Temporal lobe epilepsy and the phobic anxiety-depersonalization syndrome. Part II: Practical and theoretical considerations

T e m p o r a l L o b e E p i l e p s y a n d the P h o b i c A n x i e t y - D e p e r s o n a l i z a t i o n S y n d r o m e . P a r t II : P r a c t i c a l and Theoretical Considerations B y MAlaa'lN ROTH, M.D., F.R.C.P., D . P . M . , ANn M a x H A R P E R , M.B., CH.B., D . P . M . E H A V E S E E N f r o m t h e results of a c o m p a r a t i v e stud>, ( H a r p e r a n d Roth, 1962) t h a t t h e p h o b i c a n x i e t y - d e p e r s o n a l i z a t i o n s y n d r o m e a n d t e m p o r a l lobe e p i l e p s y , a c o m m o n f o r m of n e u r o t i c illness on t h e o n e h a n d a n d o n e t y p e of cortical e p i l e p s y on t h e other, h a v e b o t h similarities a n d diff e r e n c e s . T h e similarities arise from t h e o c c u r r e n c e in b o t h f o r m s of d i s o r d e r of s u c h p h e n o m e n a as d e p e r s o n a l i z a t i o n , dd],~ w~t e x p e r i e n c e s , h a l l u c i n a t i o n s , m c t a m o r p h o p s i a , p a n o r a m i c m e m o r y , s u d d e n p a r o x y s m s of fear a ~ d s o m e f o r m of e p i s o d i c u n c o n s c i o u s n e s s . O u r a n a l y s i s has s h o w n , howevei~, t h a t t h e diff e r e n c e s a r e e q u a l l y c l e a r a n d u n e q u i v o c a l . Sex i n c i d e n c e a n d a g e of o n s e t differ; t h e e p i l e p t i c s h a v e a s i g n i f i c a n t l y h i g h e r i n c i d e n c e of illnesses likely to l e a d to b r a i n d a m a g e , w h i l e t h e f a m i l y h i s t o r y a n d i n c i d e n c e of a n x i e t y s y m p toms in c h i l d h o o d t e n d to s u p p o r t t h e d i a g n o s i s of a n e u r o t i c illness. P r e c i p i t a t i n g f a c t o r s of an e m o t i o n a l l y o n e r o u s k i n d a r e p r e s e n t in t h e n e u r o s i s b u t a r e g e n e r a l l y a b s e n t in e p i l e p s y ; "'attacks" a r e o f t e n e m o t i o n a l l y t r i g g e r e d in t h e f o r m e r , n o t in t h e latter, a l t h o u g h an o v e r a l l i n c r e a s e in f r e q u e n c y of e p i l e p t i c a t t a c k s m a y o c c u r d u r i n g s u s t a i n e d p e r i o d s of a f f e e t i v e d i s t u r b a n c e . In t h e n e u r o s i s it is t h e e m o t i o n a l d i s t u r b a n c e s , t h e p a n i c s a n d a v o i d a n c e r e a c t i o n s , t h a t d o m i n a t e t h e p i c t u r e . T h e a t t a c k s of u n c o n s c i o u s n e s s a r e u n o b t r u s i v e , occ u r in a m i n o r i t y ( e v e n in t h e i r a b o r t i v e f o r m ) a n d d i s a b l i n g effects a r e o f t e n slight.* In e p i l e p s y , on t h e o t h e r h a n d , a t t a c k s of p a r t i a l or c o m p l e t e loss of c o n s c i o u s n e s s a r e t h e c e n t r a l f e a t u r e s of t h e illness. T h e y o c c u r in n e a r l y all cases a n d a r e t h e p r i n c i p a l s o u r c e of d i s a b i l i t y , w h i l e t h e e m o t i o n a l d i s t u r b a n c e s affect o n l y a m i n o r i t y , a l t h o u g h a s u b s t a n t i a l one, a n d in p a r t a r e p r o b a b l y rea c t i v e to t h e d i s t r e s s e d effects of t h e m a i n illness. I n e p i l e p s y a c o n s i s t e n t m a r c h of e v e n t s c h a r a c t e r i s e s t h e a t t a c k s ; a m u c h m o r e v a r i a b l e c o u r s e is o b s e r v e d in t h e n e u r o t i c t y p e s of seizure, w h i c h h a v e a c h a r a c t e r i s t i c m o d e of t e r m i n a tion. In t h e n e u r o t i c cases, p r e m o r b i d p e r s o n a l i t y s h o w s a b n o r m a l i t i e s of a f a i r l y c h a r a c t e r i s t i c k i n d a n d t h o u g h t h e o n s e t of t h e illness r e p r e s e n t s a s h a r p b r e a k in c o n t i n u i t y , t h e r e s u l t is in s o m e r e s p e c t s a c a r i c a t u r e of p r e m o r b i d p r o p e n s i t i e s . In t h e e p i l e p t i c cases on t h e o t h e r h a n d , no c o n s i s t e n t a n o m a l y of p r e m o r b i d p e r s o n a l i t y e m e r g e s . F i n a l l y , in t h e m a j o r i t y of t h e e p i l e p t i c s , t h e

W

*In tile m a j o r i t y of p a t i e n t s t h e s e a t t a c k s o c c u r in t h e a c u t e florid s t a g e of t h e illness a n d u s u a l l y b e c o m e less p r o m i n e n t as tide c o n d i t i o n e v o l v e s into a c h r o n i c n e u r o t i c d i s a b i l ity. T h u s t h e c o u r s e of t h e illness as it is o b s e r v e d o v e r m o n t h s a n d y e a r s is an a d d i t i o n a l c o n f i r m a t i o n of tide diagnosis, b u t if t h e p a t i e n t has r e c e i v e d a n t i - c o n v u l s a n t s in t h e initial s t a g e s o f t h e d i s o r d e r t h e n t h e c e s s a t i o n o f t h e a t t a c k s m a y b e i n c o r r e c t l y r e g a r d e d as s u p porting a diagnosis of epilepsy. 215 COI~II'IIEItENSIVlg PSYCIIlA'rlIY, VOL. 3, N o . 4 ( A u G u S T ) , 1969-

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E . E . G . confirms tile d i a g n o s i s w h e r e a s in m o s t n e u r o t i c s it is n o r m a l or s h o w s a m i l d non-specific a n o m a l y . T h e t h r e e cases p l a c e d in t h e "'not y e t d i a g n o s e d " g r o u p i l l u s t r a t e s o m e of tile p r a c t i c a l difficulties i n h e r e n t in tile p r o c e s s of e s t a b l i s h i n g a d i a g n o s i s in these conditions. C a s e 1 w a s a m i l d l y o b s e s s i o n a l m a r r i e d w o m a n of 38 years. E p i s o d i c att a c k s cf a n x i e t y a n d d e p e r s o n a l i z a t i o n w i t h c l e a r s y m p t o m - f r e e i n t e r v a l s h a d o c c u r r e d a t a t i m e w h e n s h e k n e w h e r m o t h e r to b e d y i n g f r o m c a r c i n o m a t o s i s , b u t h e r s y m p t c m s w e r e m i n i m a l . T h e r e w e r e n o e p i s o d e s of u n c o n s c i o u s n e s s or o t h e r s y m p t o m s s u g g e s t i n g c o n v u l s i v e a t t a c k s , b u t t h e finding of a C.S.F. p r o t e i n of 110 m g m . p e r .cent l e d to r e p e a t e d E . E . G . i n v e s t i g a t i o n s . W i t h q u i n a l b a r b i t o n e s e d a t i o n "'sharpish" w a v e s a n d r u n s of t h e t a , m o s t m a r k e d in t h e left t e m p o r a l r e g i o n , w e r e a p p a r e n t , a n d t h e s e focal a b n o r m a l i t i e s w e r e still p r e s e n t t w o m o n t h s later. B e m e g r i d e a c t i v a t i o n a n d s u b s e q u e n t E . E . G . ' s h a v e p r o v i d e d no f u r t h e r s u p p o r t for a d i a g n o s i s of e p i l e p s y . T h e p a t i e n t h a s b e e n free of s y m p t o m s for o v e r a y e a r o n a n t i - e o n v u l s a n t m e d i c a t i o n . H e n c e at n o s t a g e h a v e this w o m a n ' s a t t a c k s h a d d e f i n i t e l y e p i l e p t i c f e a t u r e s clinically n o r has t h e E . E . C . p r o v i d e d a n y definite e v i d e n c e to f a v o u r e p i l e p s y . B u t she m a y w e l l h a v e an i n t r a c e r e b r a l lesion a n d r e m a i n s u n d e r s u r v e i l l a n c e to e x c l u d e t h e p o s s i b i l i t y t h a t this is s p a c e o c c u p y i n g . T h e s e c o n d c a s e w a s on e m o t i o n a l l y u n s t a b l e s p i n s t e r , a g e d 30 years, w h o h a d e x p e r i e n c e d a v a r i e t y of e p i s o d i c t e m p o r a l l o b e p h e n o m e n a a n d a t t a c k s of u n c o n s c i o u s n e s s f o l l o w i n g t h e d e a t h of h e r f a t h e r . E s t r a n g e m e n t f r o m h e r m a n f r i e n d a little w h i l e l a t e r p r e c i p i t a t e d a s u i c i d a l a t t e m p t w h i c h r e q u i r e d inp a t i e n t p s y c h i a t r i c t r e a t m e n t , a n d t h e a t t a c k s of u n c o n s c i o u s n e s s , l a s t i n g a b o u t t h r e e m i n u t e s , h a v e c o n t i n u e d . S h e h a s n e v e r b e e n i n c o n t i n e n t in a n a t t a c k 'and she d o e s n o t b i t e h e r t o n g u e . In a d d i t i o n to t h e a t t a c k s a n d t h e i r p r o d r o m a t a s h e has a m u l t i t u d e of d i s a b l i n g p h o b i c s y m p t o m s a n d s h e t e n d s to d r i n k to excess in h e r c a p a c i t y as b a r m a i d in t h e f a m i l y b u s i n e s s . T r e a t m e n - t w i t h p h e n o b a r b i t o n e h a s p r o d u c e d little or no i m p r o v e m e n t in h e r c o n d i t i o n . E . E . G . s t u d i e s at t h e b e g i n n i n g of h e r illness five y e a r s a g o s h o w e d an excess of t h e t a in t h e t e m p o r a l r e g i o n s w i t h o c c a s i o n a l b u r s t s of s h a r p i s h d i s c h a r g e s w h i c h w e r e s o m e w h a t s u g g e s t i v e o f e p i l e p s y . S i m i l a r findings w e r e r e p o r t e d six m o n t h s later, b u t s i n c e this t i m e o n l y m i l d , n o n - s p e c i f i c a b n o r m a l i t i e s h a v e been recorded. T h i s p a t i e n t h a d b e e n t r e a t e d in t h e p a s t as a t e m p o r a l l o b e e p i l e p t i c , b u t e x a m i n a t i o n for this s u r v e y cast s o m e d o u b t on t h e v a l i d i t y of this d i a g n o s i s . B o t h t h e clinical p i c t u r e , t h e r e s p o n s e to t r e a t m e n t a n d t h e s u b s e q u e n t c o u r s e of h e r illness, n o t to m e n t i o n t h e p r e c i p i t a n t f a c t o r s a n d h e r p e r s o n a l i t y m a k e u p a r e all t y p i c a l of t h e p h o b i c a n x i e t y - d e p e r s o n a l i z a t i o n s y n d r o m e . T h e t h i r d p a t i e n t h a d also b e e n t r e a t e d as a ease of t e m p o r a l l o b e e p i l e p s y , t h e E . E . G . findings b e i n g c o n s i d e r e d to s u p p o r t this diagnosis. She w a s a 52 y e a z o l d m a r r i e d w o m a n w h o w o r k e d p a r t - t i m e in h e r sister's b a k e r y . As a c h i l d she w a s s h y a n d h a d m a n y fears. She h a s b e e n s e v e r e l y p h o b i c since t h e a~e of 30 years, w h e n s h e f o u n d h e r f a t h e r d e a d in his b e d . A p a r t f r o m h e r p h o b i a s she h a s a l w a y s b e e n sensitive a n d e m o t i o n a l , p r o n e to c o m p u l s i v e rit-

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uals a n d obsessional t h o u g h t s of d a n g e r . T h e p h e n o m e n a w h i c h l e d to t h e diagnosis of e p i l e p s y b e g a n seven years ago a n d consisted of s u d d e n jerkings of her a r m s a n d legs w i t h a s t r a n g e g r u n t i n g noise just p r i o r to sleep. A h'ttle while later she e x p e r i e n c e d a "knife-like" sensation p a s s i n g t h r o u g h her h e a d i m m e d i ately b e f o r e t h e jerking b e g a n . T h e g r u n t i n g t h e n b e c a m e l o u d e r a n d g r a d u a l l y d e v e l o p e d into shouting, of b o t h noises a n d w o r d s Such as "'hello." She claims to be conscious d u r i n g these s y m p t o m s , w h i c h h a v e n o w c o m e to d o m i n a t e t h e h o u s e h o l d ' s b e d t i m e a r r a n g e m e n t s . She feels she will n o t sleep unless she has h a d an attack. An E.E.G. was p e r f o r m e d while t h e p a t i e n t r e c e i v e d intravenous t h i o p e n t o n e . XVhen just drowsy, she b e c a m e restless a n d a t y p i c a l attack was p r o d u c e d the E.E.G. r e v e a l e d only t h e c h a n g e s c h a r a c t e r i s t i c of light sleep i n d u c e d b y t h i o p e n t o n e . S p h e n o i d a l e l e c t r o d e s w e r e i n s e r t e d d u r ing sleep; no p a r o x y s m a l or a s y m m e t r i c a l f e a t u r e s w e r e seen in t h e record. Thus, a l t h o u g h t h e clinical h i s t o r y was suggestive, s u b s e q u e n t i~nvestigations cast c o n s i d e r a b l e d o u b t on the f o r m e r diagnosis a n d s u g g e s t t h a t the p a t i e n t ' s illness m a y be a m a n i f e s t a t i o n of h e r n e u r o t i c p e r s o n a l i t y in w h i c h c o m p u l s i v e e l e m e n t s are conspicuous. Using all the d a t a a v a i l a b l e w e c a n n o w classify these t h r e e cases f u r t h e r . T h e first case r e m a i n s u n d i a g n o s e d . T h e r e m a i n i n g two cases, t h o u g h p r e v i o u s l y r e g a r d e d as epileptics, are p r o b a b l y cases of the p h o b i c a n x i e t y - d e p e r s o n a l i z a t i o n s y n d r o m e ; t h e diagnosis b e i n g c o n f u s e d in the o n e b e c a u s e of the f r e q u e n c y a n d severity of the attacks of u n c o n s c i o u s n e s s a n d in the o t h e r b y the u n u s u a l n a t u r e of the a t t a c k s a n d t h e m a r k e d obsessional coloring lent b y h e r basic p e r s o n a l i t y . T h e i m p l i c a t i o n s of these findings are b o t h p r a c t i c a l a n d theoretical. R e c e n t a d v a n c e s in the u n d e r s t a n d i n g of t e m p o r a l l o b e d i s t u r b a n c e s a n d of their e l e c t r o p h y s i o l o g i c a l correlates, h a v e t e n d e d to foster t h e v i e w t h a t all a b r u p t l y d e v e l o p i n g d i s t u r b a n c e s of b e h a v i o u r , of s u b j e c t i v e e x p e r i e n c e or of conscioushess associated w i t h a g r o u p of s y m p t o m s s u g g e s t i v e of t e m p o r a l lobe dist u r b a n c e are in fact e p i l e p t i c in c h a r a c t e r . O u r findings w o u l d s u g g e s t t h a t this v i e w often leads to a diagnosis of e p i l e p s y in a t least o n e l a r g e a n d r e l a t i v e l y c o m m o n g r o u p of p s y c h i a t r i c disorders w h i c h are d i s t i n c t from t h e convulsive states. O b s e r v a t i o n s over a period, t h e a c c o u n t s of i n d e p e n d e n t observers, rep e a t e d E.E.G. e x a m i n a t i o n s a n d a t h e r a p e u t i c test if i n t e r p r e t e d w i t h caution, will resolve t h e d i a g n o s t i c p r o b l e m in t h e g r e a t m a j o r i t y of instances, b u t in a case h e r e a n d t h e r e u n c e r t a i n t y m a y h a v e to b e t o l e r a t e d for m o n t h s or years. This is p e r h a p s p r e f e r a b l e , h o w e v e r , to an indefinite s e n t e n c e on anti-conv u l s a n t drugs. A R O U S A L , A N X I E T Y AND A D A P T I V E M E C H A N I S M S

Both tile similarities a n d differences b e t w e e n the t~vo d i s o r d e r s u n d e r enq u i r y are e x p l a i n e d to some extent b y the clinical a n d l a b o r a t o r y findings alr e a d y discussed. E a c h involves d i s t u r b a n c e s of b o t h consciousness a n d affect. Tile f o r m e r p r e d o m i n a t e in epilepsy, the affeetive d i s t u r b a n c e s in the n e u r o t i c disorders. F u r t h e r e l u c i d a t i o n of the n a t u r e of the r e l r r ~ l s h i p s b e t w e e n the t w o disorders m a y p e r h a p s be d e r i v e d f r o m c o n s i d e r a t i o n of tile k n o w n facts a b o u t the r e p r e s e n t a t i o n of m e c h a n i s m s c o n t r o l l i n g affect a n d level of con-

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sciousness in the central nervous system and the psychological advances w h i c h have clarified the association of these two variables with each other and with cerebral mechanisms. All states of consciousness have an affective e l e m e n t w h i c h provides the energising c o m p o n e n t of behaviour. W i t h o u t a d e q u a t e "'drive" or "'motivation'" cognitive functions cannot operate, and, as the registration and assimilation of percepts is incomplete or impossible, the individual can neither learn nor behave eflqciently. Even with alertness at a higher pitch, as w h e n some critical situation is being anticipated, the affective c o m p o n e n t has a d a p t i v e value, for psychologists have repeatedly d e m o n s t r a t e d that slight apprehension or increase of drive tends to favour optimal performance. C a n n o n (1939) did a great deal to advance the conception of emotion as a physiological expression of the organism's preparation for fight or flight or as an attribute carrying survival value. But an excess of affect exerts a disorganising, m a I a d a p t i v e effect. T h e r e is a considerable psychiatric literature describing the disorganisation of b e h a v i o u r that is prone to follow the extreme anxiety induced by stresses of an o v e r w h e h n i n g m a g n i t u d e such as earthquakes, floods cr prolonged exposure to battle stress (Bonhoeffer, 1919, 1922; G a u p p , 1922, Kardiner, 1941). These stresses m a y be followed by clouding of consciousness with fugues and automatic behaviour. But even such a response m a y not be wholly devoid of an adaptive component; the victims of e a r t h q u a k e s so affected are described as w a n d e r i n g about in a vacant a p a t h y or in a state of incongruous euphoria, oblivious of their surroundings, seemingly u n a w a r e of their recent h a r r o w i n g experience. But it is a c r u d e form of a d a p t a t i o n for a similar response m a y glue the careless pedestrian to the spot or cause the terrified soldier exposed to intensive b o m b a r d m e n t to w a n d e r in a clouded state towards the e n e m y lines ( M a y e r Gross et al., 1960). An analysis of the clinical features of the phobic anxiety-depersonalization s y n d r o m e suggests that we are likely to be dealing with a caricature of the normal adaptive functions of vigilance and its associated affects. In place of a normal alertness w e - h a v e a jerky, over-responsiveness particularly to unexpected stimuli, irritability, restlessness, insomnia a n d often "'closed "eye" hallucinations in the a w a k e state, \vith vivid h y p n a g o g i c hallucinations in the early stages of sleep. T h e normal physiological a c c o m p a n i m e n t s of preparation for effort do not o b t r u d e into consciousness, whereas in the neurosis w e have tremulousness a n d twitching of limbs, palpitation, excessive prespiration, giddiness, intolerance of h e a t and sometimes syncope. T h e n o r m a l emotional energisation of behavior now overflows in the form of attacks of panic; fear ef leaving familiar surroundings and of being left alone c o m m o n l y develop a s s e c o n d a r y manifestations. W h e n the condition has b e e n initiated b y a particularly severe emotional t r a u m a , a short-lived period of clouding of consciousness with fugues and automatic behaviour and at times a transient psychotic disorder, m a y m a r k the b e g i n n i n g of the illness as in the case of the psychiatric complications of w a r or major catastrophe. In the latter, the clouding of consciousness and psychotic d e r a n g e m e n t are not u n e x p e c t e d l y c o m m o n e r anrt

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t h e c h r o n i c p h a s e of t h e illness looms less l a r g e in t h e a v a i l a b l e d e s c r i p t i o n s , b u t t h e d i f f e r e n c e s a r e p r o b a b l y of a q u a n t a t i v e r a t h e r t h a n a q u a l i t a t i v e k i n d . A R O U S A L AND DEPERSONALIZATION

T h e role of d e p e r s o n a l i z a t i o n in this r e s p o n s e b e c o m e s a little c l e a r e r w h e n w e e x a m i n e t h e p s y c h o l o g i c a l a n d p h y s i o l o g i c a l a s s o c i a t i o n s of this e l u s i v e p h e n o m e n o n . \ V h e n it o c c u r s as a m a n i f e s t a t i o n of an e p i l e p t i c d i s c h a r g e f r o m or a f t e r e l e c t r i c a l s t i m u l a t i o n to t h e t e m p o r a l cortex, or as a r e s u l t of t h e adm i n i s t r a t i o n of h a l l u c i n o g e n i c d r u g s , t h e r e is a l w a y s a n a s s o c i a t e d c h a n g e in level of c o n s c i o u s n e s s , y e t o n e so s u b t l e t h a t m a n y of t h e e x p e r i e n c e s t h r o u g h w h i c h t h e p a t i e n t passes in this s t a g e a r e r e g i s t e r e d , r e t a i n e d a n d s u b s e q u e n t l y r e c a l l e d . In e x p o s u r e to s u d d e n d a n g e r , s e n s a t i o n s of u n r e a l i t y a n d r e m o t e n e s s a r e c o m m o n if n o t u n i v e r s a l a n d t h o s e w h o s u r v i v e s u c h a c u t e l y t h r e a t e n i n g s i t u a t i o n s h a v e o f t e n r e f e r r e d to t h e i r a b i l i t y to act e f f e c t i v e l y as a r e s u l t of t h e sense of d e t a c h m e n t c o n f e r r e d b y t h e e x p e r i e n c e . A n u m b e r of o u r p a t i e n t s h a v e g i v e n s i m i l a r d e s c r i p t i o n s of an u n e x p e c t e d a b i l i t y to t a k e p r o m p t a n d a p p r o p r i a t e a c t i o n in h a r r o w i n g c i r c u m s t a n c e s t h a t s e e m e d to elicit no imm e d i a t e e m o t i o n a l r e s p o n s e ( s e e case 1). It is of c o n s i d e r a b l e i n t e r e s t t h a t all t h e s e t t i n g s for d e p e r s o n a l i z a t i o n d i s c u s s e d so far, e p i l e p t i c or e l e c t r i c a l s t i m u l a t i o n of t h e t e m p o r a l lobes, a c u t e grief or d a n g e r , i n v o l v e a h e i g h t e n e d i n t e n s i t y of s t i m u l a t i o n . T h e p h a r m a c o l o g i c a l effect of h a l l u c i n o g e n i c d r u g s is likewise to a u g m e n t a r o u s a l ( B r a d l e y a n d Elkes, 1957) a n d t h e d e p e r s o n a l i z a tion w h i c h n o t i n f r e q u e n t l y follows t h e a d m i n i s t r a t i o n of E C T to p a t i e n t s suff e r i n g f r o m p r o m i n e n t a n x i e t y m a y also b e r e g a r d e d as o c c u r r i n g in c o n d i t i o n s of i n t e n s i v e s t i m u l a t i o n of t h e c e r e b r a l cortex. H e r m a n n a n d S t r 6 m g r e n ( 1 9 4 4 ) w h o s t u d i e d d r e a m y states o c c u r r i n g in a series of 644 p a t i e n t s w i t h verified b r a i n lesions, c o n c l u d e d t h a t t h e essential c o m p o n e n t of this p h e n o m e n o n w a s a d i s s o c i a t i o n of c o n s c i o u s n e s s c o m p r i s i n g c h a n g e s b o t h in e g o - c o n s c i o u s n e s s a n d c o n s c i o u s n e s s of e n v i r o n m e n t . T h e t e r m " ' d e p e r s o n a l i z a t i o n " w a s u s e d to d e s c r i b e b o t h t h e s e c h a n g e s . T h e r e is m u c h to b e said in f a v o u r of this f o r m u l a tion a n d for t h e v i e w t h a t d e p e r s o n a l i z a t i o n is t h a t d i s s o c i a t i o n or d u p l i c a t i o n of c o n s c i o u s n e s s w h i c h is p a r t i c u l a r l y a s s o c i a t e d w i t h a n y h e i g h t e n i n g of stimu l a t i o n t h a t e v o k e s a c u t e fear or anxiety. M o r e o v e r , t h e s u b j e c t i v e e x p e r i e n c e a n d o b j e c t i v e p e r f o r m a n c e of t h o s e affected, s u g g e s t s t h a t this d i s s o c i a t i o n of c o n s c i o u s n e s s has t h e effect of a t t e n u a t i n g e m o t i o n s t h a t m i g h t o t h e r w i s e e x e r t d i s r u p t i v e effects on b e h a v i o u r . H e n c e b o t h a n x i e t y a n d d e p e r s o n a l i z a t i o n a r e a p p r o p r i a t e r e s p o n s e s to s i t u a t i o n s t h a t p r e s e n t an a c u t e t h r e a t to s e c u r i t y or survival. T h e u n f a v o u r a b l e a s p e c t t h e s e r e s p o n s e s a s s u m e in t h e p h o b i c anxi e t y - d e p e r s o n a l i z a t i o n s y n d r o m e is t h e i r p e r s i s t e n c e long a f t e r t h e y h a v e c e a s e d to b e r e l e v a n t to t h e c i r c u m s t a n c e s . In this light t h e n e u r o s i s m a y b e r e g a r d e d as t h e m a l a d a p t i v e e x a g g e r a t i o n a n d p e r p e t u a t i o n of p r o t e c t i v e psychological mechanisms. * * T i l e t e n d e n c y to s y n c o p a l a t t a c k s is a t first s i g h t d i f f i c u l t to a c c o m m o d a t e w i t h i n s u c h a f o r m u l a t i o n , b u t it is o f s o m e i n t e r e s t t h a t B a r c r o f t a n d E d h o l m (1945) h a v e a d d u c e d e v i d e n c e to s u g g e s t t h a t s y n c o p e e x e r t s a h o m e o s t a t i c f u n c t i o n in r e l a t i o n t o t h e c a r d i o vascular system.

220

ROTH AND HARPER NEUROPHYSIOLOGICAL ASPECTS OF AROUSAL AND ANXIETY

T h e n e u r o p h y s i o l o g i c a l p a r a l l e l s to t h e r e l a t i o n s h i p s t r a c e d in t h e p s y c h o l o g i cal s p h e r e b e t w e e n a r o u s a l a n d a n x i e t y , a r e striking. As H e b b ( 1 9 5 5 ) h a s p o i n t e d out, a r o u s a l as a p r o c e s s i n f e r r e d f r o m n e u r o p h y s i o l o g i c a l o b s e r v a t i o n s h a s m a n y similarities w i t h t h e p s y c h o l o g i c a l c o n c e p t s of " ' m o t i v a t i o n " a n d "'drive.'" Arousal responses may be elicited from the hippocampus and the cingulate a n d h i p p o c o m p a l g y r i ( J a n s e n et al., 1 9 5 5 / 5 6 ) . W i t h i n t h e a m y g d a l a t h e a r o u s a l a r e a e x t e n d s f r o m t h e b a s o - l a t e r a l d i v i s i o n in a m e d i o d o r s a l - c a u d a l d i r e c t i o n t h r o u g h t h e i n t e r n a l c a p s u l e a n d into t h e b r a i n s t e m . ( K a a d a a n d Ursin, 1957, U r s i n a n d K a a d a , 1 9 6 0 ) . H o w e v e r , a s l i g h t i n c r e a s e in i n t e n s i t y of s t i m u l a t i o n in c e r t a i n a r e a s of t h e a m y g d a l a p r o v o k e s n o t j u s t a r o u s a l b u t a d d i t i o n a l f e a t u r e s w h i c h s i m u l a t e f e a r or a n g e r ; t h e a r o u s a l , f e a r a n d a n g e r z o n e s a p p e a r to b e i d e n t i c a l b o t h in a m y g d a l a a n d b r a i n stem. In t h e h u m a n as in t h e p r i m a t e , f e a r a n d a n g e r r e s p o n s e s h a v e b e e n e l i c i t e d b y s t i m u l a t i o n of t h e a m y g d a l a ( C h a p m a n et al., 1954). M o r e o v e r , t h e w o r k of K l i i v e r a n d B u c y ( 1 9 3 9 ) on t h e effects of b i l a t e r a l t e m p o r a l l o b e c t o m y in p r i m a t e s has s h o w n t h a t t h e l i m b i c s y s t e m p l a y s a role of p r o f o u n d i m p o r t a n c e in t h e r e g u l a t i o n of e m o t i o n a l life, a s w e l l as in t h e c o n t r o l of c e r t a i n c o g n i t i v e f u n c t i o n s . H o w e v e r it is w e l l to b e a r in m i n d t h a t i n t e n s i v e s t i m u l a t i o n , p a r t i c u l a r l y of c e r t a i n p a r ~ of t h e t e m p o r a l lobes, is p r o n e to l e a d n o t o n l y to a n x i e t y b u t also to s p r e a d e x c i t a t i o n o v e r e x t e n s i v e a r e a s of t h e c e r e b r a l cortex. I n o t h e r w o r d s , w h e n a r o u s a l is a t a r e l a t i v e l y h i g h level or d r i v e intense, a f u r t h e r i n c r e a s e in s t i m u l a t i o n m a y i n t e r f e r e w i t h t h e d e l i c a t e a d j u s t m e n t s in f u n c t i o n , p e r h a p s b y f a c i l i t a t i n g i r r e l e v a n t r e s p o n s e s ( H e b b , 1 9 5 5 ) . OVERLAP AND DIFFERENTIATION

BETWEEN

THE TWO

PHENOMENA

A l t h o u g h in t h e l i g h t of clinical o b s e r v a t i o n its s e e m s u n d e n i a b l e tl~at affect a n d t h e c o g n i t i v e f u n c t i o n s w e s u b s u m e u n d e r s u c h t e r m s as "'arousal" o r "'consciousness" e a c h e n j o y s o m e d e g r e e of a u t o n o m y , t h e o b s e r v a t i o n s t h a t h a v e b e e n d i s c u s s e d s h o w t h a t a r o u s a l a n d t h e affective c h a n g e i d e n t i f i a b l e at s o m e levels as a n x i e t y , a r e c l o s e l y a s s o c i a t e d w i t h o n e a n o t h e r p s y 6 h o l o g i c a l ly, p h y s i o l o g i c a l l y a n d in t h e i r a n a t o m i c a l r e p r e s e n t a t i o n . T h e i m p o r t a n t p a r t p l a y e d b y t h e o l d o l f a c t o r y b r a i n , of w h i c h t h e t e m p o r a l l o b e s f o r m s u c h l a r g e c o m p o n e n t s , in t h e r e g u l a t i o n of t h e s e a c t i v i t i e s p r e s u m a b l y c o n s t i t u t e s a c o n s i d e r a b l e p a r t of t h e e x p l a n a t i o n for" t h e p o i n t s of s i m i l a r i t y b e t w e e n a n e u r o s i s t h a t c o m b i n e s d i s t u r b a n c e s of affect a n d c o n s c i o u s n e s s a n d e p i l e p s y d u e to a lesion in t h e t e m p o r a l lobes. A n a d d i t i o n a l p o i n t of i n t e r e s t w h i c h m a y h e l p f u r t h e r to e x p l a i n t h e o v e r l a p b e t w e e n t h e clinical f e a t u r e s of t h e t w o d i s o r d e r s u n d e r c o n s i d e r a t i o n , is t h a t t h o s e p a r t s of t h e l i m b i c s y s t e m , s u c h as t h e a m y g d a l a a n d t h e h i p p o c a m p u s f r o m w h i c h " a r o u s a l " a n d "'anxiety" r e s p o n s e s a r e :readily elicited, also h a v e v e r y low t h r e s h o l d s for seizure discharge e v o k e d b y e l e c t r i c a l s t i m u l a t i o n ( K a a d a , 1 9 5 9 ) a n d t h e e x t r e m e f a c i l i t a t i o n of "arousal" m e c h a n i s m s t e n d s t h e r e fore to c u l m i n a t e ' i n e p i l e p t i c a c t i v i t y . W e m a y n o w c o n s i d e r w h a t f a c t o r s d e t e r m i n e tile d i f f e r e n c e s b e t w e e n t h e t w o t y p e s o f s y n d r o m e . G r o s s n e s s or s e v e r i t y of t h e u n d e r l y i n g lesion is c l e a r l y

TE~.IPORAL LOBE EPILEPSY

221

o n e of t h e f a c t o r s r e s p o n s i b l e , for in e p i l e p s y this is i d e n t i f i a b l e b y electroe n c e p h a l o g r a p h y in m o s t cases, a n d s u r g i c a l e x p l o r a t i o n u s u a l l y r e v e a l s corr e s p o n d i n g scars, h e m o r r h a g e s or t u m o u r s ( F a l c o n e r a n d C a v a n a g h , 1959). In t h e p h o b i c a n x i e t y - d e p e r s o n a l i z a t i o n s y n d r o m e , on t h e o t h e r h a n d , a l t h o u g h definite E . E . G . a b n o r m a l i t i e s in t h e t e m p o r a l a r e a s h a v e b e e n d e t e c t e d in a s m a l l m i n o r i t y of cases a n d t h e r e is a f u r t h e r v e r y s m a l l g r o u p w i t h a lesion c o n f i n e d to t h e t e m p o r a l lobes ( s e e case 5 ) , in t h e g r e a t m a j o r i t y of cases w e can no m o r e t h a n s u s p e c t "'an i n v i s i b l e lesion." D i f f e r e n c e s in l o c a l i s a t i o n a r e also v e r y likely i n v o l v e d . T h e o p p o r t u n i t i e s for i n v e s t i g a t i n g s u c h p r o b l e m s are likely to b e l i m i t e d b u t m i g h t o c c a s i o n a l l y p r e s e n t t h e m s e l v e s in t h e c o u r s e of s u r g i c a l e x p l o r a t i o n or p o s t m o r t e m s t u d y of cases w i t h gross lesions s u c h as t u r n o u t s ; t h e l o c a l i s a t i o n a n d d i s t r i b u t i o n of lesions in p a t i e n t s w h o h a d h a d i n d u b i t a b l y e p i l e p t i c a t t a c k s c o u l d b e c o m p a r e d w i t h t h o s e f o u n d in t h e m u c h r a r e r cases w h o h a d s u f f e r e d e p i s o d i c a t t a c k s d o m i n a t e d b y a n x i e t y , d e p e r s o n a l ization or lossuof c o n s c i o u s n e s s w i t h c l e a r s y n c o p a l f~eatures. O t h e r a r e a s w h i c h i n v i t e e x p l o r a t i o n a r e t h o s e w h i c h h a v e b e e n o p e n e d u p b y m e a n s of b i o c h e m ical s t u d i e s of a n x i e t y b y P e r s k y a n d his g r o u p ( 1 9 5 6 ) a n d M a s o n ( 1 9 5 9 ) , a m o n g others. S u c h i n v e s t i g a t i o n s m a y s h e d l i g h t u p o n t h e p h y s i o l o g i c a l basis of b o t h e m o t i o n a l a n d e p i l e p t i c d i s t u r b a n c e s a n d l a y b a r e t h e i r r e l a t i o n s h i p s with each other and with the cerebral mechanisms concerned with the control of n o r m a l a w a r e n e s s . SUMMARY

1. S o m e of t h e d i a g n o s t i c p r o b l e m s in t h e b o r d e r l a n d s b e t w e e n e p i l e p s y a n d n e u r o s i s a r e i l l u s t r a t e d b y t h r e e p a t i e n t s r e v i e w e d d u r i n g a c o m p a r a t i v e s t u d y of temporal lobe epilepsy and the phobic anxiety-depersonalization syndrome. It is s u g g e s t e d t h a t i n c o m p l e t e i n v e s t i g a t i o n of c e r t a i n a b r u p t l y d e v e l o p i n g dist u r b a n c e s of b e h a v i o u r or c o n s c i o u s n e s s , p a r t i c u l a r l y in a s e t t i n g of a c u t e a n d e r r o n e o u s a n x i e t y , m a y o f t e n l e a d to d i a g n o s i s of e p i l e p s y in a t l e a s t o n e r e l a t i v e l y c o m m o n g r o u p of p s y c h i a t r i c d i s o r d e r s . 2. T h e role of "arousal" a n d a n x i e t y in n o r m a l a d a p t a t i o n is d i s c u s s e d a n d t h e evidentSe p o i n t i n g to (-a) an i n t i m a t e p s y c h o l o g i c a l a n d p h y s i o l o g i c a l association b e t w e e n t h e s e p h e n o m e n a , a n d ( b ) t h e close p r o x i m i t y of t h e a n a t o m i c a l s t r u c t u r e s c o n c e r n e d w i t h t h e i r control, is s u m m a r i s e d . T h e n e u r o s i s is conc e i v e d as a m a l a d a p t i v e e x a g g e r a t i o n a n d p r o l o n g a t i o n of n o r m a l p s y c h o l o g i c a l r e s p o n s e s to stresses p r o n e to a r o u s e fear. 3. It is s u g g e s t e d t h a t t h e l o c a t i o n in t h e t e m p o r a l lobes of c o n t r o l l i n g m e c h a nisms c! o n c e r n e d w i t h a r o u s a l a n d a n x i e t y m a y a c c o u n t for t h e r e s e m b l a n c e s b e t w e e n t h e t w o t y p e s of illness. T h e d i f f e r e n c e s - p r o b a b l y d e r i v e f r o m t h e u s u a l p r e s e n c e in e p i l e p s y of a gross lesion or focal E . E . G . d i s t u r b a n c e , w h e r e a s o n l y "invisible lesions' c a n b e i n f e r r e d for t h e p a t h o p h y s i o l o g i c a l d i s t u r b a n c e u n d e r l y i n g t h e m a j o r i t y of cases of p h o b i c a n x i e t y - d e p e r s o n a l i z a t i o n s y n d r o m e . ILLUSTRATIVE C A S E HISTORIES

A Typical Case o[ the Phobic Anxiety-Depersonalization Syndrome. C a s e 1 . - - A girl of 22, e a r n e s t , r e s p o n s i b l e a n d fastidious, b u t d e p e n d e n t a n d i m m a t u r e , t h e c h i l d of a cold, d o m i n e e r i n g , m a s t e r f u l m o t h e r a n d a possessive f a t h e r w h o h a d n e v e r

2:22

~OTH

AND

HAnr'El~

g o t o n ,veil t o g e t h e r , w a s o n e d a y u r g e n t l y c a l l e d to s e e h e r f a t h e r w h o h a d c o l l a p s e d foll o w i n g an a t t a c k o f "'vertigo." S h e w a s s h o c k e d b y his a p p e a r a n c e a n d t h e r e a f t e r w a s tense, a p p r e h e n s i v e , s l e e p l e s s a n d t r e m u l o u s f o r a p e r i o d o f t w o w e e k s . A t the e n d o f this t i m e she w a s a w a i t i n g h e r h u s b a n d ' s r e t u r n f r o m a long j o u r n e y lye h a d u n d e r t a k e n in h e r f a t h e r ' s ear, s t r o n g l y a g a i n s t h e r w i s h e s , as she h a d p r e v i o u s l y a r r a n g e d w i t h h i m to t a k e h e r in t h e c a r to visit h e r f a t h e r . H e f a i l e d to r e t u r n at tile e x p e c t e d tinme a n d a f t e r t w o h o u r s o f w a i t i n g t h e r e w a s a k n o c k at time door. O n o p e n i n g it she s a w a p o l i c e m a n a n d "'felt n u m b all o v e r a n d f r o z e n to t h e spot.'" H e r h u s b a n d h a d m e t w i t h an a c c i d e n t a n d h a d b e e n a d m i t t e d to a h o s p i t a l 7 0 miles a w a y . S h e h e a r d t h e p o l i c e m a n ' s v o i c e as if it w e r e c o m i n g f r o m a g r e a t d i s t a n c e . S h e f e l t dew~id o f e m o t i o n an(l c o m p l e t e l y d e t a c h e d f r o m t h e e x p e r i e n c e . It w a s s e v e r a l h o u r s b e f o r e she l e a r n t t h a t h e r h u s b a H d h a d b e e n o n l y slightly i n j u r e d . N e v e r t h e l e s s , a c o n s t a n t f e e l i n g o f b e i n g s e p a r a t e d f r o m herself, d e t a c h e d f r o m t h e w o r l d al'ound her, a n d h a v i n g , like an a u t o m a t o n , to p e r f o r m all m o v e m e n t s b y f o r c e of will r a t h e r t h a n n a t u r a l l y a n d s p o n t a n e o u s l y , c o n t i n u e d f o r a y e a r until s h e w a s b r o u g h t f o r m e d i c a l a d v i c e . S h e h a d also e x p e r i e n c e d a t t a c k s o f u n c o n s c i o u s n e s s at w e e k l y intervals. S o m e o f t h e s e w e r e c l e a r l y s y n c o p a l in c h a r a c t e r b u t o t h e r s o c c u r r e d w i t h o u t w a r n i n g a n d she w o u l d c o m e r o u n d to find h e r s e l f lying on t h e floor. T h e r e w a s n~ h i s t o r y o f i n j u r y or i n c o n t i n e n c e . S h e also e x p e r i e n c e d " w a r n i n g a t t a c k s " in w h i c h a f e e l i n g of f a m i l i a r i t y a n d a s i n k i n g f e e l i n g in h e r e p i g a s t r i u m w o u l d o c c u r p a r t i c u l a r l y if she w a s alone in t h e h o u s e or u p s e t . S h e felt w e a k a n d faint, t h e f e e l i n g s of r e m o t e n e s s w e r e intensified a n d she u s u a l l y tried to sit d o w n . Walking more than a f e w yards from her h o m e p r o d u c e d feeli~gs of giddiness and uns t e a d i n e s s w h i c h w e r e in a b e y a n c e if s o m e o n e w a s w i t h her. T h e p a t i e n t , w h o r e f u s e d a c o u r s e o f t h i o p e n t o n e t r e a t m e n t b e c a u s e of a l i f e l o n g p h o b i a o f injections, w a s t r e a t e d with nialamide and w a s making some s y m p t o m a t i c i m p r o v e m e n t w h e n her 52 year old f a t h e r d i e d u n e x p e c t e d l y in his sleep f r o m a h e a r t a t t a c k . T h e p a t i e n t ' s d e p e r s o n a l i z a t i o n r e t u r n e d in an e x a c e r l ) a t e d f o r m , she b e c a m e terrified o f b e i n g l e f t a l o n e a n d i n c a p a b l e o f w a l k i n g or t r a v e l l i n g a n y d i s t a n c e f r o m h e r h o m e . H e r b l a c k o u t s r e t u r n e d a n d she exp e r i e n c e d o n e f u g u e - l i k e e p i s o d e in w h i c h s h e f o u n d h e r s e l f w a l k i n g w i t h time p r a m a w a y f r o m h e r h o m e , w i t h o u t k n o w i n g w h e r e s h e w a s going. H y p n o t i c suggestions r e d u c e d the severity of her anxiety attacks and the blackouts c e a s e d till f o u r m o n t h s later, w h e n s h e h a d a n o t h e r b r i e f a t t a c k in a~ r e s t a u r a n t a t t h e b e g i n n i n g o f h e r h o l i d a y . O v e r t h e ~ast six m o n t h s t h e s i t u a t i o n a l p h o b i a s , d e p e r s o n a l ization a n d " ' b l a c k o u t s " h a v e b e e n in a b e y a n c e , b u t she h a s b e e n t r o u b l e d b y s y m p t o m s s u g g e s t i v e o f p e p t i c u l c e r a t i o n a n d s e v e r e p r e m e n s t r n a l tension. She. has b e e n r e c e i v i n g a m y l o b a r b i t o n e gr. x/~ b . d . a n d q n i n a l b a r b i t o n e gr. l x~ n o c t e .

Three Female Patients with the Phobic Anxiety-Depersonalization S y n d r o m e Previously Diagnosed a s Epileptics C a s e 2 . ~ A 4 0 y e a r o l d h o u s e w i f e , w h o s e f a t h e r ,vas a d i p s o m a n i a c a n d w h o s e m o t h e r h a d r e c e i v e d i n - p a t i e n t t r e a t m e n t f o r a n e u r o t i c b r e a k d o w n . As a child s h e h a d m u l t i p l e n e u r o t i c traits; s h e w a l k e d in h e r sleep, w a s a f r a i d o f m e e t i n g p e o p l e , b i t h e r nails a n d w a s f r i g h t e n e d o f t h e d a r k . S h e also t e n d e d to f a i n t easily. H e r p a r e n t s s e p a r a t e d f o r s o m e year.,; a n d s h e w a s c a r e d for m a i n l y b y hel" g r a n d p a r e n t s . T h o u g h a c a d e m i c a l l y a b o v e a v e r a g e s h e w a s f r e q u e n t l y a w a y f r o m s c h o o l b e c a u s e o f m i n o r illnesses. H e r illness b e g a n at t h e a g e of 18 w h i l e s h e w a s s e r v i n g in t h e A.T.S. S h e b e c a m e anxious, lost a g r e a t d e a l of w e i g h t a n d s t a r t e d h a v i n g a series o f b l a c k o u t s , s o m e t i m e s as m a n y as t w o a d a y . Some of these attacks w e r e p r e c e d e d b y feelings of faintness a n d others occurred w i t h o u t w a r n i n g . O n r e c o v e r y s h e felt c o l d a n d s h i v e r y . O n t w o o c c a s i o n s s h e w a s i n c o n t i n e n t o f urine. An a t t a c k w a s w i t n e s s e d b y a M e d i c a l Officer a n d a d i a g n o s i s o f e p i l e p s y w a s m a d e ; s h e w a s p u t on p h e n o b a r b i t o n e a n d i n v a l i d e d f r o m t h e service. T h e a t t a c k s b e c a m e less i n c a p a c i t a t i n g a n d o n l y r a r e l y a s s o c i a t e d w i t h c o m p l e t e loss o f c o n s c i o u s n e s s . W h e n r e f e r r e d to t h e D e p a r t m e n t t h e y c o n s i s t e d o f f e e l i n g s o f a n x i e t y with" p a l p i t a t i o n s a n d int e n s e d e p e r s o n a l i z a t i o n , w h i c h s h e d e s c r i b e d as "'feeling d i s e m b o d i e d . " S h e o f t e n l a y d o w n to p r e v e n t h e r s e l f f r o m falling. I n a d d i t i o n s h e h a d s y m p t o m s o f p h o b i c a n x i e t y , p a r t i c u l a r l y o f q u e u e s a n d b u s e s a n d also c o m p l a i n e d o f a u d i t o r y h y p n a g o g i c h a l l u c i n a t i o n s .

TEhlPOIIAL

LOBE

EPILEPSY

223

T i l e p a t i e n t h a d m a n y h y s t e r i c a l p e r s o n a l i t y t r a i t s . S h e w a s p r o n e to d r a m a t i s e a n d a s s u m e p o s e s a n d s h e w a s l i a b l e to s u d d e n s u r g e s o f e u p h o r i a a n d d e p r e s s i o n in r e s p o n s e t o relat i v e l y t r i v i a l c i r c u m s t a n c e s . S h e w a s a l s o p e r s i s t e n t l y o b s e s s i o n a l in t h a t s h e w a s p r o n e to c o m p u l s i v e t h o u g h t s a n d m i n o r r i t u a l s , a n d e x p e c t e d h i g h s t a n d a r d s o f a c h i e v e m e n t in everything she undertook. A course of ten injections of i n t r a v e n o u s t h i o p c n t o n e p r o d u c e d a d r a m a t i c alleviation of her attacks of d e p e r s o n a l i z a t i o n a n d anxiety. She has r e m a i n e d u n d e r o b s e r v a t i o n for two and one-half years since this treatment and she has had no further "'blackouts," and has n o t b e e n r e c e i v i n g a n t i - c o n w d s a n t s . T h e s i t u a t i o n a l p h o b i a s h a v e also b e e n r e s o l v e d . A l i t t l e o v e r a y e a r a f t e r t r e a t m e n t s h e d e v e l o p e d d e p r e s s i v e s y m p t o m s w i t h eompulsivt~ t h o u g h t s of a sexual n a t u r e w h i c h n e c e s s i t a t e d t w o m o n t h s i n - p a t i e n t t r e a t m e n t . She r e m a i n s a g r o s s l y n e u r o t i c p e r s o n a l i t y b u t s h e is n o t n o w t r o u b l e d b y p s y e l i i a t r i c s y m p l o m s . Case3.--This p a t i e n t w a s a g e d 41 y e a r s w h e n first s e e n in 1954. H e r i l l n e s s b e g a n 18 years previously, after her only chiid d i e d at the age of 2 years. In 1954 she h a d an e p i s o d e o f u n c o n s c i o u s n e s s in t h e s t r e e t a n d f o l l o w i n g t h i s d e v e l o p e d a t y p i c a l p h o b i c ~ i n x i c t y - d e p e r s o n a l i z a t i o u s y n d r o m e . B e c a u s e of t h e a c c o u n t o f " b l a c k o u t s " w i t h a b d o m i n a l d i s c o m f o r t , d i z z i n e s s a n d a s m e l l of p e a r d r o p s , t e n d i n g t o o c c u r p r e m e n s t r n a l l y , a d i a g nosis o f t e m p o r a l l o b e e p i l e p s y w a s m a d e . A h i s t o r y t h a t h e r b r o t h e r h a d h a d s i m i l a r a t t a c k s a n d t h e f a c t t h a t h e r c h i l d h a d d i e d in a e o n w l l s i o n w a s i n t e r p r e t e d a s s u p p o r t i n g this diagnosis. A little over 2 years" t r e a t m e n t w i t h p h e n o b a r b i t o n e a n d p h e n y t o i n p r o d u c e d l i t t l e b e n e f i t a n d s h e "~--as r e - r e f e r r e d in 1957. T h r e e E . E . G . s ( o n e o f t h e m a s l e e p r e c o r d i n g ) w e r e w i t h i n n o r m a l limits. T h e skull x - r a y w a s n o r m a l a n d a t n o t i m e ~/md a n e p i l e p t i c attack been observed. The history was reviewed and because of the p~'ominence of the situational p h o b i a s a n d other neurotic s y m p t o m s the diagnosis was m a d e of a p h o b i c a n x i e t y - d e p e r s o n a l i z a t i o n s y n d r o m e in a h y s t e r i c a l p e r s o n a l i t y . T h e a n t i - c o n v u l s a n t s w e r e d i s c o n t i n u e d a n d s h e r e c e i v e d a c o u r s e o f i n t r a v e n o u s thiopent,.~ne w h i c h r e l i e v e d t h e more severe anxiety attacks. She was seen for a further 2 years during which time she h a d n o f u r t h e r " b l a c k o u t s , " a l t h o u g h s h e c o n t i n u e d to c o m p l a i n o f a v a r i e t y o f m i n o r p h o b i c a n d h y s t e r i c a l s y m p t o m s a n d s h e w a s also u n d e r t r e a t m e n t in t h e d e p a r t m e n t o f d e r m a t o l ogy for a r e c r u d e s c e n c e of lupus e r y t h e m a t o s u s . C a s e 4 . - - T h i s p a t i e n t w a s t h e w i f e o f a n a i r m a n . H e r i l l n e s s b e g a n 11 y e a r s a g o a t t h e a g e o f 23 a f t e r t h e b i r t h o f h e r s e c o n d c h i l d . S h e d e v e l o p e d s e v e r e h e a d a c h e s , i n t e r m i t t e n t in c h a r a c t e r , m a x i m a l in t h e l e f t f r o n t a l r e g i o n . T w o y e a r s l a t e r s h e n o t i c e d a n u n p l e a s a n t taste a n d smell w h i c h persisted for s o m e m o n t h s . T h e r e was some t e n d e r n e s s o v e r the floor o f t h e l e f t f r o n t a l s i n u s a n d m u c o - p u r u l e n t d i s c h a r g e w a s o b s e r v e d f r o m t h e p o s t e r i o r n a s a l s p a c e o n t h e l e f t side. B e c a u s e o f t h e s e f i n d i n g s a d i a g n o s i s o f f r o n t a l s i n u s i t i s w a s m a d e . T h e h e a d a c h e s a n d u n p l e a s a n t taste a n d smeU r e t u r n e d at intervals a n d she became increasingly concerned about her health. Five years ago, just after getting out of bed, she felt dizzy anti b e c a m e unconscious. H e r h u s b a n d said t h a t she w e n t very pale a n d a little later b e c a m e c y a n o s e d . She did n o t convulse. She r e c o v e r e d consciousness after a b o u t five m i n u t e s b u t r e m a i n e d c o n f u s e d f o r a f u r t h e r s h o r t p e r i o d . S h e h a d n o f u r t h e r e p i s o d e s o f loss o f c o n s c i o u s n e s s b u t c o n t i n u e d t o e x p e r i e n c e b L ' e f a t t a c k s o f s u d d e n o n s e t in w h i c h s h e f e l t s i c k a n d a f r a i d , h a d p a l p i t a t i o n s a n d f e l t u n r e a l . T h e u n p l e a s a n t t a s t e and smell sensations did not recur. F u l l i n v e s t i g a t i o n s a t t h e t i m e o f t h e first a t t a c k r e v e a l e d n o a b n o r m a l p h y s i c a l s i g n s a p a r t from the tenderness over the left frontal sinns. T h e skull x-ray was n o r m a l b u t the E . E . G . w a s r e g a r d e d as a b n o r m a l b e c a u s e o f b r i e f s y m m e t r i c a l d i s c h a r g e s o f t h e t a w a v ~ which "'suggested a diagnosis of epilepsy.'" There was no focal abnormality. A diagnosis of temporal lobe epilepsy was made and anti-convulsants administered. A year later the patient's husband was posted to the north of England and the patient was referred to our l)epartment because she was becoming irritable and depressed. She was tense, depressed a n d h a d d e v e l o p e d p h o b i c a v e r s i o n s to t r a v e l l i n g o n h e r o w n . H e r s y m p t o m s w e r e w o r s e premenstrually. The patient was treated with superficial psychotherapy, dexedrine and a n a y l o b a r b i t o n e , a n d e t h i s t e r o n e 5 m g m . b . d . s u b - l i n g u a U y b e f o r e !Jet p e r i o d s . S h e h a s had no further attacks for four years and a follow-up a year ago revealed that she had had a n o t h e r c h i l d w i t h o u t m i s h a p a n d t h a t h e r n e u r o t i c s y m p t o m s r e m a i n e d in a b e y a n c e . S h e had d~scontinued the anticonvulsants on her own initiative, without any untoward sequelae.

-o24

BOTH

AND HARPER

Three Cases of the Phobic Anxiety-Depersonalization Syndrome with Radiographic or Electroencephalographic Evidence of Temporal Lobe Dysfunctio~ C a s e 5 . - - A s e n s i t i v e , c a r e f u l , c o n s c i e n t i o u s l a d o f 19 r e c e i v e d a k n o c k - o u t b l o w in h i s l e f t t e m p o r a l r e g i o n w h i l e p a r t i c i p a t i n g in a n a v a l b o x i n g m a t c h . H e w a s u n c o n s c i o u s f o r a b o u t o n e m i n u t e a n d his l e f t t e m p l e w a s b a d l y b r u i s e d . A p a r t f r o m o c c a s i o n a l s t a b b i n g p a i n s i n t h i s a r e a , h e s u f f e r e d n o d i s a b i l i t y u n t i l tile a g e o f 31 w h e n h e w a s t r e a t e d f o r a n e u r o t i c b r e a k d o w n . H e b e c a m e d e p r e s s e d w i t h s o m e e x a c e r b a t i o n o f his r n n a i n a t i v e t e n d e n c i e s f o l l o w i n g a n i n c i d e n t in a g r a v e y a r d in w h i c h h e h a d b e e n s h o c k e d b y tile o b s c e n e ~ n d d i s r e s p e c t f u l b e h a v i o r t o w a r d s t h e d e a d o f s o m e g r a v e d i g g e r s h e w a s ass i s t i n g . F o u r y e a r s l a t e r a t a t i m e w h e n h e h a d b e e n w o r r i e d b y a n i n c r e a s e in t h e s e v e r i t y o f his h e a d a c h e s , h e e x p e r i e n c e d e p i s o d e s o f . d e r e a l i s a t i o n w h i c h g r a d u a l l y i n c r e a s e d in s e v e r i t y a n d d u r a t i o n u n t i l h e w a s c o n t i n u o u s l y d e r e a l i s e d . H e f e l t as if a veil h a d c o m e d o w n b e t w e e n h i m s e l f a n d t h e o u t s i d e w o r l d . H e f e a r e d g o i n g o u t . H e also s u f f e r e d a n u m b e r o f a t t a c k s o f o n e h o u r ' s d u r a t i o n in w h i c h a d i s p l a y o f c o l o u r e d z i g - z a g s c o n f i n e d to t h e r i g h t h a l f o f his v i s u a l fields w e r e c o m b i n e d w i t h s e v e r e b l u r r i n g o f v i s i o n . O n a d m i s s i o n h e w a s a n x i o u s , a g i t a t e d a n d a l m o s t w h o l l y p r e o c c u p i e d w i t h t h e p r o d u c t s o f his compulsive self-scrutiny. There were no al)normalities on clinical examination. Tile visual fields w e r e f u l l a n d t h e E . E . G . s h o w e d s o m e r u n s o f t h e t a f r e q u e n c y in t h e l e f t p o s t e r i o r t e m p o r a l r e g i o n , w h i c h w e r e p r o b a b l y w i t h i n n o r m a l l i m i t s . X - r a y o f his s k u l l r e v e a l e d a c a l c i f i e d i n t r a - c e r e b r a l h e m a t o m a in his l e f t t e m p o r a l l o b e . T h e p a t i e n t ' s s y m p t o m s r e s p o n d e d to p s y c h i a t r i c t r e a t m e n t a n d a f t e r s o m e t h r e e m o n t h s o f d i s a b i l i t y h e is n o w b a c k a t w o r k . C a s e 6 . - - T h i s p a t i e n t h a d b e e n p r o n e to o d d f a i n t s b e f o r e h e r p e r i o d s , w h i c h h a d always b e e n h e a v y . At the age of 28 her long a w a i t e d p r e g n a n c y e n d e d in a stillbirth a n d at m o r e o r less t h e s a m e t i m e h e r u n m a r r i e d y o u n g e r s i s t e r g a v e b i r t h to a h e a l t h y c h i l d . T h e p a t i e n t d e v e l o p e d a p h o b i c a n x i e t y s y n d r o m e w i t h dizziness, h o t flushes, occasional o l f a c t o r y h a l l u c i n a t i o n s , u n c o n s c i o u s n e s s w i t h i n c o n t i n e n c e o f u r i n e o n o n e o c c a s i o n , ddid vu a n d h y p n a g o g i c sensations. She was also p r o f o u n d l y d e p r e s s e d at times a n d m a d e a suicidal att e m p t b y g a s p o i s o n i n g . Tile E . E . G . s h o w e d slight excess of t h e t a a c t i v i t y a n d occasional s h a r p i s h w a v e s ~n t h e t e m p o r a l r e g i o n s . A n t i - c o n v u l s a n t s w e r e g i v e n w i t h l i t t l e e f f e c t , b u t h e r n e u r o t i c s y m p t o m s g r a d u a l l y a b a t e d a n d s h e r e s u m e d a n a c t i v e life h e l p i n g h e r h u s b a n d w i t h his g r e e n g r o c e r y business. F o r a y e a r she has not h a d a~y attacks a n d she has not been receiving anti-convulsant treatment. C a s e 7 . - - T h i s p a t i e n t ' s illness b e g a n at the a g e of 48 years. H e was k n o c k e d d o w n b y a m o t o r v e h i c l e a t w o r k a n d r e n d e r e d u n c o n s c i o u s f o r s o m e t h r e e to f o u r m i n u t e s . E x a m i n a t i o n in t h e c a s u a l t y d e p a r t m e n t r e v e a l e d n o e x t e r n a l i n j u r y t o t h e s c a l p a n d a n x - r a y o f t h e s k u l l s h o w e d n o e v i d e n c e of a f r a c t u r e . T h e r e w a s n o q u e s t i o n o f c o m p e n s a t i o n a n d h e m a d e a r a p i d r e c o v e r y f r o m t h e i m m e d i a t e effects of the accident. H e r e t u r n e d to w o r k t e n d a y s l a t e r a n d h i s first a t t a c k o c c u r r e d a f e w d a y s a f t e r w a r d s . I n i t i a l l y h e e x p e r i e n c e d a b u z z i n g in h i s l e f t e a r w h i c h e n d e d in a l o u d s n a p . H e t h e n f e l t " b l a n k . . . . as if h e w e r e nowhere" and experienced sensations of giddiness, palpitations, sweating and unexplainable fear. These symptoms lasted half an hour and recurred about twice a week. He never lost c o n s c i o u s n e s s d u r i n g a n a t t a c k b u t w h i l e t h e s y m p t o m s w e r e p r e s e n t h e h a d to s t o p his w o r k a n d sit d o w n . H e a l s o h a d a t t a c k s in w h i c h h e f e l t s u s p e n d e d in s p a c e a n d d u r i n g these episodes people standing near him would seem transformed into animals. The memory o f his m o t h e r w h o h a d d i e d r e c e n t l y f o r c e d i t s e l f i n t o his m i n d a n d h e h e a r d h e r c a l l i n g his n a m e . H e h a d insight into t h e h a l l u c i n a t o r y n a t u r e of this p h e n o m e n o n . In a d d i t i o n he betzame depressed, i n c r e a s i n g l y irritable a n d intolerant of c r o w d s a n d enclosed places. H e h a d s u i c i d a l t h o u g h t s a n d w a s o b s e s s e d b y t h e f e a r o f l o s i n g his s a n i t y . H e e x p e r i e n c e d frightening hypnagogic sensations of falling and suffered from initial insomnia. There w e r e n o e p i s o d e s o f t/did v u s e n s a t i o n s a n d n o o l f a c t o r y h a l l u c i n a t i o n s . As a c h i l d h e h a d b e e n a l i t t l e 'shy b u t o t h e r w i s e n o r m a l . W h i l e s e r v i n g as a p r o f e s s i o n a l s o l d i e r o n t h e N o r t h W e s t F r o n t i e r in 1 9 2 9 h e h a d h a d a b r i e f e p i s o d e o f s h e l l s h o c k . H i s personality was that of a markedly obsessional man, easily upset by inefficiency, who p l a n n e d his w o r k as a c l e r k t o t h e l a s t d e t a i l . B o t h a t w o r k a n d s o c i a l l y h e w a s r e g a r d e d as a s t a b l e m a n w h o c o u l d a l w a y s b e r e l i e d u p o n . H e w a s r e f e r r e d f o r p s y c h i a t r i c t r e a t m e n t

TElk~PORAL LOBE E P I L E P S Y

20~

a y e a r a f t e r t h e o n s e t o f his illness. B e c a u s e o f t h e n a t u r e o f h i s a t t a c k s a d i a g n o s i s o f temporal lobe epilepsy was considered. An E.E.G. recording carried out under quinalbarbit o n e i n d u c e d s l e e p s h o w e d s u s p c i o u s s h a r p w a v e s in t h e r i g h t t e m p o r a l r e g i o n , b u t f u r t h e r recordings using both intravenous thiopentone and also bemegride as a c t i v a t i n g a g e n t s f a i l e d to r e v e a l a n y a b n o r m a l i t y . ( I n a r e c e n t r e c o r d i n g , i n d u b i t a b l e r i g h t t e m p o r a l s h a r p waves and spikes were noted.) His symptolns were improved with benactyzine hydrochloride and he was then given eight injections of intravenous thiopentone which were followed by a marked reduction in t h e l e v e l o f his d i f f u s e a n x i e t y s t a t e . H e h a d n o f u r t h e r a t t a c k s a n d r e t u r n e d to w o r k . H e w a s d i s c h a r g e d f r o m the D e p a r t m e n t a n d has r e m a i n e d free of n e u r o t i c s y m p t o m s for t h r e e y e a r s , in s p i t e o f a s e r i o u s p h y s i c a l i l l n e s s o n e y e a r a g o . A f t e r g r a d u a l l y i n c r e a s i n g c o n s t i p a t i o n a n d a b d o m i n a l p a i n h e w a s o p e r a t e d u p o n a n d a n e n d to e n d a n a s t o m o s i s w a s performed for diverticulitis of the colon.

A T e m p o r a l L o b e Epileptic w i t h a Phobic A n x i e t y State C a s e 8 . - - T h i s p a t i e n t w a s t h e sixth c h i l d in a c l o s e a n d m u t a l l y i n t e r d e p e n d e n t f a m i l y . H e r m o t h e r "'lived f o r t h e c h i l d r e n " a n d h e r f a t h e r , s t r i c t b u t g o o d - t e m p e r e d , always " ' p u t t h e f a m i l y first." As a c h i l d s h e e n j o y e d a full life f r e e f r o m n e u r o t i c d i s a b i l i t i e s , though something of a tomboy. She was an average scholar, but her school work and her l a t e r w o r k a d j u s t m e n t w e r e d i s t u r b e d b y e p i l e p t i c fits. T h e s e b e g a n w h e n s h e w a s 11 y e a r s old and became more frequent when her periods began a year later, and they necessitated a y e a r ' s t r e a t m e n t in a n e p i l e p t i c c o l o n y w h e n s h e w a s 18. T h e a t t a c k s w h i c h a r e g r a n d m a l in t y p e h a v e s h o w n a m a r k e d t e n d e n c y to o c c u r in t h e p r e m e n s t r u a l p h a s e o f t h e m e n s t r u a l c y c l e . A n t i - c o n v u l s a n t t r e a t m e n t h a s r e d u c e d t h e f r e q u e n c y o f t h e fits w h i c h n o w o c c u r only about once every three months. An E.E.G. showed brief paroxysms of slow activityw i t h s p i k e s o f m a x i m m n a m p l i t u d e in t h e r i g h t t e m p o r a l r e g i o n d u r i n g h y p e r v e n t i l a t i o n . A t t h e a g e o f 21 y e a r s s h e m a r r i e d a j o i n e r - - a q u i e t p e r f e c t i o n i s t w h o w a s "'all f o r t h e h o m e . ' " A f e w m o n t h s l a t e r h e w a s c a l l e d u p f o r N a t i o n a l S e r v i c e , a n d f o r t h e first t i m e t h e p a t i e n t b e g a n l i v i n g a l o n e . H e r fits i n c r e a s e d in f r e q u e n c y , s h e b e c a m e n e r v o u s a n d depressed. Her husband was released from the army on compassionate grounds three m o n t h s b e f o r e h e w a s d u e f o r d e m o b i l i s a t i o n , a n d ~ f e w w e e k s a f t e r this t h e p a t i e n t m a d e a suicidal attempt by taking an overdose of primidone and coal gas poisoning. This was b e l i e v e d to h a v e t a k e n p l a c e in a n e p i l e p t i c t w i l i g h t s t a t e , b u t t h e r e w a s a l s o e v i d e n c e o f m a r i t a l d i s h a r m o n y a t this t i m e . H e r p s y c h i a t r i c s y m p t o m s t h e n r e m i t t e d , s h e b e c a m e p r e g n a n t a n d w a s l o o k i n g f o r w a r d to h a v i n g a f a m i l y . S h e r e m a i n e d w e l l f o r a p e r i o d o f six m o n t h s , w h e n h e r m o t h e r , o n w h m n s h e w a s v e r y d e p e n d e n t , w a s t a k e n ill w i t h a m e l e n a . T h i s p r e c i p i t a t e d a t y p i c a l p h o b i c a n x i e t y d e p e r s o n a l i z a t i o n s y n d r o m e in w h i c h s h e a l s o e x p e r i e n c e d t w i t c h i n g o f h e r e y e l i d s a n d b r i e f e p i s o d e s in w h i c h h e r m i n d b e c a m e b l a n k . S h e b e c a m e p a n i c s t r i c k e n w h e n a l o n e a n d w a s u n a b l e to s t a y in s h o p s t o c o m p l e t e h e r p u r c h a s e s . T h e s e s y m p t o m s l a s t e d a b o u t six m o n t h s a n d t h e n g r a d u a l l y i m p r o v e d . S h e h a d a n o r m a l d e l i v e r y o f a b a b y girl a n d s h e h a s r e m a i n e d f r e e o f s e v e r e p h o b i c s y m p t o m s f o r t h e l a s t t w o y e a r s , t h o u g h s h e still e x p e r i e n c e s f e e l i n g s o f p a n i c a n d u n r e a l i t y in s o m e s h o p s a t t i m e s . ACKNOWLEI~EMENTS

This study was made possible by a grant from the Mental Health Research Fund. We wish to thank Dr. Henry Miller and Dr. John Walton who made cases available to us f o r i n c l u s i o n in t h e c o m p a r a t i v e s t u d y a n d a l s o M r . R o w b o t h a m f o r p e r m i s s i o n t o i n c l u d e d e t a i l s o f a p a t i e n t o p e r a t e d o n b y M r . G o s s m a n in t h e N e u r o s u r g i c a l U n i t o f t h e N e w castle G e n e r a l Hospital. Mr. G a r s i d e , Senior P s y c h o l o g i s t , g a v e v a l u a b l e a d v i c e r e g a r d i n g t h e s t a t i s t i c a l h a n d l i n g o f t h e d a t a . D r . L e y b u r n a n d M r . O s s e l t o n a s s i s t e d in t h e c o l l e c t i o n and interpretation of the E.E.G. findings. REFERENCES

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Martin Roth, M.D., F.R.C.P., D.P.M., Professor of Psychological Medicine, Royal Victoria Infirmary and KinKs College Medical School, University of Durham, Newcastle upon Tyne, England. Max Harper, M.B., Ch.B., L.R.C.P., M.R.C.S., D.P.M., First Assistant, Department of Psychological Medicine, Royal Victoria Infirmary anal King's College Medical School, University o[ Durham, Ne~vca~le upon Tyne, England, Formerly Mental Health Research Fund Scientific Assistant.