Neuropsychiatric Aspects of Epilepsy and Psychogenic Nonepileptic Seizures

Question-and-answer flashcards covering definitions, epidemiology, pathophysiology, classifications, psychiatric comorbidities, diagnostic methods, treatment considerations, and distinctions between epileptic seizures and psychogenic nonepileptic seizures.

What is the most common psychiatric comorbidity in patients with epilepsy?

Depression (including dysthymia and major depressive disorder).

How is a seizure (ictus) defined?

A sudden, involuntary behavioral event caused by excessive or hypersynchronous electrical discharges in the brain.

What criteria define epilepsy?

At least two unprovoked or reflex seizures occurring more than 24 hours apart.

How long must seizure activity last to meet the definition of status epilepticus?

5 minutes of continuous seizure or two or more seizures within 30 minutes without full recovery in between.

What are the three temporal categories used to relate psychiatric symptoms to seizures?

Ictal, peri-ictal, and interictal.

Describe the peri-ictal period.

The time just before or after a seizure when it is unclear exactly when the ictus begins or ends.

Name the four basic EEG wave bands and their frequency ranges.

Delta ≤ 3.5 Hz, Theta 4–7.5 Hz, Alpha 8–13 Hz, Beta > 13 Hz.

What EEG pattern is characteristic of epileptic discharges?

Spikes or spike-and-wave complexes (20–70 ms spikes).

Which brain lobe is the most common focal origin of adult epilepsy?

Temporal lobe, especially mesial structures.

What 2017 ILAE term replaced “simple partial seizure”?

Focal onset aware seizure.

What 2017 ILAE term replaced “complex partial seizure”?

Focal onset impaired-awareness seizure.

List two key differences between absence seizures and focal impaired-awareness seizures.

Absence seizures are generalized from onset, last ~10 s, occur repeatedly, lack auras/confusion, and show generalized 2–4 Hz spike-and-wave on EEG.

Which neurotransmitter’s reduced inhibition is implicated in seizure generation?

Gamma-aminobutyric acid (GABA).

Which AED blocks T-type calcium currents and is especially useful for absence seizures?

Ethosuximide.

Name two AEDs with mood-stabilizing (antimanic/antidepressant) properties.

Valproate and carbamazepine (lamotrigine prevents bipolar depression).

Which AED is well known for causing irritability and aggression as a side effect?

Levetiracetam.

What psychiatric syndrome has a lifelong prevalence up to ~12 % in epilepsy?

Psychosis (interictal, peri-ictal, or postictal).

What is the typical latency and duration of postictal psychosis?

Begins after a lucid interval of 2–72 h (mean 1 day) and lasts 16–432 h (mean 3.5 days).

List three hallmark traits of the Gastaut–Geschwind personality syndrome.

Hyperreligiosity/philosophical interest, viscosity (circumstantiality), and hypergraphia.

What is the risk ratio for completed suicide in epilepsy compared with the general population?

Approximately 4–5 times higher (up to 25 × in temporal lobe epilepsy).

Which type of focal seizure aura involves déjà vu or jamais vu experiences?

Dysmnesic psychic aura arising from mesial temporal structures.

What EEG finding is associated with prolonged confusional states and focal cognitive changes?

Periodic lateralizing epileptiform discharges (PLEDs).

Define alternating (forced-normalization) psychosis.

Psychosis that appears when seizures or EEG discharges improve and remits when seizures return.

Name four potential neurobiologic mechanisms linking epilepsy and psychiatric symptoms (Table 2.4-3).

Common neuropathology/genetics, ictal facilitation of neuronal networks, absence/hypometabolism at seizure focus, neurochemical changes (e.g., dopamine, hormones).

What screening tool is tailored for depression in epilepsy?

Neurological Disorders Depression Inventory for Epilepsy (NDDI-E).

Which anxiety disorder is most common among epilepsy patients?

Generalized anxiety disorder (GAD).

State one criterion required to attribute a psychiatric syndrome to epilepsy in DSM-5-TR.

The clinician must judge that the syndrome is a direct consequence of the medical condition (epilepsy) rather than a primary disorder.

What percentage of routine scalp EEGs are falsely negative in epilepsy?

Sensitivity only 29–55 %; many single EEGs are normal and require repetition or VEEG.

Which structural lesion is most frequently found in temporal lobe epilepsy surgery specimens?

Mesial temporal (hippocampal) sclerosis.

What proportion of temporal lobectomy patients become completely seizure-free?

Over 60 % (and >80 % have at least some seizure reduction).

List two AEDs least likely to lower seizure threshold when used as psychotropics.

Haloperidol and risperidone/paliperidone (among antipsychotics).

Which psychotropic has the highest documented rate of medication-induced seizures?

Clozapine (1–4.4 %, especially with rapid titration).

Give two examples of psychotropic–AED metabolic interactions.

Carbamazepine lowers serum levels of many antipsychotics; valproate can increase lamotrigine levels (risk of toxicity).

Define psychogenic nonepileptic seizures (PNES).

Sudden involuntary episodes resembling epileptic seizures without EEG epileptiform activity and presumed psychological origin; classified within functional neurologic symptom disorder.

What is the female-to-male ratio in PNES?

Approximately 3 : 1 during reproductive years.

Average diagnostic delay for PNES from first event is .

About 5–7 years.

Name three semiologic signs that favor PNES over epileptic seizures.

Prolonged duration (>2 min), forced eye closure or flutter, responsiveness to bystander interventions (or preservation of awareness during bilateral movements).

Which seizure type can mimic PNES because of brief bizarre movements and minimal EEG change?

Frontal lobe focal seizures.

What is the first-line evidence-based treatment for PNES?

Psychotherapy, especially cognitive-behavioral therapy (CBT).

List two key points clinicians should include when explaining a PNES diagnosis.

Symptoms are genuine (not faked) and explanation of how diagnosis was made (VEEG evidence); discuss mechanisms and effective treatments.

Which factors predict better PNES outcome?

Higher education, shorter illness duration, employment, acceptance of diagnosis, social support.

What proportion of adult PNES patients also have coexisting epilepsy?

Approximately 10–20 %.

Name three physiologic paroxysms that must be differentiated from PNES and epileptic seizures.

Syncope, parasomnias, transient ischemic attacks (others include migraines, narcolepsy, movement disorders).

What personality disorder is most prevalent among epilepsy patients?

Borderline personality disorder.

What neuromodulation technique approved for epilepsy also shows antidepressant benefit?

Vagus nerve stimulation (VNS).

What psychological construct is often impaired in temporal lobe epilepsy and may influence personality?

Theory of mind (ability to understand others’ perspectives).

Which AEDs are relatively free of enzyme-inducing or inhibiting effects, simplifying psychotropic co-prescription?

Levetiracetam, lacosamide, zonisamide, gabapentin, clobazam, perampanel, ethosuximide, vigabatrin, tiagabine.