynchronous movements, pelvic thrusting, side-to-side head or body movement, closed eyes during the episode, ictal crying, memory recall and absence of postictal confusion are signs that distinguish PNES from ES. Postictal stertorous breathing proved to distinguish convulsive PNES from generalised tonic clonic seizures (GTCS) and should be added to the list of useful clinical signs. The final clinical diagnosis should encompass all available data and should not rely on any single sign alone.

  • Psychogenic nonepileptic seizures
  • ictal signs
  • video-EEG telemetry
  • EEG

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  • Funding This work was undertaken at UCLH/UCL who received a proportion of funding from the Department of Health's NIHR Biomedical Research Centres funding scheme.

  • Competing interests None.

  • Provenance and peer review Commissioned; externally peer reviewed.

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