Temporal lobe epilepsy and the phobic anxiety-depersonalization syndrome. Part I: A comparative study

Abstract

Summary 1. The occurrence of attacks of unconsciousness, depersonalization and other phenomena reminiscent of temporal lobe dysfunction is described in a common neurotic illness, the phobic anxiety-depersonalization syndrome and the implications of these findings in relation to the diagnosis of “temporal lobe” epilepsy are discussed. 2. The points of similarity and contrast between the two disorders have been systematically examined by a comparative survey of 30 of the phobic anxiety-depersonalization syndrome patients and 30 cases of temporal lobe epilepsy. The similarities comprised the occurrence of depersonalization, deja vu experiences, metamorphopsia, hallucinations, paroxysmal attacks of fear and attacks of unconsciousness in both types of disorder. A sixth of the epileptic patients had phobic symptoms similar to those of the neurotic cases. Attacks with disturbance but not loss of consciousness, depersonalization, deja vu sensations and formed hallucinations with insight were common in both conditions and there were no significant differences in frequency between epilepsy and the neurotic illness. 3. The differences comprised a significantly more common family history of neurosis, of phobias in childhood and of migraine in the neurotic cases, whose illnesses had also been usually precipitated by emotional stresses. In the phobic anxiety-depersonalization syndrome the attacks were frequently of episodic anxiety, occurring one or more times a day and severe psychiatric symptoms usually persisted between attacks. Episodes of unconsciousness and loss of the power of speech did occur but were rare. Though in both conditions the attacks began abruptly, in the neurosis they were found to have a characteristic mode of termination and they did not show the consistent march found in epilepsy. Abnormalities of basic personality were commoner in the neurotic cases, the higher incidence of marked dependence and immaturity being the only reliable differences. These features contrasted with those found in the epileptics, in whom a history of disease likely to cause cerebral damage was common and in whom attacks progressing to total abrogation of consciousness dominated the clinical picture. The epileptic attacks were found to begin at an earlier age and males predominated—a reversal of the sex incidence in the neurotic illness. A history of self injury or incontinence was significantly more common in, but not wholly confined to, the epileptics. 4. Electroencephalographic abnormalities of a specifically epileptiform kind, though not elicited in all cases, were confined to the temporal lobe epilepsy group. The phobic anxiety-depersonalization cases resembled other neurotics in that the majority of patients had normal or mild non-specifically abnormal records. Nevertheless two patients had records which were probably pathological. These findings are discussed and it is concluded that only specific E.E.G. abnormalities should be allowed to decide the issue in favour of epilepsy when the diagnosis remains in doubt after detailed clinical enquiries and a period of observation.