Cause | Psychiatric predisposition always present; comorbid depression, sexual/physical abuse, anxiety, dissociative, and somatoform disorders; differentiate culture-bound syndromes | Hypersynchronous neuronal discharge based on anatomic or metabolic disease; specific triggers uncommon, but touch, sight, sound, or mental activities, e. g., calculation, may elicit a seizure |
Onset | Onset often gradual, over minutes | Onset with brief aura or instantaneously |
Location/circumstances | Usually at home, in the presence of emotionally significant persons; do not occur while asleep | Occur anywhere, anytime, night or day, during sleep or wakefulness, and may follow a diurnal pattern |
Induction of seizure | Often inducible by suggestion, or placebo challenge, i.e., IV saline, etc; patient may hyperventilate | Not induced by suggestion; hyperventilation may induce a seizure, especially petit mal |
Vocalization/Emotion | Vocalization may take the form of sobbing, yelling, or bizarre utterances | Overt, single outcry may initiate a generalized seizure, but formed words or sobbing are rare; laughter may occur (gelastic epilepsy) |
Frequency | May be several per day | Except for petit mal and myoclonic seizures, other seizure types usually less than one per day |
Motor activity | Variability from moment to moment; arrhythmic or out-of-phase movements on the two sides; rolling, side-to-side head or trunk movements; pelvic thrusting common with thrashing type of seizures; may be simply staring or akinetic | Usually follow a stereotyped pattern, depending on seizure type; staring spells often accompanied by twitch of face, blinking, or lip smacking; pure akinetic seizures are rare; pelvic thrusting uncommonly occurs |
Duration | Often prolonged, >5 min, and may imitate status epilepticus; may come out of spell when addressed or stimulated | Usually <3 min but may have status epilepticus; addressing or stimulating the patient does not terminate the seizure |
Incontinence | Very rare | Not uncommon |
Autonomic changes | Do not occur | Increased pulse rate, sometimes cardiac dysrhythmias, pupillodilation, sweating, cyanosis, excessive salivation, and slobbering |
Injury | Unusual; tongue biting very rare | Sometimes injury from falling or tongue biting |
Postictal state | May remember events during episode; overt postictal confusion and somnolence unusual | Amnestic for time of seizure, except for some focal seizures; often postictal confusion or somnolence |
Response to anticonvulsants | No response despite therapeutic levels and multiple drugs | Depending on seizure type and cause, patient usually responds to appropriate anticonvulsants |
Objective laboratory signs | Video-EEG always normal; serum and CSF prolactin levels normal | Video-EEG always abnormal (if electrodes are properly situated); increased serum prolactin in the appropriate setting at 10-20 min after a suspected event |