A 48-year-old woman is evaluated for seizure-like episodes. She has a history of major depression and borderline personality disorder. She is currently taking escitalopram 10 mg daily. She smokes one pack of cigarettes daily and drinks one to two glasses of wine daily. You are called to the bedside during an episode. You observe her head turning vigorously side to side with large-amplitude limb shaking and upward thrusting of the pelvis. You are concerned about psychogenic seizures. Which of the following findings could assist in this diagnosis? 

A. A normal creatine kinase level within 30 minutes of the episode 

B. A normal prolactin level within 30 minutes of the episode 

C. An elevated creatine kinase within 30 minutes of the episode 

D. An elevated prolactin level within 30 minutes of the episode 

E. Decreased arousability in the period immediately following the episode

The answer is B. (Chap. 418) Psychogenic seizures are nonepileptic behaviors that resemble seizures and may be conversion reactions that occur under psychological distress. Psychogenic seizures may occur in individuals with underlying seizure disorder and may be difficult to distinguish. Clinical features prominent in psychogenic seizures include side-to-side turning of the head, asymmetric and large-amplitude movements of the limbs, twitching of all four extremities without loss of consciousness, and pelvic thrusting. Psychogenic seizures also often last longer than epileptic seizures and may wax and wane over minutes to hours. Video electroencephalogram (EEG) monitoring can be quite helpful in this situation as EEG monitoring during the episode is normal. In addition, there is no postictal period. Measurement of prolactin levels may also help to distinguish generalized and some focal seizures from psychogenic seizures because prolactin levels rise in these disorders but remain normal in psychogenic seizures. Serum creatine kinase may rise following a seizure, but this is not sensitive for detection of seizure disorder.