Stereotypy of psychogenic nonepileptic seizures: Insights from video-EEG monitoring

Purpose: To systematically study the semiology of psychogenic nonepileptic seizures (PNES) captured by video–electroencephalography (EEG) monitoring (VEM) and categorize the typical patterns observed.

Methods: VEM records of patients who underwent evaluation from January 2002 to June 2007 were reviewed to identify those who had PNES with or without a background of epilepsy. The semiology of each event was visually analyzed and entered into a statistical database. Type of movement, anatomic distribution, synchrony, symmetry, onset, offset, course, duration, vocalization, hyperventilation, eye movements, and responsiveness were evaluated. PNES were classified into distinct groups according to the predominant motor manifestation.

Results: A total of 330 PNES from 61 patients were studied. Based on semiology, six different types of PNES were observed as follows: (1) rhythmic motor PNES characterized by rhythmic tremor or rigor-like movements (46.7%); (2) hypermotor PNES characterized by violent movements (3.3%); (3) complex motor PNES characterized by complex movements such as flexion, extension, abduction, adduction, rotation, with or without clonic-like and myoclonic-like components of varying combinations and anatomic distribution (10%); (4) dialeptic PNES characterized by unresponsiveness without motor manifestations (11.2%); (5) nonepileptic auras characterized by subjective sensations without any external manifestations, marked in the VEM records as “seizure button presses” (23.6%); and (6) mixed PNES where combinations of above seizure types were seen (5.2%). In a given patient, all the seizures belonged to a single type of PNES in 82% of cases.

Discussion: PNES can be classified into six stereotypic categories. Contrary to common belief, PNES demonstrates stereotypy both within and across patients.