Classics in Epilepsy and Behavior: Commentary

Abstract

The article by Waxman and Geschwind [1] may be described as a classic, but it is also emblematic of a marked change in the history of neurology and psychiatry. They were describing a chronic personality change seen in people with epilepsy that was attributed to neurological dysfunction in the temporal lobes. It must be remembered that when this article was published, the prevailing view was that any psychopathology associated with epilepsy was secondary to the consequences of the disorder, rather than integral to the epilepsy itself. This was largely a result of the important contributions of William and Margaret Lennox (1960), who stated broadly that head injuries, sedative antiepileptic drugs, and social stigma were the problems that people with epilepsy suffered and that, if seizures could be controlled, the psychiatric problems would resolve [2]. The idea that alteration of function of the temporal lobes could lead to an organically induced personality change was quite alien to that generation. Why it was is difficult to fathom. By then, it was well established that patients could present with one of a variety of frontal lobe syndromes, which were essentially behavior changes brought about by altered function of the frontal cortex and its connections. Further, MacLean (1958) and others had shown that the limbic system was not simply a rhinencephalon, related to smell and not of great use to Homo sapiens, but was linked to several brain structures that formed circuits for the modulation of emotions [3]. Indeed, some neurological texts would have been bold enough to acknowledge such syndromes, although the term Kluver–Bucy syndrome was still largely recondite. Neurology and psychiatry were divided by the chasm of metaphysics with its ever-flowing cartesian stream, and there seemed no easy way to harmonize the two at that time. Then along came Norman Geschwind and his followers. He gave us the term behavioral neurology, essentially an offshoot of 19th-century neuropsychiatry, a world he reintroduced us to. Thus, he was familiar with the elegant and extensive writings of the French and German neuropsychiatrists of that time, leading him to write another classic, his article on disconnection syndromes [4,5]. This was an attack on modular thinking in neurology, an introduction to connectivity and circuits as explanations for behavioral changes, and an extension of neurological practice into the territory of psychiatry—aberrant behavior caused by neurological disease. However, the article on hypergraphia pushed the concept much further, as it touched on behaviors not usually discussed in neurological circles, for example, religiosity. The characteristics of Gastaut–Geschwind syndrome are now very well known, and yet there are many neurologists, even epileptologists, who find it hard to see the specimen when it flutters before them. They include such symptoms as alterations in sexual behavior, irritability, and viscosity, the last being a tendency toward slow, labored thinking, as if thoughts are emerging from treacle. This sometimes is revealed as circumstantiality, to quote the psychopathologist Frank Fish: Here thinking proceeds slowly with many unnecessary trivial details but the point is finally reached. The goal of thought is never completely lost and thinking proceeds towards it by an intricate and devious path. This disorder has been explained as the result of a weakness of judgement and egocentricity. It is an outstanding feature of the epileptic personality [6].