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News Gram™ March 2007

March 2007 ~ Volume 13, No. 8

Epilepsy is an electrical disorder of the brain that produces involuntary behaviors and experiences. One form of epilepsy, now referred to as temporolimbic epilepsy, occurs because of abnormal stimulation of the temporal lobe. Given the highly complex structure of the temporal lobe, a wide spectrum of changes in mood, cognition and perception are often seen in affected patients. As a result, this neurological condition has important implications for psychiatry – and for work-related conditions that involve head injury or psychiatric disorder.

A sample patient described in a textbook of behavioral neurology was a middle-aged woman who presented with complex visual hallucinations that dated back to her adolescence. One hallucination involved an image of six German soldiers in World War I uniforms who formed a pyramid. The second was that of an elderly woman in a rocking chair with her arms hanging over either side and looking like Whistler’s mother. In the woman’s vision, a rat-like creature nibbled at the woman’s fingers. After 20 years of such experiences, the woman had a right craniotomy that included intraoperative EEG recordings in the temporal lobe. The surgeon found a vascular malformation in right parietal lobe. While undergoing the operation, the woman experienced the image of the six German soldiers associated with a deep sense of dread and doom. Notice that the actual lesion was not in the temporal lobe, but rather, in the parietal lobe. However, the seizure activity was coming from the temporal region, which is referred to as a daughter focus.

Such a patient experienced visual hallucinations, visual alterations that are most commonly caused by toxicity or trauma as well as profound subjective changes that were terrifying to her. Episodic changes in behavior occur because of a pathological neural discharge—behaviors such as lip smacking, running in a circle, pronounced visual scanning of the environment. Occasionally, features of catatonia, stuttering and speech arrest may be seen. Subjective changes such as the feeling of something crawling on one’s skin (fourmillage or formication), focal pain and numbness and tingling may befall such a person. Objects may appear larger or smaller than they really are. There may be hot sensations, flushing and a feeling of shortness of breath.

Powerful memories may seem to attack the person. He may have the sense that someone is close to him and looking over his shoulder. Occasionally, there is the feeling that one has stepped outside one’s body or is hovering over his body. Strong emotions, usually negative ones, may make themselves felt. On a cognitive level, obsessions appear, often followed by compulsive, ritualistic behavior. Confusional states are not uncommon in such people. Finally, the individual can be frankly psychotic and aggressive.

In addition to all these strange behaviors and subjective experiences, alterations that happen for limited periods, there are also the long-term alterations in behavior and comportment, changes in the individual’s personality, that are some of the most striking, compelling and puzzling of this syndrome. For instance, 10–15% of people with temporal lobe epilepsy are also diagnosed as schizophrenic. Compare that figure with the 1% of the general population that carries the same diagnosis.

In addition to schizophrenia, temporal lobe epilepsy is frequently associated with depression. Since the left side of the brain is associated with cognition and the right side with emotional experience and expression, there has been a general impression that schizophrenia – a disorder of thought – is seen more frequently in people with left-sided epilepsy, while depression is more closely associated with right-sided disease. However, more recent studies have not confirmed this impression.

One of the most interesting aspects of this form of epilepsy can be found in the gradual personality changes associated with the disease. There is a deepening of the emotions, often a good deal of elation and grandiosity admixed with sadness and anger and aggression. Additionally, frequently there is an increase or decrease in the sexual drive. Many temporal lobe people are fascinated by their own ideas and insist on writing everything down. They develop “deep” metaphysical interests, a sense of helplessness at the hands of fate and a very serious, humorless, even viscous, sobriety to themselves. Overall, there is a greater intensity to all subjective experiences, which can lead to difficulties for such a person.

Temporal lobe epilepsy has implications for those involved in evaluating disability, especially in the case of head injury. It usually takes years for the personality disorder to develop in the wake of trauma to the head. Also, a person may have had psychiatric problems before his brain injury. Then there is the troubling fact that it is often hard to obtain a helpful EEG for this kind of epilepsy. For anyone with a seizure disorder after head trauma, it is important to think of this condition in order to affect early therapeutic intervention and enable the injured person to return to his usual way of life.

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