Ictal crying in epileptic seizures and psychogenic nonepileptic seizures: What are the hints to differentiate them?

•Ictal crying (IC) mostly occurs in psychogenic nonepileptic seizures (PNES) and is rarely seen in epileptic seizures.•We propose some semiological differences in terms of IC between PNES and ES.•Late onset and longer duration of IC, early responsiveness after seizure, eye closure and lacrimation may be supportive features for IC in PNES.•IC during ES is usually seen in patients with medical treatment refractory focal epilepsy.•Nondominant temporal lobe involvement may be associated with IC in ES. Ictal crying (IC) is a quite rare semiological manifestation of epileptic seizures (ESs) and it has been mostly reported in psychogenic nonepileptic seizures (PNESs). However, labeling IC as a pathognomonic sign of PNES can be harmful. We first aimed to investigate IC frequency in ES and PNES and highlight the differences of IC between ES and PNES. Secondly, we aimed to analyze etiology, detailed semiology, treatment options, and outcome of patients with IC in ES in more detail. We retrospectively screened all video-EEG monitoring unit reports from Hacettepe University Hospitals’ Epilepsy Center over a 20-year period (1996–2017) for the diagnosis of IC. We included the patients with IC who had at least one documented seizure. Patients who had IC with both facial expression and vocalization compatible with crying with or without weeping and subjective feeling of sadness, were included in the study. We classified patients with IC as ES and PNES. Demographic, historical, clinical, neuroimaging, electrophysiological parameters, video-EEG data, treatment options, and prognosis of all patients were recorded. Demographic, clinical, and video-EEG data were compared between ES and PNES. During the study period, 1983 patients were investigated. Six patients (all female) with ES and 37 patients (33 female) with PNES were identified. When we compared patients with PNES and ES with IC, the number of ASMs taken and duration of disease were significantly higher in patients with ES than PNES. Longer duration of seizure, longer duration of crying component, late onset of crying component in seizure, early responsiveness after seizure, not occurring during sleep, accompanied by eye closure and weeping, were found significantly higher in patients with PNES. Besides, if we analyze ES group in more detail, all had medical treatment refractory focal epilepsy and two of them whose IC was seen as an early semiological manifestation of their seizures had good outcome after nondominant an