SEMINAKS I N NEUROLOGY-VOLUME

1 1 , N O . 2 ,]UNli 1991

Psychic Phenomena in Partial Seizures Orrin Deuinsky, M.D., and Daniel Luciano, M.D.

Table 1. Psychic Phenomena in Epilepsy Cognitive 1. Dreamy state 2. Derealization 3. Depersonalization 4. Dissociation 5. Mysticallreligious experience 6. Forced thinking 7. Altered speed of thoughts 8. Distortion of time 9. Distortion of body image Dysphasic 1. Speech arrest 2. Nonfluent speech 3. Paraphasias 4. Comprehension deficit 5. Repetitive utterances 6. Dyslexia 7. Agraphia Dysmnesic 1. Deja vu 2. Jamais vu 3. Selective memory impairment Affective 1. Fear 2. Depression 3. Anger 4. Pleasure 5. Laughter (gelastic seizure) 6. Crying (dacrystic seizure) Illusions and hallucinations 1. Visual 2. Auditory

monly assumed to be simply "cxcessive electrical activity," apparently identical spontaneous seizure discharges may trigger experiential phenomena on some occasions and not o n others. Depth electrode studies demonstrate that spread of the electrical discharge, personality factors, and other unknown variables influence the development of these event^.^," Most "experiential" o r "psychic" phenomena occur only with limbic system ~timulation.~."' However, as with spontaneous discharges, stimulation of the

1)epartlnent of Neurology, N e w York University School of' Metlicinc, and the Hospital f o r Joint I)iseases, New York, New York Copyright O 3991 by Thierne Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.

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Psychic experiences in partial epilepsy are among the most f'ascinating and poorly understood neurologic phenomena. Psychic phenomena in partial seizures were recognized by Jackson in 1880, who also coined the term.' He wrote of "psychical states during the onset of certain epileptic seizures, states which are much more elaborate than crude sensations." H e described aphasia, reminiscence (d6jA vu), dreamy state, fear, pleasure, desire to attack someone, hatred, feeling of being transported to another world, and structured visual hallucinations during seizures.'." These complex changes in perception, emotion, language, and thought (Table 1 ) have been difficult to study, and the underlying pathophysiology remains poorly defined. Paroxysmal psychic phenomena are not restricted to patients with epilepsy. They occur in many normals (for example, d6ju vu and depersonalization)" and in patients with nonepileptic disorders (migraine, stroke, transient ischemic attacks; schizophrenia; depression; and bipolar, panic and depersonalization disorder^).^-" T h e diverse etiologic groups associated with these phenomena suggest that there may be several pathophysiologic mechanisms. T h e distinction between positive and negative symptoms in neurologic disorders is often difficult. Psychic phenonema may result from excitation (positive) o r inhibition (release). Kelease hallucinations occur with lesions in the sensory pathways and are more common in the acute stage. They are characterized by simple o r complex hallucinations that are typically continuous, nonstereotyped, and influenced by purposeful acts such as changing the direction of gaze.' Kelease phenomena have less localizing value than excitatory hallucinations. T h e precise mechanism underlying ictal psychic phenomena remains unknown. Although com-

PSY(;HI(: PHENOMENA IN PAK7'1A1, SEIZURES-DEVINKSY, I,UCIANO

COGNITIVE PHENOMENA T h e most substantive change in the 1981 revision of the International League Against Epilepsy (ILAE) classification o f t h e epilepsies was the designation of irnpairrnent of consciousness as the filndamental distinction between simple and complex partial seizures." T h e previous 1970 ILAE classification defined complex partial seizures as those with disturbances of "higher cortical integrative functions," whereas simple (elementary) partial seizures comprise those with symptoms referable to primary motor and sensory cortices.':' Consciousness is defined simplistically as "the degree of awareness andlor responsiveness of the patient to externally applied stimuli."" T h e current schema leaves psychic phenomena (Table I ) within the spectrum of simple partial seizures, although

in many ways these syrnptoms bridge the more ephemeral transition between preserved and impaired consciousness. Jackson also recognized the fine line between psychic phenomena and altered consciousness: The dreamy state in the uncinate group of. epilepsies varies very riiuch i l l different cases. . . in some slight epileptic paroxysms with the dreamy state-in all o f them, I believe there is a kind of' double consciousness-a "rnental diplopia." . . . there is PI-obablysome defect o f consciousness in every paroxsym with the drearny state; certairily there is in some of them. 'l'he psychical condition, theretore, is a very complex one. There is a defect of consciousness, so far negatively. Positively, there is (1) the quasi-parasitical state of consciousness (dreamy state), and (2) remnants of normal consciousness; and thus (1 and 2) there is double consciousness." T h e dreamy state is a fluid mental condition characterized by an altered sense of reality that may affect the experience and perception of one's own o r external reality. Thus, it overlaps with depersonalization (alteration o r loss of the usual experience of one's reality may be associated with a feeling of detachment o r acting as if an automaton) and derealization (alteration o r loss of the usual experience of external reality, "as if everything around me was a dream"). T h e dreamy state is often difficult for patients to describe, but the following accounts are typical: "being here, but not being here," "fadingltuning in and out," "I can hear what is being said, but I am somehow removed and don't try to talk." Consciousness and memory for events may be partial o r complete. One patient reported a "fading out" and feeling as if he was an automaton during partial seizures, associated with an olfactory hallucination and d6j2 vu, that occurred an average of twice per day. There was frequently amnesia fbr events occurring during the seizure. H e drove extensively with these seizures for 8 years (prior to coming to medical attention) but was never in an automobile accident. "Double consciousness" (dissociation) is a form of'depersonalization in which mind-body dissociation, detachment, o r autoscopy occurs. Autoscopy is the hallucination o r psychic experience of seeing oneself. 'There are two principal forms of autoscopy. T h e first, seeing one's double, is a "complex psychosensorial hallucinatory perception of one's own body image projected into external space."'" T h e subject's consciousness is usually perceived within his body. 'The second, an out-of-body experience, is the feeling of leaving one's body and viewing it from another vantage point, usually from above. In this instance, consciousness is typically experienced from outside the subject's body."' Autoscopic phenomena occur in healthy persons (especially with anxiety and stress) and with neu-

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same site with current anti other variables held constant rnay evoke a symptom on only one of many trials.' Why only a fraction of apparently identical stimuli are effective in producing these phenomena remains a mystery. Jackson's conceptualization of positive and negative symptoms is helpful in understanding ictal psychic phenomena. H e postulated that negative symptoms, varying from weakness to confusion and coma, ar-e related to dissolution of neural function." 'The positive symptoms result from activity or hyperactivity of "lower" centers, which are normal, except, "figuratively speaking, for 'insul~orclinationfrom loss of control."' T h e lesion per se does not directly produce "extravagant conduct," delusions, o r misidentification of a nurse as 21 wife. F1711us, Jackson believed that complex behavioral phenomena are never the direct product of seizure activity. Simple partial seizure symptoms are generally regarded as the product of focal, excessive electrical discharges. This mechanism works well for- sensorimotor, autonomic, and perhaps ictal emotions, but its relevance for co~nplex ictal behaviors such as aphasia and the drearny state is less certain. Focal electrical discharges in partial seizures nlay produce symptoms through excitation o r inhibition. Dkj5 vu may be an ictal errlotion of familiarity triggered by a localized excitatory discharge. Speech arrest may be a negative symptom resulting from excitation (that is, active inhibition). Neologistic speech may be a positive symptom resulting from active inhibition in partial epilepsy o r infarction of Wernicke's area in the territory of the inferior division of the middle cerebral artery. 'l'he dreamy state may include both positive and negative components (see later).

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T h e air was filled with a big noise, and I thought it had engulfed me. I have really touched God. He came into me myself, yes, God exists, I cried, and I don't remember anything else, You all, healthy people, he said, can,t imagine the happiness which we epileptics feel during the second before our attack. I don't know if this felicity lasts for seconds, hours, o r months, but believe me, for all the joys that life may bring, I would not exchange this one. Such instants were characterized by a fulguration of the consciousness and by a supreme exaltation of emotional subjectivity. (The Idiot)

102

Ecstatic or religious simple partial seizures are rare, but are well do~umented.'~,'"hese ecstatic auras are probably related to affective seizures with pleasure (see later)."'," Forced thinking occurs with partial seizures, but, like many cognitive phenomena, it has received little systematic study. Several of our patients reported a stereotyped, repetitive feeling immediately prior to complex partial seizures: as if they were "caught in a puzzle," that they were on the verge of getting the answer or making a major breakthrough into something that they can only vaguely recall. Others describe "racing, uncontrollable thoughts that make it impossible to concentrate on anything else." T h e speed of' mental processes may be altered during partial seizures. Some patients report a racing or slowing of thoughts, visual images, or auditory input. Time distortion often occurs in conjunction with altered speed of thoughts, but may be independent ("my mind is working fine; it's the world that's moving in slow motion"). Disorientation for time often occurs after complex partial and generalized tonic-clonic seizures. T h e left temporal lobe may be dominant for temporal sequencing, and seizures in this region may therefore disrupt this function. Paroxysmal disorders of body image may involve a sensation of a missing body part, illusions of corporeal transformation or displacement, or hallucinations of a reduplicated limb. T h e sensation of missing a body part is usually unilateral and may occur with partial seizures as a paroxysmal phenomenon in which the subject is aware of a loss of perception of the body part. This contrasts with left-sided neglect in patients with right parietal lesions, in which the disturbance is persistent and the

subject is unaware of the deficit. Corporeal transformation, in which parts of the body feel larger or smaller than normal or the entire body is levitated off the ground, can also result from focal seizure

discharge^.^'.^" LANGUAGE FUNCTIONS Ictal and postictal aphasias occur with partial seizures, but must be differentiated from motor speech disorders, impairment of menlory or consciousness, and confusional states, The definitive identification of peri-ictal aphasia is difficult and is often made casually and incorrectly. 1,anguage disorders may be difficult to classify accurately in alert patients with stable deficits. Thus, the clynamic and evanescent seizure presents a special problem in a ~ h a s i o l o gFurthermore, ~. of memory functions with temporolimbic partial seizures impairs confrontational naming and spontaneous word finding, further complicating the assessment of language functions. Speech arrest and dysarthria may occur with seizures that arise from the nondominant hemisphere and from nonlanguage (such as primary motor and supplementary motor) areas of the dominant hemi~phere.'~-'~ However, stimulationinduced speech arrest is most often evoked in dominant hemisphere language areas (Broca's; Wernicke's; supramarginal and angular gyri)."' Careful testing may reveal subtle language dvsfunction in patients with recurrent partial seizures with speech arrest." Nonfluent speech ("expressive") and receptive language dysfunction is most often associated with dominant temporal lobe seizure foci and may occur during ictal and postictal state^.'^-^' Since nonfluent dysphasia does not usually occur with structural lesions of the dominant temporal lobe, spread of the seizure discharge to frontal language areas most likely occurs. Differentiating postictal confusion from a comprehension deficit (that is, receptive aphasia) may be impossible. Inlmediately after complex partial seizures arising from either temporal lobe, patients are usually unable to follow simple commands such as, "Show me your left thumb." This deficit most likely represents a global reduction of cognition, not a selective receptive aphasia. Conservatively, postictal receptive aphasia should be diagnosed only if fluent, nonsensical speech with paraphasias is accompanied by a comprehension deficit.32 Isolated paraphasias and anomia most often occur during the postictal period, but may also occur during partial seizures. They occur with seizures arising from either hemisphere, but more

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rologic and psychiatric disorders. Ictal autoscopy phenomena usually occur with temporal lobe seizures. As with many other psychic phenomena of epilepsy, autoscopy may be discovered only on specific questioning. Mystical and religious feelings during partial seizures were beautifully described by one of the most prolific authors with partial epilepsy (who included an epileptic in most of his novels), Dostoevsky":

VOLUME I I , NUMBER 2 J U N E 1991

PSYCHIC PHENOMENA I N PARTIAL SEIZURES-DE~INKSY, LUCIANO

MEMORY FUNCTIONS Partial seizures often disrupt memory. Temporolimbic areas are vital for memory function and are the most common site of origin for partial seizures. Memory is often considered as an exclusively cognitive function, although it is also integrally tied to emotion. Complex partial seizures always disrupt memory function to some degree during the ictus and there is often an anterograde (usually lasting less than 5 minutes) and retrograde (usually less than 30 seconds) impairment of memory. Simple partial seizures may selectively disrupt memory consolidation o r retrieval, but such cases are uncommon because impairment of memory is often accompanied by impaired consciousness. Deja vu is a paroxysmal fe~ling of familiarity that occurs infrequently in approximately half of normal people, but may occur as a simple partial seizure. One can debate whether deja vu is an emotional o r cognitive aura. Ditja vu may be related to the entire environmental scene o r to a specific stimulus, sensory perception, o r thought, o r it may occur without any associated mental o r sensory stimulus. Some patients report that they have previously dreamed what they are experiencing. Because patients often feel that they know exactly what will occur next, the experience of clairvoyance (or precurrence as Gowers termed it") is sometimes associated." "~$2 vu usually occurs with right temporal seizure foci .36.37 J a mais vu is the feeling that things which should be familiar appear strange, foreign, o r remote; it has no lateralizing value. T h e terms dkja

entendu and jamais entendu refer to auditory experiences that seem familiar o r unfamiliar, respectively. However, the terms dkja vu and jamais vu (despite their literal application to only visual stimuli) are often used to describe any paroxysmal feeling of familiarity o r unfamiliarity. Flashbacks, forced recollection of past memories, and the experience of seeing bits of one's own life projected in a movielike collage may occur with partial seizures."'

ICTAL EMOTION Ictal emotion may be phenomenologically indistinguishable from the experience of normal humans o r those with functional psychopathology. Unlike normal phenomena that are associated with an appropriate environmental setting o r stimulus, ictal emotion occurs as a paroxysmal, spontaneous feeling. Emotional changes may occur hours before (premonitory symptoms), during simple o r complex partial seizures, o r after complex partial and generalized tonic-clonic seizure^.^"^'^^""^' Ictal emotion occurs during approximately 5 to 15% of partial ~ e i z u r e s ~ ~ ~ " includes ~ ~ ~ ~ " a~ n d broad spectrum of phenomena: fear, anxiety, anger, hate, distress, embarrassment, joy, religious ecstasy, love, and sexual p l e a s ~ r e . ~ " . ~l 'h. e~n' o m ena such as dkjA vu and jamais vu could be interpreted as the emotional perception of familiarity o r strangeness, respectively. Negative ictal affect is much more common than positive emotion^."'^."-^^ Also, loss of emotional valence ("flat affect") can occur during and after partial seizures. Ictal emotion may occur in isolation o r may color the experience of other simultaneous percepts (for example, environmental stimuli o r hallucinations)." Alternatively, seizure-related experiential phenomena such as loud noises o r threatening visual hallucinations, o r the realization that a major motor seizure may be imminent, can cause secondary affective changes. 'This should not be confused with emotion occurring as an ictal event. Emotional changes during partial seizures most likely result from direct stimulation of lirnbic areas by the electrical discharge and can be reproI n~ this " regard, icduced by electrical s t i m u l a t i ~ n . ~ tal affect is analogous to ictal sensory hallucinations. T h e vast majority of patients who experience emotion during partial seizures have temporal lobe Thus, the limbic areas of the temporal lobe appear to be most critical in the pathogenesis of ictal emotion. However, studies d o not support the concept of individual emotions encoded within discrete neuronal centers."." Investigations on the lateralization of ictal affect have not provided consis- 103

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often on the dominant side. Since complex partial seizures are usually accompanied by bilateral spread of seizure activity to limbic and in many cases to neocortical areas, it is not surprising that language dysfunction may fbllow seizures originating in the nondominant hemi~phere."~':' Ictal vocalizations may be nonverbal (grunt, cry, groan, hum, guttural sounds), unidentifiable speech, o r verbal (identifiable speech). Nonverbal vocalizatioris occur with con~plexpartial and secondary generalized tonic-clonic seizures and have no lateralizing value. Unidentifiable speech occurs during complex partial seizures arising from either hemisphere. Verbal automatisms usually occur with complex partial seizures arising from the nondominant temporal lobe and may consist of repetitive o r nonrepetitive speech.2x-:"' Rare cases of isolated alexia, agraphia, aphemia, and other selective cognitive disorders have been reported during and after partial seizures.'"

SEMINARS I N NEUROL-OGY

tent result^.^^'.^^ However, the literature review by Sackeim et a1 suggests that positive and negative ictal affects may be localized to the left and right hemispheres, r e s ~ e c t i v e l y . ~ ~

ICTAL FEAR

VOI,UME 1 I , NUMBER 2 JUNE 1991

emotional ictal symptoms, depression is often prolonged, lasting for hours or days and occasionally WeekS.20.2'2.42.5i T h e reason for such prolonged symptoms is unclear. Weil" proposed that the length of depression correlated with the duration of' temporal lobe spike activity. Others have suggested that ictal depression, like the natural emotion, tends to be a more prolonged psychic state.20."

Fear was the first recognized ictal emotion",'"' Ictal depression is evoked by epileptic disand has been the most frequently reported."."' It occurs in up to 35% of patients with temporal lobe charges from the temporal lobe, as documented by epilepsy,""although most studies have found an in- scalp and invasive electrode recordings of spontaneous seizures, as well as stimulation studies."."' cidence of 10 to I 5%.43 Ictal fear is paroxysmal in onset (and usually Several authors have reported an association of ictermination) and is undirected.'12 T h e experience tal depression with the experience of olfactory hal~~" an anteromesial temvaries from mild uneasiness to intense pani~.'~."'It l u c i n a t i o n ~ , ~ supporting must be differentiated from appropriate reactive poral localization. Gloor et al!' reported on three fear following other partial seizure symptoms that patients who experienced depression or guilt only alert the subject of an imminent major seizure. Al- when temporolimbic structures were stimulated. " ~is' - ~ ~ Despite several articles suggesting right hemithough ictal fear can occur in i ~ o l a t i o n , ~ ~ ' . ' it ictal usually associated with other ictal signs and symp- spheric dominance for negative depression does not appear to have lateralizing toms, often visceral sensations, olfactory hallucinations, or autonomic phenomena. Differentia- value." In attempting to explain the pathophysition from idiopathic panic attacks or, occasionally, ology of ictal depression, Weil" proposed that cardiogenic disorders may be difficult in such suppression of the limbic system by epileptic activCases.4~.54 Ictal fear episodes are usually brief ( I 0 to ity may lead to emotional "emptiness," which may 180 seconds), although rare cases of prolonged iso- be interpreted by the patient as depression. Along lated fear have been reported as partial status epi- somewhat similar lines, Landolt"' proposed that lepticus.51.52.5!5 ictal depression may be an example of "forced Ictal fear has consistently been described with normalization," resulting from the brain's attempt temporal lobe seizure with exceptional to inhibit epileptic activity. However, stimulation studies suggest that ictal emotion results from elec~~ cases arising from the cingulate g y r ~ s . " ,HOWever, since the cingulum connects the cingulate gy- trical activation of limbic areas. rus and limbic areas for the temporal lobe," cingulate foci may evoke fear via spread to the temporal lobe. Studies of spontaneous seizures ICTAL ANGER have shown an association of fear with anterome~ ~ , et~ a~l v o u n d that Physical aggression in epilepsy almost always sial temporal lobe f o ~ i .Gloor fear was the most common experiential phenome- occurs during the postictal confusional ~ t a t e . ' ~ . ~ ' non evoked with depth electrode stimulation and Ictal aggression is rarely directed but restraint of consistently demonstrated an association with stim- patients postictally may evoke directed physical agulation of the amygdala. Despite its localizing gression that usually abates when restraints are re, ~ ~ present discussion will not deal value, fear has not been of value as a lateralizing m ~ v e d . " , ~ ''The Sign.?0,40,42 with the broad subject of aggressive behavior in epilepsy (see articles by Perrine and by Pincus and Lewis in this issue), but with the subjective experiICTAL DEPRESSION ence of anger. Conscious ictal anger, with or without associIctal depression is a paroxysmal affective state ated aggression, is rare.2',5"ackson" reported on of variable intensity that occurs spontaneously: it is patients who experienced hatred or felt the comnot triggered by adverse life experiences or rumi- pulsion to attack others during seizures. Ictal annation over sad event^.^".^' As with ictal fear, ger is usually associated with temporal lobe seizure depression may occur as an isolated symptom, but foci but does not appear to have lateralizing more often occurs together with other partial sei- value.50In a review of more than 2000 cases of epizure symptoms. Ictal depression occurs in less than lepsy, Williams20reported ictal aggression in 0.9%, 5% of patients with partial seizures."' Unlike other all of whom had clinical or electroencephalo-

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'

graphic (EEG) evidence of temporal lobe epilepsy. lated to neurologic disorders with bilateral fronIn only one case was ictal anger seen without ag- tal, corticobulbar, diencephalic, or brainstem legression. Bingley,"' studying 90 patients with tem- siens,45.47.67.72.76 poral lobe epilepsy, reported 17% with anger and/ or aggression. 'This study did not specify whether ICTAL LAUGHTER the behavior was ictal or postictal. Currie et a14%eported ictal rage or violent outbursts in 21 (3%)of TrousseauXnfirst reported ictal laughter in 666 patients. Utilizing a simple partial seizure symptom inventory, Devinsky et a1" found that 8% 1873. It is a rare ictal manifestation with less than of 128 patients with complex partial seizures re- 200 cases reported.42T h e clinical features of ictal ported anger as the aura of at least one complex laughter vary from smirking and smiling with subpartial or secondary generalized tonic-clonic sei- tle vocalization to giggling and violent laughzure. Twenty percent of these patients reported in- t e r , 4 2 . 7 4 , ~ ~ E p i sodes usually last only seconds or sevterictal anger, highlighting the fact that anger and eral minute^,^'.'^ but rare cases of gelastic complex aggression may also be a feature of the interictal partial status epilepticus have been reported.",'" Attacks are stereotypic, unprovoked, and inapprobehavioral syndrome."'."" Anger (or aggression) is rarely evoked by cor- priate.4'."7.4 Gelastic seizures occur with or without tical stimulation.8.%.26,:ifi,63 Gloor et al,%s well as preserved consciousness or other associated ictal Mullan and Penfield,"+eporting on the experi- p h e n ~ m e n a . ~ ~ - ~ "Mood . ~ ' .during ~ ~ . ~ gelastic ~ seizures ence at the Montreal Neurologic Institute, stated may be unchanged, happy, or sad.47,G7.74.7".8'.85,86 that true ictal rage was never seen. There are, how- Episodes may alternate or fuse with crying atever, several case reports of anger or aggression ta~ks.'~.~"hey are often only one of multiple seibeing elicited by stimulation of the limbic system, zure types in a given patient.77 ~ seizures have been most often associparticularly the amygdala or h i p p o ~ a m ~ u s . ~ ' ~ ~ - ~ Gelastic ated with temporal lobe or hypothalamic foci,"4-"" but have been reported with frontal f~ci",~","~' as ICTAL PLEASURE ~~,~~ well as diffuse lesions of the n e ~ r a x i s . When compared with those of patients with hypothalamic Pleasure is a rare ictal emotion that is reported lesions, gelastic seizures in patients with temporal " ~ more often associated with apT h e expe- foci are l ~ n g e r , are by less than 0.5% of epileptics.'0~42~""."" rience varies from feelings of tranquility or joy to propriate internal affect,",74 and may be associated T h e most fa- with a pleasurable aura." Conversely, hypothaprofound religious ill~mination.'~.'" mous example of ictal ecstasy is the description by lamic lesions cause brief episodes of mechanical beDostoevsky of his own ecstatic aura (see before). havior that is a caricature of natural laughter, withThe pleasurable sensations are often accompanied out associated a f f e ~ t . ~ ' . " ~ ~ " . ~ Laughter has been associated with various seiby visceral symptoms"'." and may be accompanied zure types and ictal EEG pattern^,"^.".^"^^.^'.^ with by l a ~ g h t e r . " ~ Pleasant affective states have rarely been evoked temporal or frontotemporal lobe foci most comwith electrical stimulation of the amygdala or sep- m ~ n . ~ ~Gelastic . ~ ~ seizures . ~ ~ ,are ~ more ~ . ~common ~ tum.~.~.2ti.m-70 A s with other ictal emotions, pleasure is with dominant hemisphere foci,45.47.77 supporting associated with temporal lobe seizure f ~ c i . ' ~ - " ~ " " ~ "the ~ ~concept ~ that the left hemisphere controls positive a f f e ~ t . ~ ~ . ~ ~ Cortical stimulation rarely elicits l a ~ g h t e r . ~ . " ~ ' Laughter may occur with manual stimulation in ICTAL LAUGHTER AND CRYING ' chimthe region of the third ~ e n t r i c l e . ~ ~In~ "the Although expressing emotion, ictal laughter panzee, stimulation of the periaqueductal gray (gelastic seizures) and crying (dacrystic or quiri- evoked laughter.93 tarian seizures) represent objective behavioral manifestations that may occur with or without preserved consciousness or a congruent internal afl ICTAL CRYING fe~t.~'.".~'-~" T h e dissociation of emotional feeling and expression may reflect neuroanatomic dissoIctal crying (dacrystic or quiritarian epilepsy) ciation of these behavioral functions in cortical and is extremely rare with less than ten reported subcortical areas.4~~7.w,iz,i4-7!~ This also explains case^.^".^^ We are unable to find any cases in which why pathologic laughter or crying is frequently cortical stimulation elicited crying. However, tearseen as a nonepileptic "release" phenomenon re- ing has been reported with stimulation of the lim-

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PSYCHIC PHENOMENA I N PARTIAL SEIZURES-DEVINKSY. LUCIANO

SEMINARS I N NEUROLOGY

VOI-UME: 1 I , N U M B E R 2 J U N E 1991

bic system in animal^.!'^ As with laughter, crying may occur as a release phenomenon in nonepileptic neurologic condition^.'"^"."" Ictal crying usually occurs with other partial seizure symptoms!"' and with impairment of cons c i o ~ s n e s sWeil" . ~ ~ reported on a patient who experienced tearing secondary to ictal depression. T h e localizing and lateralizing value of ictal crying is unclear, although it may be more common with nondominant temporal f ~ c i . ~ - ' . ; " ~ 'This ~ * ~ ~find"~ ing is consistent with the concept of right hemisphere dominance for negative emotions."*~-"

because A l s o , association and limbic a r e a ~ . ~ ~ ' ~ ~ " ~ " A ation areas are often interconnected, hallucinations in one sensory modality may become niultimodal with spread of the discharge." ""' Formed hallucinations tend to be more frequent in some sensory modalities, such as vision, possibly reflecting the greater role of vision in human consciousness."

ILLUSIONS AND HALLUCINATIONS

They occur with nonepileptic lesions throughout the entire course of the visual system.'.""'."'' In such cases there is most frequently an associated visual field defect, and the perceptual phenomena are often prolonged o r continuous.'.""' Despite the poor localizing value of visual phenomena in static lesions, they carry much greater localizing value when ictal in nature7,"" and have been associated with fbci in the temporal, parietal, o r occipital reg i o n s . ~ ( i , i ( i , ~ ~ ~ ) , ~ ~ ) ~ . ~ ~ ) ~ ~ , -~The ~ : ~ . ~ ~phenomena ~ may be re-

entiated by their brevity (seconds to minutes), stereotypy, association with other seizure phenomena o r EEG changes, and response to antiepileptic drugs.100,107 Hallucinations may be formed o r unformed, simple o r c ~ m p l e x . " ~ " ' ~ ~Unformed "'~ hallucinations usually result from ictal discharges in primary sensory areas and formed hallucinations from foci 0 2,105.107.11 0 in sensory association and limbic areas.8,.,?' T h e interaction of the amygdala, hippocampus, and temporal neocortex may be critical in the pathogenesis of complex hallucinatory experience^.^,"' Penfield and Perot"'Vound that right hemisphere stimulation was more likely to evoke experiential phenomena, a finding that was not corroborated by the studies of Halgren et al%nd Gloor et al." Ictal discharges arising in primary sensory areas may become more complex with spread to associ106

Illusions and hallucinations are most common in the visual modality, occurring in from 16 to 25% of patients with temporal lobe e p i ~ e p s y ~ 5 1 . 1 ~ i . ~ ~ . l ~ ~ 1 0 ! l . l 1'

stricted to the contralateral homonymous visual field o r may be more diffuse, especially with temporal foci. I O O . I U I5~ .They I O ~ ,may I occur in the setting of a clear o r clouded sensorium.""' Epileptic visual illusions include distortions of luminescence, shape, size, color, motion, and distance~2'L,!19,100,1~~5,10!~,I 14.1 I f ; - 7 Ictal illusory reduplication of stimuli in time and space has been reported in the form of cerebral diplopialpolyopia, palinopsia, and visual allesthesia.""'~"'7~1"'~11"-'2' Illusions of visual reduplication have most often been reported with structured lesions and seizure foci in the right parieto-occipital lobe. ""'.""-12' Epileptic visual hallucinations arising from the occipital cortex are simple images, such as of colors, shapes, lights, o r scintillating scotomata, which often m o v e . ~ 4 , ~ ~ ~ ~ ~ . I~: I ~. I ~~ I i 'Temporal i - ~ i ~ ~ X ~ or parietal lobe seizures usually give rise to formed and complex visual ha~~ucinations~~2.1~0.10.i.107.1~~ I he right hemisphere is involved in the majority of cases. 109.1 1 I T h e images range from the perception of simple static objects to elaborate scenes, which progress in time and space. These phenomena may consist of true memories.y2~"'~'.'2Negative ictal visual hallucinations (visual field defects) and visual agnosia have been reported."".":'.""

AUDITORY PHENOMENA Ictal auditory illusions include distortions in volume, pitch, o r character."."","'" Sounds may have an echoing, "underwater," distant, o r muffled

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In perhaps no other area of epileptic senliology does the phenomenology more closely approximate the realm of functional psychiatric illness than with illusions and hallucinations. Paroxysmal phenomena in all sensory modalities occur in both functional and epileptic - - disorders.' Thus, the classic separation of auditory hallucinations as functional and visual hallucinations as organic is simplistic and potentially misleading. An important distinction in this regard is that patients with ictal hallucinations are aware of the illusory nature of the percept and experience it as superimposed o n reality while patients with psychiatric disorders often regard the percept as Unlike hallucinations, which are percepts without antecedent stimuli, illusions are perceptual distortions of actual stimuli. Illusions and hallucinations have been described as nonepileptic "release" phenomena in both peripheral and central lesions of several sensory systems."9'".""-"" They occur in systemic illness, d r u g intoxications, sensory deprivation, and psychiatric illness, and in normal perSOnS.4.~oo,~o~~o~ Ictal phenomena may be dif-fer-

VISUAL PHENOMENA

PSYCHIC PHENOMENA I N PARTIAL SEIZURES-DEVINKSY, LUCIANO

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