Investigators at the National Institute of Mental Health and Neurosciences, Bangalore, India, conducted a retrospective analysis of semiologic patterns of psychogenic non-epileptic seizures (PNES) diagnosed by video EEG in 56 children aged < 18 years (mean age 12.3 yrs; range 2-17 yrs). Age at onset of PNES was 8.9 yrs (range 0.4-15.8 yrs); age at diagnosis 11.9 yrs (range 2-17 yrs); delay in diagnosis 3.2 yrs (range 0-15 yrs). Associated diagnoses included anxiety in 16%, stress in 10%, and depression (10%). Coexistent epilepsy in 16% patients was complex partial in 8.9%, generalized tonic-clonic in 5.4%, and simple partial in 1.8%. Prior to VEEG, 33 (59%) patients were initially misdiagnosed as epilepsy and were treated with AEDs; in 14 patients (25%) the initial diagnosis of PNES was unchanged after VEEG. EEG during a PNES showed various artifacts, depending on the type of movement or coma-like state. MRI performed in 14 patients with PNES alone was normal in 12 (86%) and showed non-specific white matter signal changes or UBOs in 2. Characteristic signs of PNES were flexion/extension movements, moaning and gasping, tremors, flaccidity, vocalization, hyperventilation, and pelvic thrusting. Eyes were closed in 25 (45%) and remained open during the PNES in 55%. The EEG technician's simple motor commands were followed by 55% during the event. PNES was classified in 5 categories: I. Abnormal motor (hypermotor (23%) and partial (14%)); II. Affective/emotional behavior 3.6% (moaning, grunting); III. Dialeptic 14% (coma-like state, flaccidity); IV. Aura 5.4% (subjective feeling, dizziness); V. Mixed (39%). [1]

COMMENTARY. Video-EEG is important in the diagnosis and differentiation of epileptic seizures from PNES. Epilepsy and PNES are coexistent in 16% of cases. In a previous semiologic analysis of 27 childhood PNES cases based on video-EEG monitoring, mean duration of PNES was longer compared to epileptic seizures, eyewitnesses were almost always present, eyes were closed at the onset in only 15% of events, tremor was the most frequent motor sign, and dialeptic PNES was most frequent among younger children [2].