Epilepsy & Behavior 1, 2736 (2000)

doi:10.1006/ebeh.1999.0021, available online at http://www.idealibrary.com on

REVIEW
Epilepsy and Behavior: A Brief History

Shawn L. Masia and Orrin Devinsky 1

NYUMt. Sinai Comprehensive Epilepsy Center, NYU School of Medicine,
New York, New York 10016

Received October 21, 1999; accepted for publication November 5, 1999

Behavioral changes both real and imagined have formed a halo around epilepsy since antiquity.
The myth of epilepsy as a curse has been largely vanquished in modern cultures, but the disorder
remains a social stigma for many patients. In ancient Rome people with epilepsy were avoided for fear
of contagion, in the Middle Ages they were hunted as witches, and in the first half of our century they
were labeled deviants and their marriage and reproduction were restricted by eugenistic medical
doctors. Religious conversion experiences can occur in temporal relationship to changes in seizure
frequency. Many religious leaders may have had epilepsy. However, changes in religious sentiment
are not characteristic of epilepsy patients. Recognized since the late 19th century, postictal psychosis
has stimulated theories regarding the mechanism of mania and psychosis. Understanding the patho-
physiology of behavioral changes in epilepsy may offer insight into the psychopathology of other
diseases. 2000 Academic Press
Key Words: epilepsy; behavior; history; religion; crime; Hippocrates; psychosis; womens studies;
personality; therapy.

Epilepsy has been recognized since the earliest med-
ical writings. Behavioral changes both real and
imagined have formed a halo around the disorder
since antiquity. The earliest medical texts on epilepsy
were on Egyptian papyri and Babylonian cuneiform
tablets. The Babylonians (circa 1050 bc) believed that
epilepsy was caused by demons and ghosts who con-
trolled some individuals (1). Early beliefs on supernat-
ural causation were probably fostered by both the
frightening appearance of the tonic clonic seizure and
the behavioral changes that are associated with epi-
lepsy and related neurologic disorders. The myth of
epilepsy as a curse from the gods has been largely
vanquished in Western cultures, but the disorder re-
mains a social stigma for many patients, as it has
throughout history. Further, the history of epilepsy
and epilepsy-related behavioral changes is compli-
cated because throughout most of recorded history
1
To whom correspondence should be addressed at NYUMt.
Sinai Comprehensive Epilepsy Center, 560 First Ave., Rivergate
Fourth Floor, New York, NY 10016. Fax: (212) 263-8342.
and medicine, episodes labeled as seizures were com-
posed mainly of tonic clonic and conversion events,
while complex partial and other minor seizures
were rarely recognized or correctly classified.
FROM ANTIQUITY TO THE 18TH
CENTURY
The Greek physician Hippocrates wrote the first
book about epilepsy, On the Sacred Disease, around 400
bc. He recognized that epilepsy was a brain dysfunc-
tion and argued against the ideas that seizures were a
curse from the gods and that people with epilepsy
could predict the future. Hippocrates wrote:
I am about to discuss the disease called sacred. It is not in my
opinion any more divine or more sacred than other diseases, but has
a natural cause, and its supposed divine origin is due to mens
inexperience, and to their wonder at its peculiar character. Now
while men continue to believe in its divine origin because they are
at a loss to understand it, they really disprove its divinity by the
facile method of healing which they adopt, consisting as it does of

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28 Masia and Devinsky

purifications and incantations. But if it is to be considered divine In the late 18th century, Cullen defined a new category
just because it is wonderful, there would be not one sacred disease of neurologic disorders that lacked a localized or de-
but many. (2, p. 139)
fined lesion as the neuroses, including epilepsy, hys-
teria, and chorea (5).
Superstition and intense stigma surrounded epi-
lepsy for the next two millennia despite Hippocrates
authority. For centuries, epilepsy was considered a
THE 19TH CENTURY
curse of the gods or an evil possession, leading to
social isolation for the one who had epilepsy and, in
The first asylums were created to house psychiatric
many cases, for his or her family as well. In some
and epileptic patients during the early 19th century.
cultures, people with epilepsy were isolated from oth-
The fear that epilepsy was contagious was con-
ers to prevent spread of the disorder. In Roman times,
firmed, probably through the production of nonepi-
others would spit at people with epilepsy, to throw
leptic psychogenic seizures in the psychiatric popula-
back the contagion. Slaves could be returned as de-
tion. The astute observation but incorrect theory led to
fective merchandise and a refund demanded if epi-
a separation of these two groups. For example, one of
lepsy was identified. References throughout ancient
the founders of psychiatry, Etienne Esquirol, feared
Greek and Roman medical texts indicate that the per-
the spread of epilepsy to those who only had mental
son with epilepsy was viewed with disgust and that
disorders (6). However, asylums provided the first
the connotations of sacred may have largely re-
opportunity to closely study and systematically ob-
flected the frightening, awesome, and taboo aspects of
serve epilepsy in a population. The segregation of the
the disorder. The seizure of a persons soul and body
two populations also led to the creation of hospitals
by gods or demons may have simultaneously made
for the paralyzed and epileptic in the late 1800sfrom
epilepsy sacred and untouchable (3). In most ancient
Queen Square in London (1860) to Blackwells Island
societies, people with epilepsy hid their horrid disor-
in New York (1867).
der as best they could.
In the early 19th century, marriage was sometimes
Possession, magic, and witchcraft became dominant
recommended by doctors, mainly for women with
themes applied to epilepsy and its origins during the
epilepsy, as a method to improve seizure control. For
Middle Ages; diagnosing and treating possession
example, Prichard (1822) described a woman who had
were the focal points of epilepsy care. The handbook
catamenial epilepsy for 4 years. When she married
on witch hunting, Malleus Maleficarum, written by two
and became pregnant, seizures ceased. Prichard and
Dominican friars under papal authority in 1494, iden-
others believed that marriage could improve catame-
tified witches by the presence of certain characteris-
nial seizures, even if a woman did not become
tics, including seizures. The book also said that
pregnant (7). Subsequent studies by Gowers and
witches could cause epilepsy to develop:
Escheverria disproved this notion (8).
Legal barriers to marriage for men and women with
For although greater difficulty may be felt in believing that
witches are able to cause leprosy or epilepsy, since these diseases epilepsy represent a black page in the history of epi-
generally arise from some long-standing physical predisposition or lepsy in the United States. These laws persisted in
defect, none the less it has sometimes been found that even these some states into the mid 19th century. Based on his
have been caused by witchcraft. (4) experience with outpatients and his role as the medi-
cal superintendent of the Craig Colony for Epileptics
The Malleus brought a wave of persecution and tor- (the first major epilepsy colony in the United States,
ture and contributed to the socially sanctioned execu- located in upstate New York), Spratlings landmark
tion of between 100,000 and 1,000,000 women. American monograph on epilepsy (9) offered a pessi-
During the 18th centurys Enlightenment, the Hip- mistic view on epilepsy and marriage:
pocratic belief epilepsy as a physical disorder of the
brain, not a supernatural curse gained acceptance. The marriage of epileptics is sometimes urged for its supposed
During the same time, interest in the role of the moon favorable influence on the disease, but so far as my observation goes
as a cause of epilepsy and insanity (lunacy is from the . . . (marriage has) no beneficial effect on the disease . . . marriage
confers a license for the creation of a diseased progeny generally
word luna, meaning moon) had wider acceptance, as
lower in mental, moral, and physical stamina than their antecedents.
did the role of masturbation. The use of amulets, rings, This fact alone should be sufficient to deny the epileptic the right of
charms, holy rituals, incantations, human skull bones, marriage in fully ninety-five out of every hundred cases. (pp. 302
and magical therapies waned during the 18th century. 303)

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Epilepsy and Behavior: A Brief History
The negative social and medical views on epilepsy
spilled over into the eugenics movement, a malformed
child of social Darwinism that sought to limit the
reproduction of inferior people, including those with
epilepsy. Connecticut enacted the first eugenics laws
against people with epilepsy in 1895. In the early
1900s, epilepsy colonies were established in many
states. At the time, the creation of these colonies was
considered a very progressive approach to epilepsy
care. These colonies offered rest, bromides, and sys-
tematic study and a way for wealthy families to rid
themselves of the embarrassment and discomfort of
epilepsy. In a popular American text on neurology,
Munson (1913) provided a sobering social view of
epilepsy:
Institutional treatment for all epileptics is advocated as far as the
public purse will permit . . . prophylaxis by legal means as far as
possiblesegregation, operation, limitation of marriage; but above
all by the education of the public to the dangers of matings between
the unfit. (10)
On limiting marriage among persons with epilepsy,
Munson said, Legal limitation of marriage . . . is not
. . . sufficiently far-reaching, as many of the most dan-
gerous matings (from the eugenics standpoint) are
consummated outside the bonds of wedlock (10, p.
271).
By the mid 20th century, Americans viewed epi-
lepsy as both a social and a medical disease. Individ-
uals were isolated and legislated against in employ-
ment and in laws regarding driving, marrying, repro-
ducing, and becoming a parent. Families hid the
presence of epilepsy, fearing stigma against them-
selves and limited marriage opportunities for rela-
tives. By 1966 only 3 states (West Virginia, North
Carolina, and Virginia) had eugenic marriage laws
against epilepsy, while 13 states still had eugenic ster-
ilization laws against people with epilepsy (although
they were rarely enforced at this late date) (11).
EPILEPSY AND RELIGION
The association between epilepsy and religion,
noted by Hippocrates, persisted for more than 2000
years in societal and medical writings. The religious
nature of people with epilepsy was stressed by 19th-
century physicians such as Esquirol (1838), Benedict
Morel (1860), and Henry Maudsley (1879). Maudsley
noted that Siberian medicine men of his day always
preferred pupils with epilepsy (12). In the late 19th
29
TABLE 1
Religious Figures Alleged to Have Had Epilepsy
St. Paul (16)
St. Cecelia (16)
Mohammed (16)
Saul, First King of Israel (16)
St. Ignatius of Loyola (18)
St. Teresa of Avila (18)
Anne Lee (founder of the Shakers sect) (88)
Buddha (16)
Jacob Boehm (16)
George Fox (founder of the Quakers sect) (16)
century, Howden reported on a patient who had a
conversion experience following an epileptic fit: He
maintained that God had sent (the vision) to him as a
means of conversion, that he was now a new man and
had never before known what true peace was (13).
Howden viewed religiosity as a personality trait, de-
scribing a strong devotional feeling, manifesting it-
self . . . in decided religious delusions among those
with epilepsy. However, Howden, Gowers (1881), and
others viewed this trait as a craving for sympathy by
the desperate, helpless, intellectually deteriorating ep-
ileptic (1315).
Epilepsy and seizures have allegedly afflicted a
large number of major religious leaders (Table 1). On
the road to Damascus, the Apostle Paul described a
sudden flash of light from heaven which surrounded
him. He fell to the ground and heard a voice, which he
believed was the voice of Jesus. He then reportedly
suffered from blindness for 3 days. Bryant (1953) as-
serted that a tonic clonic seizure was responsible for
St. Pauls experience and that his thorn in the flesh
was his description of his epilepsy (16). However,
alternative explanations for St. Pauls illness include
chronic appendicitis (17) and migraine (18).
A similar controversy surrounds the case of Mo-
hammed, founder of Islam. Evidence suggests that
Mohammed was slightly hydrocephalic and that sei-
zures began at age 3 and continued throughout his life
(17). Lennox described preictal states of depression
and ringing bells and seizures which consisted of fixed
eyes and convulsive head movement, often ended
with copious perspiration, and occasionally led to col-
lapse and generalized convulsions (18). Accounts from
the Koran are suggestive of epilepsy:
Inspiration cometh in one of two ways; sometimes Gabriel com-
municateth the revelation to me as one man to another, and this is
easy; at other times it is like the ringing of a bell, penetrating my
very heart, and rending me. (16)
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30
Fydor Dostoevskys seizures often began with an
ecstatic aura (3). Dostoevsky recalled an aura that he
had upon receiving a visit from an old friend:
They talked . . . finally . . . on religion. The friend was an atheist,
Dostoevsky a believer; both were passionately convinced, each in
his way. God exists, he exists, Dostoevsky finally cried, beside
himself with excitement. At the same moment the bells of the
neighboring church rang for Easter matins. The air was vibrant and
full of sound. And I felt . . . that heaven had come down to earth
and had absorbed me. I really perceived God and was imbued with
Him. Yes, God exists. (19)
His account of the experience continued and offered
more insight into the experiences of Mohammed. He
said:
All you, healthy people . . . do not even suspect what happiness is,
that happiness which we epileptics experience during the second
before the attack. In his Koran Mohammed assures us that he saw
paradise and was inside. All clever fools are convinced that he is
simply a liar and a fraud. Oh no! He is not lying! He really was in
paradise during an attack of epilepsy, from which he suffered as I
do. I do not know whether this bliss lasts seconds, hours, or months,
yet take my word, I would not exchange it for all the joys which life
can give. (19)
James Leubas classic monograph (1925) on reli-
gious mysticism provides a nonmedical perspective:
Among the dread diseases that afflict humanity there
is only one that interests us quite particularly; that
disease is epilepsy (20). Throughout the 20th century,
there were many anecdotal reports relating epilepsy
and heightened religious sentiment (2125). In 1970,
Dewhurst and Beard (26) reported six temporal lobe
epilepsy patients, with either bilateral or unilateral
independent epileptiform discharges, who underwent
sudden religious conversion. Some of these patients
had prior or active psychiatric disorders. However, in
five of the six cases, the conversion occurred immedi-
ately following either an isolated seizure or a cluster of
seizures. Dewhurst and Beard viewed the conversion
experience through Jacksons (1876) theory (27): the
duplex nature of the discharge caused loss of func-
tion of the highest centers with a superimposed in-
creased function of the lower centers. The resulting
alteration in the level of consciousness provides a
suitable psychological milieu for a religious conver-
sion experience to take place.
EPILEPSY, HYSTERIA, AND
BEHAVIORAL CHANGES IN WOMEN
Two surveys of the history of epilepsy (3, 18) show
a strong male bias in the medical writings on epilepsy
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Masia and Devinsky
from ancient to more recent times. The notable excep-
tions regard two areas of aberrant behavior: witchcraft
and hysteria (conversion disorder). The Kahun Papy-
rus, an ancient Egyptian medical document (1900 bc),
identified many disorders believed to arise from ab-
normal movement of the uterus, including blindness,
the inability to open ones mouth, a desire to stay in
bed all day, and generalized body ache (28). The Hip-
pocratic writings named this hysteria (from womb,
hystera). Initially, Greek writings related hysteria with
respiratory difficulties. Women deprived of sexual re-
lations developed a dry, atrophic uterus that would
rise in the body to find moisture and impede breath-
ing. When the womb came to rest in the abdomen, it
caused epilepsy (28, 29). Differential diagnosis, essen-
tial for appropriate therapy, was sometimes accom-
plished by digital pressure on the womans lower
abdomen. If the pressure was felt, the disorder was
hysteria; if not, it was probably epilepsy (28, 29). This
technique was subsequently reintroduced with modi-
fication (ovarian compression) by Charcot in the late
1800s (30). Later, Greeks believed that hysterical loss
of consciousness due to upward migration of the
womb was not accompanied by convulsive move-
ments. Paracelsus, in the early 16th century, observed
that if the womb touches the heart the convulsion is
similar to epilepsy with all its symptoms (31).
The modern history of hysteria and epilepsy began
with Willis, who in 1684 first suggested that hysteria
was a disorder of brain function and emphasized the
association of epilepsy and hysteria, speculating that
both disorders have similar mechanisms (28). The co-
existence of hysteria and epilepsy within one patient
was first recognized in 1836 by Beau. Shortly after,
Esquirol (1838) observed hysteric patients who are at
the same time epileptics . . . With a little practice one
could recognize very well, when the attacks are sepa-
rate, to which of the two diseases the convulsions
belong to which the patient is actually prey (6).
Around the same time, Landouzy postulated the co-
existence of two neuroses, with distinct attacks, to
which he gave the name hystero-epilepsy with sep-
arate crises (32). Subsequently, the coexistence of the
two disorders was discussed by Trousseau (33),
Dostoevsky in The Brothers Karamozov (34), DOlier
(35), and Gowers (15), with attention focused on dif-
ferentiating the two types of seizures.
Modern psychiatry was partly ushered in by Mes-
merism, which laid the foundation for hypnosis and
the first rigorous study of hysteria in the late 1800s
(28). Many of Mr. Mesmers clients were women with
probable somatoform or conversion disorders. The
Epilepsy and Behavior: A Brief History
study of hysteria was later advanced by Charcot and
colleagues at the Salpetriere in Paris, where studies on
hysteria and hysteroepilepsy flourished (30). Char-
cots work on hysteria helped stimulate Freuds inter-
est in psychiatry and early development of psychoan-
alytic theory.
Henry Maudsley considered feelings of sexual pas-
sion a factor in causing insanity in women: . . . its
influence on every pulse of organic life, revolutioniz-
ing the entire nature, conscious, and unconscious . . .
when there is no vicarious outlet for its energy . . .
restlessness and irritability . . . instinctive frenzy (36).
Echeverria elaborated upon this model: It is not,
therefore, difficult to understand how unnatural at-
tempts to menstruationfirst evidence of puberty
may superinduce the actual appearances of epilepsy
in a constitution so much disturbed and irritable (37).
He then noted the clear relation, in many women,
between an exacerbation of epileptic attacks and uter-
ine functions, specifically from unhealthy excitement
by the established uterine discharge.
EPILEPSY AND PERSONALITY
The notion of an epileptic personalitythat there is
a nearly ubiquitous and characteristic negative set of
behavioral changes in epilepsy patients evolved
slowly, a collage formed by stigma, misunderstand-
ing, and the diverse behavioral changes that occur in
epilepsy patients who often had concurrent CNS dis-
orders (e.g., neurosyphilis). Prior to 50 years ago, ep-
ilepsy was often diagnosed only if convulsions oc-
curred. This excluded many patients with partial, ab-
sent, and myoclonic seizures, but included many with
conversion seizures. Thus, the causes of epilepsy, cri-
teria for diagnosing epilepsy, and psychiatric nomen-
clature that formed the basis of defining an epileptic
personality have changed dramatically during the
past century.
Modern views evolved during the 19th century.
From his extensive experience with a private outpa-
tient population with idiopathic epilepsy, Reynolds
(38) concluded that epilepsy does not necessarily in-
volve any mental change and that depression of spirits
and timidity are common in males and excitability of
temper occurs in both sexes. Gowers also recognized
that many epilepsy patients had normal personality
and intellect, but that many others developed inter-
paroxysmal behavioral changes (15). He suggested
that behavioral changes resulted mainly from epi-
lepsy. The early 20th century brought divergent views
31
on people with epilepsy and behavior. Kinnier Wilson
offered a psychosocial view: On epileptic tempera-
ment inordinate stress has been laid. Life is difficult
for these patients, and much that is attributed to tem-
perament can with greater reason be assigned to
chronic invalidism and unlucky circumstance (39).
Sjobring synthesized the negative epileptic personal-
ity: a mental change of a specific nature takes place in
individuals suffering from epileptic seizures. They be-
come torpid and circumstantial, sticky and adhesive,
effectively tense and suffer from explosive outbursts
of rage, anxiety, etc. (40).
The association of temporal lobe epilepsy (TLE) and
behavioral changes began when Gibbs (1951) noted
frequent behavioral disorders among patients with
temporal lobe seizure foci (41). Gastaut and colleagues
recognized that many behaviors in TLE patients (de-
creased sexual appetite, hypoactivity, increased ag-
gressivity) were opposite to those in patients with the
KluverBucy syndrome (KBS) (42). KBS is character-
ized by (i) prominent oral exploratory behavior, (ii)
increased sexual appetite, (iii) visual agnosia, (iv) dis-
tractibility and increased environmental exploration,
and (v) decreased aggressivity following bilateral tem-
poral lobe ablations (43). Evidence from the KBS, first
described in male rhesus monkeys, as well as other
clinical data (e.g., human and animal rabies infections
with prominent lesions in amygdala and hippocam-
pus) helped establish the link between TLE and al-
tered behavior.
Against the background of a confused but largely
negative portrait of behavior in patients with epilepsy,
Waxman and Geschwind proposed a syndrome of
nonpsychopathologic interictal personality changes in
patients with TLE deepened emotions, circumstan-
tiality, altered religious and sexual concerns, and hy-
pergraphia (44). Deepening of emotions was a central
feature characterized by intense interpersonal contact
and sustained intense affect. Some features were not
necessarily maladaptive or negative; the syndrome
was one of behavioral change rather than behavioral
disorder. Bear and Fedio expanded this syndrome to
18 traits, based on a literature review, and found an
increased frequency of all 18 traits in patients with
temporal lobe epilepsy when compared with normal
or neurological controls (45). The identification of
characteristic behavioral changes, supported by a clin-
ical study with highly significant findings, fostered
controversy and met with limited support from repli-
cation studies (46 53). The methodologic issues and
current status of this debate have been recently re-
viewed (54, 55). Behavioral changes do occur in pa-
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32 Masia and Devinsky

TABLE 2
Interictal Personality Traits Attributed to Patients with Epilepsy

Trait Clinical observation

Aggression Overt hostility, rage attacks, violent crimes, murder

Altered sexual interest Loss of libido, hyposexualism, fetishism, transvestism, exhibitionism, hypersexual episodes
Circumstantiality Loquacious, pedantic, overly detailed, peripheral
Decreased emotionality Emotional indifference, lack of initiative, dullness, hyperexcitability
Dependence, passivity Helplessness, at hand of fate, always requires assistance
Elation, euphoria Grandiosity, exhilarated mood, diagnosis of bipolar disorder
Emotional lability Prominent mood changes with minor or no stimuli
Guilt Tendency to self-scrutiny and self-recrimination
Humorlessness, sobriety Overgeneralized ponderous concern, humor lacking or idiosyncratic
Hypergraphia Keeping extensive diaries, detailed notes, writing
Hypermoralism Attention to rules with inability to distinguish significant from minor infraction, desire to punish
Hypomoralism Lack of attention to rules, lack of understanding or concern of good and bad
Increased emotionality Deepening emotions, sustained intense affect, increased sensitivity, brooding
Irritability Increased anger, temper
Obsessionalism Ritualism, orderliness, compulsive attention to detail
Paranoia, jealousy Suspicious, overinterpretation of motives and events, diagnosis of paranoid schizophrenia
Philosophical interest Nascent metaphysical or moral speculations, cosmological theories
Religiosity Holding deep religious beliefs often idiosyncratic, multiple conversations mystical states
Sadness Hopelessness, discouragement, self-deprication, diagnosis of depression, suicide attempts
Sense of personal destiny Egocentricity, personal events highly charged, devine guidance ascribed to many features of patients life
Viscosity Stickiness, tendency to repetition

tients with TLE and other epilepsy syndromes. How-
ever, the spectrum, frequency, and specificity of dif-
ferent behavioral changes remain uncertain. Table 2
lists the various interictal behavioral traits attributed
to patients with epilepsy.
POSTICTAL PSYCHOSIS
(A.K.A. EPILEPTIC MANIA)
Hughlings Jackson considered the behavioral
changes during the postictal period as a key to under-
standing psychiatric disorders. By 1889 when he wrote
his classic paper On Post-epileptic States: A Contri-
bution to the Comparative Study of Insanities, post-
ictal behavioral changes were receiving increased at-
tention (27). Both Savage (1886) and Clouston (1887)
recognized that the paroxysmal and intermittent men-
tal symptoms in epilepsy patients were most often
postictal (56, 57). Savage noted: It is common to meet
with cases in which immediately before or after the fit,
an outburst of uncontrollable fury of the most destruc-
tive kind takes place (57).
Jackson reversed his early (1867) belief that epileptic
mania was the direct result of an epileptic discharge
from some portion of the brain. Initially, he consid-
ered that in some cases of true mania a prior seizure is
not witnessed and the mania occasionally replaces a
fit. However, he later (1873) stated that The duplex
condition is found . . . when the discharge is over. The
mental Automatism is one of the indirect results of the
(epileptic) discharge (27).
Jackson explained postepileptic states and other
mental disorders by a model in which the highest
centers, the organ of mind, were composed of four
theoretical layers (which he did not believe corre-
sponded to layers of cerebral cortex). Thus, after a
seizure all the cells involved in the discharge tempo-
rarily lost their function. This transient lesion led to
the production of both positive and negative symp-
toms (27). Negative symptoms included the paralysis
noted by Robert Todd years earlier (58) and, in severe
cases, coma. Jackson proposed that if the first layer of
the highest center were to discharge, its exhaustion
would lead to dissolution of the second layer, which
would remain active and would be expressed due to
its loss of inhibition or modulation by the higher layer.
He wrote:
Thus in the first degree of post-epileptic states the patients then
highest layer is the second layer of his normal highest centres, and
his mentation is correlative with activities of that layer. What we call
the insane mans extravagant conduct displays his Will; what we
call his illusions are his Perceptions (Memory); what we call his

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Epilepsy and Behavior: A Brief History
delusions are his beliefs (his Reasoning); and what we call his
caprice is evidence of his Emotional change. (27, p. 498)
While the functional loss of the first layer might lead
to impairment of consciousness, temporary lesions of
the second layer would lead to loss of consciousness
and the subsequent expression of the third and fourth
layers, which could resemble insanity to the observer.
Thus, deprived temporarily of his or her highest fac-
ulties, the patient would unconsciously express lower
level automatisms, which could consist of relatively
complex behaviors ranging from the harmless to the
homicidal:
In the process of slow re-evolution, during return to complete
consciousness after slight fits, there are really often actions which
are little heeded as post-epileptic states; the patient may take out his
watch, look at his papers, ask what day it is, what oclock it is, etc.
(reorientation). (27, p. 493)
EPILEPSY AND CRIMINAL
RESPONSIBILITY
The 19th-century debate over whether people with
epilepsy should be held responsible for crimes they
committed during or around the time of a seizure was
mired in conceptual differences concerning the subject
of consciousness. Both Benedict Augustin Morel and
Jules Falret noted aggressive behavior in people with
long-standing or severe epilepsy. Morel (1853) de-
scribed the phenomenon of epileptic fury, a person-
ality disturbance which would arise like lightning
and [become] condensed in terrible deeds (59). Falret
emphasized that the aberrant behavior expressed be-
fore, during, and after seizures consisted entirely of
automatisms and was devoid of premeditation and
motivation (60), much like the unconscious cerebra-
tion described by the English neurologist Carpenter
(61). Falret believed the patient was therefore not at all
responsible for violent acts committed by him in the
midst of this completely automatic, though short, de-
lirium (62, p. 321), whether these actions be homi-
cidal or otherwise criminal. He did, however, note
rare exceptions in which these acts could be driven by
motives or calculation, but that these were often the
result of the seizures disruption of the individuals
control over unacceptable feelings and motivations.
Echeverria (1873) discussed the case of David Mont-
gomery, a man who murdered his wife, a known
33
prostitute, after a week of seizures which left him
agitated and delusional (63). In describing the crime to
police, Montgomery stated, I stood with the ax about
five minutes looking at her, and seemed impelled to
strike her, and though I did not want to, I had to strike
the blow and my temper got the upper hand of me
(63). He later fell asleep, and when he woke he was
disoriented to his surroundings and denied any mem-
ory of murdering his wife. During Montgomerys trial,
Dr. William A. Hammond stated that deliberation
takes away the idea of an insane act, and, therefore, if
the prosecution could prove that Montgomery delib-
erated, the jury should convict him of murder (63).
Echeverria, however, countered this argument stating
that the week of seizures that preceded the murder,
along with a seizure which may have occurred the
morning of the murder, left Montgomery in a state of
unconscious cerebration and that as such he was not
in volitional control of his actions (64).
P. Samt (65, 66) reintroduced Hoffmans (67) theory
of psychic equivalents to explain epileptic insanity.
He felt seizures need not take the form of stereotypical
convulsions and could rather consist of psychomotor
disturbances. This idea conflicted with Jacksons the-
ory of dissolution discussed above, as Jackson be-
lieved that epileptic insanity was the result of exhaus-
tion of the highest cerebral faculties and the subse-
quent release of inhibition of lower faculties (27).
Psychic equivalents could take the form of extreme
violence or delirium and were often accompanied by
impairments of memory (65, 66). After reviewing
more than 40 cases of epileptic insanity, Samt con-
cluded that consciousness was a relative state and
could at times be partially impaired. Memories of
events during seizures were sometimes present post-
ictally and interictally, but were fleeting for most pa-
tients. In order for a person to have any memory at all,
however, he must have had some measure of con-
sciousness during his seizure.
The benefit of over a century of perspective has not
simplified the debate. Postictal agitation and nondi-
rected aggression are common in patients with postic-
tal psychosis (68). However, other accounts of criminal
behavior caused by epilepsy are rare and often uncon-
vincing (69). Directed violence during an epileptic
seizure is very rare (70, 71). The claim that people with
epilepsy have an increased incidence of interictal vio-
lence compared to the rest of the population (7275)
has not been substantiated in large-scale studies (48,
70, 76, 77).
Copyright 2000 by Academic Press
All rights of reproduction in any form reserved.
34
THERAPIES FOR EPILEPSY
Historically, therapies prescribed for epilepsy have
been extremely varied and limited only by imagina-
tion and the size of the human mouth, but not neces-
sarily pain tolerance or efficacy. Edward Sieveking,
the English neurologist, observed, There is scarcely a
substance in the world capable of passing through the
gullet of man that has not at one time or another
enjoyed the reputation of being an anti-epileptic (78).
Swallowed remedies included cups of blood from re-
cently dead humans, powdered human skull, mistle-
toe, digitalis, silver nitrate, zinc oxide, and vulture
liver (3, 79). Other therapies included bloodletting,
purging, vomiting, diuresis, sweating, recommenda-
tion for increased coital activity or abstinence, press-
ing a hot metal button or iron on the head to drain a
pernicious humor, or trephining (opening) the skull to
allow evil spirits to escape.
Onanism had long been considered a cause of epi-
lepsy as well as of madness. Even Gowers, in 1881,
noted:
It was very difficult to determine the influence of masturbation
as a cause of epilepsy. The habit is common in epileptic boys, as
in others, but we cannot infer that, in all such cases, it is the cause
of the disease. The etiological relation can only be regarded as
established when the arrest of the habit, as by circumcision,
arrests the disease. But the converse is not true; the continuance
of the disease after the arrest of the practice does not disprove
the relationship, because, when the convulsive habit is estab-
lished, it frequently persists after its cause has ceased to be
effective. (14)
Georges Huette reported (1850) the effectiveness
of bromides in causing impotence in men and treat-
ing vivid imagination and masturbation (80). Based
on these results, Locock (1857) began to use bro-
mides for hysteria in young women (81). With some
success in this disorder, he extended the bromide
therapy to hysterical epilepsy when the epileptic
attacks only occurred during the catamenial pe-
riod, except under otherwise strong exciting causes
(3, p. 398). Seizures were cured in 13 of 14 of these
cases (81). Reynolds (1861) did not share his suc-
cessful responses (38). Wilks, who doubted Lococks
theory of bromides acting on ovarian irritation, re-
ported his successful therapy of men and women
with epilepsy in 1861 and was largely responsible
for the widespread use of bromides in antiepileptic
drug therapy (82).
Copyright 2000 by Academic Press
All rights of reproduction in any form reserved.
Masia and Devinsky
PATHOPHYSIOLOGY OF BEHAVIORAL
CHANGES IN EPILEPSY
As early as the times of antiquity, interictal person-
ality changes were noted in those patients who devel-
oped chronic epilepsy. The changes were believed to
relate to the nature of the disease itself or from the
wounds suffered during paroxysms (83). A behavioral
change associated with a localization-related epilepsy
suggests that specific structures are involved in the
pathogenesis, but how? Structural lesions such as me-
sial temporal sclerosis or dysplasia may contribute to
but not be associated with the frequency or intensity
of behavioral changes. An insightful hypothesis was
offered nearly 40 years ago by Sir Charles Symonds,
the epileptogenic disorder of function (84). While
discussing the pathophysiology of interictal psychosis
in TLE patients, he suggested:
If then neither the fits nor the temporal lobe damage can be
held directly responsible for the psychosis, what is the link? . . .
Epileptic seizures and epileptiform discharge in the EEG are
epiphenomena. They may be regarded as occasional expressions
of a fundamental and continuous disorder of neuronal function.
The essence of this disorder is loss of the normal balance between
excitation and inhibition at the synaptic junctions. From moment
to moment there may be excess either of excitation or inhibi-
tion or even both at the same time in different parts of the same
neuronal system. The epileptogenic disorder of function may be
assumed to be present continuously but with peaks at which
seizures are likely to occur.
Gastaut first recognized that some personality
traits in temporal lobe epilepsy patients are the
opposite of KBS symptoms (42, 85). Geschwind sug-
gested that KBS reflects sensorylimbic disconnec-
tion (86). Bear posited that in contrast to KBS, be-
havioral changes in temporolimbic epilepsy result
from a sensorylimbic hyperconnection (87). Given
the persistent difficulties defining the features, fre-
quency, and specificity of behavioral changes in
different epilepsy syndromes, the uncertainty re-
garding the mechanisms of underlying behavioral
change in epilepsy continues.
SUMMARY
Throughout history, people with epilepsy have suf-
fered from a social disease as much as from a neuro-
logic disorder. In ancient times they were believed to
be cursed, in the Middle Ages they were hunted as
witches, and in modern times they were labeled as
Epilepsy and Behavior: A Brief History
deviants and restricted in marriage and child-rearing 11.
by medical doctors waving the banner of eugenics.
12.
While the 18th-centurys Enlightenment ushered in
the scientific study of epilepsy, 150 years passed be- 13.
fore a rational classification system for seizures was
developed. Misconceptions regarding what behaviors 14.
occur during and after seizures and what behaviors
typically occur between seizures persist. Similarly, 15.
medical views on epilepsy fostered misguided thera- 16.
pies from ancient Greek to 20th-century societies and
did little to lessen the social stigma of having epilepsy. 17.
Ironically, the institutionalization of patients with ep-
ilepsy led to greater study and understanding of the
disorder.
18.
Misperception about people with epilepsy and
their behavior remains an active problem. The per- 19.
vasive, negative portrayal of behavioral changes in
people with epilepsy has led many in our society to 20.
hide their disorder. Clinical practice and an exten-
21.
sive literature are consistent with behavioral
changes in people with epilepsy. However, these 22.
changes often defy traditional syndromic categori-
zation. Further research and experience are neces- 23.
sary to further define the behavioral changes that
accompany epilepsy. As Hughlings Jackson and
Norman Geschwind suggested, understanding the
24.
pathophysiology of behavioral changes in epilepsy
may offer a window for studying the psychopathol- 25.
ogy of other diseases (27, 86).
26.
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