THE EPILEPTIC PSYCHOSES
Ancient history contains numerous references to epilepsy. The "Morbus
sacer" of the Romans was apparently a subject of great interest to
Hippocrates,[325] who wrote, over two thousand years ago, "The sacred
disease appears to me to be no wise more divine nor more sacred than
other diseases; but has a natural cause, from which it originates
like other affections. Men regard its nature and cause as divine from
ignorance and wonder, because it is not at all like other diseases."
Presumably for a somewhat similar reason the disease was also referred
to as the "Morbus Sideratus," it being thought that those affected
were "star struck" or smitten in some mysterious and supernatural
manner. By others it has been suggested that the theory regarding the
divine origin of the disease was attributable to the seizures which
always preceded the prophesies of the priests of Apollo. Herodotus is
responsible for the statement that Cambyses, the king of the Persians,
was subject to the "sacred disease" from birth. Such historians as
Hippocrates and Euripides have definitely established the status
of Hercules as a confirmed epileptic. "Morbus Herculeus" was one
of the earliest designations of the disease. It was referred to by
Plutarch in his writings. Suetonius describes the emperor Caligula
as unquestionably afflicted with epilepsy. No less an authority than
Lombroso speaks of Napoleon, Molière, Julius Caesar, Petrarch, Peter
the Great, Mohammed, Händel, Swift, Richelieu, Charles V. Flaubert,
Dostoieffsky and St. Paul as all being victims of the same affection.
Truly this is a noble assemblage,—one which might readily make the
disease fashionable!
Maudsley ("Body and Mind") was convinced that Swedenborg suffered from
a form of epileptic insanity. The following quotation from his diary
would lend some color to that theory:—"There happened to me something
very curious. I came into violent shudderings, as when Christ showed
me His Divine Mercy. The one fit followed the other ten or fifteen
times." After his fifty-fifth year, according to Maudsley, Swedenborg
was permanently insane. The historian Sloan in his "Life of Napoleon"
accepts as an established fact the statement that this great military
strategist was an epileptic. Appian's "Roman History" certainly
justifies Lombroso's reference to Julius Caesar: "At length, whether he
lost all hope, or else for the better preservation of his health, never
more afflicted with the falling sickness and sudden convulsions than
when he lay idle, he resolved upon a far distant expedition against
the Gatae and the Parthians." Washington Irving in speaking of some
of the peculiar experiences of Mohammed suggests that, "Some of his
adversaries attributed them to epilepsy." Even a very brief review of
the historical aspects of this disease should perhaps not omit the
contribution made by Shakespeare: "My Lord is fallen into an Epilepsie.
This is his second Fit." (_Othello_)
Epilepsy and the mental disturbances associated with it are so
intimately related that they can hardly be considered separately.
Notwithstanding that fact it must be admitted that there is no sharply
circumscribed clinical entity properly definable as epilepsy. Nor is
there anything distinctive about the psychotic manifestations occurring
during the course of that disease, although Tuke's Dictionary mentions
over thirty different varieties. In the most exhaustive study of
epilepsy ever made in this country Spratling[326] reported that memory
defects were noted in ninety per cent of the patients examined by him.
It should be borne in mind that the group studied did not include
any committed mental cases. He found from eight to ten per cent so
slightly affected as to be legally "sane," "except at the brief moment
of attack." Fifty per cent were mentally incompetent with rational
intervals and forty per cent were "continually irresponsible." This
latter class included from twenty to twenty-five per cent of imbeciles
and idiots and from fifteen to twenty per cent recognizable as insane
"by law and medicine alike." The prevalence of mental disease in a
hospital population composed exclusively of epileptics is shown by his
statement that of 801 patients examined at Craig Colony forty-one could
not tell their own names; 166 did not know their age; 267 could not
name the year, 263 the month, and 226 the day of the week; 238 did not
know where they were; 378 were unable to state the year of their birth,
183 the last place of residence, 219 the name of the institution, and
248 the length of time there; in addition to this, 224 could not write
well enough to sign their own names. It is interesting to note that
the disease had its onset in 38.5 per cent of his cases before the age
of ten years, in 43.5 per cent between the ages of ten and twenty,
and in 9.5 per cent between the ages of nineteen and twenty-nine.
Gowers found that seventy-six per cent developed symptoms before
the age of twenty. Spratling classified the mental conditions found
in epileptics as follows:—Psychic epilepsy, epileptic automatism,
pre- and postparoxysmal mental disturbances, paroxysmal states
(epileptic mania), and interparoxysmal conditions. The latter included
transitory ill-humor, slight dulling or clouding of the intellect,
feeblemindedness, imbecility, idiocy, epileptic dementia and acute
confusional insanity which he says belongs to the manic-depressive
group. He warns against the danger of classifying as dementia
conditions due entirely to the use of bromides.
L. Pierce Clark[327] looks upon epilepsy as the logical development
of a well defined individual make-up described as the "epileptic
constitution" and existing from the earliest childhood. In support
of that theory he has reviewed the contributions of other writers on
this subject. He found that Vogt called attention to the epileptic
"poverty of ideas, prolonged reaction time, egocentricity, many
religious reactions and acts of servility." Jung referred to a series
of superficial associations, influencing the ideas of the patient,
somewhat similar to those occurring in imbecility and sometimes
observed in normal individuals of the uneducated class. Roemer speaks
of a disturbance of "secondary identification" involving memory
pictures with special sense recognition unimpaired. Eintinger described
an essential poverty of affectivity and Wiersma, periodical variations
in attentiveness. Ritterhaus defined the epileptic mental content
as one of poverty of ideas, prolonged reaction time, egocentricity,
emotional reactions and circumstantiality. Arndt included in the
epileptic character peculiar inward fervor, characteristically
egotistic in nature, and resembling the alcoholic temperament. Bianchi
believed that the disease developed on a personality basis strongly
suggesting the criminal type. He spoke of an inadaptability to the
environment, the preponderance of individualistic instinct, cruelty,
laziness, evil life, precocious and excessive development of the sexual
instinct, irascibility and impulsiveness. Turner described an epileptic
"temperament." He found these individuals to be egotistical, conceited,
pretentious in conversation, emotionally unstable and sometimes
obstinate or over-religious. Hartmann and di Gaspero noted as
prodromal manifestations, abnormal changes of temper, excitability,
anxious fears, sudden depressions, restlessness, irritability,
distrust, memory falsifications, and violent impulses. Voisin found
that less than ten per cent of epileptics showed a perfect balance
in the emotional make-up. Hübner expressed the opinion that true
dipsomania occurs chiefly in epileptics. He found alternations in the
character of the individual in from ninety to ninety-five per cent of
his cases.
Clark's[328] conclusions were summarized by him as follows:—"1. There
is more or less constant affective defect in all epileptics, sane as
well as insane; that such defect is due to an inherent make-up of the
psyche in which mainly an egocentricity and a highly sensitized feeling
are given to the individual; and that from this constitutional make-up
or alteration the ultimate deterioration of the psyche, intellectually
as well as emotionally, is gradually developed, step by step, and if
the state is not corrected that this finally and logically ends in
so-called epileptic dementia. 2. The epileptic alteration is seen to
proceed from the mental make-up or constitution of the individual
epileptic long before his malady reaches the convulsive stage and that
the one is but a further and final unfoldment of the former." As Clark
expresses it, "The nucleus of this personality defect is a temperament
of extreme hypersensitiveness and egotism and all that these two
main characteristics entail ... a personality defect which makes its
possessor incapable of social adaptation in its best setting and which,
if it remains uncorrected, renders the individual inadequate to make a
normal adult life." He looks upon the epileptic reaction as a "more or
less direct outcome of the epileptic's inability to stand the stress
and harassments of life from which he seeks automatic or unconscious
withdrawal." This exhibits itself as a loss of spontaneous interest,
day-dreaming, lethargy, somnolence, etc., terminating finally in
epileptiform attacks when the strain becomes too great. A rather
complete description of the "epileptic character" appeared in Schüle's
"Klinische Psychiatrie" in 1886.
An analysis of these mental mechanisms leads naturally to certain
therapeutic indications. In view of the history of the bromide
therapy, since the time of its introduction by Laycock as the ideal
form of treatment in 1851, such suggestions should be given serious
consideration. Clark advocates the early use of educational methods in
correcting the defects of the epileptic constitution. Thus he would
obtain control of the egocentricity and hypersensitiveness by reducing
environmental stresses, teaching adjustment to the surroundings, and
finding suitable and normal outlets for the spontaneous desires of the
individual. He is of the opinion that in the apparently deteriorated
cases mental interests can be restored and emotional and mental
dilapidation greatly improved. He has reported a series of cases
showing that the frequency and severity of seizure can be greatly
influenced "with the more or less permanent arrest of the disorder
in not a few cases."[329] A subsequent study of the mental mechanisms
involved was summarized by Clark[330] in these words: "It is fairly
obvious that the mental content in epilepsy proves that the epileptic
regresses from the displeasurable difficulties of life, and in the
first states of the fit the stress alone may be uncovered; whenever the
patient reaches a deeper unconscious state, he gains the level of an
easily recognized sexual striving."
Kraepelin[331] would differentiate between "symptomatic" forms of
epilepsy due to organic diseases, injuries or growths; and the
"genuine" variety not associated with any coarse brain lesion. He
describes as indications of impending attacks, occurring several hours
or even days before, headache, irritable ill-tempered moods, general
discomfort, weakness, palpitations, oppression, anxiety, vertigo,
nausea, hot and cold sensations, sense deceptions of various kinds,
muscular twitching, sexual excitement, disturbed sleep, unpleasant
dreams, etc. Binswanger found these symptoms present usually in the
severer forms of the disease. Finkh found them in twenty-five per cent
of his cases. Psychic, sensory, motor and vasomotor aura are described.
Kraepelin after discussing first the paroxysmal attacks occurring
in the disease speaks of the various forms of psychic epilepsy as
constituting the second important group of clinical manifestations
to be considered. These conditions may be looked upon as pre- or
post-epileptic insanity, depending on their relation to convulsions, or
may be entirely independent of them or considered as equivalents.
The most common form of psychic epilepsy he describes as periodical
ill-humor. It begins sometimes with sexual excitement (Ducosté). The
patient becomes moody, surly, irritable, quarrelsome, gives up his
work, refuses to eat and complains of everything around him. In some
cases uneasiness, gloom or depression are manifested and suicidal
tendencies may develop. Consciousness is clear although the patients
complain that they cannot think or are confused and forgetful. Some
have headache, perspire, show dilated pupils, vasomotor disturbances,
nausea, etc. The picture is often complicated by alcoholic indulgence
with attacks resembling dipsomania. This sometimes results in an
epileptic clouded or dream state in which the patients become
blustering, abusive, and violent or make senseless journeys. They may
manifest a sudden impulse to wander from place to place without any
apparent reason. Sexual excitement frequently occurs, with masturbation
and exhibitionism, attacks on children or homosexual tendencies.
Usually there is no recollection of these episodes. Occasionally
expansive or ecstatic moods appear and rarely a flight of ideas is
noted. These attacks of ill-humor usually last from a few hours to
several days, often disappearing suddenly. Alcoholism always lengthens
the duration. In some cases active hallucinations and clouding of
consciousness occur. Dreams are common. Others show anxious states
with hallucinations and sometimes well marked delusions. An actual
delirium may appear, although usually only for a very short time.
The hallucinations and delusions may persist for months, suggesting
dementia praecox.
A second large group shows a more marked clouding of consciousness.
These are the characteristic twilight or dream states of epilepsy.
Thought is confused, desultory, retarded or incoherent. Sometimes there
is a tendency to rhyme and repeat questions, or even a genuine flight
of ideas. The mood may be depressed, anxious or irritable, although
ecstatic states occur. The patient may become quiet, inaccessible,
stuporous or cataleptic. Some, however, become excited. Later, defects
of memory occur and amnesic periods may extend over a considerable
length of time. The patellar reflexes may be increased and the pupils
dilated and sluggish. There may be a contraction of the field of vision
or disturbance of color sense, tactile sensation, smell and taste,
with muscular weakness, Babinski reflexes, speech defects, dizziness,
uncertain gait, nystagmus, etc. Somnambulism is sometimes encountered
in epilepsy, although it is strongly suggestive of hysteria. The great
majority of cases present the picture of a simple dreamy stuporous
condition. Apprehension is clouded, the patients become confused,
cannot control their thoughts, mistake the persons around them, lose
themselves on the street, and wander away. They destroy their clothes,
undress in the street, etc. Sexual excitement, exhibitionism and
masturbation are common. Characteristic dream states may appear as
equivalents.
A delirious confusion with hallucinations and delusions often
develops. Some cases have a very strong religious coloring and
believe themselves to be in heaven or hell—hear the voice of God,
angels, etc. Grandiose ideas may appear and wonderful adventures are
narrated. The mood is variable and may be either anxious, cheerful or
erotic. There is a marked tendency to violence and the patients may
be very restless and agitated. Delusions are common and often lead to
suicidal attempts. Some exhibit an anxious delirium accompanied by
numerous hallucinations. The patient is clouded as well as disoriented
and delusions develop early. Fabrications sometimes appear in this
condition. These deliria may last a few hours or several weeks.
Profound and more or less long continued epileptic stupors may
complicate the situation.
A "conscious delirium" of longer duration is observed in some
instances. The sensorium is not so much clouded, and the patient
appears quite clear. Hallucinations and illusions usually develop
early in the attack. Pleasurable, grandiose ideas often appear. The
attitude in a general way resembles that of a confused disorientation.
Anxious moods may develop, or rarely cheerful tendencies. Consciousness
becomes dreamy, with hallucinations of a religious coloring. Patients
with an apparently clear sensorium may commit numerous foolish or even
criminal acts without any apparent insight into their significance.
Such conditions as this may last weeks or months. Self-accusation may
occur between attacks. These individuals are quite likely to start on
absolutely aimless journeys which may be the outcome of an alcoholic
debauch. The dream state in such cases may have a decided alcoholic
coloring with characteristic hallucinations or humorous tendencies.
This may be mixed with religious ecstatic manifestations. Dream states
only occur once or twice during the lifetime of an epileptic or may be
comparatively frequent. Many patients never have them.
Aschaffenburg found fainting attacks in seventy-four per cent,
convulsions in forty-two per cent, stupors in forty-four, petit mal
in fifty-eight, dream states in thirty-six, and ill-humor in from
sixty-four to seventy per cent of his cases. In his Munich clinic
Kraepelin studied 515 epileptics. Eighty-six and eight-tenths per
cent of them had attacks of unconsciousness, probably often reported
as convulsions, 23.3 per cent had dizzy spells, 9.7 per cent stupors,
15.1 per cent petit mal, 3.3 per cent attacks of various kinds
without unconsciousness, 16.5 per cent dream states, 1.9 per cent
somnambulisms, 36.9 per cent ill-humor, 13.8 per cent excitements,
mostly alcoholic complications, and 2.5 per cent had status epilepticus.
An epileptic weakmindedness develops in many cases. The field of
thought is contracted and egocentric in character with delayed
associations as shown by Jung. The patient is egotistical, interested
in petty details, and strongly inclined to religious tendencies. He
always minimizes the severity of the disease which, in his opinion,
is improving rapidly. He is likely to develop mild paranoid ideas and
feels that he has been mistreated or that others are prejudiced against
him. These individuals are usually moody, irritable, dull, emotionally
unstable and excitable. They are often overactive but not industrious.
Many show a persistent "wanderlust." Werther reported that between
seven and eight per cent of his cases were tramps or beggars. Quite
a few show criminal tendencies. They nearly always have a marked
susceptibility to alcohol which greatly aggravates their symptoms.
Kraepelin is inclined to look upon the epileptic personality as a
result of the disease and not the soil in which it develops.
In the more advanced deteriorations or epileptic dementias there is
a marked mental dulness with poverty of thought, loss of memory,
irascibility and occasional violence. Kraepelin refers to a genuine
"epileptic physiognomy" which is often observed. Strabismus, nystagmus,
ptosis, tremors and many other neurological symptoms are frequently
found. Clark and Scripture have described a characteristic "voice" in
epilepsy. Besta found a subnormal temperature in sixty-six per cent of
his cases. Very elaborate studies of the blood have been reported from
time to time. The secretions and excretions have been made the subject
of exhaustive research and the changes in metabolism have been gone
into thoroughly.
The pathology of epilepsy has been given careful consideration by
Alzheimer. In cases of status epilepticus he found extensive acute
alterations, more particularly in the Betz cells, with swelling of
the neurones, crumbling of the Nissl bodies, and dislocation of the
nucleus to the apex. Here and there the ganglion cells were entirely
destroyed and others showed regressive changes. Karyokinetic figures
are seen in the glia cells, which are usually swollen, show ameboid
changes and contain degenerative products. Accumulations of broken
down cell products are found around the vessels. A sclerosis of the
cornu ammonis, usually unilateral, was reported by Bourneville in
14.8 per cent, by Pfleger in fifty-eight per cent, and by Alzheimer
in from fifty to sixty per cent of the cases of epilepsy examined.
This consists of an atrophy of the cells in a well defined area and
their replacement by a network of fibres. The cells are shrunken or
entirely gone, while there is a great increase in the neuroglia
elements with many free nuclei. The walls of the vessels are thickened
and "stäbchenzellen" appear. The significance of these findings is not
known. Nissl looks upon them as only a part of a general involvement
of the cortex. Widespread cell changes were frequently reported by
both Nissl and Alzheimer. A marked increase in the neuroglia has been
found particularly in the superficial layers of the cortex,—the
so-called "marginal gliosis" of Chaslin. The vessels show an intimal
proliferation and a thickening of the walls, with occasional mast-cells
in the lymph spaces. Ranke has called attention to the presence or
persistence of "Cajal" cells in the ordinarily cell free layers of the
cortex. These are large transversely placed ganglion cells, common in
the superficial layers of the cortex of the newborn but not found in
the normal adult brain. This condition is looked upon as a cortical
development defect. These so-called "Cajal" cells are also found in
some of the mental deficiencies. Nevertheless it must be conceded that
there are no definitely characteristic pathological changes so constant
as to render certain the differentiation of this disease postmortem.
No forms of insanity perhaps are clinically so difficult and
unsatisfactory from the standpoint of classification as are the
epileptic psychoses. The various mental manifestations of the disease
may very logically be described as: 1. Pre-paroxysmal episodes, 2.
Paroxysmal states, 3. Post-paroxysmal episodes, 4. Inter-paroxysmal
conditions to be specified, as excitements, depressions, anxieties,
confusion, stupor, dream states, paranoid conditions, etc., and 5.
Epileptic deterioration. There is some question as to whether the
various psychic epilepsies, so called, are sufficiently clear-cut to
constitute clinical entities.
The delimitation of these psychoses for statistical purposes is
described in the Association's manual as follows:—
"In addition to the epileptic deterioration, transitory psychoses
may occur which are usually characterized by a clouded mental state
followed by an amnesia for external occurrences during the attack. (The
hallucinatory and dream-like experiences of the patient during the
attack may be vividly recalled.) Various automatic and secondary states
of consciousness may occur.
"According to the most prominent clinical features the epileptic mental
disorders should therefore be specified as follows:—
"(a) Epileptic deterioration: A gradual development of mental
dullness, slowness of association and thinking, impairment of memory,
irritability or apathy.
"(b) Epileptic clouded states: Usually in the form of dazed reactions
with deep confusion, bewilderment and anxiety or excitements with
hallucinations, fears and violent outbreaks; instead of fear there may
be ecstatic moods with religious exaltation.
"(c) Other epileptic types (to be specified)."
During a period of sixteen years in the New York state hospitals
(ending October 1, 1888) 3,167 of 84,152 admissions were cases of
"epilepsy with insanity." This meant an admission rate of 3.76 per
cent. It must be borne in mind, however, that the differentiation
between epilepsy with insanity and psychoses clearly due to epilepsy
was not attempted at that time. During a subsequent period of
eight years in the same institutions, when what is essentially the
present classification was in use, the admission rate for epileptic
psychoses was 2.42 per cent. In 1919 with 3,011 first admissions to
the Massachusetts state hospitals only fifty cases (1.66 per cent)
were reported as showing psychoses due to epilepsy. Six hundred and
twelve cases, constituting 3.33 per cent of 18,336 first admissions,
were reported by twenty-one hospitals in other states. An analysis
of a total of 70,987 first admissions in forty-eight state hospitals
therefore showed that 1,865, or 2.62 per cent, were epileptic
psychoses. After reading the statements contained in various textbooks
regarding the extraordinary frequency of epileptiform seizures in
dementia praecox, it is difficult to escape the conclusion that
the percentage of epileptics has been underestimated rather than
exaggerated.