Table 2 Differences between clinical features of true status epilepticus and psychogenic status epilepticus.
| Clinical features | True status epilepticus | Psychogenic status epilepticus |
|---|---|---|
| Sex | Occurs in both male and female patients | Observed in a higher proportion of female patients20 |
| Psychiatric history | History of abuse is as prevalent as in other medical disorders | Prevalence of abuse, traumatic life events, comorbid psychiatric disorders and treatment is higher than that observed in patients with epilepsy20 |
| Onset | Sudden | Gradual |
| Motor activity | Tonic–clonic limb jerking | Preparatory movements, body stiffening, thrashing, pelvic thrusting, back arching and head rolling |
| Progression of motor activity | Initially well‐defined or continuous episode; limb movements are usually synchronous; in prolonged status, subtle limb movements, epileptic nystagmus and focal twitching may be observed | Stopping and restarting of motor activity; out‐of‐phase, asynchronous limb movements; non‐physiological progression of activity is more common; subtle eye movements are rare |
| Vocalisation | At the start of seizure | In the middle of seizure; sobbing, crying and shouting are frequent |
| Eye open or closed | Forceful eye closure is uncommon | Eyes held shut, resisting passive lid opening |
| Ocular deviation | Upward or to one side, where present | Geotrophic eye movement; patients tend to look away from the examiner |
| Pupillary light reaction | Poorly reactive | Briskly reactive |
| Tongue biting | On the side of the tongue | On the tip of the tongue |
| Cyanosis | Frequent | Uncommon |
| Responsiveness during episode | Usually motor activity is not modified by outside stimuli; no withdrawal response to painful stimuli noted | When restrained by examiner, modification of activity with more vigorous and violent movements observed; limb withdrawal to painful stimuli more commonly observed |
| Consistency of seizure pattern | Usually stereotyped | Variable |
| Recovery | Clinical and EEG recovery is gradual; organic amnesia for the episode observed after recovery | Prompt clinical and EEG recovery; non‐organic amnesia observed |
| Episodes in sleep | Can occur | Uncommon; to exclude feigned sleep with EEG monitoring |
| Avoidance testing manoeuvres | On releasing the patient's hand over face, no attempt observed at self‐protection; (care should be taken not to cause trauma to patient) | Active resistance of hand falling over face or termination of activity |
| Induction by suggestion and saline injection in the follow‐up clinic after recovery | Controlled induction of seizure is unusual; however, caution should be exercised not to trick the patient | Creating a permissive setting to bring on a typical episode and evaluation with EEG monitoring enables better characterisation of the spell |
EEG, electroencephalographic.