behavioral

sciences
Editorial
Epilepsy: A Multifaced Spectrum Disorder
Luigi Vetri 1, * , Michele Roccella 2 , Lucia Parisi 2 , Daniela Smirni 2 , Carola Costanza 3 , Marco Carotenuto 4
and Maurizio Elia 1

1 Oasi Research Institute-IRCCS, Via Conte Ruggero 73, 94018 Troina, Italy
2 Department of Psychology, Educational Science and Human Movement, University of Palermo,
90128 Palermo, Italy
3 Department of Sciences for Health Promotion and Mother and Child Care “G. D’Alessandro”,
University of Palermo, 90128 Palermo, Italy
4 Clinic of Child and Adolescent Neuropsychiatry, Department of Mental Health, Physical and Preventive
Medicine, University of Campania “Luigi Vanvitelli”, 81100 Caserta, Italy
* Correspondence: [email protected]

Epilepsy is one of the most widespread chronic conditions, affecting about 50 mil-
lion people worldwide. It consists of a group of neurological disorders characterized by
recurrent epileptic seizures due to abnormal electrical activity in the brain. Epilepsy has
numerous etiologies, some of which are still completely unknown; seizures can produce a
plethora of different clinical manifestations, with a wide range of severities and varying
impacts on individuals and their families.
In addition to seizures, the complex phenotypic picture of people with epilepsy is often
complicated by the presence of psychiatric and medical comorbidities. Several diseases and
conditions, including depression, anxiety, dementia, migraines, heart disease, peptic ulcers
and arthritis, are more common in people with epilepsy than in the general population.
Many patients also report cognitive problems. Therefore, epilepsy has been progressively
recognized as a condition reaching well beyond seizures, and today it can be properly
considered as a multifaced spectrum disorder.
The ILAE recently defined epilepsy as a brain disorder characterized not only by
recurrent seizures, but also by psychosocial consequences [1].
On the other hand, the new classification (2017) recognizes comorbidities as a signifi-
cant and essential element of the diagnostic process [2]. Similarly, the WHO, in a global
Citation: Vetri, L.; Roccella, M.; report on epilepsy, also underlined the importance of coexisting psychiatric disorders and
Parisi, L.; Smirni, D.; Costanza, C.; the need to recognize and treat them to ensure the adequate and effective global care of
Carotenuto, M.; Elia, M. Epilepsy: A
patients with epilepsy [3].
Multifaced Spectrum Disorder. Behav.
The neuropsychological definition in the clinical context is very important for under-
Sci. 2023, 13, 97. https://doi.org/
standing the different aspects of the disease—the clinical symptoms, psychiatric comorbidi-
10.3390/bs13020097
ties, pharmacotherapy, social functioning, and the definition of cognitive impairments—
Received: 9 January 2023 and, therefore, this discipline is important for obtaining a correct diagnosis and planning
Accepted: 18 January 2023 appropriate neurorehabilitation interventions, considered as both cognitive recovery and
Published: 23 January 2023 compensation of deficits [4].
The neuropsychological evaluation in patients with epilepsy does not differ much
from the evaluations conducted on patients with other neurological conditions or with
other chronic diseases. Generally, the evaluation includes the main cognitive domains: intel-
Copyright: © 2023 by the authors.
lectual and adaptive development, attention, memory and learning, language, visuo-spatial
Licensee MDPI, Basel, Switzerland.
abilities, executive functions, sensorimotor skills, teaching skills, emotional behavioral
This article is an open access article
functioning and quality of life [5].
distributed under the terms and
conditions of the Creative Commons
Understanding the complex dynamics of interaction between clinical, cognitive, af-
Attribution (CC BY) license (https://
fective, psychosocial and neurobiological factors is very important for clinical practice in
creativecommons.org/licenses/by/
epileptology. In this case, the neuropsychologist is called to carry out the integration of the
4.0/).

Behav. Sci. 2023, 13, 97. https://doi.org/10.3390/bs13020097 https://www.mdpi.com/journal/behavsci

Behav. Sci. 2023, 13, 97 2 of 3

factors mentioned above, thereby contributing in a deeper way to the understanding of the
patient with epilepsy and also favoring patient management.
Through the understanding of cognitive and neurobehavioral perturbations, due to
the presence of seizures and/or underlying injuries of the nervous tissue, and to the effect
of antiepileptic drugs on cognition, it is possible to trace the neuropsychological profile of
every single patient. Therefore, this profile constitutes the sum of effects of epilepsy, of
the bimodal contribution of the pharmacological treatment, of the presence of psychiatric
comorbidities, and of the impact of a chronic disease and its related cognitive-affective
problems in everyday life on the patient’s cognitive performances.
There are several factors characterizing epilepsy that can affect individuals’ neuropsy-
chological performances. Therefore, it should come as no surprise that these repercussions
are so frequent. The main factors are the etiology of seizures (probably the most impor-
tant variable), the site and extent of the lesion causing epilepsy, seizure frequency, age
of onset, seizure type, antiepileptic drugs side effects, and the frequency of subclinical
epileptic anomalies.
A holistic evaluation of the patient with epilepsy is particularly appropriate in the
case of pre-operative diagnostic monitoring of patients with drug-resistant epilepsy can-
didates for surgical therapies. In this case, the neuropsychological evaluation, assessing
the patient’s cognitive-behavioral profile, can contribute to the definition of the topo-
graphic location of seizure discharges and to the anatomic demarcation of epileptic circuits.
Moreover, the detailed neuropsychological exam can contribute to the prognosis of the
surgical outcome, both in terms of the therapeutic monitoring of seizures and of possible
psychiatric comorbidities.
Psychosocial factors in patients with epilepsy probably represent the factors that best
define the psychopathology, particularly if they are associated with other stressful events,
lack of awareness, maladaptation to the condition of epilepsy, perception of support or
neglect and social stigma.
Psychopathology in patients with epilepsy, according to a recent review, is more
frequent than once was believed. Mood and anxiety disorders are the more frequent
psychiatric comorbidities, with a prevalence of 35% and 25.6%, respectively. Psychotic
disorders are rarer, with a frequency of 5.7%; the frequency of obsessive compulsive
disorder is even lower, while substance abuse is present in 8% of cases. Suicide risk is,
overall, greater, at 9%. However, several authors appropriately propose that these results
suggest introducing screening measures for anxiety–depressive disorder as part of the
training for epilepsy care [6,7].
The presence of psychiatric comorbidities does not only influence quality of life, but it
also negatively affects the global prognosis of the individual with epilepsy. An interesting
recent study showed how, compared to the general population, both subjects with both
epilepsy and psychiatric comorbidities and those without comorbidities present a higher
mortality risk. However, subjects with epilepsy and at least a psychiatric comorbidity
have a morality rate 1.4 times higher compared with people who have epilepsy without a
psychiatric illness, after adjusting for age and sex [8].
Psychiatric diseases are not the only ones complicating the clinical profile of subjects
with epilepsy; endocrine/metabolic disorders, respiratory diseases, urogenital diseases and
cardiovascular diseases are up to eight times more frequent and contribute to substantially
increase the burden for people with epilepsy [9,10].
Moreover, during infancy and adolescence, people with epilepsy experience cognitive
and behavioral problems, and these difficulties are frequently related to neurodevelopmen-
tal disorders such as autism spectrum disorder, attention-deficit hyperactivity disorder, and
learning challenges. Epilepsy and neurodevelopmental disorders co-occur, according to
the overlap model in which these conditions shared a common genetic susceptibility [11].
A holistic view of patients with epilepsy has many potential implications for the con-
dition’s management and treatment. Unfortunately, the scientific evidence about the effect
of antiepileptic drugs on comorbid psychiatric disorders remains suboptimal, and more
Behav. Sci. 2023, 13, 97 3 of 3

often in clinical practice a psychotherapeutic approach should be taken into consideration

to avoid polypharmacotherapy.
In conclusion, for a better global care of the patient with epilepsy, a new paradigm is
mandatory, encompassing the broader range of cognitive and behavioral comorbidities of
epilepsy, reflecting the heterogeneity of their phenotype, and enhancing the complexity of
etiological factors such as neurobiological diversity, genomics influences, and resilience fac-
tors. Ultimately, this will place the focus on the individual patient and raise the possibility
of a precision medicine approach [12].

Author Contributions: Conceptualization and Writing—original draft preparation, L.V., M.R., L.P.
and C.C.; Writing—review and editing, M.C., D.S. and M.E. All authors have read and agreed to the
published version of the manuscript.
Funding: This research received no external funding.
Informed Consent Statement: Not applicable.
Acknowledgments: Special acknowledgements are due to Rossella Maria Rindone for the English
linguistic revision of the manuscript.
Conflicts of Interest: The authors declare no conflict of interest.

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