Epilepsia, 51(7):1159–1168, 2010
doi: 10.1111/j.1528-1167.2010.02560.x
FULL-LENGTH ORIGINAL RESEARCH
Stereotypy of psychogenic nonepileptic seizures: Insights from
video-EEG monitoring
*yUdaya Seneviratne, zDavid Reutens, and yxWendyl D’Souza
*Department of Neuroscience, Monash Medical Centre, Melbourne, Australia; yDepartment of Neuroscience, The Alfred Hospital,
Melbourne, Australia; zCentre for Advanced Imaging, The University of Queensland, Queensland, Australia; and xThe Department of
Medicine, The University of Melbourne, St. Vincent’s Hospital, Melbourne, Australia
SUMMARY
Purpose: To systematically study the semiology of psycho-
genic nonepileptic seizures (PNES) captured by video–
electroencephalography (EEG) monitoring (VEM) and
categorize the typical patterns observed.
Methods: VEM records of patients who underwent evalua-
tion from January 2002 to June 2007 were reviewed to
identify those who had PNES with or without a back-
ground of epilepsy. The semiology of each event was visu-
ally analyzed and entered into a statistical database. Type
of movement, anatomic distribution, synchrony, symme-
try, onset, offset, course, duration, vocalization, hyper-
ventilation, 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 stud-
ied. Based on semiology, six different types of PNES were
observed as follows: (1) rhythmic motor PNES character-
ized by rhythmic tremor or rigor-like movements
Psychogenic nonepileptic seizures (PNES) are a common
problem encountered by epileptologists (Ghougassian et al.,
2004). The prevalence of PNES is estimated to be 2–33 per
100,000 (Benbadis & Hauser, 2000) compared to the preva-
lence of 4–6 per 1,000 in epilepsy (Hauser & Kurland,
1975). The average delay between the onset of seizures and
the diagnosis is 7 years (Reuber et al., 2002). The average
medical cost per patient with PNES for a period of 6 months
is estimated to be around 8,000 USD (Martin et al., 1998),
which means that every PNES patient will utilize healthcare
resources worth 112,000 USD before the diagnosis of PNES
is established. Therefore, this condition is a significant neu-
rologic disorder with considerable social and economic
implications. Making a firm diagnosis is vital, and is shown
Accepted February 5, 2010; Early View publication April 2, 2010.
Address correspondence to Dr Udaya Seneviratne, Department of
Neuroscience, Monash Medical Centre, Clayton VIC 3168, Australia.
E-mail: wusenevi@optusnet.com.au
Wiley Periodicals, Inc.
ª 2010 International League Against Epilepsy
1159
(46.7%); (2) hypermotor PNES characterized by violent
movements (3.3%); (3) complex motor PNES character-
ized 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 char-
acterized by unresponsiveness without motor manifesta-
tions (11.2%); (5) nonepileptic auras characterized by
subjective sensations without any external manifesta-
tions, marked in the VEM records as ‘‘seizure button
presses’’ (23.6%); and (6) mixed PNES where combina-
tions 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 cat-
egories. Contrary to common belief, PNES demonstrates
stereotypy both within and across patients.
KEY WORDS: Nonepileptic seizures, Pseudoseizures,
Semiology, Video-EEG use in epilepsy.
to reduce the subsequent healthcare utilization costs signifi-
cantly (Martin et al., 1998).
The diagnosis of PNES is challenging. Seizure semiol-
ogy, psychiatric history, seizure provocation techniques,
postictal prolactin assay, and psychological testing are
various diagnostic methods with varying strengths and
drawbacks (Kuyk et al., 1997; Crager et al., 2002). How-
ever, there is general agreement that video–electroencepha-
lography (EEG) monitoring (VEM) is the gold standard test
(Reuber & Elger, 2003).
Pattern recognition of events forms the cornerstone of
interpreting video-EEG findings. Several studies have
described various semiologic features of PNES (Gulick
et al., 1982; Luther et al., 1982; Gates et al., 1985;
Meierkord et al., 1991; Leis et al., 1992; Saygi et al., 1992;
Lancman et al., 1993; Scheepers et al., 1994; DeToledo &
Ramsay, 1996; Geyer et al., 2000; Vossler et al., 2004;
Chung et al., 2006). However, the lack of a classification
system of PNES is a major drawback in its recognition and
management. This affects homogeneity of data across
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U. Seneviratne et al.
different studies as well as understanding of the long-term
prognosis of different subgroups.
The current study was planned against this backdrop. We
sought to systematically study the semiology of PNES based
on inpatient VEM. By performing detailed semiologic anal-
ysis of all witnessed PNES, we sought to categorize the typi-
cal patterns observed.
Methods
We retrospectively reviewed medical records and video-
EEG records of all adult patients who underwent monitoring
at two tertiary care epilepsy centers from January 2002 to
June 2007. Those who were diagnosed with PNES with or
without a background of epilepsy were selected for this
study. The diagnosis of PNES was made on the basis of the
consensus of at least two epilepsy specialists who based
their opinion on the clinical details and video-EEG monitor-
ing, independent of the current study. The following criteria
were used to diagnose PNES: at least a single typical clini-
cal event was captured on EEG, the EEG did not show any
electrographic ictal rhythm during the event, no postictal
slowing was seen on the EEG immediately after the event,
and there was no evidence of an alternative neurologic
diagnosis such as a movement disorder for this event. When
epilepsy was coexistent, it was diagnosed on the basis of
supportive history with neuroimaging, interictal epilepti-
form discharges on video-EEG or previous EEG, and
captured epileptic seizures on video-EEG.
All patients had continuous in-patient VEM for a period
typically ranging from 1–8 days. Scalp electrodes were
placed in accordance with the 10–20 international electrode
system. Antiepileptic drugs (AEDs) were usually discontin-
ued or reduced during the recording period. EEG and audio-
visual signals were acquired and analyzed using
Compumedics (Compumedics Ltd, Melbourne, Australia)
and Vanguard (Lamont Systems, Cleveland, OH, U.S.A.)
digital video-EEG systems.
Video-EEG studies of all selected patients were reviewed
by an epilepsy specialist (U.S.). Video segments of all clini-
cal events and the corresponding EEG studies were
reviewed several times separately as well as in synchrony,
until the investigator was satisfied that all the details were
visualized and tabulated.
The semiology of each clinical event was visually ana-
lyzed in detail and entered into an SPSS statistical database
(SPSS Inc, Chicago, IL, U.S.A.). Type of movement, ana-
tomic distribution of the movement (extremities, head,
trunk, pelvis), synchrony, symmetry, eye movement,
responsiveness, vocalization, hyperventilation, onset
(abrupt or gradual), offset (abrupt or gradual), course, and
duration of the event were tabulated.
We used the predominant motor movement to classify
the PNES into distinct groups. Other characteristics were
subsequently analyzed in each group. The pattern of
Epilepsia, 51(7):1159–1168, 2010
doi: 10.1111/j.1528-1167.2010.02560.x
stereotypy of the PNES type within and across patients
was studied.
Because this was a descriptive study, no statistical infer-
ences could be drawn. Summary statistics included mean,
standard deviation, minimum, maximum, and median for
continuous variables and numbers and percentages for cate-
gorical variables. The statistical analysis was carried out
using the SPSS software program.
The study was approved by the human research ethics
committees of Alfred Hospital and Monash Medical Centre,
Melbourne, Australia, where it was conducted.
Results
A total of 330 PNES from 61 patients were studied. The
mean number of PNES recorded per patient was five. There
were 45 female and 16 male patients with ages ranging from
16–83 years (mean 38 years). The mean age of onset of
PNES was 29 years. The age range of onset was 9–80 years,
and late onset of the condition was seen in a minority (four
patients at or above the age 55). The mean duration of VEM
was 3 days (range 1–8 days).
Detailed visual analysis of all PNES revealed three types
of motor manifestations, based on which six different PNES
seizure types were delineated as follows (Table 1):
1. Rhythmic tremor, trembling or rigor like movements
constituted 46.7% of all PNES. We labeled this
group as Rhythmic Motor PNES. These seizures
were characterized by rhythmic movements involving
the extremities and trunk typically in a symmetric
and synchronized fashion. Upper limb involvement
was more common than the lower limb involvement.
Patients with rhythmic motor PNES were unrespon-
sive during the seizures, which means they did
not respond to external stimuli (i.e., they appeared
unconscious), and approximately 10% demonstrated
vocalizations and hyperventilation. About two-thirds
had abrupt onset and offset.
2. Hyperkinetic or hypermotor movements. This group was
labeled as Hypermotor PNES and constituted 3.3% of all
nonepileptic seizures. These patients typically demon-
strated violent thrashing, punching, or kicking type of
movements involving the extremities and trunk. In the
extremities, the movements were always bilateral, asym-
metric, and asynchronous.
3. Complex motor movements. This group was labeled as
Complex Motor PNES and represented 10% of all PNES
in the cohort. These seizures were characterized by com-
plex and multifocal movements of both proximal and
distal extremities consisting of flexion, extension, abduc-
tion, and adduction with or without clonic-like and myo-
clonic-like components of varying combinations. The
movements were always asymmetric, asynchronous, and
migratory in anatomic distribution. Back-arching and
pelvic thrusting was commonly seen in this group.
 Table 1. Comparison of different semiologic characteristics between PNES groups
Rhythmic Motor PNES Hypermotor PNES Complex Motor PNES Dialeptic PNES Nonepileptic Auras Mixed PNES
Type of movement Rhythmic tremor or rigor like Violent, thrashing, kicking Complex Nil Nil Any of the above
UPL involvement 62.3% (BL 54.5%; UL 7.8%) 72.7% (all are BL) 78.8% (all are BL) Nil Nil 88.3% (BL 82.4%; UL 5.9%)
UPL symmetry and 91.7% of BL are symmetric and All asymmetric and All asymmetric and Nil Nil All BL are asymmetric and
synchrony synchronous asynchronous asynchronous asynchronous
LL involvement 55.8% (BL 52.6%; UL 3.2%) 100% (all are BL) 100% (all are BL) Nil Nil 88.3% (all are BL)
LL symmetry and 95.1% of BL are symmetric and All asymmetric and All asymmetric and Nil Nil All BL are asymmetric and
synchrony synchronous asynchronous asynchronous asynchronous
Eyes (at the event Closed 94.2%, open 5.2%, not Closed 54.5%, not Closed 63.6%, open Closed 73%, rapid Open 100% Closed 82.4%, rapid blinking
onset) visible 0.6% visible 45.5% 6.1%, not visible 30.3% blinking 16.2%, 17.6%, open 0%
not seen 10.8%
Head Nodding 5.8%, shaking 16.2% Shaking 18.2%, no movement Shaking 3%, nodding 3% No movement No movement Nodding 11.8%, no
81.8% movement 88.2%
Trunk Rhythmic (rigor-like) 65.6% Back arching 27.3%, no Back arching 51.5%, no No movement No movement Back arching 64.7%, rhythmic
movement 72.7% movement 48.5% 17.6%
Pelvis Swinging 65.6%, thrusting 0.6% Thrusting 45.5%, no Thrusting 69.7%, No movement No movement Thrusting 17.6%, swinging
movement 54.5% swinging 12.1% 17.6%
Responsiveness Unresponsive 83.8% Unresponsive 100% Unresponsive 100% Unresponsive 100% Responsive 100% Unresponsive 100%
Vocalization 9.7% 45.5% 57.6% 5.4% Nil 64.7%
HV 13.6% 36.4% 15.2% 16.2% Nil 88.2%
Onset Abrupt 68.8%, gradual 31.2% Abrupt 81.8%, gradual 18.2% Abrupt 30.3%, Abrupt 100% Abrupt 100% Abrupt 94.1%, gradual 5.9%
gradual 69.7%
Offset Abrupt 66.9%, gradual 33.1% Abrupt 81.8%, gradual 18.2% Abrupt 15.2%, Abrupt 100% Abrupt 100% Abrupt 29.4%, gradual 70.6%
gradual 84.8
Course Steady 65.6%, waxing/waning Steady 45.5%, waxing/waning Steady 72.7%, Steady 97.3%, Steady 100% Steady 58.8%, waxing/waning
34.4% 54.5% waxing/waning waxing/waning 41.2%
27.3% 2.7%
Mean duration (min ) 2.6 0.9 3 9.5 0.19 4.1
PNES, psychogenic nonepileptic seizures; UPL, upper limb; LL, lower limb; UL, unilateral; BL, bilateral; HV, hyperventilation; head shaking, side to side movement ‘‘no-no’’ gesture; head nodding, anterior posterior
movement ‘‘yes-yes’’ gesture.
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U. Seneviratne et al.

Figure 1.
Electroencephalography (EEG)
study of dialeptic psychogenic
nonepileptic seizures (PNES). This
patient remained unresponsive
during the episode. Note rapid eye
blinking and preserved background
alpha rhythm.
Epilepsia ILAE

Compared to hypermotor PNES (type 2), these move-
ments were more subtle and less aggressive, sometimes
with an apparent nonphysiologic migratory quality.
4. Prolonged, motionless, unresponsive patients with no
motor manifestations. We classified these patients as
Dialeptic PNES, which constituted 11.2% of all
PNES. These patients presented in a coma-like state.
There were no movements, and they remained unre-
sponsive to all external stimuli. A minority demon-
strated hyperventilation. These seizures tend to last
longer than other PNES (ranging from 2–57 min,
mean 9.5 min) and the vital signs and EEG were
unchanged during the seizure.
5. Nonepileptic auras (23.6%). These events were charac-
terized by various subjective sensations without any
external manifestations, marked in the VEM records as
‘‘seizure button presses.’’ The EEG and electrocardiogra-
phy (ECG) remained normal during these episodes, with
no alternative systemic or biochemical explanation. The
usual terms used by the patients to describe these sensa-
tions were, ‘‘I am going through a trance,’’ ‘‘I feel
weird,’’ and ‘‘zoning out.’’
6. Mixed PNES (5.2%). These PNES would present as a
combination of any of the preceding types.
Ictal eye closure at the beginning of the seizure was wit-
nessed in most patients across all PNES types. Rapid eye
blinking was also seen in some patients with dialeptic and
mixed PNES.
EEG demonstrated characteristic patterns in different
PNES types due to movement and muscle artifacts. In dia-
leptic PNES and nonepileptic auras, EEG remained
unchanged (Fig. 1). Rhythmic motor PNES produced a typi-
cal EEG pattern consisting of 6–9 Hz rhythmic ‘‘slow
waves’’ due to movement artifact admixed with normal
background EEG (Fig. 2). This was a very regular rhythm
with no evolution in amplitude or distribution. In hypermo-
tor PNES the entire EEG was obscured by muscle artifacts.
At the offset the EEG returned to normal background
rhythm immediately (Fig. 3). The ictal EEG in complex
motor NES was somewhat similar to that of hypermotor
PNES, but the muscle artifact was less dense, and some
‘‘slow waves’’ were visible underneath due to movement
and electrode artifacts (Fig. 4).
Eight patients (13.1%) had coexistent epilepsy consist-
ing of temporal lobe epilepsy in four, primary generalized
epilepsy in three, and frontal lobe epilepsy in one. Their
PNES were semiologically different from the epileptic
seizures.

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Figure 2.
Electroencephalography (EEG) of rhythmic motor psychogenic nonepileptic seizures (PNES). (A) This patient had rhythmic tremor–
like movements of the trunk and extremities for 4 s. Note rhythmic ‘‘slow waves’’ due to movement artifact with an abrupt onset and
offset. The normal background rhythm resumes instantly with the offset of the event. (B) Another patient who had rhythmic rigor-like
movements of the trunk with side-to-side head shaking. Rhythmic ‘‘slow waves’’ have slower frequency compared to A. Neither EEG
studies demonstrate any evolution of the ictal rhythm.
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doi: 10.1111/j.1528-1167.2010.02560.x
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U. Seneviratne et al.

Figure 3.
Electroencephalography (EEG) of
hypermotor psychogenic
nonepileptic seizures (PNES).
Abrupt onset of violent thrashing-
type movements of the extremities
was seen in this patient. Note the
dense muscle and movement
artifact.
Epilepsia ILAE

We also studied the degree of stereotypy within patients.
In a given patient, all PNES belonged to the same semiolog-
ic type in 82% of cases.
Discussion
We provide a detailed analysis of semiologic features of
PNES in a systematic manner. Based on that, we have delin-
eated six stereotypic PNES types. This has potential impli-
cations for diagnosis and prognosis, with a number of
studies indicating that outcome of PNES may vary among
different types (Selwa et al., 2000; Reuber et al., 2003).
A number of studies have described different semiologic
features of PNES (Gulick et al., 1982; Luther et al., 1982;
Gates et al., 1985; Meierkord et al., 1991; Leis et al., 1992;
Saygi et al., 1992; Lancman et al., 1993; Scheepers et al.,
1994; DeToledo & Ramsay, 1996; Geyer et al., 2000;
Vossler et al., 2004; Chung et al., 2006). However, patients
with PNES usually present as a combination of multiple
features. Therefore, it would seem logical to group these
patients depending on such combinations. A few authors
have made attempts to identify distinct semiologic groups
of PNES. One such study based on video-EEG of 110
patients classified nonepileptic seizures into two groups:
attacks with collapse and limpness and attacks with promi-
nent motor activity (Meierkord et al., 1991). In a literature
survey of 62 patients, four groups were identified as tonic–
clonic, complex partial type attacks, combination of attack
types, and special types (swoons, tantrums, arc-de-cercle or
opisthotonus, and conscious simulation) (Van Merode et al.,
1997). Another study on a cohort of patients in a neuropsy-
chiatry ward classified ‘‘pseudo-seizures’’ into swoons, tan-
trums, and ‘‘abreactive attacks’’ (Betts & Boden, 1992).
Cluster analysis was used by another group to classify
PNES. They studied 27 patients and identified three groups
labeled as psychogenic motor seizures, psychogenic minor
motor or trembling seizures, and psychogenic atonic
seizures (Groppel et al., 2000).
Consequently, it appears that there is no strict uniformity
in nomenclature and classification between the different
PNES types described in different studies. However, the
semiologic PNES categories delineated in our study can be
identified among those. ‘‘Swoons’’ described by Van
Merode et al. (1997) and Betts and Boden (1992) are similar
to dialeptic PNES. These patients have also been identified
as ‘‘psychogenic pseudosyncope’’ (Benbadis & Chichkova,
2006), and ‘‘psychogenic unresponsiveness’’ (Abubakr
et al., 2003). Although detailed clinical features of ‘‘psycho-
genic atonic seizures’’ in the reference Groppel et al. (2000)
are not available, we suspect this group also represents

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ƒ!
Figure 4.
Electroencephalography (EEG) of complex motor psychogenic nonepileptic seizures (PNES). (A) This patient demonstrated complex,
irregular, asynchronous, flexion, extension, abduction, and adduction movements of extremities. Note the abrupt onset of artifact.
(B) EEG showing the ongoing seizure of the same patient. Note the artifact is less ‘‘dense’’ compared to Figure 3. Some ‘‘slow waves’’
are visible underneath. (C) The offset is gradual. The normal background rhythm returns immediately with no postictal slowing.
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U. Seneviratne et al.
Figure 4.
Continued
Epilepsia ILAE
dialeptic PNES. Typical ‘‘swoon’’ attacks are characterized
by sudden collapses followed by apparent coma-like state
with no response to external stimuli and without any convul-
sive movements (Betts & Boden, 1992). In our series the
collapse component was not witnessed in most patients, as
they were confined to the bed for monitoring. We believe
the key semiologic feature in this group is prolonged unre-
sponsive state.
Rhythmic motor PNES are identified as ‘‘trembling sei-
zures’’ in the study conducted by Groppel et al. (2000),
whereas the group described as ‘‘psychogenic motor sei-
zures’’ most likely represents hypermotor PNES and com-
plex motor PNES. The phenomenon of nonepileptic auras
has been recognized by some other authors as well (Lempert
& Schmidt, 1990; Lancman et al., 1993).
Type 3 (complex motor PNES) represents a group of sub-
jects with highly heterogeneous movements including clo-
nic-like and myoclonic-like movements. In this group,
psychogenic myoclonic-like body jerks in particular pose a
Epilepsia, 51(7):1159–1168, 2010
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diagnostic challenge of differentiating from epileptic gener-
alized myoclonus and nonepileptic nonpsychogenic myoc-
lonus. EEG interpretation is made difficult by the
predominant muscle artifact, which tends to mask the dis-
charges in cortical myoclonus.
All VEM patients were reviewed by a multidisciplinary
team including epilepsy specialists and movement disorder
neurologists. Challenging cases where cortical, subcortical,
or spinal myoclonus (Shibasaki, 2000) were considered
after consensus opinion were subsequently evaluated with
more detailed imaging of the neuroaxis and electrophysio-
logic testing before being excluded.
Electrophysiologic studies can be very useful in differen-
tiating true myoclonus from psychogenic myoclonic-like
jerks as seen in PNES (Shibasaki, 2000; Brown & Thomp-
son, 2001). Cortical myoclonus is often stimulus-sensitive,
irregular, and usually accompanied by EEG correlates of
polyspikes and spike-and-wave discharges (Shibasaki,
2000).

When surface electromyographic (EMG) recordings are
used, psychogenic jerks are characterized by long EMG
bursts (>70 ms) with a triphasic pattern of activation of ago-
nist and antagonist muscles (Brown & Thompson, 2001).
Simultaneous recording of EEG and EMG to demonstrate
their temporal relationship (EEG–EMG polygraphy) should
be considered in patients with myoclonus. Jerk-locked back
averaging (JLBA) is a technique employing this principle.
In cortical myoclonus JLBA elicits a positive–negative
biphasic spike over the corresponding cortical region 20–
30 ms preceding the EMG activity of myoclonus (Shibasa-
ki, 2000). In psychogenic myoclonus the same technique
can be used to demonstrate movement-related cortical
potentials (MRCPs), which are not elicited in true myoclo-
nus. MRCPs are characterized by slow-rising negativity
(Bereitschaftspotential) over the central cortical region
starting 0.7 to 2.1 s before the onset of jerks (Terada et al.,
1995).
Characteristic EEG patterns in PNES are an interesting
finding. Movement, muscle, and rhythmic artifacts as
‘‘ictal’’ electrographic features of PNES have been
described (Vinton et al., 2004; Benbadis, 2006). We have
demonstrated that different PNES types are associated with
distinctive EEG patterns due to characteristic muscle,
movement, and electrode artifacts.
There are some limitations of this study, however. All
patients were recruited from two tertiary centers, thereby
introducing a potential selection bias. It is possible that
more severe forms of PNES constituted the cohort and
milder forms with different semiology were not represented.
Although a community-based sample more representative
of PNES outside a tertiary setting would rectify this poten-
tial bias, case ascertainment is likely to be challenging.
Type 5 (nonepileptic auras) without outward visual mani-
festations poses perhaps the greatest diagnostic challenge to
our proposed observational classification system. Although
we acknowledge that ultimately we are unable to defini-
tively exclude their epileptic nature, we still feel this group
is a distinct category of PNES for several reasons. First, this
category is well recognized by previous authors, suggesting
that our findings are consistent with the literature (Lempert
& Schmidt, 1990; Lancman et al., 1993). Secondly, none of
the patients with nonepileptic auras had coexistent epilepsy,
making these phenomena less likely to represent merely a
less severe form of partial seizure. Thirdly, patients with
nonepileptic auras in our study cohort had no other corrobo-
rative clinical, EEG, or radiologic features to suggest an
underlying consistent structural or functional abnormality.
Finally, the verbatim language descriptors used by the
patients were qualitatively and quantitatively (i.e., multiple
symptoms) different from epileptic auras described previ-
ously. Patients used terms such as ‘‘I feel weird’’ and ‘‘I am
going through a trance’’ often with extended duration.
Placebo induction has been proposed as a reliable tool for
identifying PNES (Bazil et al., 1994), and could have been
1167
Stereotypy of Nonepileptic Seizures
useful in this challenging group. However, there are some
reservations with use of this technique. First, this method
has been shown to induce atypical nonepileptic events and
true epileptic seizures in some patients, thereby leading to
incorrect diagnosis (Walczak et al., 1994). Second, the ethi-
cal validity of the test has been questioned by some authors
given the ‘‘deceptive’’ nature of the technique, as the doctor
is unable to give a complete explanation to the patient
(Kuyk et al.,1997).
All video-EEG studies were visually analyzed and classi-
fied by a single observer. Therefore, our findings need to be
validated for interobserver reproducibility.
Despite these limitations, our study highlights the impor-
tance of semiology in the diagnosis and classification of
PNES. Recognition of semiology is of prime importance in
the diagnosis of epileptic seizures. Proposal for a semiologic
classification of epileptic seizures underscores this fact
(Luders et al., 1998). This is of even greater relevance in
PNES, as there are no defining electrophysiologic chara-
cteristics for this condition.
A more semiologically focused classification system of
this commonly encountered disorder may aid in improved
recognition and diagnosis. It is hoped that this may lead to
improved standardization across different studies and ulti-
mately better etiologic understanding and management of
this important public health issue. The current study demon-
strates that PNES are semiologically stereotypic. Therefore,
a classification based on semiology seems logical and prac-
tical.
PNES are generally considered to present with multiple
seizure types within and between patients. Contrary to
popular belief, we have demonstrated from a large series
of patients from two tertiary care centers that PNES are
highly stereotypic both within and across individual
patients.
Acknowledgments
We would like to thank Belinda Briggs, EEG Scientist, Department of
Neuroscience, Alfred Hospital, Melbourne, for providing technical support
and helping with data collection.
Disclosure
Dr. Udaya Seneviratne reports no disclosures. Professor David Reutens
reports no disclosures. Dr. Wendyl D’Souza is funded by a National Health
Medical Research Council of Australia Post-Doctoral Health Professional
Fellowship. He is on the Zonergan Australian Scientific Advisory Board
and has received an investigator-initiated study grant from UCB-Pharma
Australia. We confirm that we have read the journal’s position on issues
involved in ethical publication and affirm that this report is consistent with
those guidelines.
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