Partial epilepsy with ‘‘ecstatic’’ seizures

Bjørn

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AAsheim Hansen

and Eylert Brodtkorb

a,b,*

Department of Neuroscience, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway

Department of Neurology, St. Olav

s Hospital, University Hospital, 7006 Trondheim, Norway

Received 16 June 2003; revised 16 September 2003; accepted 16 September 2003

Abstract

Reports focusing on auras of ecstasy or pleasure have been limited largely to single case descriptions. We examined 11 con-secutive patients with such ictal symptoms. Eight had sensory hallucinations, four had erotic sensations, five described ‘‘a religious/spiritual experience,’’ and several had symptoms that were felt to have no counterpart in human experience. Ictal EEG recordingswere performed in four patients; two had seizure onset in the right temporal lobe and two in the left. In seven the onset could not bedefinitely localized. The diagnosis of epilepsy was often delayed. Eight patients wished to experience seizures; self-induction waspossible in five and four showed treatment noncompliance. In patients with insufficient drug intake, in whom good complianceshould be expected, it is relevant to consider seizures with pleasant symptomatology. According to the literature, experiential andecstatic seizures seem to have had a substantial impact on our cultural and religious history.

Keywords:

Epilepsy; Ecstatic seizures; Pleasant seizures; Self-induction; Noncompliance; Religion

1. Introduction

It has been known since the late 19th century that‘‘psychic’’ phenomena can be part of epileptic seizures.In 1938 Penﬁeld and Kristiansen discovered that suchsymptoms could be reproduced by electrical stimulationof the temporal lobe and introduced the term

experien-tial seizures

[1]. The semiology of these seizures typicallycombines elements of perception, memory and affect [2].Although fear by far is the most common affectivesymptom [3,4], several patients experiencing varyingdegrees of pleasure during partial seizures have beendescribed. Of 100 patients with emotional symptoms aspart of a seizure, only 7 described pleasure [3]. However,in another series of 52 such patients as many as 12 re-ported pleasurable emotions [4].The symptomatology of ‘‘ecstatic seizures’’ is definedas ictal sensations of intense pleasure, joy, and con-tentment [5]. Cognitive and spiritual experiences mayoccur as components [5,6]. Patients with these phe-nomena are rare and may remain undiagnosed for years[7,8]. There is little doubt that the Russian writer Fy-odor Dostoevsky experienced emotions of ecstatic orpleasant quality during his epileptic seizures and ‘‘Dos-toevsky epilepsy’’ is being used as a synonym to epilepsywith such seizures [3,9,10].To our knowledge, this study is the first focusing on alarger series of patients with ecstatic seizures. We discussthe seizure semiology and the clinical characteristics of these patients, and compare our findings with previouscase reports.

2. Patients and methods

Eleven patients with epilepsy and ictal symptoms withpleasant emotions were consecutively recruited from ourepilepsy outpatient clinic. Medical histories and resultsfrom EEG and brain imaging examinations were ob-tained from hospital records. The patients gave in-formed consent and semistructured interviews wereperformed (personally or by telephone). The patientswere speciﬁcally asked about ictal symptoms of aﬀect,memory, and perception, and whether they ever had

Corresponding author. Fax: +47-73867581.

E-mail address:

eylert.brodtkorb@medisin.ntnu.no(E. Brodtkorb).1525-5050/$ - see front matter

Epilepsy

Behavior

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considered their ictal symptoms to represent spiritual orreligious events.The side localization of seizure onset was categorizedas ‘‘uncertain’’ when only interictal EEG, imagingﬁndings, or reported ictal or postictal symptoms showedlateralizing features. When at least two of these pa-rameters indicated the same hemisphere, side localiza-tion was considered ‘‘probable.’’ The side was regardedas ‘‘deﬁnite’’ when evidence for seizure onset was dem-onstrated by ictal video-EEG recordings.

3. Results

3.1. Demographic and clinical data

Median age was 48 years (range: 23–62). Median agefor seizure onset was 7 years (range: 3–42). Four patientswere male. Eight patients had simple partial seizures(SPSs) as well as complex partial seizures (CPSs) andgeneralized tonic–clonic seizures (GTCs) (Table 1).Threehad only one seizure type in the form of SPS evolving toCPS. Five patients had symptomatic epilepsy; six hadcryptogenic. In seven, several years (range: 4–28) hadelapsed between the first partial seizure and first gen-eralized seizure. Seven patients continued to have sei-zures, whereas four were seizure-free on treatment.Neurological or intellectual deficits were not present.

3.2. Seizure semiology

The various ictal elements are listed in Table 2. Tenpatients reported ecstatic sensations in the form of anintense feeling of pleasure and contentment. One (pa-tient 9) described more excitement than pleasure, how-ever, of a quality that gave rise to a wish forexperiencing further attacks.

3.2.1. Patient 1

The ﬁrst seizure occurred during a concert when hewas a teenager. He remembers perceiving short mo-ments of an indeﬁnable feeling. Such episodes recurredand a few months later evolved into a GTC. He char-acterizes these sensations as ‘‘a trance of pleasure.’’ ‘‘It islike an emotional wave striking me again and again. Ifeel compelled to obey a sort of phenomenon. Thesesensations are outside the spectrum of what I ever haveexperienced outside a seizure.’’ He also describes coldshivering, increased muscle tension, and a delicioustaste, and he swallows repeatedly. He enjoys the sensa-tions and is absorbed in them in a way that he can barelyhear when spoken to. When in a particular, relaxedmood, he can sometimes induce seizures by ‘‘opening upmentally’’ and contracting muscles. He denies any reli-gious aspects of the symptoms. ‘‘It

s the phenomenon,the feeling, the ﬁt taking control.’’ It lasts a few minutesand afterward he is tired with diﬃculties expressinghimself for about 1hour.

3.2.2. Patient 2

Seizure onset occurred at the age of 7. He felt a twitchin the right side of his face like a sort of a grin and ‘‘aprofound relaxation, a plus in daily life.’’ In the begin-ning, the attacks often occurred when passing a partic-ular place on his way to school. He could trigger themby concentrating on recalling former ﬁts. Later the sei-zures lost some of their pleasant character. At present,he feels that objects in focus move closer and becomeenlarged and that the surroundings feel strange andunfamiliar as if he is in another world. When undis-turbed, he can still enjoy them. Sometimes a strong d

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aavu sensation accompanied by nausea dominates, a sen-sation that usually heralds a GTC.

3.2.3. Patient 3

Her seizures have always been stereotypical, startingwith an epigastric sensation spreading to chest andarms. ’’It

s like a warm, woolly, pleasant feelingspreading through my skin.’’ At this early stage, she mayabort further seizure progression by concentrating, butrarely does so because the feeling is usually over-whelming, and she ‘‘gives herself up and enjoys the

Table 1Demographic and clinical data of patients with ecstatic seizuresPatient Age (years) Sex Onset age (years) Age at diagnosis (years) Seizure type Etiology1 23 M 16 16 SPS, CPS, GTC

Trauma2 55 M 7 15 SPS, CPS, GTC Cryptogenic3 62 F 23 35 SPS, CPS, GTC Cryptogenic4 41 F 29 34 SPS, CPS, GTC Cryptogenic5 37 F 7 11 SPS, CPS, GTC Mesial temporal sclerosis6 51 M 42 46 SPS, CPS? Cryptogenic7 41 F 7 39 SPS, CPS, GTC Cryptogenic8 53 F 39 40 SPS, CPS Cryptogenic9 30 F 3 28 SPS, CPS Meningoencephalitis10 48 F 7 35 SPS, CPS, GTC Meningitis/tumor11 48 M 7 16 SPS, CPS, GTC Tumor

SPS, simple partial seizure; CPS, complex partial seizure: GTC, generalized tonic–clonic seizure.668

B. A˚ sheim Hansen, E. Brodtkorb / Epilepsy & Behavior 4 (2003) 667–673

seizure.’’ Eyewitnesses may notice a slight faintnesswhich she is not aware of herself. She sits down for a fewminutes and when she comes to herself, she has head-ache and nausea. She has never thought of trying toinduce seizures due to the unpleasant character of thepostictal symptoms. These attacks started in her earlytwenties but she kept them a secret until they evolvedinto a GTC at 35.

3.2.4. Patient 4

The attacks started in her late twenties. ‘‘I had anintense sensation in my stomach as if I were a teenagerhelplessly in love. Sometimes I heard voices, enjoyableand frightening at the same time.’’ These sensations in-variably were followed by anxiety and fear accompaniedby shuddering and an urge to swallow. They often oc-curred during relaxation after deep concentration. She isan artist and when having an attack at the end of aperformance in a church, she imagined the voice to comefrom God. This episode was terrifying. She considersherself an agnostic and feared for her mental health.After two GTCs initiated by the same sensations, theattacks were diagnosed as epileptic in the beginning of her forties. The explanation of the attacks as being ep-ileptic was felt as both a relief and a disappointment.Antiepileptic drug therapy has been succesful. ‘‘Nowa-days I sometimes miss the attacks; they gave me feelingsI thought I was too old to experience.’’

3.2.5. Patient 5

She had had uncontrolled partial seizures startingwith febrile convulsions from early childhood. At age34, she was successfully treated with surgery for mesialtemporal sclerosis. She described her seizures as in-tensely unpleasant in the form of ‘‘ictus emeticus’’ withnausea and vomiting evolving to CPSs with automa-tisms. After surgery, she has had only sporadic auras,but now dominated by pleasant emotions and onlyrarely with mild components of gastrointestinal dis-comfort. It starts with a buzzing sound in her ears and afeeling of unfamiliarity with her surroundings accom-panied by a vague erotic component. Along with thesemental symptoms, she feels a delightful woolly feeling inher head. She acts unremarkably and knows what isgoing on. When listening to music, she sometimes caninduce these attacks by deep concentration. In retro-spect, she recognizes these sensations as the initialcomponents of her previous seizures. Before surgery shepaid little attention to them as they were quickly re-placed by nausea. Now they are more pronounced, andas they never progress further, the fear for them hasgone and she is able to enjoy them.

3.2.6. Patient 6

This man has a multifaceted symptomatology and atendency to interpret bodily sensations as supernaturalphenomena. Nevertheless, from the beginning of hisforties, he experienced distinct, stereotypical attackswith a ‘‘change of concept of the surrounding world.’’He reports an ‘‘oscillating erotic sensation, like twin-kling polar light’’ in his pelvic region and down the in-side of his thighs. This is described as diﬀerent fromsexual excitement, more like ‘‘an erogenous charge of the skin.’’ He may also have a clairvoyant feeling of a‘‘telepathic contact with a divine power.’’ These sensa-tions are of short duration and may be accompanied byfaintness and followed by drowsiness. With carbamaz-epine treatment, the frequency of these attacks has beenconsiderably reduced.

3.2.7. Patient 7

The seizures started with a sudden feeling of ‘‘cross-ing a line as if the world was divided.’’ She perceived asmell of sawdust and a stereotyped image of herself as achild superimposed on her real vision. Her grandfather,whom she loved deeply, came walking toward her, try-ing to give her some sort of a message which she neverwas able to grasp. This scene was accompanied by anintense happy feeling, which she wanted to prolong.Sometimes, she could elicit the attacks by trying to recallthe smell of sawdust. The attacks started during earlyschool years, but were ﬁrst diagnosed as being epilepticafter the event of secondarily generalized seizures at age39. After the introduction of antiepileptic treatment shehas been seizure-free.

3.2.8. Patient 8

The attacks started toward the end of her thirties.Initially, she feels an intense thirst and an urge toswallow. Subsequently, she hears a sound of increasingintensity which turns into beautiful symphonic music.This is accompanied by a peculiar smell of herbs andincense (which she otherwise has felt only once in her lifewhen visiting a market in Bali). When she is alone, shemay give herself completely up to a delightful sensationof ‘‘inebriation and ﬂoating’’ and she feels that her mindleaves the body. The episodes may end with an urge tourinate. Afterward she is drowsy and has diﬃcultiesexpressing herself.

Table 2Various experiential ictal elementsPleasant/ecstatic 11‘‘Mental diplopia’’ 6Visual 5Olfactory/gustatory 5Religious/spiritual experience 5Auditive 4Erotic 4D

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