Dissociative States With Abnormal EEG Multiple Personality and the Illusion of Possession M-Marsel Mesulam, MD

\s=b\Twelve patients with clinical and EEG this is difficult to prove since EEGs She is successfully attending a graduate manifestations reminiscent of temporal were not obtained and since hyster- course in journalism and holds a part-time lobe reported symptoms of dis- oepileptic convulsions were considered job. Although there is no family history of she suffered head sociative states. In seven of these common in cases of dissociative state. epilepsy, reports having trauma with apparent loss of consciousness the clinical picture was consis- This is based on 12 cases with a patients, report at the age of 1 year. tent with whereas the clinical reminiscent of multi¬ multiple personality, picture The EEG was abnormal on two consecu¬ other five had the illusion of supernatural ple personality and supernatural pos¬ tive determinations. One showed transient possession. These cases suggest that in session. These patients had EEGs that sharp waves and theta slowing over the left selected instances dissociative states displayed different degrees of abnor¬ temporal leads, and the second showed may constitute complex behavioral mani- mality, suggestive of focal electrical intermittent sharp waves over central festations of chronic limbic epilepsy. disturbance predominantly in the regions bilaterally and independently dur¬ (Arch Neurol 1981;38:176-181) temporal lobes. The apparent associa¬ ing drowsiness and light sleep, with a on the left side. Results of tion between these rare syndromes predominance and focal disturbances of cortical elec¬ neurological examination revealed no ab¬ normalities. such as trical in of the brain experiences, activity regions Clinical as well as the of a "Pjissociative the limbic notes, reports multiple personality and demonic related to system may pro¬ boyfriend, indicate that three autonomous possession, are enigmatic and rare vide an insight into etiological mecha¬ personalities, with different tempera¬ phenomena that are often attributed nisms. ments and responding to different names, to psychiatric causes. Although the REPORT OF CASES intermittently take hold of her conscious¬ etiological mechanisms remain con¬ ness. "Edna" (primary personality, the Each of the 12 cases reported here was woman troversial, a between patient) is an intelligent young relationship seen at the Behavioral Neurology Unit, these two conditions has been who is conscientious, dependent, and sug¬ sug¬ Boston, an outpatient clinic with a special the dominant second on clinical ~3 An asso¬ gestible. "Linda," gested grounds.1 interest in the psychiatric manifestations personality, gives free expression to hostil¬ ciation of these dissociative states of epilepsy and other neurological disor¬ and has tortured animals with has been but ity apparently epilepsy implied, ders. In the period of approximately one and entered fights. "Hanna" has a diminu¬ not elaborated. For example, pro¬ year during which these 12 cases were tive role and personifies gullibility, imma¬ longed fugue states with behavioral seen, 307 patients were referred to the turity, and sexual vulnerability. The switch alterations and subsequent Behavioral Neurology Unit, and the ques¬ from one personality to another is abrupt tion of was raised in may appear as a sign or even as the psychomotor epilepsy and complete. For instance, toward the end clinical manifestation of 61 of these. The EEG recordings were of a psychiatric interview with Linda, only psycho- with the standard ten to 20 motor performed Edna suddenly emerged and apologized for epilepsy.4" Furthermore, par¬ electrode Hyperventila- the abnormalities in the EEG scalp placement. having missed appointment, claiming oxysmal tion, photic stimulation, sleep tracings, and total amnesia for the previous hour. Linda have been described in at least one nasopharyngeal leads were obtained from apparently behaves as a co-conscious case of Al¬ multiple personality.7 virtually all the patients. The EEGs were observer when Edna is in control, but can¬ though the clinical descriptions sug¬ performed and interpreted by independent not interfere with ongoing activity. Edna, gest that many additional cases in the observers. on the other hand, denies direct awareness earlier literature were also epileptic,8 Multiple Personality of Linda, but surmises the latter's experi¬ ences through written notes that they Case l.-This is a 19-year-old, left- exchange. handed woman. She has never had a con¬ Edna and Linda have distinctly different Accepted for publication June 30, 1980. vulsion. Brief "absence" attacks were styles of speaking. Edna has a high-pitched From the Behavioral Unit Neurology and Bul- since the of 12 At the uses and con¬ lard reported age years. voice, frequently stereotypes and Denny-Brown Laboratories of the Har- the that could and writes with her left hand. vard Neurological Unit, Beth Israel Hospital, present, only experiences tractions, Boston. conceivably be attributed to seizures are Linda, on the other hand, speaks in a Reprint requests to Neurological Unit, Beth poorly defined episodes of visual blurring low-pitched and gutteral tone, uses precise Israel Hospital, 330 Brookline Ave, Boston, MA and distorted color . These last articulation without stereotypes or con¬ 02215 (Dr Mesulam). ten to 60 minutes and occur once a week tractions, and writes with her right hand.

Downloaded From: by a Northwestern University User on 07/20/2018 Edna projects an image of naivete and chiatrist at knife-point for several hours spontaneously emerge to talk to him. Each submissiveness, whereas Linda imparts a and was then amnesic for the event. When personality announces its intended age, sense of authority and self-importance. she reverted to her customary self and and the patient's overall behavior changes These two personalities communicate by heard about this, she apparently felt such accordingly. For example, the younger per¬ writing notes to each other. The following remorse that she brought her psychiatrist a sonalities have a better command of Ger¬ notes were written alternately, but appar¬ vial of her own blood. The emergence of man than of English, show a preference for ently with many hours intervening, by multiple personalities was observed by a the music of the 1950s (although she now Edna and Linda on the same sheet of former roommate, who described two enjoys only classical music), write better paper. abrupt deviations from the patient's usual with the left hand, and act in a manner a childish more is cus¬ Edna (neat, left-handed script): How self. One represents little girl, petulant and immature than the other a tough, and threatening for the patient. These transforma¬ come you do better than me in practically angry, tomary person. the self is tions are not without For every course... ? Although customary inconsistency. Linda (less legible, right-handed script, amnesic for the activities of the other instance, a personality who declared her¬ it has indirect of self to be 6 years old would write and speak apparently written many hours later when personalities, knowledge their with a much too advanced for she captured consciousness): Scholastic existence because the personalities vocabulary write notes to each other, as in case 1. that age. The patient is completely amnesic endeavors come naturally to me. was for these and her husband is the Edna: You aren't that smart though. I The patient given carbamazepine, episodes but no to treatment could be sole source of information this wouldn't want to trade with ever. response concerning you ascertained. unusual phenomenon. On the other Because you are a cruel monster I'll never hand, This case forms a transition be¬ the additional personalities probably share envy you. co-consciousness with the customary self, Linda: Sour grapes my child; we under¬ tween multiple personality and multi¬ since they can be called into existence, stand one another only too well. I will ple fugue states. In contrast with always be dominant. 1, the different virtually at will, by her husband. The vari¬ patient personalities ous personalities apparently do not com¬ do not seem to have an recur¬ The patient was given phenytoin, carba¬ orderly municate with each other by note. The mazepine, phénobarbital, and psychothera¬ rence or autonomous existences. In¬ patient calls the other personalities "little py. Although the dissociative episodes stead, there are periods of acting-out people," believes that they are each inde¬ decreased on this regimen, the contribu¬ that are then not available to the pendent personalities who happen to share tion of each therapeutic component to the consciousness of the customary self. a common body, and does not appear par¬ overall improvement is impossible to This type of criminal fugue has some¬ ticularly mortified at being the source of so assess. times been described as typical of singular a phenomenon. The EEG is consistent with an multiple personality in epileptics.8 In Phénobarbital decreased the episodes of seizure disorder even dizziness and loss of consciousness, but did underlying some instances, her altered states are no convulsions ever not alter the dissociative phenomena. though have sufficiently prolonged that she can occurred. The of The number of different presence autonomous find herself in a different city, with a personali¬ with commu¬ ties is and the personalities individual different identity, and answering to a potentially limitless, nicative the fact that Edna has variable is rather styles, different name. The length of such distinguishing age no direct awareness of the experi¬ episodes makes it unlikely that the than individual behavioral traces. In ences of whereas Linda is Janet's this case would Linda, altered behavior is merely a reflection terminology, constitute an of directly conscious of Edna, the com¬ of an ictal confusional state. More¬ example complex munication between the two writ¬ somnambulism.8 The EEG is min¬ by over, the fact that the different per¬ only of an ten notes, and the emergence of a sonalities exchange notes and that imally suggestive underlying dominant second who is seizure disorder. the feel¬ personality abrupt transitions from one personali¬ However, more and ings of sudden dis¬ aggressive independent ty to another occur are features quite dread, epigastric make this case very much like the characteristic of multiple personality. tress, olfactory hallucinations, and classic case of Miss Beauchamp The EEG is distinctly abnormal. déjà vu are reminiscent of psychomo- described and fits well tor epilepsy. by Prince,1 Case 3.—This is a 27-year-old, ambidex¬ Janet's" of som¬ category dominating trous woman. She has never had convul¬ Case 4.—This is a 37-year-old, right- nambulism. sions, but reports frequent experiences of handed woman. There is no history of Case 2.—This is a 21-year-old, right- sudden dread, associated with epigastric convulsions in the patient or in members of handed woman. She has never had convul¬ distress, episodes of olfactory hallucina¬ her family. She reports frequent episodes sions. She reports having had auditory tions (bleach or ammonia), dizziness, and of "staring," memory lapse, and disorien¬ hallucinations (church bells), as well as often loss of consciousness. She denies the tation. She has sought outpatient psychiat¬ frequent experiences of déjà vu and deper- experience of , but re¬ ric treatment on several occasions for sonalization. She is a troubled young ports frequent feelings of déjà vu. She is a vague symptoms that have a depressive woman with several psychiatric hospitali- highly capable young woman who has com¬ component. She completed college and has zations and many instances of outbursts of mand of English, German (her native done very well in additional graduate rage, assault, car theft, and arrest. tongue), Italian, and Latin, and who plays courses. Although born a Jew, she is now a The EEG showed bitemporal spikes, pre¬ the flute well. devout Roman Catholic with a strong dominantly on the right side. The results of The EEGs gave variable results. One awareness of the persecution of the Jewish neurological examination and computer¬ showed sharp wave activity, predominant¬ people. She is a prolific writer of poetry ized tomographic (CT) scan were within ly on the right. Two subsequent EEGs were and short stories. Her manner of speech normal limits. unremarkable. A fourth with nasopharyn- displays a high degree of circumstantiality On one occasion, she said that she had geal leads showed two very brief sharp in her thought processes. found herself in a different city where wave discharges that emanated from the The EEG shows rhythmic bursts of theta people called her by another name. She has left nasopharyngeal lead and extended to activity in the right temporal lobe during no recollection of how she got there or what the left anterior temporal region. The waking and a spike focus over the right she had done when answering to the other results of neurological examination were anterior temporal region during drowsi¬ name. On another occasion, she found her¬ normal. ness. Results of neurological examination self with a bloody stick next to an uncon¬ According to her husband, the patient were unremarkable. scious man and surmised that she was shows abrupt changes in ongoing behavior, The patient referred herself to the psy¬ responsible for the assault even though she and "personalities" that represent the chiatric services with a chief complaint of recalled no details. She once held her psy- patient at younger ages (4, 7, 16 years, etc) "multiple personality" and provided a writ-

Downloaded From: by a Northwestern University User on 07/20/2018 ten description of her condition and thera¬ The patient related the occurrence of mental states to such an extent that peutic goals. dissociative episodes four or five years ago. they assume psychological indepen¬ At that time, she strongly believed that she dence. The EEG is consistent with I would like to fuse my three personali¬ alternated among two or three different ties. When I am in my first personality, partial epilepsy. persons, each with a different character, all colors all brown or more brownish appear simultaneously in existence, and each Case 7.-This is a 33-year-old, right- in hue. I feel more cry more pain intensely, aware of the others. She even called herself handed woman. There is no history of relate more to other easily, directly people "Susan-1" or on convulsion in the patient or her family. She of their emotions "Suzan-2," depending with better perception which personality she represented. The "s" reports frequent attacks of anxiety, deper- and have a more emotionally proper reac¬ vu. personality embodied a protecting and sonalization, and déjà Multiple psy¬ tion to I feel alive and have a people. strong character, whereas the "z" personal¬ chiatric hospitalizations indicate a diagno¬ fear and nervousness. Also, my generalized ity represented a defenseless child in need sis of hysterical psychiatric reaction. sense of time is more urgent and I realize of she now realizes Despite her borderline level of intelligence that I could die. This is the that protection. Although personality that this must have her and absence of any intellectual interest, I awful traumas represented subjec¬ had when I experienced tive of different she writes extensively about God and and it is blocked fear. When I do interpretation tempera¬ mainly by mental states, she clearly states that four moral precepts. snap into this personality, I feel intense or five years ago she was convinced that The EEG during drowsiness shows mid- fear and shakiness for a minute or so. there were two or three autonomous per¬ temporal spikes, more on the left. My second personality is my usual one. I sons inhabiting the same body. Her first question during her initial visit see all the colors, feel less sharply, pain Because dissociative states were no lon¬ was whether it was possible to be "two treat like and refuse to look people objects ger at the time of persons in one." She then explained that at them. I feel that I am someone else who present examination, their to anticonvulsants could not she felt as if she were two different per¬ did not traumas and do not response experience be assessed. However, the abdominal pains, sons. One is good and religious, whereas need to be afraid they will ever happen hallucinations, and attacks of fear re¬ the second is the opposite. On further I feel I do not have much of a sense again. sponded well to administration of questioning, she explained that she really of I am smarter in this phéno¬ mortality. personal¬ barbital. did not believe that these two were auton¬ ity but unresponsive. omous but, rather, that they represented My third personality is color-blind At the time of the dissociative epi¬ two aspects of her personality. know who I always. I do not where I am or sodes, this patient presented a clinical Her behavior showed no alteration while I into am with when snap this personality. profile very much like that of she received phenytoin. I not like and make obscence and patient do people in whom was sarcastic remarks. 4, multiple personality This is the mildest case of dissocia¬ not associated with amnesia. The EEG since the can make The was but tion, patient easily patient given phenytoin, in this case indicated partial epilep¬ the distinction between autonomous she did not comply with a drug trial. sy- and different While the absence of amnesia personalities tempera¬ Case 6.—This is a 30-year-old, left- mental states. Nevertheless, it is makes this case an unusual of example handed white woman. She gave no personal interesting that her opening state¬ it is to multiple personality, important or family history of convulsions. There is a ment in her first visit referred to the Prince10 emphasize statement by vague description of black-out spells. She being "two persons in one." The EEG that amnesia is not a necessary com¬ also describes sudden distortions of color is abnormal and consistent with tem¬ ponent and that the fundamental fea¬ perception (things appear yellow-orange) poral lobe epilepsy. ture of the syndrome is the alteration that precede a temper outburst, as well as of character. Such alterations are auditory hallucinations of hearing several Possession described this The conversations simultaneously. Multiple clearly by patient. have followed Case 8.—This is a 26-year-old, right- absence of amnesia results in a more psychiatric hospitalizations suicidal intentions. She completed college, handed Roman Catholic woman. She coherent The EEG is con¬ of altered con¬ self-report. but is now working as a janitor. reports multiple episodes sistent with an underlying seizure The EEG shows paroxysmal theta and sciousness associated with lip smacking and movements. There are also focus. Furthermore, her religiosity, sharp waves over both temporal lobes while rocking circumstantiality, and hypergraphia alert. Neuropsychological testing shows a panic episodes, auditory and visual halluci¬ and constitute a cluster of behavioral verbal IQ of 104, a performance IQ of 103, nations, déjà vu, déjà vécu, depersonal- ization. Many psychiatric hospitalizations changes that is seen in patients with and a memory quotient of 106. The patient described the feeling that became necessary after psychotic breaks, psychomotor epilepsy." attacks of and suicide Dur¬ there are two additional people inside her. rage, attempts. Case is her she was institutional¬ 5.-This a 27-year-old, right- One is a black girl named Mary, who ing adolescence, woman. no or ized for four with handed She gives personal emerges to the surface for very short peri¬ years life-threatening family history of convulsions. Episodes ods of time and who is aggressive and anorexia nervosa. She is now attending characterized extension courses at the level and by the abrupt emergence of combative. Mary resembles a black china college abdominal As. nausea, pain, fear, visual distor¬ doll that was the patient's favorite toy. An obtaining mostly and tions, frightening auditory and visual additional personality is characterized as a The EEG showed anterior bitemporal hallucinations are vu A scan of reported. Déjà occurs 2-year-old boy with a gentle disposition. At spikes. CT and results neurologi¬ cal examination are within normal limits. frequently, depersonalization rarely. She least on one occasion, she looked at the has a of anorexia nervosa The stated her conviction that history and many mirror expecting to see a little black girl patient recent for she is the devil. She feels that psychiatric hospitalizations sui¬ and was surprised to see her own reflec¬ possessed by cidal ideation. The patient is successfully tion. there is a demon in her body who cackles employed in a professional career that While receiving valproate sodium, the inside her head. She hears his voice telling requires complex numerical skills. She has visual and auditory hallucinations de¬ her to do horrible things, ranging from no history of head trauma or febrile sei¬ creased, but the effect of this medication throwing cups of coffee at other people's zures. to an on the dissociative states could not be faces killing herself. During episode An EEG obtained during an episode of assessed. of possession a priest was brought to see abdominal showed focal but she on the Bible he had pain paroxysms of The absence of amnesia the her, spit spikes in the nasopharyngeal leads, more places brought along. She was subsequently taken in the same as prominently on the right. Results of neuro¬ patient category through the rite of exorcism. She cannot logical examination and the CT scan were patients 4 and 5. The patient appar¬ recall the episode since she lost conscious¬ normal. ently personifies different tempera- ness at the onset, but felt much relieved

Downloaded From: by a Northwestern University User on 07/20/2018 when she recovered her senses. The priest devil was playing horrible tricks with his also describes olfactory (rotten peanuts) then announced that she had been exor¬ body. When he was offered the alternate and auditory hallucinations, dream-like cised. A conversation with the patient was explanation that it might merely feel as if states of unreality, and the feeling that she recorded: he were possessed, the patient repeated his is watching herself from the outside. She Patient: I remember feeling possessed conviction that the devil was actually has had multiple psychiatric hospitaliza¬ inside his As for this demonic for suicidal intent. She is a at Mass and I remember going over to see a body. proof tions, mostly possession, he related frightening night¬ very intelligent woman who has been drift¬ priest... a priest coming to see me and mares and thoughts of raping his own ing through the world without consistent saying that he thought I was possessed and He that there jobs or me to another and daughters. kept repeating interpersonal relationships. referring priest... are Several EEGs are as to "demons within me." reported showing going see him. after in left leads. Physician: What is possession? The patient did very well receiving "dysrhythmia" temporal and The various However, the EEG was in Patient: Satan takes over carbamazepine phenytoin. performed my body. ictal manifestations and he another institution and neither the trac¬ Physician: What does that feel like, how disappeared that he was possessed. ings nor the final report was available to do you know? stopped believing us. Psychological showed a verbal Patient: He talks to me, he tells me to do Patients 8 and 9 have several simi¬ testing IQ of 123, performance of IQ of 119, and a terrible things. larities. share a literal belief in They memory of 118. Results of neuro¬ Physician: Are you at those quotient actually, the reality of possession and they both examination were within normal convinced that Satan is in logical times, your body have strong feelings of depersonaliza- limits. or do you just think it feels that way? tion and ictal dread. Their conditions The patient says, "The devil, I know it's Patient: I think I was possessed. responded to administration of con¬ inside of me." This conviction is based on a While receiving several drugs, including ventional anticonvulsants. It is inter¬ voice that she hears inside her head that phenytoin, carbamazepine, phénobarbital, esting that patient 9, the only man in tells her to do negative things. In addition, and acetazolamide (Diamox), the episodes the is also the in she also experiences multiple personali¬ of and di¬ series, only patient panic, lip smacking, possession whom the seizure disorder is not idio¬ ties—one who wears bright colors, another minished in frequency. who wears dark colors. She calls them pathic. "different within and "I This patient was convinced that her people me," says Case 10.—This is a 23-year-old, ambidex¬ am there, and they are there, and they are body was possessed by the devil. She trous woman. There is no history of convul¬ a part of me but it's just like one part of me was clear in that this quite stating sions in the patient or family members. becomes stronger and outweighs every¬ was a to describe not just metaphor She reports olfactory hallucinations (burnt thing else. And, you know, two of them can unacceptable traits in her character, rubber), sudden attacks of fear, and devia¬ exist at the same time and they can have but a clear conviction of being invaded tions of the head to the right. The experi¬ conversations..." by an alien entity. ence of déjà vu or depersonalization are Response to medication cannot be denied. She had a very poor performance in assessed. Case 9.—This is a 38-year-old, right- school and can only hold menial jobs. She handed Roman Catholic man who had no This combines the features usually has a rather placid temperament. patient prior history of neurological or psychiatric One EEG shows of of possession and multiple personali¬ An abscess of the paroxysm sharp impairment. right parie- waves, and another shows paroxysm of ty. was excised tooccipital region surgically theta waves while awake. No localization is and he did well a Case 12.—This is a 44-year-old woman. postoperatively despite obvious. shows a ver¬ residual left visual field deficit. Several Psychological testing She reports having had full-blown grand bal IQ of 98, performance IQ of 77, and a months he as if mal seizures for the past ten years. The later, reported experiences memory quotient of 84. head is "I have no thoughts," frequency is now two to three seizures per "my empty," She an unusually strong reli¬ are displays year. She reports had expe¬ "I feel hypnotized." These feelings the belief having strong associated with abdominal gious involvement, including riences of déjà vu, jamais vu, and deperson- blurry vision, that she has seen and the devil. of imminent God, Mary, alization. She has a history of many psy¬ discomfort, sensation death, She feels "different" at certain times. Dur¬ intense and the conviction that his chiatric hospitalizations. Her psychiatric fear, these she "can tear the is controlled external forces. ing episodes, just history includes sexual acting out, drug body being by whole place apart, walk through walls." Two after surgery, he had a abuse, and multiple delusional states. She years grand When she feels that way, she can look at mal seizure that completed college as well as graduate prompted hospitalization. the mirror and not touch The with recognize herself, courses on creative writing. She writes patient completed eighth grade herself and not feel it. When asked for an as a was extensively, and has practiced Presbyteri- difficulty and works laborer. He explanation for these alterations, she not but become preoc¬ anism, Judaism, and Episcopalianism. unusually religious, volunteered the belief that she was with after and mostly The EEG shows bilateral spikes over the cupied religion surgery "the devil" at those times. The interview started to write excessively even though he temporal lobes and surrounding regions. was recorded and she said, "I know this will was illiterate. The results of neurological examination virtually sound weird and I never saw The Exorcist, The EEG showed a wave and were not remarkable. Psychological testing sharp spike but I did ask the doctor if he I was thought shows a verbal IQ of 134, a performance IQ focus mostly on the right midtemporal Do think I need to evil possessed. you get of 104, and a memory quotient of 120. area. The CT scan showed an area of low out of me?" in the spirits On repeated occasions, she has believed density right parietooccipital region. The response of her condition to pheny¬ examination showed sensory that she was the Messiah and that she has a Neurological toin and phénobarbital was difficult to extinction on the left. special mission to fulfill. Some of these even she a certain voluminous assess, though reported last for almost a year. During one The patient kept notes con¬ decrease in the of the dissocia¬ episodes frequency of these she believed she was called by God cerning his spells: tive episodes. to enter politics, ran for an important 9:45—inside me I am scared but I am In this case, the experience of dem¬ public office, and almost won the election. it I to live a going through try good life, onic was much less intense One subjective description she offers for and I to have faith. possession try good than in the first two cases. these grandiose episodes is being "pos¬ 11:00—1 feel like the devil is trying to get However, many of the features are reminiscent sessed by God." in me. Phenytoin controls the grand mal sei¬ 11:30-While Bible I've a of cases 8 and 9. reading my got zure, but its effects on the messianic states good feeling inside me. Case 11.-This is a 29-year-old, right- cannot be determined. In the course of his he handed woman. She the occurrence hospitalization, reports that frequently expressed the conviction that he of generalized convulsions with loss of con¬ Several authors stress the point was possessed by the devil and that the sciousness, but the details are vague. She possession need not be demonic.- The

Downloaded From: by a Northwestern University User on 07/20/2018 experience of "ecstasy" can be consid¬ portionately large number of referrals drank his blood. Two other famous ered a form of beatific possession, and in whom severe psychiatric distur¬ reports, that of Louis Vivé19 and that this patient seems to manifest it. bances occur in conjunction with epi¬ of Ansel Bourne,2" also contain evi¬ lepsy; nevertheless, the high incidence dence for multiple personality in the COMMENT of these otherwise rare syndromes presence of a convulsive disorder. A and their association with abnormal similar association occurs in the case Each of the patients was initially EEGs raise the possibility that multi¬ of Tucker and~ Shields.21 Furthermore, seen in psychiatric consultation. The ple personality and possession may Jackson's celebrated patient Dr , diagnosis of hysteria was considered constitute one behavioral manifesta¬ who suffered from psychomotor epi¬ in cases 1, 3, and 7 and that of schizo¬ tion of abnormal electrical activity in lepsy, also displayed unusual behav¬ phrenia in cases 8 and 12. However, the temporal lobes. This conclusion is ioral alterations. Jackson and Col- atypical features in these patients, as consistent with many other clinical man22 wrote, "On another occasion well as in the other cases, prompted series in which a large spectrum of there were postepileptic actions by subsequent neurological evaluation behavioral alterations, ranging from during 'unconsciousness,' of a kind that led to the discovery of the abnor¬ unusual religiosity to hysteria and which in a man fully himself would be mal EEG. paranoid psychosis, has been attrib¬ criminal, and must have led to very In these 12 cases, clinical syndromes uted to psychomotor epilepsy.13'1" Al¬ serious consequences had not, fortu¬ reminiscent of multiple personality or though focal EEG abnormality may nately, his condition been known." possession emerged on a background occur in otherwise idiopathic hysteria Thus, the case of Dr was probably of an abnormal EEG. Four of the or , the incidence of this the first published description of a patients (cases 1 through 4) had a appears to be quite low. In fact, in a person in whom multiple personality colorful and dramatic clinical picture study of 410 schizophrenic patients, emerged on the background of psycho¬ consistent with the classic descrip¬ focal EEG abnormality was found in motor epilepsy. There are two reasons tions of multiple personality. Another only 1%.17 Nevertheless, the possibility for believing that the literature may three were convinced that they were must be considered that the associa¬ underestimate this association. First, possessed, two by the devil (cases 8 tion reported in our cases merely there was a common tendency to and 9) and one by a benevolent power reflects the chance occurrence of an ascribe convulsions to hysteroepilep- (case 12). These seven patients dis¬ abnormal EEG in patients with other¬ sy, especially when they occurred in played the most florid symptomatolo¬ wise functional psychiatric distur¬ the presence of dissociative states.23 gy and volunteered the relevant bances. Some of the patients (cases 8, However, as Gastaut11 has pointed details spontaneously. In the other 9, 10, and 12) were taking phenothia- out, many of these atypical convul¬ five cases, the symptoms were either zine compounds, so that some of the sions may well have been manifesta¬ milder (cases 6,7,10,11) or dormant at EEG abnormalities in these cases tions of what would now be called the time of the clinical interview (case could conceivably be attributed to the psychomotor epilepsy. Second, in the 5). With the exception of two cases effect of these drugs. Furthermore, absence of the EEG, patients without with mild or questionable readings since a suspicion of epilepsy was the motor convulsions like the ones (cases 3 and 11), the EEG was distinct¬ basis for referral to our clinic, this described earlier would pass unnoticed ly abnormal, with a predilection for sample does not rule out the possibili¬ even if they had paroxysmal abnor¬ the temporal lobe. With three excep¬ ty that most cases of dissociative malities of cerebral electrical activity. tions (8, 9, and 12), there were no states remain free of any abnormality Thus, the association of multiple per¬ convulsions or definite automatisms. in their EEGs. sonality with epilepsy is probably In the absence of such motor manifes¬ Several instances of prolonged higher than that suggested by a sur¬ tations, the description of these fugues have been described in epilep¬ vey of published cases. patients as epileptic may be ques¬ tics.40 However, the specific correla¬ The relationship between epilepsy tioned. However, the occurrence of tion between epilepsy and dissociative and possession is more difficult to electrical temporal-lobe paroxysms states has not been stressed, even surmise. Convulsions are very fre¬ and concomitant psychomotor phe¬ though isolated cases with such an quently described in cases of demonic nomena in patients who do not display association have been reported. Most possession.1·2 It is likely that most of abnormal movement is well known.12 convincing is the case described by these are of a hysterical nature, espe¬ Thus, in these patients, the words Horton and Miller,7 a 16-year-old cially since it is not unusual for the "epilepsy" and "seizure" refer pri¬ girl whose EEG contained parox¬ phenomenon of possession to spread marily to an abnormality in the EEG ysmal discharges and abortive spikes contagiously among members of a consistent with an underlying focus of and who showed a classic case of group, and since epilepsy would pathological irritation. amnesic somnambulism with four dis¬ almost certainly not manifest a simi¬ Multiple personality and possession tinct personalities. There are at least lar epidemiology. A second difficulty are rare occurrences in contemporary five other cases in the literature in arises because the word "possession" psychiatric practice. Nevertheless, the which a similar association with epi¬ has several distinct uses. It has been experience of the Behavioral Neurolo¬ lepsy can be inferred on the basis of used to describe not only invasion by a gy Unit shows that of 61 patients in the clinical description, but in which spiritual entity, but also a state of whom the possibility of psychomotor confirmatory EEG evidence is lack¬ inspiration and even the mere pres¬ epilepsy was raised, 12 gave a history ing. Sörgel, the case of von Feuer¬ ence of a disease state, especially epi¬ consistent with these syndromes. Fur¬ bach,18 was an epileptic who showed a lepsy. Thus, in the frequently quoted thermore, a similar clinical picture dramatic dissociation into decent and passage from the New Testament was not encountered among the 246 criminal personalities. The decent per¬ (Mark 9:17-27), the "dumb spirit" who patients with other primary diagnoses sonality was amnesic for the activities throws the man on the floor and who were seen during the same time of its criminal counterpart, including makes him foam at the mouth seems span of approximately one year. Our one episode during which Sörgel to represent ordinary epilepsy, even clinic undoubtedly attracts a dispro- chopped up an old woodcutter and though this passage is often quoted as

Downloaded From: by a Northwestern University User on 07/20/2018 an example of demonic possession and cinations or illusions; purely affective, in susceptible persons. its successful exorcism. As a conse¬ as in the case of spontaneous dread, The question is asked why some quence of the high frequency of hys¬ panic, and sadness; or a combination patients with terical convulsions and a lack of uni¬ of the two, as in the case of déjà vu, merely have personality traits, such as formity of nomenclature, it is very jamais vu, depersonalization, or feel¬ religiosity or humorlessness, whereas difficult to ascertain the association ings of unreality. others manifest the dramatic symp¬ of possession with epilepsy. Although The pattern of anatomical connec¬ toms of dissociative states. Although the superstitious tendency in the past tions suggests that the temporal lobe our sample is too small for such anal¬ was to attribute epilepsy to possession is involved in the integration of affec¬ yses, a review of the seven cases in by evil spirits, it is interesting that tive tone with sensory information which the EEG abnormality was the cases reported here suggest that and, perhaps, thought processes. Un¬ asymmetrical suggests that the left focal epilepsy may in some cases lead der usual conditions, the affective hemisphere was rarely the dominant to the illusion of possession. tone imparted to perception or focus in right handers (2/7 cases), It is becoming increasingly clear thought is expected to reflect the sub¬ whereas the occurrence of a right- that a bewildering variety of behav¬ ject's past experience, present inter¬ sided focus in right handers or left- ioral changes occur in conjunction nal state, and the value of the relevant sided focus in left handers was more with partial epilepsy located in the mental experience. In patients with frequent (5/7 cases). Hence, dissocia¬ temporal lobe.11 Although the precise temporal lobe epilepsy, this relation¬ tive phenomena may be more likely to reasons for this association remain ship may be severely disrupted by the occur in patients whose predominant speculative, several anatomical fea¬ presence of an autonomous and parox¬ EEG abnormality is in the nondomi- tures of the temporal lobe deserve ysmal focus of neural discharge. This nant temporal lobe. It is conceivable comment. First, the temporal lobe, focus may lead to unpredictable affec¬ that autonomous mental events that and especially its medial portions that tive coloring of mental activity and originate in the nondominant hemi¬ so often become the focus of psycho¬ may disrupt the balance between sphere are more likely to lead to disso¬ motor epilepsy, contain not only struc¬ affect on one hand and perception and ciative states, whereas those that tures such as the fusiform and para- thought on the other. Thus, in addition originate in the hemisphere dominant hippocampal gyri (where complex sen¬ to ictal experiences such as hallucina¬ for language may be more likely to be sory associations are formed), but also tions, panic, or déjà vu, more complex adopted as part of the self. Larger structures such as the amygdala and and pervasive interictal behavioral series of patients will need to be hippocampus, which are pivotal com¬ changes may become established as a investigated to test the validity of this ponents of the limbic system and manifestation of chronic temporal hypothesis. which have direct access to the hor¬ lobe epilepsy. In some instances, these monal, visceral, and motivational changes take the form of character N. Geschwind, MD, commented on the manu¬ mechanisms of the hypothalamus.24 traits, such as aggressiveness, relig¬ script. T. Brott, MD, initiated our interest in this case 1. D. there are or and become phenomenon by referring Bear, MD, Moreover, powerful monosy- iosity, humorlessness, and L. Schenk contributed clinical information. connections in the medial into the fabric of the naptic tem¬ incorporated R. Regan gave secretarial assistance. poral lobe between sensory associa¬ underlying personality. In other cases, tion cortex and limbic structures.25'27 these changes may be so drastic or Nonproprietary Name and Thus, the ictal manifestations of tem¬ may occur in such a manner that Trademark of Drug poral lobe epilepsy may be either integration becomes impossible and purely sensory, as in the case of hallu- dissociative states emerge, especially Valproate sodium-Depakene Syrup.

References

1. Huxley A: The Devils of Lodoun. New York, 1906;1:170-187. Proc Soc Psych Res 1891;7:221-257. Harper & Row Publishers Inc, 1953. 11. Bear D, Fedio P: Quantitative analysis of 21. Tucker RB, Shield JA: Amnesia: Report of 2. Oesterreich TK: Possession Demoniacal and interictal behavior in temporal lobe epilepsy. a case apparently benefited by operation. Other, Ibberson D (trans). New York, University Arch Neurol 1977;34:454-467. J Abnorm Soc Psychol 1928;23:40-44. Books, 1966. 12. Pincus JH: Can violence be a manifestation 22. Jackson JH: Colman WS: Case of epilepsy 3. Prince M: Dissociation ofa Personality. New of epilepsy? Neurology 1980;30:304-307. with tasting movements and 'dreamy state': York, Longmans, Green & Co, 1925. 13. Gastaut H: The Electro-Clinical Very small patch of softening in the left uncinate 4. Aggernaes M: The differential diagnosis Correlations. Springfield, Ill, Charles C Thomas gyrus. Brain 1898;21:580-590. between hysterical and epileptic disturbances of Publisher, 1954. 23. Charcot JM, Marie P: Hysteria mainly hys- consciousness or twilight states. Acta Psychiatr 14. Geschwind N: Behavioral changes in tem- tero-epilepsy, in Tuke DH: A Dictionary of Psy- Scand Suppl 1965;185:1-101. poral lobe epilepsy. Psychol Med 1979;9:217-219. chological Medicine. Philadelphia, P Blakison & 5. Akhtar S, Brenner I: Differential diagnosis 15. Pritchard PB III, Lombroso CT, McIntyre Son, 1892, pp 627-641. of fugue-like states. J Clin Psychiatry 1979; M: Psychological complications of temporal lobe 24. Van Hoesen GW, Pandya DN, Butters N: 26:381-385. epilepsy. Neurology 1980;30:227-232. Cortical afferents to the entorhinal cortex of the 6. Zlotlow M: Temporal lobe 'spike focus' asso- 16. Slater E, Beard AW, Glithero E: The rhesus monkey. Science 1972;175:1471-1473. ciated with confusion, complete amnesia and schizophrenia-like psychoses of epilepsy. Br J 25. Herzog AG, Van Hoesen GW: Temporal fugues in a paranoid schizophrenic. Psychiatr Q Psychiatry 1963;109:95-150. neocortical afferent connections to the amygdala 1968;42:738-748. 17. Goon Y, Robinson S, Lavy S: Electroen- in the rhesus monkey. Brain Res 1976;115:57-69. 7. Horton P, Miller D: The etiology of multiple cephalographic changes in schizophrenic pa- 26. Van Hoesen GW, Rosene DL, Mesulam personality. Comp Psychiatry 1972;13:151-159. tients. Isr Ann Psychiatry 1973;11:99-107. M-M: Subicular input from temporal cortex in the 8. Sutcliffe JP, Jones J: Personal identity, 18. Taylor WS, Martin MF: Multiple personali- rhesus' monkey. Science 1979;205:608-610. multiple personality and . Int J Clin Exp ty. J Abnorm Soc Psychol 1944;39:281-300. 27. Rosene DL, Van Hoesen GW: Hippocampal Hypn 1962;10:231-269. 19. Camuset L: Un cas de d\l=e'\doublementde la efferents reach widespread areas of cerebral 9. Janet P: The Major Symptoms of Hysteria. personalit\l=e'\,periode am\l=e'\siqued'une an\l=e'\echez un cortex and amygdala in the rhesus monkey. New York, Macmillan Publishing Co Inc, 1929. jeune homme hysterique. Rev Philosoph 1882; Science 1977;198:315-317. 10. Prince M: Hysteria from the point of view 13:676-678. of dissociated personality. J Abnorm Psychol 20. Hodgson R: A case of double consciousness.

Downloaded From: by a Northwestern University User on 07/20/2018