Skip to main content Accessibility help

The forsaking of the clinical EEG by psychiatry: how justified?

  • Nash N. Boutros (a1)


Despite decades of publications attesting to the role of the clinical EEG in diagnosing and managing psychiatric disorders, the procedure remains highly underutilized in the practice of psychiatry. The visually inspected EEG (vEEG) can detect various forms of abnormalities, each with its own clinical significance. Abnormalities can be paroxysmal (i.e., suggestive of an epileptic-like process) or stationary. The most important unanswered question remains the value of detecting epileptiform activity in a nonepileptic psychiatric patient in predicting favorable responses to anticonvulsant treatment. Despite the many shortcomings of vEEG, the available evidence suggests that in the presence of paroxysmal activity in a nonepileptic psychiatric patient a trial of a psychotropic anticonvulsant may be warranted if standard treatment has failed. More research on the contribution of paroxysmal EEG abnormalities to the problem of episodic psychiatric symptoms (e.g., panic attacks, dissociative episodes, repeated violence) is sorely needed. It is postulated that at least some of these conditions may represent an epilepsy spectrum disorder. Similarly, the significance of the presence of a slow-wave activity (whether focal or generalized) also deserves further well-designed research to ascertain the exact clinical significance. Nonetheless, the available data suggest that further medical workup is necessary to ascertain the nature and degree of the pathology when present.


Corresponding author

*Address correspondence to: Nash N. Boutros, Department of Psychiatry, University of Missouri–Kansas City, 1000 East 24th Street, Kansas City, Missouri 68108. (Email:


Hide All
1. Shelley, BP, Trimble, MR, Boutros, NN. Electroencephalographic cerebral dysrhythmic abnormalities in the trinity of nonepileptic general population, neuropsychiatric, and neurobehavioral disorders. J Neuropsychiatry Clin Neurosci. 2008; 20(1): 722.
2. Boutros, NN, Kirollos, S, Pogarell, O, Gallinat, J. Predictive value of isolated epileptiform discharges for a favorable therapeutic response to antiepileptic drugs in nonepileptic psychiatric patients. J Clin Neurophysiol. 2014; 31(1): 2130.
3. Struve, FA, Boutros, NN. Somatic implications of generalized and/or focal slowing in psychiatric patients. Clin EEG Neurosci. 2005; 36(3): 171175.
4. Coburn, KL, Lauterbach, EC, Boutros, NN, Black, KJ, Arciniegas, DB, Coffey, CE. The value of quantitative electroencephalography in clinical psychiatry: a report by the Committee on Research of the American Neuropsychiatric Association. J Neuropsychiatr Clin Neurosci. 2006; 18(4): 460500.
5. Bonanni, L, Franciotti, R, Nobili, F, et al. EEG markers of dementia with Lewy bodies: a multicenter cohort study. J Alzheimers Dis. 2016; 54(4): 16491657.
6. Hegerl, U, Hensch, T. The vigilance regulation model of affective disorders and ADHD. Neurosci Biobehav Rev. 2014; 44: 4557.
7. Grossi, E, Olivieri, C, Buscema, M. Diagnosis of autism through EEG processed by advanced computational algorithms: a pilot study. Comput Methods Programs Biomed. 2017; 142: 7379.
8. Boutros, NN, Bowyer, S, Wang, J, Urfy, MZ, Loeb, JA. Epilepsy spectrum disorders: a concept in need of validation or refutation. Med Hypotheses. 2015; 85(5): 656663.
9. Boutros, NN, Torello, M, McGlashan, TH. Electrophysiological aberrations in borderline personality disorder: state of the evidence. J Neuropsychiatr Clin Neurosci. 2003; 15(2): 145154.
10. Boutros, NN, Galloway, MP, Ghosh, S, Gjini, K, Bowyer, SM. Abnormal coherence imaging in panic disorder: a magnetoencephalography investigation. Neuroreport. 2013; 24(9): 487491.
11. Elisevich, K, Shukla, N, Moran, JE, et al. An assessment of MEG coherence imaging in the study of temporal lobe epilepsy. Epilepsia. 2011; 52(6): 11101119.
12. Engel, J Jr. A proposed diagnostic scheme for people with epileptic seizures and with epilepsy: report of the ILAE Task Force on Classification and Terminology. Epilepsia. 2001; 42(6): 796803.
13. Boutros, NN, Gjini, K, Moran, J, Chugani, H, Bowyer, S. Panic versus epilepsy: a challenging differential diagnosis. Clin EEG Neurosci. 2013; 44(4): 313318.
14. Boutros, NN, Gallinat, J, Pogarell, O. Isolated epileptiform discharges in nonepileptic psychiatric patients: to treat or not to treat? J Clin Neurophysiol. 2014; 31(4): 395.
15. Toni, C, Cassano, GB, Perugi, G, et al. Psychosensorial and related phenomena in panic disorder and in temporal lobe epilepsy. Compr Psychiatry. 1996; 37(2): 125133.
16. Hoffman, EJ, Mathew, JS. Anxiety disorders: a comprehensive review of pharmacotherapies. Mount Sinai J Med. 2008; 75(3): 248262.
17. Hill, D, Watterson, D. Electroencephalographic studies of psychopathic personalities. J Neurol Psychiatry. 1942; 5(1–2): 4765.
18. Williams, D. Neural factors related to habitual aggression: considerations for differences between those habitual aggressive and others who have committed crimes or violence. Brain. 1969; 92(3): 503520.
19. Howard, RC. The clinical EEG and personality in mentally abnormal offenders. Psychol Med. 1984; 14(3): 569580.
20. Boutros, NN, Lajiness-O’Neill, R, Zillgitt, A, Richard, AE, Bowyer, SM. EEG changes associated with autistic spectrum disorders. Neuropsychiatr Electrophysiol. 2015; 1: 3.
21. Gillberg, C, Schaumann, H. Epilepsy presenting an infantile autism? Two case studies. Neuropediatrics. 1983; 14(4): 206212.
22. Hollander, E, Dolgoff-Kaspar, R, Cartwright, C, Rawitt, R, Novotny, S. An open trial of divalproex sodium in autism spectrum disorders. J Clin Psychiatry. 2001; 62(7): 530534.
23. Chez, MG, Chang, M, Krasne, V, Coughlan, C, Kominsky, M, Schwartz, A. Frequency of epileptiform EEG abnormalities in a sequential screening of autistic patients with no known clinical epilepsy from 1996 to 2005. Epilepsy Behav. 2006; 8(1): 267271.
24. Swatzyna, RJ, Tarnow, JD, Turner, RP, Roark, AJ, MacInerney, EK, Kozlowski, GP. Integration of EEG into psychiatric practice: a step toward precision medicine for autism spectrum disorder. J Clin Neurophysiol. 2017; 34(3): 230235.
25. Frye, RE, Butler, I, Strickland, D, Castillo, E, Papanicolaou, A. Electroencephalogram discharges in atypical cognitive development. J Child Neurol. 2010; 25(5): 556566.
26. Larsson, PG, Bakke, KA, Bjørnæs, H, et al. The effect of levetiracetam on focal nocturnal epileptiform activity during sleep: a placebo-controlled double-blind cross-over study. Epilepsy Behav. 2012; 24(1): 4448.
27. Pressler, RM, Robinson, RO, Wilson, GA, Binnie, CD. Treatment of interictal epileptiform discharges can improve behavior in children with behavioral problems and epilepsy. J Pediatr. 2005; 146(1): 112117.
28. Tharp, BR. Epileptic encephalopathies and their relationship to developmental disorders: do spikes cause autism? Ment Retard Dev Disabil Res Rev. 2004; 10(2): 132134.
29. Kleen, JK, Scott, RC, Holmes, GL, Lenck-Santini, PP. Hippocampal interictal spikes disrupt cognition in rats. Ann Neurol. 2010; 67(2): 250257.
30. Khan, OI, Zhao, Q, Miller, F, Holmes, GL. Interictal spikes in developing rats cause long-standing cognitive deficits. Neurobiol Dis. 2010; 39(3): 362371.
31. Gallinat, J, Hegerl, U. Limbic ictus as a condition for anxiety attacks [in German]. Nervenartzt. 1999; 70(3): 206215.
32. Brown, TM. Basic mechanisms in the pathogenesis of delirium. In: Stoudemire A, Fogel BS, Greenberg DB, eds. Psychiatric Care of the Medical Patient, 2nd ed. New York: Oxford University Press; 2000: 571580.
33. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Arlington, VA: American Psychiatric Association; 2013.
34 Tonkonogy, J, Geller, J. A neuropsychiatry service in a state hospital: Adolf Meyer’s approach revisited. Psychiatr Q. 2007; 78(3): 219235.
35. Engel, GL, Romano, J. Delirium, a syndrome of cerebral insufficiency. J Chronic Dis. 1959; 9(3): 260277.
36. Javanbakht, A, Amirsadri, A, Arfken, C, Dewald, O, Boutros, NN. Standard EEG study of acute psychiatric patients with difficult to assess mental status. Am Assoc Emerg Psychiatry. 2012; 10(1): 510.
37. Cascino, GD, Trennerry, MR, So, EL, et al. Routine EEG and temporal lobe epilepsy: relationship to long-term monitoring, quantitative MRI, and operative outcome. Epilepsia. 1996; 37(7): 651656.
38. Leach, JP, Stephan, LJ, Salveta, C, Brodie, MJ. Which electroencephalogram (EEG) for epilepsy? The relative usefulness of different EEG protocols in patients with possible epilepsy. J Neurol Neurosurg Psychiatry. 2006; 77(9): 10401042.
39. Goodin, DS, Aminoff, MJ. Does the interictal EEG have a role in the diagnosis of epilepsy? Lancet. 1984; 1(8381): 837839.
40. Marsan, CA, Zivin, LS. Factors related to the occurrence of typical abnormalities in the EEG records of epileptic patients. Epilepsia. 1970; 11(4): 361381.
41. Losey, TE, Uber-Zak, L. Time to first interictal epileptiform discharge in extended recording EEGs. J Clin Neurophysiol. 2008; 25(6): 357360.
42. Chochoi, M, Tyvaert, L, Derambure, P, Szurhaj, W. Is long-term electroencephalogram more appropriate than standard electroencephalogram in the elderly? Clin Neurophysiol. 2017; 128(1): 270274.
43. Boutros, N, Mirolo, HA, Struve, F. Normative data for the unquantified EEG: examination of adequacy for neuropsychiatric research. J Neuropsychiatry Clin Neurosci. 2005; 17(1): 8490.
44. Hughes, JR, Wilson, WP, eds. EEG and Evoked Potentials in Psychiatry and Behavioral Neurology. Boston: Butterworths; 1983.
45. Hughes, JR. EEG in Clinical Practice, 2nd ed. Boston: Butterworth–Heinemann; 1994.
46. Boutros, NN. Introduction to controversial sharp waves or spike patterns. In: Standard EEG: A Research Roadmap for Neuropsychiatry. New York: Springer Science; 2014: 151157.
47. DeLong, GR, Rosenberger, PB, Hildreth, S, Silver, I. The 14- & 6-associated clinical complex: a rejected hypothesis revisited. J Child Neurol. 1987; 2(2): 117127.
48. Boutros, NN, Hughes, JR, Weiler, M. Psychiatric correlates of rhythmic midtemporal discharges and 6/second spike and wave complexes. Biol Psychiatry. 1986; 21(1): 9499.
49. Hughes, JR, Gruener, G. Small sharp spikes revisited: further data on this controversial pattern. Clin Electroencephalogr. 1984; 15(4): 208213.
50. Anderson, RL, Vanderspek, HG. Psychomotor variant status epilepticus. Clin Electroencephogr. 1974; 5: 129132.
51. Krauss, GL, Abdallah, A, Lesser, R, Thompson, RE, Niedermeyer, E. Clinical and EEG features of patients with EEG wicket rhythms misdiagnosed with epilepsy. Neurology. 2005; 64(11): 18791883.
52. Small, JG. Small sharp spikes in a psychiatric population. Arch Gen Psychiatry. 1970; 22: 277284.
53. Small, JG, Milstein, V, Medlock, CE. Clinical EEG findings in mania. Clin Electroencephalogr. 1997; 28(4): 229235.
54. Struve, FA, Saraf, KR, Arko, RS, Klein, DF, Becka, DR. Relationship between electroencephalographic dysrhythmia and suicide ideation and attempts in psychiatric patients. In: Shagass C, Gershon S, Friedhoff AJ, eds. Psychopathology and Brain Dysfunction. New York: Raven Press; 1977: 199221.
55. Boutros, NN. The history of the Electrophysiology and Clinical Neuroscience Society (ECNS), part II: The American Psychiatric Electrophysiology Association (APEA): history and mission. Clin Electroencephalogr. 2000; 31(2): 6770.
56. Boutros, NN. Philosophical differences in standard EEG interpretation between neurology and psychiatry: a historical perspective. In: Standard EEG: A Research Roadmap for Neuropsychiatry. New York: Springer Science; 2014: 315.
57. Bowyer, SM. Coherence a measure of the brain networks: past and present. Neuropsychiatr Electrophysiol. 2016; 2: 1.
58. Noebels, JL. The biology of epilepsy genes. Annu Rev Neurosci. 2003; 26: 599625.
59. Aarts, JH, Binnie, CD, Smit, AM, Wilkins, AJ. Selective cognitive impairment during focal and generalized epileptiform EEG activity. Brain. 1984; 107(Pt 1): 293308.
60. Fisch, BJ. Interictal epileptiform EEG activity: diagnostic and behavioral implications. 2002 ACNS presidential address. J Clin Neurophysiol. 2003; 20(3): 155162.
61. Pogarell, O, Hegerl, U, Boutros, N. Clinical neurophysiology service in psychiatry departments. Psychiatr Serv. 2005; 56(7): 871.
62. Boutros, NN. Diffuse electroencephalogram slowing in psychiatric patients: a preliminary report. J Psychiatry Neurosci. 1996; 21(4): 259263.


The forsaking of the clinical EEG by psychiatry: how justified?

  • Nash N. Boutros (a1)


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed