Epilepsy & Behavior 15 (2009) 425433
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Epilepsy & Behavior
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International Classics in Epilepsy and Behavior: 1974
Personality changes in temporal lobe epilepsy q
Norman Geschwind 1
Department of Neurology, Harvard Medical School, Cambridge, MA, USA
Our topic tonight is the personality changes in temporal lobe
epilepsy. This follows naturally from the second lecture in this ser-
ies on the physiological basis of emotional behavior. The personal-
ity alterations in temporal lobe epilepsy are our best illustration of
the anatomical and physiological organization of emotion. There
are other conditions in which one sees some aspects of change in
emotional behavior, but none are very common and none reveal
the events contributing to change in emotional behavior as well
as temporal lobe epilepsy. In my last lecture we discussed the pa-
tient of Plum and Reeves who had a congenital tumor near the ven-
tromedial nuclei of the hypothalamus. This patient had exactly the
same syndrome as do animals with destruction of that region. The
patient became massively obese and became very aggressive. That
isolated case provides only limited insights into mechanisms.
There is one disease a cardinal feature of which is change in
emotional behavior, and in fact this is a disease whose name obvi-
ously means rage in all languages except English. It is a disease
which in French is called rage, in German is called tollwut, which
means rage, in Italian rabbia, and in English rabies. Rabies also
means rage but the derivation is less obvious. The word rabid
as applied to dogs describes the very striking change in the dog
who becomes an animal who transmits the disease by biting. The
effect of the lesion causes the dog to bite more readily, providing
the virus a means for transmission to the next host. Oddly, rage
behavior as a characteristic of rabies was always well known, but
it took a very long time for people to appreciate that the localiza-
tion of its lesions was giving a message about the localization of
rage in the nervous system. Gastaut, the French neurologist inter-
ested in temporal lobe epilepsy, pointed out that the lesions in ra-
bies occur in the limbic system in areas similar to the ones that
John Flynn reported in simulation-induced rage. Rabies is not a
very good disease to study. It is an acute disease. It is invariably
fatal and the changes which occur are very rapid and very
dramatic.
Temporal lobe epilepsy is therefore unique in a very special
way. Among all of the psychiatric disorders known to mankind, it
is the one cause of serious psychiatric symptoms whose mecha-
nism we understand fairly well. This makes temporal lobe epilepsy
a tremendously important disorder, although it remains very
widely neglected. If you take the large number of patients in
q
This article has been reprinted with permission from Department of Neurology,
Harvard Medical School.
1
Edits and footnotes by Orrin Devinsky.
1525-5050/$ - see front matter ! 2009 Elsevier Inc. All rights reserved.
doi:10.1016/j.yebeh.2009.04.030
mental hospitals with schizophrenia, you can say that this is an
important and common disorder, but nobody to my knowledge
knows the cause or mechanism of schizophrenia. Second, there
are many organic behavior disorders in which we know the cause
but not the mechanism. Consider atropine, an anticholinergic drug
that is often used to treat Parkinsons disease. It can produce a
paranoid psychosis that disappears when the drug wears off or
can be reversed instantly by giving an anticholinesterase agent
such as phyostigimine. This is an empirical fact. But we cannot
explain why someone becomes psychotic on atropine.
Some people who become hypoglycemic on insulin develop ex-
tremely paranoid and curious behavior. This is an empirical fact
but we do not understand the inner mechanism. The importance
of temporal lobe epilepsy is that the mechanism of the behavior
disorder seems more apparent. As a result, as an avenue of study
in psychiatry and behavioral disorders, it should be one of the ma-
jor interests. However, it is not an area of active research. People
study disorders of obscure etiology when they have a common dis-
order of clear etiology that could be studied much more fruitfully.2
First, I will be talking about the very frequent, chronic change in
personality in temporal lobe epilepsynot an acute change in per-
sonality, but one that develops, continues, and typically gets more
and more striking with the passage of time; a personality that the
patient shows all the time, not an acute and self-limited change re-
lated to a seizure. Second, I speak of personality change much more
broadly than personality disorder. Many patients are immedi-
ately recognizable as having characteristic personality changes of
temporal lobe epilepsy, and yet in many instances one would not
want to call this a personality disorder because it may not affect
the patients adjustment or the adjustment of other people around
him.
One feature in temporal lobe epilepsy is that it leads to religious
conversions.3 I do not consider religious conversion a disease any
2
Geschwind argues here for the study of disorders in which there is a clue as to the
mechanism of behavioral change over those in which the etiology is obscure.
However, he also argued for the study of rare and obscure disorders. His common
example was Addisons disease in the period before 1950. With the decline in
tuberculosis in the first half of the century and, with it, the most common cause of
adrenal insufficiency, Addisons disease became quite rare. Yet the intensive study of
this uncommon disorder led to the discovery of adrenocorticotrophic hormone and
mineralocorticoids and corticosteroids, which revolutionized therapeutics in medi-
cine [1].
3
Religious conversion in temporal lobe epilepsy is quite uncommon, although it is
probably more common in these patients than in those with other neurological
disorders. See Dewhurst and Beard [2] and Leuba [3].
426 N. Geschwind / Epilepsy & Behavior 15 (2009) 425433
more than peoples political views. The fact that somebody becomes
a Democrat or an Episcopalian is of no concern to me any more than
if they become a Republican or a Buddhist. Temporal lobe epilepsy
causes people to undergo religious conversions. This need not be
considered as a disorder. In the same manner, temporal lobe epilepsy
may cause a change in certain peoples sexual behavior. Again, this
should not necessarily be regarded as a disorder if it is not disabling
to the patient or to those around him. Many of the behavioral
changes in temporal lobe epilepsy are not behavioral disorders per
se, although in certain cases, a frank behavior disorder does occur.
The reading includes several papers that deny the existence of
personality change in temporal lobe epilepsy. These papers are
exercises in learning how to read the literature. Some of these
papers are extremely revealing about the pathology of statistics.
Consider the book by Guerrant and colleagues called Personality
and Epilepsy.4 They did a controlled study, at the University of
California, San Francisco, comparing a group of temporal lobe epilep-
tics, a group of non-temporal lobe grand mal epileptics, and a group
of hospital controls without epilepsy. They found no difference in the
incidence of behavior disorder in the three groups. That was a large
and expensive study. Consider the enormous number of people stud-
ied and the undoubted thousands of pounds of paper employed in
testing the patients. You may well ask: why am I giving a lecture
when these people showed that there was no statistical difference
between the groups? Careful reading of the book reveals a rather fas-
cinating thing. The incidence of significant behavior disorder in the
temporal lobe epilepsy group was over 80%. That may seem like a
high figure to some of you except that the incidence of behavior dis-
order in the normal group was about 80%.
The authors made one serious error: they should have picked a
criterion of behavior disorders in which normal individuals have a
100% incidence. Then you would not be able to show that any
group had a higher incidence of behavior disorder. This is rank
nonsense, a typical example of a very silly technique, counting
the numbers of people with any given disorder and choosing a very
weak criterion. Consider another example. Suppose I wanted to
prove that there was no increase in the incidence of liver cirrhosis
in alcoholic patients. Most of us in medicine would regard that as
ridiculous, since a very high percentage of people with cirrhosis are
likely to be alcoholic. However, it depends on your criterion for
alcoholism. So I choose the following criterion for alcoholism: any-
body who takes one drink a month is an alcoholic. If you use that
criterion, you would not find a significant difference between peo-
ple with cirrhosis of the liver and the controls. You cannot get away
from the facts by choosing a silly criterion. You have to consider
the intensity or severity of behavior disorder. Any criterion for
behavior disorder which makes 80% of normal individuals abnor-
mal is simply ridiculous. The book, however, is even more ridicu-
lous. First, they dont give you certain pieces of information such
as mental hospitalizations and arrests. The criteria for behavior
disorder are based entirely on the Minnesota Multiphasic Personal-
ity Inventory. The MMPI revealed striking differences between the
temporal lobe epilepsy and control groups. The controls scored
very high on the neuroticism scale and the temporal lobe epilepsy
patients scored significantly higher on the scale for psychosis.
Although this fact is in the book and is highly statistically signifi-
cant, this does not appear in the summary. This leads me to con-
clude that the authors were out to prove, come hell or high
water, that there was no difference in behavior in temporal lobe
epilepsy patients.
Another common argument about behavioral change in tempo-
ral lobe epilepsy is that there is no difference in the frequency of
behavior disorder in temporal lobe epilepsy and non-focal grand
4 8
See Guerrant et al. [4].
mal seizures. This is a thing which many people make a great deal
of and they stress very strongly. For example, Stevens reported a
32% incidence of mental hospitalizations in temporal lobe epilepsy
patients in a Seattle clinic.5 She observed that this very high figure is
not significantly different from the incidence of mental hospitaliza-
tions in her grand mal epilepsy patients. Several others make the
same point: there is no difference in the frequency of behavior dis-
order in temporal lobe and idiopathic grand mal epilepsies. This
may be true, but Im not quite sure why that fact is important. For
example, I presume that people with severe thrombocytopenia bleed
as frequently as people with hemophilia. Both are still bleeding dis-
orders. The fact that theres another disease in which behavior disor-
der occurs is not a terribly interesting point, and Im not sure what it
proves. There may be an increased incidence of behavior disorder in
many forms of epilepsy, but it misses a very important point. The
critical issue is not whether there are equal incidences of behavior
disorder, but whether the behavior disorder is different in the two
groups. For example, I accept that in certain institutions in Boston,
the incidence of behavior disorder among patients with epilepsy
might be extremely high. At Boston City Hospital, the most common
cause of seizures is alcohol withdrawal. Alcohol withdrawal seizures
are typically non-focal grand mal seizures. At Boston City Hospital,
theres thus a high incidence of people with epilepsy, defined by
recurrent seizures, with behavior disorders because they are alcohol-
ics. The frequency of behavior disorder may be higher in that group
than in the temporal lobe epilepsy group.
The important issue is that temporal lobe epilepsy patients are a
very different group in terms of the kind of personality compared
to those with idiopathic nonfocal grand mal seizures. Further, pow-
erful evidence shows that the behavioral change results from the
patient having temporal lobe epilepsy, in contrast to behavioral
disorders in idiopathic grand mal epileptics. For example, the alco-
holic who drinks and then has a withdrawal seizure obviously is a
man in whom epilepsy is some remote effect of the behavior
disorder.
Personality change in epilepsy is a very old observation. The psy-
chiatric textbooks in the late 1800s commonly refer to the epileptic
personality.6 The descriptions of the epileptic personality in these old
psychiatric textbooks fit the modern temporal lobe epilepsy patient.
In Freuds essay on Dostoevsky, he quite clearly writes We know
that epilepsy produces these remarkable changes in the personal-
ity.7 The concept of the epileptic personality came under very heavy
attack. The reasons for the attack are understandable, an example
where some perfectly good data were discarded for the wrong
reasons. In the late 1800s, people began to recognize that epilepsy
patients suffered many disabilities in society which were clearly
unreasonable. There were many laws preventing individuals with
epilepsy from marrying, driving cars in any circumstances, and many
other restrictions, which have now been abolished in most places.8
A very active movement later emerged to eliminate all of these
medieval ideas. A concerted attack developed against every stigma
associated with epilepsy. The epileptic personality came under
attack very rapidly. Although personality changes in epilepsy were
widely reported, they didnt have the methods available to distin-
guish the different kinds of epilepsy. For instance, the electroen-
cephalogram didnt come into use clinically until after 1930.
There are a wide variety of personalities among epilepsy patients,
and people had no clear way to distinguish temporal lobe epilepsy
5
See Stevens [5] and Small et al. [6].
6
Many of the textbooks on psychiatry and epilepsy in the late 18th and early 20th
centuries included chapters or sections on behavioral disorders in epilepsy. These
more often concerned epileptic insanity or mania after seizures (many likely
representing postictal psychosis). See [711].
7
See Freud [12].
Check EFA regarding sterilization law.
 N. Geschwind / Epilepsy & Behavior 15 (2009) 425433
patients from others. The whole concept of the epileptic personal-
ity was therefore rejected. We were told that it is incorrect to speak
of the epileptic personality or certain characteristic personality
changes associated with temporal lobe epilepsy. Also, as dynamic
psychiatry grew, it fostered a very powerful tendency to reject all
organic explanations for personality, and these were thrown out
en masse. This was a typical attitude of the 1920s: under no cir-
cumstances could any aspect of personality be related to the brain.
The attempt to relate personality to epilepsy was thus unaccept-
able. Finally, the concept of the epileptic personality was thrown
out because it defied common sense. For example, in the 1880s
the epileptic personality included excessive religiosity. Well that
didnt make any sense: Why should a discharging lesion within
the brain make someone excessively religious? This was nonsensi-
cal, and as a result it could not be true. It happens to be true and
has a very simple explanation.
Contrary to what people believe about science, that theories are
fragile and facts are accepted strongly, the reverse is quite true.9
Nobody will accept a fact if they dont know how it fits theoretically.
They will say that its wrong even if there is no evidence against it.
This occurs in physical chemistry and it certainly occurs in the per-
sonality changes of epilepsy. Religiosity was a perfect example of
something that nobody could fit in and so it got thrown out.
There are two behavioral syndromes that can occur in temporal
lobe epilepsy: acute and chronic. Were talking about chronic
changes. People often conceive of personality change in temporal
lobe epilepsy as occurring during seizures. I see many patients re-
ferred for possible temporal lobe epilepsy. The typical story is a
college student who got drunk on a given night and beat up six
policeman. He was arrested and the next day denies any memory
of the event. Somebody says the only explanation is that this must
be temporal lobe epilepsy. This was an acute episode occurring out
of the blue in some very nice boy. Hes amnesic for the episode and
this suggests that he had a seizure during this period. This is what
many people picture as being the personality disorder of temporal
lobe epilepsy.
Personality alteration during seizures occurs, but is exceedingly
rare. I have only seen this once, and Ive seen dozens of people with
temporal lobe epilepsy with personality change. I have never seen
a temporal lobe epilepsy patient who has manifested aggression
during a seizure, although Ive seen many temporal lobe epilepsy
patients who have been quite aggressive. In fact, in some instances
they committed murder. The aggressiveness that I have seen has
always been interictal, not related to seizures. Now again there
may be a small number of temporal lobe epilepsy patients who
are aggressive during seizures, but its rare. In general, during a
temporal lobe seizure, the patient is unable to carry out any very
complicated or difficult act.
Another myth concerns fugue states. In such a state, a man gets
up in the morning, disappears from his home, and turns up 2 weeks
later in Minneapolis in different clothes, etc., and doesnt remem-
ber the 2 weeks. This classical fugue state suggests to some that
it must be temporal lobe epilepsy. I have never seen a prolonged
fugue state in temporal lobe epilepsy.10 People who have seen
9
Geschwind paraphrased here and credited a George ____, a professor of physical
science at MIT. I suspect it was George Keyes, a professor of chemistry at MIT, but
have been unable to find the quote. However, Charles Darwin provided a similar
insight, nearly a century before. False facts are highly injurious to the progress of
science, for they often long endure; but false views, if supported by some evidence, do
little harm, as every one takes a salutary pleasure in proving their falseness; and
when this is done, one path towards error is closed and the road to truth is often at
the same time opened [13].
10
Fugue states are indeed rare. Most of the literature found in a Pubmed search of
fugue and epilepsy concerns nonepileptic seizures. The rare cases with epilepsy
are often more of confusion and relate to nonconvulsive status and postictal amnestic
states.
427
much more temporal lobe epilepsy than I, such as Dennis Williams
in England, have never seen one either. During the seizure the
patient is typically not in a state to carry on this kind of activity
even if he sometimes seems in reasonable contact with the
environment.
The one patient whom I saw with behavioral changes during a
seizure was a woman, in 1955, who came into the emergency ward
of Boston City Hospital acutely psychotic. She was pregnant at the
time and was raving on about being the messiah. She was seen on
the accident floor since at that time, there was no inpatient psychi-
atric service at BCH. She was diagnosed as an acute catatonic
schizophrenic and was about to be transferred to Boston State Hos-
pital. While waiting for the ambulance, she had a frank seizure,
which didnt seem to fit in very well with the catatonic schizophre-
nia, so she was admitted to the Neurology Service. After she recov-
ered from her postictal state she returned to an agitated state,
talking about the messiah and the messages from beyond. While
in this state, an EEG revealed steady firing in one temporal lobe.
She remained in this state for several days as we couldnt get it un-
der control with medication. Finally the seizure stopped and she
became quite normal. She remained normal for several days and
then suddenly became psychotic again and her temporal lobe
was firing again. However, she is a unique case in my experience.
Ive seen that same patient 15 years later and she now has chronic
personality disorder and it is not occurring during seizures.
Whereas when I saw her the first time, she would get better as
the seizure stopped, now she shows a persistent personality
disorder.
The personality change of temporal lobe epilepsy is a chronic
syndrome in which the onset of the behavioral change follows
the onset of the seizures. The behavioral changes often continue
for many years, gradually getting intense. Why isnt this behavioral
change simply the response of the patient to an unpleasant illness?
The answer is because this behavioral change does not occur in
other much more unpleasant illnesses. Patients with amyotrophic
lateral sclerosis suffer from perhaps the worst disease known to
man, in which people with full consciousness slowly become par-
alyzed, retain full sensation, and simply lose all motor control. I
have never seen a patient with ALS develop a personality disorder
or anything vaguely approximating what occurs in temporal lobe
epilepsy. Furthermore, in temporal lobe epilepsy, the personality
often occurs in people for whom the seizures are not a significant
disability. For example, Ive seen this personality change in a cou-
ple of patients who never had an overt seizure, but only had an EEG
alteration, so the patients dont even know they have epilepsy. The
possibility that this personality is a response to the illness is also
excluded by its being very specifically associated with this illness
and with nothing else. You may ask why I speak of a personality
change in temporal lobe epilepsy particularly and not a personality
change with temporal lobe disease? Some people say, doesnt this
simply mean that you damage the temporal lobe, and if you de-
stroy some of the temporal lobe, then the personality changes. That
wont work either; its got to be in association with epilepsy for the
following reason. If you take many patients with temporal lobe
epilepsy who have surgery, for example, the largest series is
Murray Falconers in London, where hes operated now on over
200 patients, the operation has been done primarily to control epi-
lepsy, not to control behavior. The interesting thing is that, as
Faulkner reported, when seizures are controlled after removing
the epileptic focus, in a very large percentage, the personality
change reverses or the personality disorder improves. Now obvi-
ously, the patient has an even larger lesion in the temporal lobe
after Dr. Falconer has amputated the anterior pole of the patients
temporal lobe. And despite having a larger lesion, the behavior gets
better. So it is very clear in my mind that you are talking about a
disorder associated with the presence of epilepsy: a stimulating
428 N. Geschwind / Epilepsy & Behavior 15 (2009) 425433
lesion in the temporal lobe is essential, and not a destructive
lesion.
Consider the dramatic case of Mitchell, Falconer, and Hill11. This
man was brought into a large psychiatric hospital in London. He was
brought in because he was frankly psychotic and his wife described
some very bizarre behavior. The full story was obtained from the pa-
tient by the psychiatrist at the hospital. Ever since his childhood, he
had found that if he looked at a safety pin it gave him a curiously
pleasurable feeling. The pleasurable feeling he got from looking at
a safety pin was clearly a sexual feeling. He found that if he looked
at a safety pin long enough, he would have an orgasm. He soon dis-
covered that he could induce an orgasm not by looking at an actual
safety pin, but even by thinking of a safety pin. Now he kept this a
secrethe somehow felt that other people would find this unu-
sualand he told nobody about it, but would himself secretly go
off into some private place and fantasize his safety pin or look at a
safety pin to get this curious sexual feeling and indeed then have
an outright orgasm. He served, as I recall, in the armed forces during
the war in Britain; nothing particular was noticed there although the
same thing kept up, and after the war he married. When having
intercourse with his wife, the experience was not as pleasurable as
fantasizing or looking at an actual safety pin. So while he had inter-
course with his wife, he would think about the safety pin.
During his marriage, he would still continue to look at the safety
pin in private. But after a time his behavior changed, and he would
sometimes take out a safety pin and look at it in his own home. His
wife would see him do this, would notice that he got a very strange
expression on his face, and that after doing this for a time would
get up, appear to be rather confused, and would then insist on
putting on his wifes clothing. She didnt realize at the time that
he was inducing the orgasm, obviously having some change in
mental states because of this, and then would insist on putting
on his wifes clothes; he showed this curious phenomenon of trans-
vestism in this circumstance. His behavior became more and more
bizarre since he began do publicly what he had done privately be-
fore, his thought processes became more bizarre, and he was
frankly psychotic at the time he was admitted.
Hearing that story, what do you suppose would happen to that
patient in most institutions? I suspect that in the majority of Amer-
ican mental hospitals he would not have been worked up as he was
in England, but one of the first things they did was an EEG. And
they discovered the very interesting phenomenon that he had a
very clear epileptic focus in one temporal lobe. They then discov-
ered that when the patient looked at a safety pin the epileptic fo-
cus, which was simply this area of chronic firing, would begin to
build up and he would have a full-fledged epileptic seizure precip-
itated by looking at the safety pin. In other words, this was not a
purely psychological reaction to the safety pin; this was, in fact,
a frank convulsion produced by looking at the safety pin, and he
would, as the seizure built up and he had the frank convulsion,
have an orgasm at the same time. In some manner the safety pin
was acting as a stimulus in certain portions of the brain involved
in sexual behavior, and he was doing what animals do in certain
experiments, self-stimulation of certain portions of his own brain.
He was operated on by Murray Falconer. In Falconers operation,
he does a very standard en bloc removal of the anterior portion of
the temporal lobe on the affected side. He removed the area con-
taining the focus and, within this, found a frank lesion. This was
probably a congenital tumor hamartoma in the temporal lobe,
which they find in a fair percentage of their cases. Following the
operation the patients seizures came under control and the fetish-
ism for the safety pin disappeared completely. So that the patient
11
See Mitchell et al. [14].
found that when he looked at a safety pin, it did not give him
any of the sensations that it had previously.
Now thats a rather dramatic case, but I want to stress it because
I think that if you told that story at random it would seem to be
perfectly impossible that you were dealing here with an organic
cause. It shows certain features about the personality change in
temporal lobe epilepsy; it doesnt show all of them. The first is
the occurrence of learning. The reason I say learning is that the
safety pin precipitated both the pleasurable sensation and the sei-
zure, and removal of the focus abolished that. There are thousands
of stimuli in the environment, and that the fact of the safety pin
being so specifically related to this clearly shows that learning
must have played some role. This stimulus, in some manner, was
connected in some very specific way; it had learned how to fire
his focus and then in turn to fire other areas within the brain. So
the occurrence of learning is important. Second is a change in sex-
ual behavior. This is a very characteristic feature of people with
temporal lobe disorders. Another feature in this patient is that he
became frankly psychotic so he had the extreme form of thought
disorder.
That patient is obviously atypical, but let us consider what a
typical patient with temporal lobe epilepsy looks like. Let me take
another example from my own experience because I think this is
again a very, very revealing patient. This patient was one of a pair
of identical twins. I stress that these were identical twins. The pa-
tient himself had a strong history of psychiatric disorder and had
had a mental hospitalization in which he was diagnosed with
schizophrenia. His identical twin brother had no history of mental
disorder and was dramatically different from the patient in every
possible way. These identical twins were nothing like each other.
In this particular patient the interesting thing was that the history
of behavior disorder appeared to antedate the epilepsy. So he had a
behavior disorder for a long time. Then he began to have seizures.
An EEG was done and he had a clear-cut temporal focus. This man,
like the man with the safety pin, had a frank lesion in his temporal
lobe, a glioblastoma, a malignant astrocytic tumor of his temporal
lobe that almost certainly had been present for some years.
It was very striking if you asked the patient Harry, what do you
feel about this illness that you have? He responded: I feel that
this illness was visited upon me by God because it has enabled
me to learn the full depths of human goodness. I would never have
met all of these absolutely marvelous people who have been in-
volvedwho have shown these tremendous depths of love that I
have met because of the illness. That was after surgery. I went
on and asked, what do you feel about your wife? He said he felt
very specifically that his wife was an angel who had been placed
there by God specifically for the purpose of helping him during this
hour of terrible need. Now he also was constantly talking about
love and human goodness and all the marvelous people around
him. We also found it very difficult to get rid of him. This charac-
teristic of stickiness is a very striking feature of the patients who
very often will keep on telling you about this.
On the other hand you would have thought from this descrip-
tion that he would be a very nice patient to have around, but this
is not the case, for he would get extremely angry. For example, on
one particular morning when I arrived he was enraged, and I asked
Whats wrong? He said he was sitting and he was smoking and
one of the nurses came up to him and said, You cant smoke in
bed. And I said, Well dont you think thats reasonable? He said,
I think its perfectly reasonable, I wanted to be sure that this nurse
could promise me that she knew that no other patient in this hos-
pital was smoking in bed. I didnt see any reason why I should be
picked on when she wasnt seeing to it that this prohibition was
being universally enforced. Now this again is very characteristic:
the patient is tremendously concerned with right and wrong, he
becomes tremendously concerned with small details of moral
 N. Geschwind / Epilepsy & Behavior 15 (2009) 425433
issues and is very finicky about them, and again and again one sees
it.
I had one patient who was very angry because the nurse told
him that he couldnt use a cigarette lighter, because for some crazy
reason that hospital had a rule that you couldnt use cigarette light-
ers. Now I dont know what particular insanity motivated that rule,
but the interesting thing was that this man, on being told this,
wanted to be sure that no other person in the hospital was using
a cigarette lighter and wanted it to be shown to him that we had
gone to the trouble to see that no other patient was using a ciga-
rette lighter. Second, this man had quite frequently struck his wife
and had often gotten into fights with people. Again, the fights were
very typically precipitated with concerns over his rights and over
small moral issues.
One of my patients who was very active in a very right-wing
political movement in Boston was a tall, huge burly man. Many
times he threatened the nurses because they would bring in his
lunch and it wasnt hot enough, or it wasnt served at the right
time, or some other patient was served before him, or he would
get angry because some patient who was disabled would have
the lunch placed at the bedside and wasnt fed. He would immedi-
ately say, This is a dreadful thing, how can they do this, Im going
to see the hospital director. At the same time this man, who was
always so concerned about rights, would literally threaten some of
the nurses with physical mayhem at the same time he was talking
about his concern with what was morally right. If you were talking
about a child, he would say how important it was that your chil-
dren do exactly what is correct, and yet at the same time he was
prepared to be violent. When stopped for speeding, for example,
he had beaten up a policeman.
A characteristic of these patients is that they will show this kind
of aggressiveness particularly on moral issues. One of my patients
was a professor of geology who had taught at one of the military
academies. He, at one point, challenged the boxing instructor at
the academy into the ring. He came out of it, by the way. I said
to him Whatever possessed you to do that? He said, Well this
man cast aspersions on my honor, and I wasnt going to have that;
it didnt matter to me that he was the boxing instructor. And he
went into the ring with this man because he was going to show
him. This same man, by the way, came in to see me one day, and
he was all disheveled. He had taken the bus from western Massa-
chusetts. On the bus, he discovered that the bus driver was smok-
ing. He went up to the bus driver and said, Dont you see the rules
are that youre not supposed to smoke. The bus driver said, Can
it, buddy. He went back, sat down, thought about it for some time,
and decided that this was quite wrong. That if the rule said you
dont smoke, you dont smoke. So he got up again, went up to
the bus driver, and told him to stop smoking. The bus driver said,
Scram, buddy, mind your own business. He then removed the
cigarette from the bus drivers mouth. After pulling over, the bus
driver got up, they had a fight, the other passengers threw the pa-
tient off the bus, and he then eventually arrived in Boston for his
appointment with me and was now all set: he was going to sue
the bus company because of this particular event. So this tremen-
dous moral concern with small details is a very striking feature.
Another feature exemplified by the identical twin patient was
how his illness had taught him how God was participating in his
affairs. He was very religious, very interested in religious matters,
constantly talked about religion, constantly talked about Gods par-
ticipation, how God had visited this illness upon him. If you talked
to his brother, the identical twin, and youd say, Your brothers
very religious. Hed say, Oh yes, Harry really takes all these things
very seriously. And youd ask, Are you religious? and he replied,
Well, you know, I go to church but I dont take it at all like Harry.
In fact he couldnt understand his brothers tremendous concern,
and he used to say it seems to me Harry takes things much too
429
seriously, do you think if I took him fishing on Sunday he would
calm down? It was a very nice illustration of this man with this
cosmic personality versus this all-American-boy brother, and they
were as unalike as any two people that you could pick on the face
of this earth. And I stress again, identical twins, genetically the
same, and growing up in the same environment.
Religiosity as a feature of temporal lobe epilepsy was described
in the 1800s.12 Now its a very striking feature, a paper from Eng-
land, describing multiple religious conversions in temporal lobe epi-
lepsy.13 This is a phenomenon that Ive personally observed in many
temporal lobe epilepsy patients. One that Ive seen recently is a girl
in her twenties who is now in her fifth religion. Religious conver-
sions are a very striking feature. You get these multiple religions
in many of these patients, and second, the concern with religion is
very deep indeed. For example, one of my patients is now a spirtu-
alist, having been through several previous religions; his previous
one was Unitarianism. Hed actually given that up because he had
actually gotten into a fistfight with a Unitarian minister over a theo-
logical point, something which I find inconceivable. And only some-
one like this could really get so involved in this. Furthermore, a story
I like to tell, it happens to be true, is that I was at a meeting some
years ago and a psychiatrist from Santiago, Chile, was talking to
me about temporal lobe epilepsy and said Oh you know weve made
the most marvelous observation in Santiago about temporal lobe
epilepsy. Hed discovered something that I dont think has ever been
discovered before, that temporal lobe epilepsy patients had religious
conversions. I said yes, I knew about that. In fact, he said we have a
rule in our hospital in Chile, that if a patient comes in and somebody
says, we have a psychotic Baptist in the hospital, we know in Chile it
has to be a temporal lobe epileptic. I told this young Chilean psychi-
atrist that might hold in Santiago, but it wouldnt hold in Texas. So
you have this very striking feature.
The interesting thing about the religiosity is that it takes several
forms. First, there are the multiple religious conversions. But in
some patients it takes a curiously inverted form. For example,
Ive had the experience of seeing a patient and asking him, Are
you religious? The patient says, Im not at all religious. Then I
ask, Why not? and the patient says, Because I spend all of my
time reading books on religion, and Ive gone into this with great
care and Ive decided it is not true. All he does is read books on
religion and has innumerable arguments about this thing, but this
is clearly the main concern in his life. There is another curious form
of the apparently nonreligious patient. For example, one patient, an
army first sergeant, had been discharged because his behavior got
him into trouble. He got arrested because he would occasionally go
up to people in the street and suddenly punch them. Some people
immediately say: Oh, thats typical, it must be occurring during a
seizure. But it wasnt occurring during a seizure. When you ques-
tioned him about it why he went up and struck people on the
street, he said it was because they were talking about him, and
when you pressed him about it, it was because he thought people
were saying he was a homosexual. And he would then go up and
punch these people because he was sure they were saying that.
Now hed had mental hospitalizations, and he was then discharged
from the army. When I saw him, and I asked him, by the way, Are
you religious? He said, No Im not at all religious. I then asked,
Why not? He said, Well, because I am certain that if I set foot
in church God will strike me dead with a thunderbolt. I then asked
Why do you believe that? He said, This is because when I was in
the army in Korea, I decided, while I was in a foxhole, that I refuse
to believe in a God who could do such terrible things to people.
And, as a result, all of the trouble that Ive had has been Gods
12
Some examples include Equirol [15], Morel [16], and Maudsely [17].
13
See Dewhurst and Beard [2].
430 N. Geschwind / Epilepsy & Behavior 15 (2009) 425433
punishment on me for doing that. For example, his wife had been
killed in an automobile accident. She had been driving the car and
they were both in the car when they had the accident. His view
was that his wifes death in this accident was Gods punishment
on him for his rejection of God. This is the man who said he wasnt
religious.
On the same day that I saw that patient, I had another man
come in and I asked, Are you religious? and he said, Well, you
know, I go to church occasionally, I wouldnt call myself particu-
larly religious. I asked, Youre not terribly interested in religion?
He said, No. I accepted that at the time because I was a bit naive
about this. Later on in the conversation I asked him to describe
how he spent this week. He spent his week by going to church.
He was a Protestant. He went to church twice on Sunday, which
is abnormal enough I thought. But then he went to the church
several further times during the week on at least three or four
other occasions where he would have a meeting with the minister
once or twice a week and talk to him personally and also go to
other activities during the week, and was obviously very, very,
involved.
I saw a patient this afternoon who said that he was not partic-
ularly religious. But when you went in detail into his activities, you
would discover that while he used to go to Mass once in 3 weeks,
he now went every week, and that he went to church when it was
empty at least every day and spent some time just sort of sitting
there because he found it calmed him down. And so, again, even
when the patient denies it, you will find that hes very involved.
A patient I saw at the Massachusetts Mental Health Center, a young
boy with temporal lobe epilepsy, was presented to me by the res-
ident who said to me, we dont think hes particularly religious.
When the patient came in, I asked him, Are you religious. He said,
Nope. I asked, Why not? He said because the rabbi in my con-
gregation is not theological. And it was very striking that when
pushed, the reason he didnt go was because this man wasnt con-
cerned about the religion in a profound and deep enough way, and
this was why he wasnt going to be involved. And in fact he said,
My parents go but theyre prepared to accept this, I am not. This
is a very striking feature.
A thing thats very closely related to this is the concern of the
patient with cosmic issues. Patients in some instances can be con-
cerned with religion, but many, you discover, are concerned with
the fate of the world. In one patient I had, certainly his major con-
cern was Communism in the world. In varying forms, you find a
tremendous concern with philosophical issues. The other thing
about this that is very striking is that it is often dramatically out
of keeping with the patients intellectual level. So you see a patient
in which you find that the kind of books hes reading just dont
seem to make any sense in terms of his educational background,
or his intellectual level, or the educational levels of those around
him. Second, when its very striking is when you see it over a rel-
atively short period of time in adulthood. For example, one patient
that I recall very clearly was a postman. He was a man who was
apparently rather quiet, sedate in his habits, whose major occupa-
tion had been watching television in the past. He had a ruptured
aneurysm and part of the temporal lobe was removed so that they
could coat the aneurysm. He then developed temporal lobe epi-
lepsy from the operative site. Four years later, he came in and he
was reading all sorts of books on deep philosophical matters, and
writing long essays on deep philosophical matters and discussing
these things. He was completely different from the way hed been
before, and it was rather bizarre, because it was strikingly out of
keeping with his background or his intellectual level; he was obvi-
ously way over his head in this sort of matter. Obviously, every
once in a while, you see a temporal lobe epilepsy patient with
interests of this type, whos perfectly capable of handling them
intellectually, but it is very striking to see this interest in people
who havent had it before and who come from a background where
this is the last thing you expect them to be interested in.
Another thing that is related to this cosmic concern is that tem-
poral lobe epilepsy is a disease that does something which may
seem quite incredible: it causes patients to write. This tendency
for patients to produce enormous amounts of writing is a very dra-
matic feature. Dr. Stephen Waxman and I had a paper accepted this
Friday.14 Steve Waxman got interested in the phenomenon because
he had heard it mentioned; he went out and started looking. As soon
as you begin to talk about it, patients turn up. In fact, today I men-
tioned this to somebody, and he said, Oh, I have three temporal lobe
epileptics who always bring me in things that they write. Once you
start looking for this you discover it. In fact, what struck me about
Steve Waxmans study was that he found depths to this that I had
not realized in the past; the phenomenon is even more dramatic
than Ive appreciated. Now the patients will, for example, keep dia-
ries. The diaries are kept in excruciating detail, so that the patient
will write, At 9:37 A.M. I had a very slight seizure, characterized
by a slight feeling of numbness in the left ear 1 1/2 inches above
the tip of the earlobe, going on in this manner and describing this
in great detail day after day. You find other patients who will, for
example, write a description of all of their activities on each day.
Then at the end of the month they write a summary, then write a
summary of the summary. Other patients write hundreds of poems,
short aphorisms. The patients also underline things. One patient
underlines in red and blue. Its very common for patients to capital-
ize and insert quotation marks. Its also a means of showing that par-
ticular items are of very great importance. The content of this tends
to be very pedantic, with minute descriptions of the patients ac-
tions, and very often the same kind of cosmic concern and aphorisms
of deep and not very clear meaning. There is a Zen Buddhist flavor to
it and this goes on for page after page after page.
For one patient, Dr. Waxman hired a public stenographer to
whom the patient dictated for 20 hours. And so he had his writing
done vicariously by this public stenographer. The interesting thing
is, of course, that most patients with temporal lobe epilepsy write
very badly. The one counterexample to that was the one person
with temporal lobe epilepsy, and very characteristic temporal lobe
personality changes, who was one of the worlds greatest writers,
and that is Dostoevsky.15 Dostoevsky typified many personality fea-
tures of the temporal lobe epileptictremendous concern about
moral details, many of them small details, extremely pedantic, he
was angrily impulsive, an impossible person to live with in every
way, and extremely aggressive, even toward people who had be-
friended him. Yet he was also deeply emotional and despite these
negative personality traits, many of those close to him felt a strong
emotional bond.
The sexual changes in temporal lobe epilepsy are very striking
and the most common one is loss of sexual interest. In the earliest
descriptions of this, people spoke of impotence in temporal lobe
epilepsy, because many of the patients, when asked about their
sex lives, said they were incapable of having sexual intercourse.
But it became clear later from the work of people like Dr. Blumer
that what they were really describing was loss of libido.16 Hyposex-
uality is the most common, but other kinds of sexual changes do oc-
cur. You recall that when I described the case of Mitchell and
colleagues, I told you that that patient would attempt, after a seizure,
to put on his wifes clothes. In England, Davies and Morgenstern
went out and found, among the temporal lobe epileptics, several
other patients who were transvestites.17 Transvestism is not simply
14
See Waxman and Geschwind [18].
15
Geschwind was familiar with Alajouanines contribution [19]. Geschwind also
wrote on this topic [20].
16
See Blumer and Walker [21].
17
See Davies and Morgenstern [22].
 N. Geschwind / Epilepsy & Behavior 15 (2009) 425433
something that one comes across very commonly, and to find several
temporal lobe epilepsy patients with it is a very striking feature in-
deed. Im sure that the great majority of transvestites dont have
temporal lobe epilepsy, but its interesting that for whatever reason
it can cause this. Although Ive seen many women with temporal
lobe epilepsy, someone called to my attention a phenomenon that
I hadnt observed before. The last four women I have seen have all
been bisexual, which again is a rather striking finding.
How does one put this syndrome together? You have a rather
remarkable personality change. For example weve talked about
aggression. Let me just say one more word about aggressiveness.
Ive seen one patient who murdered two of her siblings. The case
of Davidson is a striking and dramatic case of a boy in Canada
who murdered a girl. Davidsonss case is very revealing in this re-
spect: here is a boy with temporal lobe epilepsy who had carried
out this brutal axe murder and the boy had perfect recollection.
The way they knew that he carried out the axe murder was that
he came and said that he had carried out the murder. The police
at first did not believe him because it seemed so unlikely, and it
was only because he was able to describe certain details, which
no one would have known unless he had been at the scene of the
crime and knew exactly what was there, did they realize that he
committed the crime. He was perfectly aware of what he was
doing, and this in my opinion is characteristic of the temporal lobe
epilepsy patient when he is aggressive, that he is perfectly aware of
what he to doing.
Weve talked about aggressiveness, about religiosity, about
these cosmic concerns, religious conversions, about this tendency
to write enormous amounts, about sexual changes. How does
one put all of these things together? If you think of this disorder,
its quite useless to go to the psychiatric textbooks and decide,
yes this disorder fits the description of organic brain syndrome.
It says in textbooks that patients with organic brain syndrome
are aggressive and patients with temporal lobe epilepsy can be
aggressive. The reason that that is useless is because the temporal
lobe epilepsy patient has a very special flavor and constellation of
features. His aggressiveness is completely different from the
aggressiveness of the patient with, lets say, bilateral frontal lobe
disease. You take the patient with frontal lobe disease whos
aggressive, and hes very likely to be aggressive in response to
some immediate stimulus. For example, youre drawing blood from
him and he gets angry because it hurts and he takes a swing at you.
This aggressiveness disappears instantly. You step back and you
ask, By the way, how was lunch? He says, great. And thats it.
On the other hand it is typical of the patient with temporal lobe
epilepsy to remind you of an issue he had gotten angry over 5 years
ago. And he will say, I remember the time that you told me that I
couldnt use the cigarette lighter and I was very angry about it. So
that the aggressiveness has a totally different flavor in the two dis-
orders and to lump them together is just ridiculous. The point
about the temporal lobe epilepsy patient is that he is the opposite
in every way from the frontal patient.
Characteristic of the patient with temporal lobe epilepsy is this
tremendous deepening of emotional life. If we think about every-
thing except the sexual behavior, this description brings together
all of the aspects of the patients. Consider the tremendous serious-
ness that these patients have. It is very rare to see a temporal lobe
epilepsy patient whom one would call gay and light, even though
some of them occasionally have a rather heavy-handed humor.
The reason that they are very serious is because everything is seri-
ous, because their emotions run so deep on all issues. Their religi-
osity fits in the same manner. Obviously its a well-known
phenomenon that under conditions of great stress many people be-
come religious if emotional life deepens. This is not an unexpected
thing. The cosmic concerns fit into this. The writing fits into it.
These people write because what they have to say is so important.
431
They underline. Every event of their life is of major importance and
therefore it must be recorded. Many of these patients hide these
writings. If you ask, Why did you hide them? well theyre not
quite sure. But again its obvious that this is something terribly
important and some of them will tell you that theyre concerned
about these things being stolen. The aggressiveness obviously fol-
lows from that, because if you find out why these patients have
been aggressive, you find they have been aggressive on matters
of great importance, in other words they attach enormous impor-
tance to all sorts of aspects of their lives, and when somebody vio-
lates these very important rules, the patients become very angry.
Why do you get this personality change in which you get this
deepening of emotional life? The answer to this is supplied by con-
sidering the location of the lesions producing temporal lobe epi-
lepsy. These lesions are characteristically on the inner surface of
the temporal lobe. Most characteristically these are lesions in
which you are getting discharges going into funicular and other
structures of the surfaces of the temporal lobe. These lesions lie di-
rectly in structures with pathways into the parts of the brain that
are involved in emotional behavior. So they are acting in part as
stimuli on this pathway, sending stimuli into the parts of the brain
involved in emotional behavior. Theyre modifying those things
that are passing through to the limbic system, to the emotional
portions of the brain.
A clue to this is shown by another finding. If you take the onset
of epileptic seizures, there are certain epileptic seizures in which
an emotion is a characteristic of the seizure onset. There are many
seizures in which an emotion is clearly not part of the seizures; in
other words, you take seizures that arise in the classical motor cor-
tex or in the supplementary motor area or in the occipital lobe, or
in many parts of the brain, emotion is not part of the seizure. But
emotions very frequently occur as part of the onset of the temporal
lobe seizure. Now if you look at the emotions that occur during the
onset of the seizure, on the whole, what does the patient describe
to you? He describes, very often, fear; thats a very common feel-
ing. Another common feeling is that everything around is very
strange and bizarre and unusual. And he may have the feeling that
things are strangely familiar or strangely unfamiliar. Or have the
feeling that hes seen all of this before, or that everything is trans-
formed in an indescribable way. Or in some less common in-
stances, he may have feelings which are quite pleasant. But
usually the pleasant feelings are cosmic in character. For example,
if you read the descriptions of Dostoevskys epilepsy, at the onset
of his seizures, was this feeling of indescribable pleasure. And he
said it was worth sacrificing the entire world for this moment be-
cause it was the sudden glow, the sudden revelation, you under-
stood everything, the entire universe was unfolded before you.
Clearly this feeling of cosmic consciousness occurred during the
seizure. And it need not surprise you that certain drugs produce
an effect of this kind, and there is a certain amount of physiological
evidence that some of these drugs have their effect in the medial
portion of the temporal lobe. Theres some evidence for LSD and
also evidence for some of the drugs in the cocaine group, that they
act very specifically in the medial temporal lobe.18 In fact people
take these drugs for precisely the same experiences that the tempo-
ral lobe epilepsy patient gets for nothing. Furthermore, stimulation
in the temporal lobe has been done in very large numbers of patients
in Montreal, patients who are going to have surgery for their epi-
lepsy. To find exactly where their epileptic focus is, they are im-
planted with electrodes for a time, usually 2 or 3 days before the
operation, and these areas are stimulated to locate the area precisely.
Penfield pointed out that when you stimulate in the temporal lobe
you find in very large numbers of cases that you in fact get emotional
18
See Serafetinides [23] and Schwarz et al. [24].
432 N. Geschwind / Epilepsy & Behavior 15 (2009) 425433
responses from the patients, responses of fear, sexual sensations.19
Its interesting by the way, that anger is rather uncommon. And I
stress that because it illustrates one of my points that although
aggressiveness is common in temporal lobe epilepsy, it is not com-
mon during seizures. Because when you stimulate directly you dont
get anger, you get many of the other sensations. In spontaneous tem-
poral lobe seizures, anger is a very unusual sensation. Ive heard pa-
tients describe fear, cosmic feelings, and indescribable elation, but
not anger. One question is why does aggressiveness occur in these
patients as a common feature. I can explain why during a seizure a
patient might cause an emotional sensation, but why does the pa-
tient have this ongoing personality alteration and why do you need
epilepsy for it?
First, some animal studies show long-lasting effects of seizures
in the temporal lobe. Belluzzi and Grossman and some other
authors have shown these very long-lasting effects.20 So that, for
example, even a single seizure in the amygdala would produce
behavioral effects that could last for a very long time. I dont think
that is any accident that these parts of the brain are especially in-
volved in learning. If you think a bit, you can see why they are in-
volved in the mechanisms of learning. An important feature of
learning in the animals is reinforcement. And you reinforce some-
thing by essentially giving them a stimulus to the limbic system.
Hence, learning is going to be very dependent on things in the limbic
system. It is therefore not surprising that limbic stimuli may produce
a long-lasting effect. Even a single seizure discharge often affects
behavior for a long time.
Now, lets consider what happens to a patient with temporal
lobe epilepsy on any given occasion. You can picture this man
walking into a room, looking up, seeing the clock. At that moment,
as he is seeing the clock, perhaps he gets a very small discharge,
not a frank seizure now, we are talking about these little spikes
that are going on all the time, a small discharge occurring in his
amygdala and he gets the strange feeling that something is terribly
important. You then say to yourself, What has happened to this
person? He isnt aware that something is firing in his amygdale;
he is aware that he walked into the room and looked at the clock
and this has been followed by a sensation that something terribly
important is happening. Now what do you do in the circumstance
that you get this strong emotion and you dont know the cause?
The answer was given in a fundamental form by Freud in his theory
of paranoia. Once there is paranoia, the mechanism is that some-
body comes into contact with a person who is like some really
important figure. Then he has an emotional response to this per-
son, but he is unaware why he is having the emotional response
because this is repressed. So he now simply is aware of anger but
he is not aware of the cause because that is hidden from him. What
does he do when he is angry and he doesnt know the cause? He
then attributes this to something in the environment. The mecha-
nism of paranoia is the attribution of the emotion to some logical
sequence of events in the environment.
In temporal lobe epilepsy, the patient is having an emotion
whose cause he doesnt know, and what does he do? He does ex-
actly the same thing. He attributes it to something in the environ-
ment. Now I will give you a couple of examples to illustrate this
mechanism. In the last lecture we talked about Schachters exper-
iment in which he gave injections of epinephrine.21 When he gave
injections of epinephrine to people who didnt know they were get-
ting epinephrine, and did not know the injection would produce the
rapid heartbeat, the change in blood pressure, or the jitteriness,
these people responded to the person who was in the room with
them by getting angry at him. Those people who knew they were
19
See Penfield and Perot [25] and Mullan and Penfield [26].
20
See Belluzzi and Grossman [27].
21
See Schachter and Singer [28].
getting the injection had no trouble at all interpreting their feelings
and not attributing it to the person in the environment. When they
had this whole series of sensations, they could attribute it to the per-
son in the environment; they could attribute the emotion to him.
Another example of this, I think a rather nice one, is what occurs
in patients with lesions in the corpus callosum when their right
hemisphere is presented with an emotional stimulus. In a rather
nice report, Gazzaniga and Sperry described one of their patients
with a callosal syndrome who when shown items in the right vi-
sual field, could name them correctly, but when shown items in
the left visual field, was not able to name them.22 The information
was going only to the right hemisphere. He could show that the right
hemisphere knew what he was seeing by various methods. Now they
then tried an experiment to see what would happen if you put emo-
tional stimuli. If they flashed in the right visual field of this patient a
nude woman, his response would be to giggle and say that was a
nude.21 He was an old man. When they flashed the nude in the left
visual field, at some other time, he would give the typical response if
you asked, What was this? He would say, Well I just saw a flash of
light? There was some light because he wasnt blind. But the inter-
esting thing was that when the nude was flashed to the left visual
field the patient would begin giggling. That fit with the nude going
to the right hemisphere; the right hemisphere had the emotional re-
sponse to this and giggled. The examiner then asked the patient,
Why did you giggle? Now remember we are not talking to the
right hemisphere, which doesnt understand that, but we are talking
to the left hemisphere, which hadnt seen the nude. So the left hemi-
sphere knew something was funny and what response would you
get from the left hemisphere? So here is a very good example where
you are conscious of an emotion but you dont know the cause. Now
you can picture the left hemisphere saying, Gee I dont know why I
am laughing. But this is not what the patient does. The patient says,
You know this is a stupid experiment or it seems to me that I dont
know why you are wasting your time; that is a funny piece of appa-
ratus. This is pleasant paranoia; in other words he is attributing his
amusement to something in the environment. Its not paranoia in the
usual sense when you have a pejorative overtone to it, but it is the
same mechanism. I am sure that in that experiment, if they had
flashed to the patients left hemisphere something that made his
right hemisphere angry, they would have gotten the same response.
The patient would then have been angry and they would have asked,
Why are you angry? And he would have said, I am tired, it is hot
in here and I want to go home, or something of this sort. The same
thing occurs in patients whose amygdala is stimulated. The patient
whose amygdala is stimulated responds emotionally: he sometimes
gets angry, he sometimes gets afraid. Whatever the response, the pa-
tient rarely says, I am afraid or something similar; he nearly al-
ways attributes it to something in the environment again.
References
[1] Geschwind N. Introduction. Psychiatric complications in the epilepsies:
current research and treatment. McLean Hosp J 1977;June:68.
[2] Dewhurst K, Beard AW. Sudden religious conversions in temporal lobe
epilepsy. Br J Psychiatry 1970;117:497507.
[3] Leuba JH. The psychology of religious mysticism. London: Kegan Paul; 1925. p.
204.
[4] Guerrant J, Anderson WW, Fischer A, Weinstein MB, Jaros RM, Deskins A.
Personality in epilepsy. Springfield, IL: Charles C Thomas; 1962.
[5] Stevens JR. Psychiatric implications of psychomotor epilepsy. Arch Gen
Psychiatry 1966;14:46171.
[6] Small JS, Milstein V, Stevens JR. Are psychomotor epileptics different? Arch
Neurol 1962;7:3308.
[7] Griesinger W. Mental pathology and therapeutics. Robertson CL, Rutherford J,
Transl. London: New Sydenham Society; 1867.
22
Discussed by Gazzaniga and Sperry [29], Sperry et al. [30], and Sperry [31]. Note:
Gazzaniga would later describe the lie by the left hemisphere as the interpreter
[32].
 N. Geschwind / Epilepsy & Behavior 15 (2009) 425433
[8] Maudsley H. The physiology and pathology of the mind. New York: Appleton;
1867.
[9] Hammond WA. A treatise on insanity and its medical relations. New
York: Appleton; 1883.
[10] Spratling WP. Epilepsy and its treatment. Philadelphia: Saunders; 1904.
[11] Bleuler E. Textbook of psychiatry. Brill AA, Transl. New York: Macmillan; 1924.
[12] Freud S. Dostoevsky and parricide. In: Strachey J, editor. Standard edition of
complete psychological works. Vol. 21, London: Hogarth Press; 1961. p. 17794.
[13] Darwin C. The descent of man and selection in relation to sex. Vol. 2, London:
John Murray; 1871. p. 385.
[14] Mitchell W, Falconer MA, Hill D. Epilepsy with fetishism relieved by temporal
lobectomy. Lancet 1954;272:62630.
[15] Equirol E. Mental maladies: a treatise on insanity. Hunt EK, Transl.
Philadelphia: Lea & Blanchard; 1845.
[16] Morel BA. Traites des maladies mentales. Paris: Masson; 1860.
[17] Maudsely H. The pathology of mind. London: Macmillan; 1879. p. 446.
[18] Waxman SG, Geschwind N. Hypergraphia in temporal lobe epilepsy.
Neurology 1974;24:62936.
[19] Alajouanine T. Dostoiewskis epilepsy. Brain 1963;86:2108.
[20] Geschwind N. Dostoevskys epilepsy. In: Blumer D, editor. Psychiatric aspects
of epilepsy. Washington, DC: American Psychiatric Press; 1984. p. 32534.
[21] Blumer D, Walker AE. Sexual behavior in temporal lobe epilepsy: a study of the
effects of temporal lobectomy on sexual behavior. Arch Neurol
1967;16:3743.
433
[22] Davies BM, Morgenstern FS. A case of cysticercosis, temporal lobe epilepsy,
and transvestism. J Neurol Neurosurg Psychiatry 1960;23:2479.
[23] Serafetinides EA. The EEG effects of LSD-25 in epileptic patients before and
after temporal lobectomy. Psychopharmacologia 1965;7:45360.
[24] Schwarz BE, Bickford RG, Mulder DW, Rome HP. Mescaline and LSD-25 in
activation of temporal lobe epilepsy. Neurology 1956;6:2758.
[25] Penfield W, Perot P. The brains record of auditory and visual experience: a
final summary and discussion. Brain 1963;86:595696.
[26] Mullan S, Penfield W. Illusions of comparative interpretation and emotion:
production by epileptic discharge and by electrical stimulation in the temporal
cortex. AMA Arch Neurol Psychiatry 1959;81:26984.
[27] Belluzzi JD, Grossman SP. Avoidance learning: long-lasting deficits after
temporal lobe seizure. Science 1969;166:14357.
[28] Schachter S, Singer JE. Cognitive, social, and physiological determinants of
emotional state. Psychol Rev 1962:37999.
[29] Gazzaniga MS, Sperry RW. Language after section of the cerebral commissures.
Brain 1967;90:13148.
[30] Sperry RW, Gazzaniga MS, Bogen JE. Interhemispheric relationships: the
neocortical commissures; syndromes of hemisphere disconnection. In: Vinken
PJ, Bruyn GW, editors. Handbook of clinical neurology. Vol. 4. Amsterdam:
North-Holland; 1969. p. 17784.
[31] Sperry RW. Brain bisection and mechanisms of consciousness. In: Eccles JC,
editor. Brain and conscious experience. New York: Springer; 1966. p. 298313.
[32] Gazzaniga MS. The split brain revisited. Sci Am 1998;279:505.