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Patients with epileptic and nonepileptic seizures are commonly encountered in clinical practice, and they can pose a difficult diagnostic problem. We present two cases that show the difficult task of differentiating between true epileptic and nonepileptic or psychogenic seizures in some patients. The clinical presentations were complex and the use of video-monitored EEG alone was insufficient to make definitive diagnoses. Ictal and interictal Tc-99m HMPAO brain perfusion SPECT imaging examinations were used to help establish the correct diagnoses. This report describes the advantage of using the brain perfusion SPECT imaging examination. The injection of stabilized Tc-99m HMPAO during an ictal event followed by appropriate medical therapy provides a method of obtaining a reasonable image of relative perfusion (activity) during the seizure. These images can then be compared with interictal examinations and an epileptic or nonepileptic focus may be localized. The Tc-99m HMPAO brain perfusion SPECT imaging study was helpful in establishing the correct diagnosis in both cases.

ObjectivesA retrospective study was conducted to evaluate clinical usefulness of video EEG monitoring in patients with suspected epileptic seizures. Material and methodsA total of 444 patients who had diagnostic video EEG from January 1989 to December 1992 were studied after excluding those with known medically refractory focal epilepsy undergoing presurgical evaluation. Most were outpatients and had video EEG monitoring during normal working hours over 1–5 days. ResultsThe procedure had a success rate of 73%; characteristic events were captured and categorized in 53% of the patients. Patients with an event frequency of at least one per week or those who had events characterized by motor manifestations showed a higher yield. Thirty-two percent of the patients had psychogenic seizures. Thirty-four percent of the patients had either epileptic seizures recorded during the study or showed clear-cut interictal epileptiform abnormalities providing strong evidence of underlying epileptic process. ConclusionIn patients with frequent paroxysmal events, a video EEG study provides diagnostically critical information. It can be performed usually as an outpatient investigation.

Serum levels of prolactin may increase as a consequence of epileptic seizures. The hormone release is caused by the propagation of epileptic activity, usually from the temporal lobe to the hypothalamic-pituitary axis. Due to the intensity of the epileptic afterdischarge, a rise is seen in approximately 60% of complex partial seizures. Prolactin usually fails to rise after psychogenic seizures, therefore, postictal prolactin levels can be used to differentiate between epileptic and psychogenic seizures. However, a subclassification of epileptic seizures by means of prolactin measurement is not possible. In repetitive seizures, prolactin may show a decrease in its postictal release. This is more common in status epilepticus, probably as a result of a diminished propagation of ictal activity during the course of status epilepticus. The influence of chronic epileptic discharges and anticonvulsant medication on prolactin release is moderate.

Ictal weeping may help distinguish psychogenic nonepileptic seizures (PNES) from epileptic seizures. However, the prevalence of weeping during PNES or epileptic seizures is unknown. We reviewed videotapes of recorded events in 84 consecutive patients with PNES or epilepsy. Weeping was observed during 14% of PNES in 31% of patients with PNES. Ictal weeping was not observed in any epileptic seizures occurring in 48 patients. The differences were highly significant. One patient with epileptic seizures originating in the right temporal lobe wept soon after the end of a seizure. Depression was not more common in PNES patients with than without ictal weeping. Weeping during an apparent seizure strongly argues that the event is not epileptic.

Psychogenic seizures are unusual during the first decade of life. To compare the clinical features of psychogenic seizures in young children with those of teenagers, the long-term electroencephalographic and video monitoring studies of all patients younger than 18 years of age with recorded episodes diagnosed as psychogenic seizures were reviewed from a single hospital during the past 7 years. The 27 patients were divided into 2 age groups: group A, 6-9 years (n = 5), and group B, 10-17 years (n = 22). All patients had habitual episodes recorded during monitoring. Although the adolescents displayed clinical patterns similar to adult patients with psychogenic seizures, the children demonstrated a clinical pattern characterized mainly by prolonged staring and unresponsiveness. The most common behaviors in the adolescent group were tremor (45%), intermittent stiffening (41%), and out-of-phase movements of the extremities (36%). Fifteen percent of the patients had a history of seizures. This study suggests that young children with psychogenic seizures have clinical profiles different from that of teenagers.

Psychological correlates of psychogenic seizures were studied. The MMPI, Portland Digit Recognition Test (PDRT; a forced choice measure of motivation), disability status, Face-Hand Test, and Finger Agnosia were compared in 53 patients with medically intractable seizure disorders who underwent intensive EEG monitoring. Using conventional neurologic criteria, 64% had diagnoses of epileptic seizures (ES) and 36% had psychogenic seizures (PS). PS patients were significantly higher in number of somatoform MMPI profiles and likelihood of applying for financial benefits, and significantly lower on the PDRT. PS patients made more Finger Agnosia errors. Differences on the Face-Hand Test were of borderline significance. The results support the existence of multiple psychometric correlates of PS.

Placebo infusions are occasionally used to elicit psychogenic seizures. How frequently placebo infusions elicit patients' typical events, atypical and potentially confusing events, or even epileptic seizures is not known. We report the results of placebo infusions during video EEG in 68 patients who also had events recorded without placebo. A single investigator administered a saline placebo that was represented to the patient as an activating substance. We compared the events recorded without placebo with events recorded with placebo. Twenty patients had only epileptic seizures without placebo; with placebo, two of 20 (10%) had their typical epileptic seizures and three of 20 (15%) had atypical nonepileptic events. Forty patients had only psychogenic seizures without placebo; with placebo, 33 of 40 (82%) had their typical psychogenic seizures and three of 40 (8%) had atypical events. Eight patients had both psychogenic and epileptic seizures without placebo; with placebo, four of eight had their typical psychogenic seizures. Thus, placebo infusion elicits typical psychogenic events in most patients with psychogenic seizures, but atypical events or epileptic seizures may occur in a minority and lead to incorrect diagnosis.

The authors administered the Structured Clinic Interview for DSM-III-R (SCID) to 20 outpatients with nonepileptic seizures documented by video-EEG. Fourteen (70%) had one or more non-somatoform DSM-III-R diagnoses. All 14 met criteria for panic disorder. Comorbid mood, psychotic, substance abuse, and eating disorders were also noted. Meticulous use of the SCID, with extensive follow-up, may have resulted in enhanced detection of panic disorder in patients who do not spontaneously report panic symptoms. Panic attacks may play a more important role in nonepileptic seizures than has been generally recognized, especially in outpatients with a chronic course of illness.

An undescribed association between syncope and Raynaud9s disease is presented. Ten females and one male, aged 19–64 years, with syncope and Raynaud9s disease were seen over a period of 6 years. The features in all suggested brainstem syncope. Nine had active, and one a history of, migraine. Three had previous diagnoses of non-epileptic attack disorder (psychogenic seizures). Syncope and Raynaud9s disease improved in parallel, in all patients, after treatment with a calcium channel blocker (Nifedipine). Migraine also improved in five patients. A chance association between syncope and Raynaud9s disease is statistically unlikely, and a pathophysiological link between the two is explored. Syncope in this condition may result from transient brainstem ischaemia, and brainstem spreading depression might also be involved. Syncope is relatively common, but the cause is unknown in more than one-third of patients. The association described here is important in establishing an exact diagnosis in some patients with syncope, and in providing new treatment options.

The clinical characteristics, psychosocial background, neuropsychological testing, clinical and social outcome were analysed in 93 adults with psychogenic seizures (PS). Thirteen (14%) were males and 80 (86%) were females. Mean age was 31.7 years (range 16 to 55 years). Lack of responsiveness associated with motor activity was the most common finding. Neuropsychological testing done in 46 cases revealed hysteroid traits and coping mechanisms and depression to be the most prevalent underlying problems. History of sexual abuse was evident in 10 (10.7%) cases. Social impact analysis revealed that of 62 patients who were working at the onset of PS, 34 were not working at the time of the diagnosis of PS. In 25 cases, PS were the reason for not working. After a mean follow-up of 60.7 months done in 63 patients, 16 (25.4%) patients were seizure-free. There were no obvious significant predictors of poor prognosis.

Summary: Psychogenic seizures are unusual after age 60 years, A 73-year-old woman had onset of psychogenic seizures at age 69 years. Five to six attacks occurred each month, usually at night, characterized by an initial subjective sensation and headache followed by generalized stiffening and shaking. Continuous EEG-closed circuit television (EEG-CCTV) monitoring clearly showed these episodes to be nonepileptic. Discontinuation of antiepileptic drugs (AEDs) did not increase the frequency or severity of attacks. Epileptiform discharges were not recorded during the awake, drowsy, or sleeping states. Psychiatric evaluation identified significant turmoil in the patient's life and a history of childhood sexual and physical abuse. Psychogenic seizures may begin in old age and should be considered in the differential diagnosis of intractable seizures in the elderly. Predominantly nocturnal occurrence should not exclude the diagnosis.

Psychogenic seizures appear in the literature under various synonyms (Table 1) and refer to events that are characterized by a change in behavior, sensory, and/or motor activity that appear epileptogenic but are functional in etiology. A corollary to this definition is that psychogenic seizures, unlike seizures of neurogenic origin, are events that have no associated alteration in brain electrical activity. Patients with psychogenic seizures are distinguished from malingerers in that a malingerer is aware of feigning his symptoms, often for well-defined purposes, whereas psychogenic seizure patients are unaware of the psychiatric cause of their behavior. Likewise, psychogenic seizures are distinct from the chronic factitious disorder with physical symptoms (Munchausen’s syndrome), in that the latter is characterized by the voluntary simulation of illness for the sole purpose of gaining admission to medical care.’ Psychogenic seizures can be divided into two major categories: (1) those in which motor abnormalities predominate the clinical presentation thus mimicking convulsive seizures, and (2) those in which altered mental status predominates without a significant motor component, thus mimicking the absence of seizures.2,3 Psychogenic seizures can be extremely difficult to differentiate from neurogenic seizures and, when inappropriately labeled, can result in patient mismanagement with the potential for iatrogenic harm.3-9 Altered mental status, without associated motor activity, as the major manifestation of a psychogenic seizure is less of a management dilemma for the emergency physician than convulsive psychogenic seizures, because once the patient has been stabilized, there is time to systematically evaluate the patient, including obtaining an electroencephalogram (EEG) and specialty consultation, before treatment. On the other hand, emergency medicine physicians confronted with a patient with persistent or recurrent tonic-clonic motor activity often feel compelled to assume a neurogenic basis for the activity and to pharmacologically intervene. There are a number of reports in the literature of psychogenic seizures being treated as if they were neurogenic in origin,4*6*9 and

Of the conditions labeled “epilepsy” through the ages, many were certainly not epileptic in nature. As knowledge about nonepileptic seizures has expanded, it has became evident that psychogenic seizures are common and that many of these patients have a previous history of sexual molestation. The sexual molestation of a young woman, Marie Catherine Cadiere, for a period of 18 months by a Jesuit priest in 1728 was carefully documented in the legal proceedings that followed and provide a painful and yet clear portrait of psychogenic seizures at a time of history colored by religious fervor, the omnipotence of the church, and mass superstitions.

ObjectivesThis paper aimsa)to explore the difficulties in differential diagnosis between epileptic crises and psychogenic non epileptic seizures (pseudoseizures),b)to suggest therapeutic guidelines for psychogenic non epileptic seizures. Our purpose is to present a literature review on this subject and to discuss the problems involved.MethodTypical systematic review of recent articles regarding this topic at the internet search engines of PubMed and Scopus. We used the following keywords: psychogenic seizures, psychogenic non epileptic seizures (PNES), pseudoseizures, conversion disorder, dissociative disorder.ResultsA large percentage of the seizures are found to be psychogenic non epileptic. Most of the patients are firstly treated by neurologists and only a percentage of close to 1/3 of these are referred to psychiatrists for further therapy. The differential diagnosis is difficult because most of the patients actually suffer from both epileptic and non epileptic seizures and usually come to the emergency clinics with either. Video EEG and therapeutic hypnosis are considered to be helpful techniques.ConclusionsIn order to treat patients suffering from psychogenic non epileptic seizures there must be a close collaboration between the neurologists, the psychiatrists and the emergency physicians considering both the medication prescribed and the therapeutic guidelines followed.

Of all partial seizures, those of frontal lobe origin (FLPS) are most bizarre and are often mistaken for psychogenic seizures (PS). The reverse can also be true. To clarify the confusing clinical presentation of these different seizure types, we compared the clinical ictal characteristics of 63 FLPS in 11 patients with 29 PS in 12 patients. Patients with PS had significantly later age at onset and longer ictal duration. There was no statistically significant difference between the two groups with respect to history of psychiatric disorder, ictal pelvic thrusting, rocking of body, side-to-side head movements, or rapid postictal recovery, all of which previously have been reported as characteristic features of PS. Turning to a prone position during the seizure occurred only in FLPS. Nocturnal occurrence, short ictal duration, younger age at onset, stereotyped patterns of movements, and MRI and EEG abnormality suggested FLPS.

Psychogenic seizures can mimic convulsive epilepsy and with repetitive attacks, iatrogenic complications from aggressive treatment of status epilepticus can occur. We studied neuropsychiatric features of 20 patients in whom psychogenic seizures were intractable and at times continuous. Nineteen of 20 patients seen were female, and all but one were under 40 years of age. All had convulsive attacks resistant to various medications, normal neurological examinations, and negative imaging studies and electroencephalograms (EEGs). Sixteen had previous evidence of epilepsy and the other four had epileptic relatives. Seizures were atypically prolonged, included back arching and pelvic thrusting, and persisted despite intravenous diazepam and therapeutic phenytoin and phenobarbital levels. Seizures terminated spontaneously in five, were stopped by suggestion in four, and persisted until respiratory arrest or elective intubation in 11. Ten patients had conversion disorder, six borderline or mixed personality disorder and four mental retardation. Fifteen had had some precipitating stressor and the remainder had histories of exhibiting attention-seeking behaviour. Nine of 10 patients with conversion disorder had 'conversion V' Minnesota Multiphasic Personality Inventory (MMPI) profiles, while personality disorder patients had elevation of several psychopathological scales. Patients with conversion disorder gradually improved with anticonvulsant discontinuation, while retarded individuals were helped by behaviour modification, situational change or neuroleptics. Personality disorder patients continued to have attacks and eventually discontinued follow-up. Clinical evidence of non-epileptic seizures includes clinical atypicality and long duration, exacerbation by medications and frequent attacks despite normal examination and studies.(ABSTRACT TRUNCATED AT 250 WORDS)

We analyzed ictal features of psychogenic seizures using video-EEG recordings in 47 patients and reviewed the medical records to determine if patients received antiepileptic drug therapy and whether they were treated pharmacologically for status epilepticus. Unresponsive behavior in the absence of motor manifestations was the single most common ictal presentation. Motor characteristics previously considered to distinguish psychogenic seizures (out-of-phase limb movements, side-to-side head movements, pelvic thrusting) were infrequent. Most patients (74%) received anticonvulsants, and six were treated as status epilepticus. Slow, subtle writhing or in-phase limb movements were most likely to be mistaken for status epilepticus. Physicians, assuming that the spells constituted a neurologic emergency, omitted the neurologic examination and chart review and proceeded with aggressive pharmacotherapy based merely on observation.

The prevalence of psychogenic non-epileptic seizures is difficult to estimate. We propose an estimate based on a calculation. We used the following data, which are known or have been estimated, and are generally accepted. A prevalence of epilepsy of 0.5–1%; a proportion of intractable epilepsy of 20–30%; a percentage of these referred to epilepsy centers of 20–50%; and a percentage of patients referred to epilepsy centers that are psychogenic non-epileptic seizures: 10–20%. Using the low estimates, the prevalence of psychogenic non-epileptic seizures would be 1/50 000. Using the high estimates, the prevalence of psychogenic non-epileptic seizures would be 1/3000. The prevalence of psychogenic non-epileptic seizures is somewhere between 1/50 000 and 1/3000, or 2 to 33 per 100 000, making it a significant neurologic condition.

The case of a 12-year-old girl with anti-methyl-D-aspartate receptor (NMDAR) encephalitis is reported by researchers from Augsburg and Bonn, Germany, and Oxford, UK.

We studied 20 patients with continuous repetitive psychogenic seizures simulating status epilepticus. Most patients received intravenous doses of multiple anticonvulsants. Our definition used for status epilepticus was that of Delgado-Escueta et al, 1 at least 30 minutes of repetitive seizures without regaining consciousness. Nineteen of 20 patients were young women, all but one under 40 years of age. Sixteen of these patients had a history of childhood seizures. In over 50% of patients, seizures continued until respiratory arrest and intubation occurred. Thorough neuropsychological testing and psychiatric interview were done after cessation of the acute episode. Long-term outcome and prognosis depended on definitive psychiatric diagnosis. Repetitive psychogenic seizures simulating status epilepticus are not uncommon, and such patients may incur serious iatrogenic complications from treatment for status epilepticus. Appropriate management and long-term prognosis may be determined by the type and severity of the underlying psychiatric disorder.

The medical records of 27 children admitted to the MINCEP Epilepsy Program for evaluation of intractable epilepsy but later shown to have nonepileptic events by EEG with simultaneous video monitoring were reviewed. Four groups were identified: pure psychogenic events (5 patients), psychogenic events plus epileptic seizures (3 patients), pure nonepileptic physiologic events (5 patients), and nonepileptic physiologic events plus seizures (14 patients). Historical data, physical examinations, and neurodiagnostic evaluations (including previous EEGs, neuroradiologic evaluations, and neuropsychologic testing) were reviewed. Children in all groups, except for those with pure psychogenic seizures, had a history of multiple seizure types identified by parents or caretakers. A history of status epilepticus was obtained in 64% (of 22 patients), including 11 of 14 patients with physiologic events plus seizures. Abnormal findings on neurologic examination were common, especially in children with nonepileptic physiologic events. All but two patients had a history of interictal epileptiform abnormalities on previous routine EEGs. Based on identification of nonepileptic events, antiepileptic drugs (AEDs) were discontinued completely in eight patients (30%) and the total number of AEDs was reduced in nine others (33%). A diagnosis of nonepileptic events should be considered in all children with refractory seizures or multiple seizure types. Abnormal findings on routine (interictal) EEG may actually confound the diagnosis. Intensive neurodiagnostic EEG-video recording is the preferred method for distinguishing nonepileptic from epileptic seizures.

Chung et al.1 have underlined the useful clinical features of “eyes open” vs “eyes closed” seizures. Another simple and rapid bedside technique that I have found helpful is not emphasized in discussions on clinical features of psychogenic events. The oculocephalic reflex has been reviewed by Plum and Posner2 in the setting of neurologic and psychogenic coma and a similar approach should apply to the patient during an epileptic or psychogenic seizure. It is essentially impossible for a patient to mimic the eye movements or positions of either the absent oculocephalic reflex …

Episodic changes in behavior or consciousness that mimic epilepsy yet have no obvious organic cause have been variably referred to as nonepileptic seizures (NES), pseudoseizures, psychogenic seizures, nonconvulsive psychogenic attacks, and hysterical fits. 1-6 They encompass a whole range of motor, sensory/experiential, and emotional manifestations. These phenomena are ubiquitously defined by being observable and without electroencephalographic correlates before, during, or after their occurrence. Alper and coworkers 1 define two groups of patients with NES: one group satisfies the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition7 (DSM-III-R) criteria for conversion disorder; the other meets the criteria for an Axis 1 DSM-III-R syndrome other than conversion disorder. In this latter group, patients have episodes of anxiety, psychosis, or impaired impulse control. The challenge to clinicians now is to address the issues of pathogenesis and treatment in the context of abnormal biological functioning of the brain. One possibility

INTRODUCTION Non epileptic psychogenic seizures (NEPS) is a pathological condition that arouses the interest of many specialists due to the fact that, every day, it gives rise to problems in different fields especially in diagnosis and therapeutics. This means that sometimes the right diagnosis is reached after a period of explorations and treatment which later turn out to be unnecessary, and have important repercussions on the patient s family and social life, and, financially, on the health care system. METHOD We review the literature on the subject that has been published over the last five years, with the aim of contrasting and integrating the different positions that are currently held. We draw attention to the better known aspects, on which there is a more general agreement, and others that are still subject to controversy and debate; we also attempt to lay down a set of guidelines, bearing in mind the gaps that are still to be filled, to aid future research. CONCLUSIONS 1. NEPS is very difficult to diagnose. It is important to have a good clinical history to be able to identify possible stressors. Video EEG can be of great help, although it is very expensive and not available to all Neurology services. 2. Before deciding on the final diagnosis, frontal, frontomesial and temporal lobe seizures must be taken into account since they sometimes present symptoms that are similar to those of NEPS. 3. The association with different psychiatric pathologies has been shown to exist, and more than one psychopathogenic mechanism may be involved as a mediator in the appearance of NEPS. 4. Therapy begins with the presentation of the diagnosis, which must be performed with due care and attention, and is aided by a multidisciplinary treatment.

INTRODUCTION Recognition of different ictal motor patterns in psychogenic seizures may be useful in terms of differentiation from epileptic seizures and may also improve understanding the underlying psychopathology. OBJECTIVE To outline recognizable ictal motor patterns that may help to distinguish psychogenic motor seizures from epileptic convulsive episodes. PATIENTS AND METHODS Chart review from 54 patients with motor psychogenic seizures and no clinical or EEG evidence of concomitant epilepsy. RESULTS Only 5 patients (9.2%) experienced more than one ictal motor pattern along their illness. Categorization into four subtypes according to ictal motor behaviour was possible in all other patients: psychogenic seizures with flaccid unconsciousness (32.6%), combativeness (32.6%), a hypermobile subtype (24.4%) as defined by the presence of intentional movements or slow rhythmic oscillations of a segment or the entire body, and rigidity (10.2%). CONCLUSIONS Many psychogenic motor seizures consistently present with recognizable motor phenomena which may be readily identified providing the availability of a reliable witness. Psychogenic seizures as presented spontaneously in a general neurology setting may differ from those reported in biased referrals to video-EEG laboratories. Recognition of characteristic patterns may help differentiation from tonic-clonic convulsions, avoid unnecessary examinations, and may provide insights into their underlying psychopathological mechanisms.

Reply from the Authors: We appreciate Dr. Sonnen's interest in our paper. He reports a case of a patient with psychogenic seizures (PS) controlled with a low dose of valproic acid. He questions the psychogenic diagnosis in our patient and suggests that placebo testing can trigger epileptic status …

Reply from the Author: There are a number of techniques proven useful over the years for treating patients with both acute and chronic disorders and, as Dr. Benbadis indicates, many pamphlets are available that discuss both neurologic and psychiatric disorders. Even though he and his colleagues reported that they could …

We report a patient who developed sustained psychogenic seizures after undergoing a provocative technique (PT) for the diagnosis of psychogenic seizures.Because patients are at risk for severe agitation with PT, these diagnostic maneuvers should be used selectively, and the clinician should be prepared to deal with this complication. NEUROLOGY 1996;46: 546-547

We evaluated plantar responses after 75 epileptic seizures and 21 psychogenic seizures in 53 patients undergoing video-EEG monitoring. Extensor plantar responses (EPRs) were found after 27% of epileptic seizures in 42% of patients with epilepsy. EPRs were not found after psychogenic seizures but were seen after 52% of tonic-clonic seizures. Unilateral EPRs were usually contralateral to the side of seizure onset.

The British have a way with words, as indicated in this book's title. The book is written by a pediatric neurologist at the Royal Hospital for Sick Children in Glasgow, Scotland. In response to widespread overdiagnosis of epilepsy and lack of understanding of various "spells" in children, the author has compiled a highly useful monograph. It is refreshing in this day and age of high-tech neurodiagnostic evaluations to see this fine clinical approach to important and common clinical problems. Chapters include reviews of epileptic and nonepileptic seizures, differential diagnosis, syncopes, anoxic seizures, psychogenic seizures, fits and faints in special settings, and prognosis. The special settings include sleep, gastroesophageal reflux, bathing and water immersion, blood and gore, head injury, startle-surprise-or-fright, schools, places of worship, and hairdressers. Each chapter is enlivened by case histories to illustrate the author's clinical points. Noting that "some neurologists have a remarkable zeal for the early treatment

A total of 110 patients underwent diagnostic evaluation for attacks of uncertain origin by means of video-EEG telemetry and had a diagnosis of pseudoseizures confirmed. Eighty-six patients (78%) were female, mean age of onset 25 years, and mean duration of attacks was 3 years. Many of the patients had erroneously been thought to be suffering from epilepsy. The attacks could be divided into two broad categories: attacks of collapse (one-third) and attacks with prominent motor activity (two-thirds). In some patients, the attacks were associated with incontinence and injury. The differential diagnosis and clinical features of the attacks are described. Additional psychiatric features were present in 52 (47%) patients. Follow-up (for a median 5 years; range, 1 to 14 years) showed that 40% of these patients stopped having pseudoseizures. This favorable outcome was associated with being female, leading an independent life, a formal psychological approach to therapy and counseling, and the absence of coexisting epilepsy, but not with the duration of pseudoepilepsy, prior episodes of pseudostatus, the coexistence of overt psychiatric disease, or the clinical features of the attacks.

Essential in the diagnosis of epilepsy are repeated seizures due to discharge of electrical activity in the brain neurons, occurring without massive provocation. It is important to differentiate between epileptic seizures from syncopal reactions, cardiac dysrhythmias, vascular causes, metabolic disturbances, and psychogenic seizures. The type of seizure should always be established. It is of utmost importance to find the primary etiology of the seizure and to clarify the role of predisposing factors and the risk for seizure recurrence. Numerous important technical advances in the last few years have been of great benefit in the examination of patients with suspected epilepsy. It is worth keeping in mind, however, that the diagnosis of epilepsy is a clinical diagnosis, and it is not proper to speak of epilepsy until the patient has had two or more epileptic seizures within a relatively short interval and without massive provocation.

A review of the diagnostic and treatment approaches to psychogenic seizures has been offered. Two case reports of psychogenic seizures precipitated by loss and associated with depressive symptomatology have been presented. A literature review of cases seems to substantiate the frequency for the association between the development of psychogenic seizures and loss/depressive symptomatology. Symptom relief can be achieved with the utilization of a crisis intervention style psychotherapy. Antidepressant medication may also have a useful role in the treatment of some psychogenic seizures.

This article reports the case of a 9½ year old child with a history of psychomotor epilepsy which was uncontrolled by multiple anticonvulsant medications. When admitted to the psychiatric inpatient service, he was treated with a combination of pharmacological, behavioural and psychodynamically oriented approaches. A period of intensive family counseling was conducted to clarify the parents’ concerns about causality of the seizures and methods for dealing with them. This combined approach led to a complete cessation of reported seizures and a decreased number and dosage of anticonvulsant medications.The authors discuss the reluctance of some physicians to accept the co-existence of neurogenic and psychogenic seizures in a given patient.Patients with pharmacologically uncontrolled seizures must be identified and accurately diagnosed (neurogenic and/or psychogenic) to prevent complications such as over-medication and to administer appropriate treatment. Multiple disciplinary therapy including psychodynamic, pharmacological, behavioural and educational approaches should be implemented.

Measurement of postictal serum-prolactin concentrations in epileptic seizures in order to distinguish them from psychogenic seizures is at present used only rarely and non-systematically. Studies of 209 Grand mal seizures, 232 complex-partial seizures, 102 simple-partial seizures and 15 generalized seizures published between 1980 and 1987 differ in their standards of seizure classification as well as in their criteria for evaluating increases in postictal serum-prolactin concentrations. A significant rise was seen in 88% of Grand mal seizures, 78% of complex-partial seizures, 22% of simple-partial seizures and 6% of generalized seizures. The discussion of both these general findings and our own investigations is based on the presentation of neuroanatomical and neurophysiological principles of prolactin secretion.

A unique illness consisting largely of quadriplegia in an 18-year-old woman with neurogenic and psychogenic seizures is described and discussed in detail. The precise nature of the illness remains obscure, although it was predominantly hysterical. The concept of hysteria is reappraised and examined in terms of the mind-brain problem of philosophy.

• We prospectively correlated daily serum creatine kinase (CK) levels with the occurrence of different types of epileptic and nonepileptic seizures documented by video EEG recording in 22 hospitalized patients. Prolonged postictal CK elevations, 8.0 to 19.2 times baseline, were seen following six (15%) of 41 generalized tonoclonic seizures. No CK elevations were seen following 147 complex partial, focal motor, absence, and tonic seizures or 55 psychogenic seizures, 89% of which involved vigorous muscular activity. Six of 12 patients with generalized tonoclonic seizures had postictal CK elevations compared with none of six patients with psychogenic seizures and none of 15 patients with complex partial, focal motor, absence, and tonic seizures. Thus, postictal CK determination can serve as an adjunctive test for differentiation between psychogenic and epileptic generalized tonoclonic seizures.

Psychogenic seizures are characterized by peculiarities of symptomatology, specific personality type, and poor response to medication. Psychogenic seizures are found most commonly in people with histrionic personality disorders which render them vulnerable to past sensitizing events. Syntactic and affective cognitions, coinciding with the past sensitizing event or events, determine which circumstances precipitate psychogenic seizures. Specific methods of hypnosis significantly relieve or cure these patients. Three case histories are presented.

A clinical case study of a 13-year-old girl admitted to a mental health center because of psychogenic seizures is presented. Hypnoanalysis and posthypnotic suggestions were helpful in managing the girl's seizure episodes.

Of 19 adolescents with diagnosed psychogenic seizures, 13 had hysterical convulsions and 4 had amnesiac fugues. Sixteen of the patients were given a diagnosis of hysterical neurosis; 2, process schizophrenia; and 1, borderline psychosis. Thirteen of the patients were initially diagnosed incorrectly as having epilepsy and were treated for an average of 15 months with anticonvulsant medication. The therapist should always consider the possibility of psychogenic factors in children and adolescents who suffer from seizures.

We describe two patients with psychogenic seizures of rare semiology. Both patients (a 23-year-old man and a 26-year-old woman) attended the emergency department because status epilepticus with myoclonic seizures had been diagnosed. Seizures were documented with video-electroencephalography. Semiology of seizures were brief myoclonia of both arms resulting in a short elevation of both arms without impairment of consciousness. Ictal EEG registration was without abnormal finding. Psychiatric diagnostic assessment suggested a dissociative disorder and mild depression, respectively. During psychiatric treatment seizures occurred only rarely within a 3–5 months follow-up. One should be aware that juvenile myoclonic epilepsy may be mimicked by psychogenic seizures

Rationale: The study aim was to assess patients' understanding of and reaction to a diagnosis of non-epileptic attack disorder and to explore whether these factors contribute to outcome. Method: Eighty-four patients diagnosed with non-epileptic attack disorder participated in the study. Participants answered questions about their seizures and understanding and reaction to the diagnosis. Data were collected by semi-structured telephone interview. Questionnaires were sent to the patients' general practitioners (GPs) to gather information regarding the patient's seizure status, prescription of anti-epileptic drugs and opinion regarding the diagnosis. Results: At the time of follow-up, a third of participants reported being seizure free. A total of 63% did not have a good understanding of the diagnosis, most were unclear about the precipitating factors and the most common reaction to the diagnosis was confusion. Many reported a negative impact of NES on everyday life. Sixty-five percent reported receiving psychological follow-up but the number of sessions attended was few (median 2). There was evidence that the reaction to the diagnosis contributed to the outcome in particular an angry outcome was associated with a poor prognosis. Ten GPs did not agree with the diagnosis. Conclusion: Patients understanding and reactions to a diagnosis of non-epileptic attacks are important factors that should contribute to the development of more tailored treatment approaches.