Abstracts

To determine if whispering or feeble motor displays in response to commands during the initial post-ictal recovery of responsiveness can help to differentiate epileptic from psychogenic seizures. Video-EEG recordings from 100 consecutive adult admissions to the EMU during 2003 and 2004 were reviewed. The medical history and clinical follow-up after EMU dismissal were also reviewed. Cases were divided into three diagnostic categories: 1) epileptic seizures (ES), 2) physiological events (phyE) that included movement disorders, parasomnias, and syncope, 3) psychogenic nonepileptic seizure (pNES) that included the somatoform, dissociative, and anxiety disorders with panic attacks. Cases without a recorded spell or with only brief subjective symptoms without loss of responsiveness were excluded from the analysis. Specific attention was paid to the behaviors occurring during the first 1 to 2 minutes of verbal and motor responsiveness in the post-ictal recovery phase. Whispery verbal responses were identified by low volume, soft speech using breath instead of phonation. A feeble motor response to command involved movement of the correct limb in a manner lacking force, strength, or effectiveness and typically not completing the task. Twenty five (25%) had pNES, 43 (43%) had ES, 9 (9%) had phyE, and 23 (23%) had no recorded symptoms or only brief subjective symptoms without loss of responsiveness. PNES cases consisted of 21 (84%) somatoform or dissociative disorder (all females) and 4 (16%) anxiety disorder with panic attacks (1 female). No cases of malingering or facticious disorder were diagnosed. The 25 pNES patients experienced approximately 240 events (range 1-22/patient).
The initial 1 to 2 minutes of verbal or motor response in the post-ictal recovery phase were associated with whispering or feeble motor responses to command in 16 (21%) of all cases and 76% of pNES cases due to a somatoform or dissociative disorder. These signs were not seen in any of the panic disorder, phyE, or ES cases. In 132 (73%) of the seizures in patients with a somatoform or dissociative disorder, both seizures with motor manifestations as well as those with loss of responsiveness without motor manifestations, one or both of these signs were observed. The 5 pNES patients who did not display a whispery voice or feeble movements, and did not have a panic disorder, showed previously reported signs of indifference, telegraphic speech, or regression to child-like speech patterns post-ictally. Psychogenic seizures due to somatoform or dissociative disorders are commonly associated with the presence of a whispery voice or feeble motor responses to commands during the initiation of post-ictal recovery of responsiveness. These signs were not commonly seen after epileptic seizures. A prospective study of a larger population would be helpful to determine the predictive value of these signs.