Epikpsiu, 41( 1):81-84, 2000
Lippincott Williams & Wilkins, Inc., Philadelphia
0 International League Against Epilepsy
Clinical Research
Discriminating Between Epileptic and Nonepileptic Events:
The Utility of Hypnotic Seizure Induction
John J. Barry, Orit Atzman, and Martha J. Morrell
Summary: Purpose: To determine the validity of the Hyp-
notic Induction Profile (HIP) followed by seizure induction
during continuous video-electroencephalographic (EEG) moni-
toring to discriminate between epileptic (EE) and nonepileptic
events (NEE).
Methods: Eighty-two patients admitted to the Stanford Com-
prehensive Epilepsy Center for differential diagnosis of sei-
zure-like events were evaluated. Exclusion criteria included
inability or refusal to complete the HIP, lack of a “typical”
event, an IQ <70, present evidence of psychosis, or a physi-
ological cause for NEE. Sixty-nine patients met these criteria.
While undergoing continuous video-EEG monitoring, the pa-
tient completed an HIP, an inventory designed to measure the
degree of hypnotizability. An attempt was then made to induce
the patient’s typical events under hypnosis by using a split-
screen technique. An event without an EEG correlate was
thought to represent an NEE. A diagnosis of NEE was made
Distinguishing epileptic (EE) from nonepileptic events
(NEEs) is often extremely difficult. Historical, psycho-
metric, and behavioral information is frequently useful,
but even trained neurologists using videotape correctly
differentiate EEs from NEEs in only 70% of cases (1).
The task is even further complicated by the co-
occurrence of both EEs and NEEs in 540% of cases (2).
Morbidity with misdiagnosis also can be significant
(3,4).
Three types of suggestion techniques have been de-
scribed in the literature. Ideally, all take place while the
patient is simultaneously monitored with continuous
video-EEG. Both saline infusion and the alcohol-patch
techniques induce a psychogenic event by the use of an
agent to provoke a typical “seizure.” The former is given
intravenously, and the latter applied to the patient’s neck
Accepted August 5, 1999.
Address correspondence and reprint requests to Dr. J. J. Barry at
Stanford Department of Psychiatry, Stanford University Medical Cen-
ter, MC572.3, Stanford, CA 94305, U.S.A. E-mail: jbarry@leland.
stanford.edu
Preliminary results presented at the American Epilepsy Association
Meeting, Baltimore, Maryland, December 5-9, 1995.
81
independently by the neurology team and was compared with
results obtained with the hypnotic evaluation.
Results: Results for patients with EE were compared with
those with NEE and a group consisting of both EE/NEE. All
patients with NEE were then contrasted with the EE group. HIP
scores for the EE patients indicated lower hypnotizability than
the NEE group and were statistically significant when NEE
patients and those with NEEEE were combined. The sensitiv-
ity of seizure induction in the diagnosis of NEE was 77%, with
a specificity of 95%.
Conclusions: The HIP coupled with seizure induction is a
useful technique to aid in the diagnosis of patients with NEE.
It is sensitive and specific, and it may provide the patient with
a useful behavioral tool to control NEEs. It may also furnish a
conduit for long-term treatment. Key Words: Hypnotic induc-
tion profile-Epileptic events-Nonepileptic events-
Induction-Dissociation.
(5,6). The patient is told that these agents often stimulate
an event and that the information obtained will help in
the understanding and treatment of the condition. Ongo-
ing controversy exists concerning the impact of these
procedures on the patient-physician therapeutic alliance
(2). Hypnosis also has been used to differentiate between
EE and NEE and may have distinct advantages.
In 1950, Peterson et al. (7) attempted to use hypnosis
to discriminate NEE patients from those with EE. They
used a “recall” technique and assumed that patients with
epilepsy would not have the capacity to remember the
specifics of their seizures, in contrast to NEE patients.
He found that only those patients (n = 35) with events
of psychogenic origin could recount explicit details of
their “seizures,” whereas all of the EE patients (n = 30)
were amnestic for their events (7).
In 1955, Schwartz (8) used hypnosis
.. in an attempt to
induce typical “seizures” during EEG monitoring in a
group 26 patients. We successful in Only the lo
NEE patients. None of the EE group had their seizures
instigated during a trance state (8).
The Hypnotic Induction Profile (HIP) was developed
by H. and D. Spiegel to provide a clinically useful scale
82 J. J. BARRY ET AL.
of hypnotizability that would predict response to treat-
ment and help distinguish different types of psychopa-
thology (9). It consists of a hypothesized biologic mea-
sure of a patient’s capacity to experience hypnosis, the
eye roll. This was a “serendipitous” observation and re-
mains controversial (10). In addition, there is an ideo-
motor and subjective-experience component. The sum-
mation of selected components of the scale yields an
“induction” (IND) score, which will hereafter be termed
the HIP score. In addition, a profile score reflects the
patient’s capacity to be hypnotized and the actualization
of this potential (9). The HIP also correlates well with
other scales of hypnotizability (1 1 ), although some con-
troversy exists when comparing it with experimental re-
search hypnotic measuring devices (10).
HIP scores also have been shown to help in clinical
diagnostic evaluation. Groups of patients whose psycho-
pathology is characterized by high dissociability such as
posttraumatic stress disorder (PTSD) have significantly
higher scores than do patients with, for example, schizo-
phrenia (12).
This study evaluated two separate facets of the hyp-
notic evaluation attempting to discriminate EE from
NEE. The first investigated the utility of the HIP score
alone. The second involved hypnotic seizure induction
using a split-screen technique. Patients were then taught
self-hypnosis to induce and terminate events (13).
METHODS
The results of all psychiatric referrals for differential
diagnosis of seizure-like events over a 4-year period,
from 1992 to 1996, were reviewed. Patients were admit-
ted to the Stanford Comprehensive Epilepsy Center and
underwent continuous video-EEG monitoring to capture
approximately three “typical” events. A diagnosis of epi-
lepsy or of “pseudoseizures” was made by the treating
neurology team using information independent of the
hypnotic induction or seizure provocation. Eighty-two
patients were evaluated by one of the authors (J.J.B).
Patients were excluded from the study evaluation be-
cause of an inability or unwillingness to complete the
HIP, lack of a “typical” event, an IQ <70, present evi-
dence of psychosis, or symptoms explained by an under-
lying medical cause, such as insulinoma.
All patients were offered the option of using hypnosis
to elicit a typical event and to help control those events.
An HIP score was obtained with a range from zero,
showing no hypnotizability, to a maximal hypnotic po-
tential, a 10. The patient was then hypnotized again and
taught relaxation followed by the use of a split-screen
technique. The patient was instructed to imagine a blank
screen and then to divide it in half, the left side marked
with “RELAX’ and the right with “SEIZURE.” The pre-
vious image associated with a feeling of calm and safety
was placed on the left, and the patient was then instructed
to shift to the right side. The patient was asked to imag-
ine experiencing one of his or her typical events, If nec-
essary, characteristic, idiosyncratic features of the pa-
tient’s “seizure” were suggested and induction ensued.
If successful, the subject would then terminate the
event by shifting to the left side of the screen and was
encouraged to move back and forth, starting and stopping
the event, until confident that they could both self-induce
and abolish the seizure. The EEG obtained during the
procedure was evaluated for any evidence of epileptic
activity.
Data were analyzed as follows. A one-way analysis of
variance (ANOVA) was used to compare mean HIP
scores for patients with EE, NEE, and a combined-
diagnosis group composed of patients who displayed
NEE with the seizure-induction procedure, but who also
were found to have EE during other portions of the
evaluation. The HIP scores of patients with NEE and
NEE/EE were then pooled and compared with the EE-
only group by using a two-tailed t test. Finally, the sen-
sitivity (the probability that a patient with a positive di-
agnosis of epilepsy will have a positive test) and speci-
ficity (the probability that a patient with a negative
diagnosis will have a negative test) (I 4) of hypnotic sei-
zure induction to diagnose NEE was ascertained.
RESULTS
Eighty-two patients (20 man and 62 women) were
screened. Thirteen did not meet inclusion criteria. Sixty-
nine patients were included in the analysis with ages
ranging from 19 to 59 years, including 17 men and 52
women. Twenty-two patients were diagnosed with EE,
and all had localization-related epilepsy. Two had frontal
epilepsy without clear lateralization. The rest of the EE
patients had ictal events localized to the temporal lobe:
seven right and 12 left. Another patient had bilateral
temporal epileptic discharges.
Thirty-six patients had NEE alone. Another 11 dis-
played both EE and NEE. Of these 1 1 patients, seven had
localization-related epileptic events, five with left and
two with a right temporal lobe focus. Of the four remain-
ing patients in this group, one individual had primary
generalized epilepsy, and another had an abnormal in-
terictal EEG. The remaining two patients had a reliable
clinical history confirming a diagnosis of epilepsy.
Mean HIP scores were compared by using a one-way
ANOVA. Patients with epilepsy had a lower mean HIP
value (5.18; SD, 3.31) in contrast to those with NEE
(6.80; SD, 3.14) and patients in the combined diagnostic
group (6.92; SD, 1.99). There was no statistically sig-
nificant difference, however, comparing these means (p
 HYPNOTIC SEIZURE INDUCTION
= 0.117, cli 2). By using a two-tailed t test, mean HIP
scores of all patients with NEE (6.83; SD, 2.87) were
compared with those with EE (5.18; SD, 3.31), and a
significant difference was found ( t = -2.116, dJ 67; p
= 0.038; refer to Table 1).
The capacity of hypnosis with seizure induction to
evoke a typical event was then determined. One patient
did have an epileptic seizure (confirmed by video-EEG
monitoring) while undergoing hypnotic induction. This
appeared to be a chance occurrence, because this patient
was not hypnotizable (HIP, 0), had a decrement profile
and had many EEs that day. A repeated attempt to induce
an EE in this patient with hypnosis was unsuccessful.
Hypnotic induction of an EE could not be ruled out, and
a specificity of 95% was therefore obtained.
Of 47 patients with NEE, 36 had seizures induced
during hypnosis, providing a sensitivity of 77% (refer to
Table 1).
DISCUSSION
This study used hypnosis to differentiate EEs from
NEEs. The patient’s capacity to be hypnotized was mea-
sured by using the overall “induction” score on the HIP.
Individual differences, as determined by the HIP, differ-
entiated patients with EE from NEE only when the NEE
and NEE/EE groups were combined. However, HIP
scores were obtained only once, and some patients may
require several tests to reach a baseline (10). In addition,
the author (J.J.B.) was the only evaluator, introducing
potential bias and possibly compromising reproducibili-
ty. After the HIP was completed, an attempt was made to
induce a typical event by using hypnosis. Patients with
NEE were correctly identified by hypnotic seizure induc-
tion 77% of the time. Specificity of the procedure was
95%.
In other studies, suggestion techniques have been used
as diagnostic procedures. Walczak et al. ( 5 ) used the
saline placebo infusion method in 68 patients and found
that 82% of the 40 patients with NEE had typical psy-
chogenic events induced by the procedure. In two pa-
tients with epilepsy, this technique resulted in the induc-
TABLE 1. HIP + diagnosis by seizure induction
Hypnotic Induction Diagnosis by
Profile scores seizure induction
Group No. Mean SD Sensitivity Specificity
EE 22 5.18” 3.31
NEE 36 6.80“ 3.14
EE/NEE 11 6.92“ 1.99
NEE + EE/NEE 47 6.83” 2.87
All patients 69 77% 95%
EE, epileptic events; NEE, nonepileptic events.
‘‘ Means are not different statistically (p = 0.1 17).
’ Means are statistically significant (p = 0.038).
83
tion of true epileptic seizures. Lancman et al. (6) used the
alcohol-patch technique in 93 patients with NEE and in
20 patients with EE and found a diagnostic sensitivity of
77.4% and a specificity of 100%. Ethical concerns re-
garding the use of these procedures has been discussed
by Devinsky and Fisher (15). Walczak et al. (16) found
no long-term adverse effects from this method. Notably,
psychogenic status epilepticus has been induced by such
procedures (17). One of the distinct advantages of hyp-
nosis with seizure induction for differential diagnosis is
its safety and that the patient is completely informed of’
its purpose and technique.
It is important to consider how hypnosis may aid in the
differentiation of NEE from EE. In general, the HIP is
considered a measure of hypnotizability (9). Many au-
thors have equated this ability with overall dissociability
(10). Dissociation has been viewed as a defense mecha-
nism maintained and overused since childhood because
of early trauma, often in the form of sexual abuse (1 8).
NEE patients frequently have similar histories of abuse
(19), and this may account for their comparatively el-
evated scores on the HIP. Hypnosis and suggestion tech-
niques might initiate NEE by heightening the ability of
these patients to filter out distracting stimuli and attend,
uncritically, to the instructions of the examiner. This pos-
sibility has been at least partially confirmed in studies
demonstrating hypnotic alteration of physiological states
associated with selective attention (20). This effect of
hypnosis can be seen particularly in certain psychopatho-
logic conditions (e.g., dissociative disorders, a category
that might also include NEE).
In this study, there was a subset of patients with epi-
lepsy and NEE. Several studies have shown a higher
frequency of temporal lobe epilepsy in patients with dis-
sociative disorders, such as Dissociative Identity Disor-
der (formally called Multiple Personality Disorder) (21-
23). However, many of these reports are case studies or
are methodologically flawed. Ross et al. (24) used the
Dissociative Experiences Scale to measure dissociability
and found little difference between patients with com-
plex partial seizures and a neurological control group.
Dissociative symptoms in epilepsy patients usually are
interictal, and arise later in life. They may have a differ-
ent pathophysiologic and psychological mechanism, be-
cause these patients generally do not have the extensive
histories of sexual or physical abuse seen in the NEE
group (25,26). This cohort of patients with combined
NEE/EE needs further characterization.
The HIP with seizure induction is a useful diagnostic
tool to differentiate EEs from NEEs. It helps the clinician
introduce the diagnosis of NEE, as the patient is provided
with a way to understand the occurrence of NEE and a
means of controlling the events non-pharmacologically
(13). It fosters a therapeutic alliance with the patient,
which is so crucial to the treatment process. As this al-
Epilep&ia, Vul. 41, No. l , 2000
84 J. J. BARRY ET AL.
liance develops, the frequency of NEE often decreases.
Somatic language is replaced by verbal reports of dis-
tress. Psychotherapy and pharmacotherapy can then be
used to full advantage.
In the author’s experience, patients have generally re-
sponded to the hypnotic process with enthusiasm and
gratitude. It also is easy for the clinician to learn and may
provide a significantly less expensive diagnostic tech-
nique than inpatient monitoring. Hypnosis offers a useful
addition to the armementarium in the diagnosis of NEE.
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