Dissociation in epilepsy: rethinking boundaries between psychiatry and neurology

Background: Dissociation, a disruption in the coherent integration of experience, is increasingly recognized as a clinically relevant yet underexplored phenomenon in epilepsy. While psychobehavioral symptoms such as anxiety and depression are routinely addressed in epilepsy care, dissociation remains understudied and formal assessment frameworks to better evaluate and integrate dissociative phenomena could be further developed and applied in epilepsy care.

Objective: This narrative review synthesizes current evidence on the phenomenology, determinants, neurophysiology, and measurement of dissociation in epilepsy, aiming to bridge psychiatric and neurological perspectives by reframing dissociation as a condition dynamically interacting with epilepsy.

Method: We conducted a structured narrative review, following a comprehensive literature search to identify empirical or theoretical studies addressing dissociation in epilepsy.

Results: Dissociation is a frequent but overlooked feature in epilepsy, manifesting during seizures and interictally. Evidence, though limited, suggests dissociation and epilepsy may be best conceptualized as interacting conditions, shaped by shared neurobiological substrates, common risk factors, and reciprocal effects. These could involve disruptions in large-scale brain networks implicated in embodiment, sensory integration, agentivity, emotional regulation, and perception. Additional contributors may include seizure-related trauma, chronic stress, and the psychosocial burden of epilepsy. We integrate preliminary findings from theoretical models, neuroimaging studies, and intracranial stimulation to highlight the complex interactions between epilepsy and dissociation across ictal, interictal, and postictal states.

Conclusions: Despite its clinical relevance, dissociation remains insufficiently integrated into epilepsy research and care. We advocate for improved assessment, interdisciplinary models, and targeted research to clarify underlying mechanisms. Recognizing the bidirectional relationship between epilepsy and dissociation challenges traditional disciplinary boundaries and supports a more integrated understanding of brain-mind interactions.