Psychogenic seizures: ictal characteristics and diagnostic pitfalls

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.