J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.50.6.673 on 1 June 1987. Downloaded from Journal of Neurology, Neurosurgery, and Psychiatry 1987;50:673-681 Temporal lobe epilepsy: origin and significance of simple and complex auras DAVID C TAYLOR, MOIRA LOCHERY From the University Department ofPsychiatry, Child and Adolescent Psychiatry, Manchester, UK SUMMARY The aura experience of 88 patients with temporal lobe epilepsy was recorded, classified and analysed. Despite the great richness of the 215 experiences described, correlations with left or right brain, nature of lesion, age of onset, etc. were only apparent when a classification into three aura groups was used. "Simple primitive" auras as sole auras were more likely with early onset epilepsy, in lower IQ patients, in males, from the right temporal lobe, and with mesial temporal sclerosis. Exclusively "intellectual" auras were confined to a group of high IQ males. The number of aura experiences described per person correlated with Verbal IQ for males but not females, but also varied with side, sex, and nature of lesion. The results are discussed in terms of the necessary conditions for aura and their relevance and in relationship to the results of brain stimulation studies by Penfield and others. Protected by copyright. Between those happenings that prefigure it medicines, and being unhappy and immature, And those that happen in its anamnesis described the onset of her occasional seizures. "The Occurs the Event, but that no human wit first thing is that everything I can hear becomes Can recognize until all happening ceases.1 louder. Then the echoes begin. Then the dream starts Aura is the brief subjective experience giving immedi- in which I'm in a railway train which goes round and ate precognisance of some epileptic fits. Ounsted2 round in a loop faster and faster until it crashes. Then realised that aura was a universal phase in par- I wake up." What are the neurological and oxysmal behaviours, the immediate, specific, subjec- psychiatric implications of such aura experiences? tive, warning of the system going absolute. The par- The study of aura has a respectable history since oxysmal behaviours all involve systems which are the introduction of the term by Pelops, the master of biologically necessary, closely related to the emotions Galen,3 to describe the "breath of air" which was his or to affects, and not entirely under conscious control, patient's premonition of a seizure. Reported auras such as sneezing, laughing, crying, raging, vomiting, seem stable between cultures and over historical time. labour and of Bernard of Gordon's patient reported "a confusion in defecating, urinating, orgasm. Many http://jnnp.bmj.com/ these behaviours become incorporated into seizures the head, and a darkness in the eyes" (1542)4 and as the integrative functions of the temporal lobe, Gastaut etal (1959)5 "a black fog before the eyes". mediating between neuro-vegetative function and We owe the realisation of the existence of psychical higher order thought, are thrown into chaos. disorder in the seizure to Griesinger (1867)6 (or possi- A 12 year old girl, verbal IQ 133, referred for steal- bly to Cheyne),7 "Thus we may frequently observe ing, wetting, soiling, failing in school, not taking her attacks sometimes preceding and sometimes alterna- ting with intermittent convulsions which consist prin- cipally in psychical anomaly either entirely without or An early draft of this paper was given at the Royal Society of Medi- with very limited, disorder of movement." He on September 26, 2021 by guest. cine on I December 1982. Brief summaries of attempts at analysis on described mental pain, incoherence, painful dreams, the aura data are given in McLean Hospital Journal, June 1977. "a state of dreaming". Priority for the description of Address for reprint requests: Prof D C Taylor, University the "dreamy state" is more usually, but falsely, attrib- Department of Psychiatry, Child and Adolescent Psychiatry, Jesson uted to Jackson, but Jackson did localise its origin House (RMCH), Manchester Road, Swinton, Manchester M27 1 FG, within the temporal lobe in his patient Dr z.8 Dr Zs UK. account of his own aura was ". .. my attention was Received 16 August 1986 and in revised form 4 December 1986. suddenly absorbed in my own mental state of which I Accepted 5 December 1986 knew no more than it seemed to me to be a vivid and 673 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.50.6.673 on 1 June 1987. Downloaded from 674 Taylor, Lochery unexpected 'recollection'-of what, I do not from local storage or by evocation from facilitated know.. ." Such emanations provided crucial material pathways.'7 (4) Brains that describe complex auras for the contemporary development of ideas about the may be different in various ways from those that do multi-layered structure of mind,9 the unconscious,10 not. That is, they may have unusual organisation as a and much material for psychoanalytic speculation. result of compensation for some kind of injury during Who directs behaviour when the self is absent? Who development. "8 reports the experience? Considering the early recog- This study of aura was aimed to address some of nition of the potential of studying aura there is a sur- these issues through detailed analysis of a group of prising dearth of enterprising studies subsequently. patients about whom a great deal was already In their massive Pan American study, Lennox and known. 19 - 23 Cobb1" recognised 327 different sensations in the 1527 cases described to them by reports from many doctors. The classification of these sensations was Method then and has been since, idiosyncratic and unrelated to which, however remotely, The group was composed of 88 patients from the series sub- to the structural lesions mitted to temporal lobectomy by the late Murray Falconer. they seem causally connected.'2 The fundamental It included all 47 of the then available patients with "alien difference, in qualitative terms and in psychological tissue" (AT) in the resected lobe and this group was con- import, between formed complex experiences on the trasted with 41 available patients with "mesial temporal one hand and crude visceral or trifling peripheral sen- sclerosis" (MTS) who were operated upon contem- sations on the other, has passed largely unremarked. poraneously. Thus, until the pathological findings were Aura has potential interest to classical neurology, in made available there had been originally, at the time of his- the location of lesions within the brain; to tory taking, no reason to distinguish one group from the neurophysiology in the mechanisms concerned with other. The 88 patients contained 54 males and 34 females; 41 were operated on the left and 47 on the right temporal lobe. the experience; to developmental medicine in Throughout the analysis of the information derived from Protected by copyright. differences in their expression with age of onset of temporal lobectomy, the important variables have been epilepsy; to psychology through their association with shown to be: age at onset of epilepsy, type of pathological cerebral organisation of function and their changes in the resected lobe, sex, side of operation, intel- relationship to other skills; and to psychopathology ligence, mental state, and social performance. These were in terms of their content in relation to mental state selected as the principal factors in this analysis too. and personal experience. Verbal and Performance IQs refer to those Wechsler Tests The study ofaura has become inextricably involved which were done on the nearest date before the operation.24 in brain stimulation experiments since the time of Handedness was taken from the neurosurgeon's operation notes and "left-handed" refers to any patient listed as not Penfield's'3 work on his unanaesthetised patients. fully right-handed. The results of these studies will also be discussed here. Age at first fit coded the age in years at the time of the first Aura must occur when there is still functioning, epileptic seizure ever, and not the age at "established" epi- remembering, brain. The report may be only a lepsy. The Social Score was a global assessment made on the retained fragment of the whole experience. Aura basis described in Taylor and Falconer'9 ranging from 7 for would usually consist of recognisable states, states the best to 32 for the worst social adjustment. This score was that have names, though "indescribable feelings" are made again at the follow-up assessment. Scores below 15 reported. To be recognisably an "aura" it would need were regarded as "good" adjustment and above 15 was http://jnnp.bmj.com/ to be consistent from one fit to the next. Though "bad". Psychotic refers to the 13 patients previously auras do change over time, the change is usually a analysed25 with chronic schizophrenia-like psychosis. Out- come in terms of seizures was rated in a manner which was condensation from complexity.14 not scalar but covered complete relief, current fit freedom, The basis of simple auras might only mean the improvement, no improvement, worse, and relapse after energising of areas of brain responsible normally for improvement. Aura was amply described in the clinical notes the registration of peripheral or central vegetative made before the operation. The clinicians taking the detailed events. This seems relatively simple. Four of the pos- history over the years were psychiatrists well versed in elic- sible bases for complex aura are: (1) that it is experi- iting subjective information. They were also guided by a on September 26, 2021 by guest. enced as an aspect of primary process thinking by a schedule of auras about which they made specific enquiry. A generally, but partially, impaired brain.'5 Here the progressive analysis was made by reading the data sheets is explain the consistency of aura.