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GEORGE F. MAHL, Ph.D.,' ALBERT ROTHENBERG, M.D., JOSE M. R. DELGADO, M.D., and HANNIBAL HAMLIN, M.D.
During interviews, intracerebral electrical stimulation of sharply localized areas in the temporal lobe of a young woman with psychomotor epilepsy consistently produced ego-alien ideational experiences similar to those observed by Penfield. The responses were associated with considerable anxiety and with evoked electrical seizure activity. The use of the interview as the observational situation and careful study of the interview tape-recordings made it possible to discover that the content of the ideational experiences was often a function of her prestimulation "mental content." This finding led to an examination of Penfield's formulations and to some alternative hypotheses about mechanisms that might be involved in psychic responses to temporal-lobe stimulation IHIS is a report of some observable psychological effects of intracerebral stimulation in a patient with psychomotor epilepsy. Diagnostic study with the implanted electrode technique developed by Delgado- :t u provided the opportunity to make these observations. Our interest in responses to brain stimulation originated with Penfield's report20' 21 of perceptual and memorial responses to openfield stimulation of the temporal lobe in the human, and with Kubie's general discussionlr> based partly on Penfield's work. Others had also demonstrated, in animals, correlations between functions of the frontotemporal region and emotions17 : " as well as feedFrom the Departments of Psychiatry and of Physiology, Yale University School of Medicine, New Haven, Conn. Presented in part at the Annual Meeting of the American Psychosomatic Society, Rochester, N. Y., April 1962. Received for publication Jan. 21, 1964. 'Fellow, Center for Advanced Study in the Behavioral Sciences, Stanford, Calif., during period of study reported.
ing and sexual activity. The arousal of fear, which could motivate learning, by stimulation of areas related to the frontotemporal region had also been demonstrated.4' 5 In a previous paper14 we reported a wide range of responses to frontotemporal stimulation during interviews in a boy with psychomotor epilepsy. Perceptual-cognitive changes, similar to those observed by Penfield, varied from discrete sensory experiences to deja vu-like phenomena. Emotional effects ranged from stimulation-bound, friendly interaction with the interviewer, to erotic bodily sensations and direct verbalization of the wish to be a girl. The responses seemed to be a function of the site of stimulation within a given interview; some stimulation effects varied from interview to interview. Questions arising from the preceding investigations guided the present study. Given the fact that a patient was being studied diagnostically with the implanted-electrode technique, which makes it possible to observe stimulation effects in
the relatively unrestricted interview situation repeated over a number of days: 1. What, if any, perceptual, memorial, emotional, and behavioral events would result from stimulation of the surface and deeper areas of the frontotemporal region in this individual? 2. If such events did occur with stimulation would they be a function of localization of stimulation? 3. Would they be a function of electrical seizure activity? 4. Would the possible psychological results of stimulation be codetermined by the interview interaction? Would they be constant or variable from interview to interview?
INTRACEREBRAL ELECTRICAL STIMULATION
menses and the second included tonic and clonic movements. At that point she was hospitalized at Massachusetts General Hospital for clinical studies. EEG revealed higher voltage on the left, spiking and short runs of 4-6 c.p.s. primarily in the left temporal and parietal regions. Some activity was also seen occasionally on the right side in the same areas. Hyperventilation increased the abnormality, especially on the left, and the response to photic stimulation was normal. The record was considered moderately abnormal with a preponderance in the left temporal area. Left carotid arteriogram was normal and pneumoencephalogram was unremarkable. On discharge from the hospital, the patient was placed on Dilantin sodium." The Patient Although she experienced no major episodes involving loss of consciousness The subject was a 27-year-old woman or tonic-clonic movements during a 3of Italian extraction. She was a house- month period on Dilantin, her "funny wife who had been married 8 years and feelings" continued at a frequency of 1had one child, a 5-year old daughter. 2 times a week. She was then started on Her general health had been good aside Mysoline.f Nevertheless, these latter from a long history of periodic head- seizures became as frequent as twice a aches which she associated with "ner- day by the time the present study ocvousness." curred. The patient had a history, however, of At that time the patient spontaneously approximately 5% years of psychomotor reported that she had three separate seizures and petit mal-like spells. She types of seizures, involving: also had had at least one grand mal 1. The aura of an ill-defined taste or seizure. Although there was some indication she might have had some seizures smell, anxiety, and a sensation in her earlier, the patient first became specific- chest (When she experienced these ally aware of "forgetting spells" around "funny feelings," she often tried to dethe time of her only pregnancy. Shortly scribe them to herself. As she did so thereafter she began experiencing brief she spelled out a word, letter by letter, episodes of "funny feelings" consisting "g-l-u-f") 2. All of the foregoing combined with of ill-defined gustatory or olfactory sensations combined with a feeling of anxi- a perceptual change in which the enviety and a sensation in her chest which ronment seemed dull and unfamiliar and she could only describe with a clutching she could not read print on a page, toor gripping gesture of the hand. These gether with feeling acutely anxious and episodes gradually increased in frequen- wanting to go home from wherever she cy. A year prior to the present study she was 3. The aura of taste or smell, spelling had two spontaneous seizures, with loss of consciousness for approximately 1-2 *Parke, Davis & Company, Detroit, Mich. min. Both seizures occurred during her +Ayprst Laboratories, New York, N. Y.
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of "g-l-u-f," and a "blank spell" wherein she did not hear what people said The patient also frequently experienced an urge to defecate and urinate, but it was not clear whether it accompanied any particular type of seizure. Generally, she could not describe the taste or smell, although on one occasion she experienced a "gassy" smell. During her brief "blank spells," she usually continued whatever motor act she was performing, according to other observers. Although relatively little personal history is available, the patient appeared to be of average intelligence, rather warm, and free of major psychiatric disorder. Qualities of somewhat excessive dependence on the interviewer, some seductiveness, and a slight tendency to histrionics combined with a marital sexual history bordering on frigidity led the investigators to regard her as being mildly or moderately hysterical in personality structure. The role of her personality in the somewhat confused picture of psychomotor symptoms described above remains indeterminate. Procedure Data Recording and Collection The patient entered the hospital (a large state mental institution where the investigation was conducted) on Sept. 29, 1955. Final preoperative evaluation included medical and psychological interviews and EEG study with scalp electrodes. Medication ceased upon admission and was withheld during the course of the investigation. The patient was left-handed from birth. Because of the apparent left-sided preponderance of the abnormality, the decision was made to implant two multilead electrodes and one surface electrode in the left frontotemporal region. This was done on Sept. 30 through a burr hole with the patient under local anesthesia. The electrodes, pictured in Fig. 1, have been described in detail elsewhere.2':t Each needle is approximately 12 cm. long (50 mm. being in the brain substance) and 0.5
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FIG. 1. Plate and needle electrodes. mm. in diameter. The needle electrode contains seven leads which terminate at as many points 8 mm. apart. The final lead terminates at the tip. Each plate electrode, made of polyethylene, is approximately 12 cm. long and also contains seven leads which terminate 5 mm. apart along the length of the plate. The leads of each electrode protrude externally to a socket. Figure 2 indicates the location of the electrodes. We succeeded in obtaining lateral, but not coronal X-rays. A crisis of nausea and faintness in the patient developed each time X-ray was attempted, preventing the taking of coronal X-rays. The result is that our ability to locate the electrode positions is impaired. Our opinion is, however, that (1) the plate was located on the inferolateral part of the left frontal lobe, with Contact 1 at the pole; (2) the anterior needle (Ant. Ndl.) was located in the inferior part of the fronto-temporal region (The tip was curved and probably in the left temporal pole.); and (3) the posterior needle (Post. Ndl.), starting in the middle
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FIG. 2. Lateral X-ray showing electrode positions in left frontotemporal area. Plate extends forward on surface of inferolateral part of left frontal lobe. Tip of anterior needle is curved within pole of temporal lobe. Posterior needle is directed toward midline. temporal convolution, was directed toward the midline. (Contact 1 at the electrode tip was probably close to the midline. Points 3 and 4 were probably within the white matter of the temporal lobe.*) EEG recording was done continuously throughout the interviews to be described, and at other times as well. Bipolar recordings, usually of adjacent pairs of electrode points, were made with an eight-channel Grass recorder, Model 111-13. Electrical stimulations were applied through various electrode point pairs with a Grass stimulator (Model S-4, containing an isolation
"Recording and stimulation by means of the implanted electrodes indicated definite abnormality in the tip of the left temporal lobe. Consequently, the anterior 5 cm. of this lobe was resected on Oct. 18, 1955. Histological examination of the specimen revealed the needle tracts. The subsequent medical history of this patient was as follows: Medication with mysoline was continued after the operation of Oct. 18 through 1956, and through a pregnancy in 1957. Medication was gradually decreased during 1958 and by June 1961 the patient had taken no medication for 2 years. At that time she had occasional petit mal episodes lasting a few seconds, with rare gustatory aura and occasional difficulty in name-finding.
unit), set to deliver unidirectional pulses, 0.5 msec, in duration, at a frequency of 100 c.p.s. The stimulations lasted 5 sec. and ranged from 5 to 10 v, 0.5-1.0 ma. One of us (G.F.M.) participated in a series of "unstructured" interviews with the patient in order to provide a natural, spontaneous flow of behavior which might reflect effects of stimulation. The interviewer attempted to engage in interaction with the patient that was largely determined by her needs, interests, affects and immediate experiences. Illustrative interview summaries presented later convey the general nature of the interviews. Table 1 presents general information about the interviews. There were two preoperative interviews for contrast with the six postoperative interviews. Two of the latter were without stimulation. Thus, the plan permitted contrasting the stimulation interviews with both pre- and postoperative, nonstimulation interviews. The schedule also allowed for some check on the role of increasing familiarity between the patient and the interviewer, or other progressive changes over time, for one of the postoperative nonstimulation interviews preceded the stimulation interviews while the other followed them. The stimulation schedules themselves are shown in Table 2. There are two important features about these schedules. The first pertains to which electrode point pairs were stimulated in the interviews. Stimulations at all needle points and various plate points were done in Interviews 4, 5, and 6 in order to survey the stimulation effects. By the end of Interview 6, it appeared to the interviewer that plate stimulations were evoking no psychological responses, in contrast to quite obvious results of the needle stimulations. Therefore, the schedule for Interview 7 called only for needle stimulations, and these at the higher level of the voltage range used. Stimulations at Post. Ndl. 1-2 were omitted in Interviews 6 and 7 because they had produced intense pain in the patient's jaw and tongue in Interviews 4 and 5. The second important feature of the schedule pertains to the temporal sequence of the stimulation sites. Within each interview the general plan was to stimulate each pair of points in a given sequence and again
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TABLE 1. GENERAL INFORMATION ON INTERVIEWS OF PATIENT WITH
Date and time
11 A.M. P.M.
10/ 1/55 4:30 P.M. 10/ 1/55
Preop. sitting, normally clothed; recorded int. Preop.; Pt. in bed, hospital garb; recorded int. Electrode implant., local anesth. Postop.; Pt. in bed; EEG recording, recorded int. Postoperative; Pt. in bed; EEG recording, Electrical stimulation, recorded int. Same as Int. 4 Same as Int. 4 Same as Int. 4 Same as Int. 4 except nostim.
5 6 7 8
80 65 60 40
16 14 9 0
with that sequence inverted. Further, the sequence for Interviews 6 and 7 reversed that for Interviews 4 and 5. The temporal characteristics of the schedules provide some control for sequential effects of stimulation or interview interaction that would prevent valid observation of stimulus localization. The interviewer knew the stimulation schedule for each interview—the points to be stimulated, the sequence, and the planned approximate times of stimulation. He also could anticipate the exact moment of stimulation, for the coinvestigator (J.D.) administering the stimulations from the adjacent room signalled them by means of a dim light placed out of sight of the patient but visible to the interviewer. In our previous study the interviewer did not know when stimulations occurred, but a trained psychological observer was monitoring both the interview and the administration of stimuli. The observer was thus able to inform the coinvestigator of any detrimental effects of particular stimulations and also to note important effects of particular stimulations that indicated further stimulation at
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those sites should be repeated. We feel that this procedure involving an "uncontaminated" interviewer and an informed psychological observer as a monitor is superior to that using the informed interviewer. In the present study, however, we had no trained observer to fill the monitoring role. In our opinion, it was not in the best interest of the patient or the research to have, in addition, an uninformed interviewer. The patient was told the general diagnostic purpose of the electrode implantation and that both stimulation and recordings would be done at times by means of the electrodes. She was also told that sometimes stimulation produced reactions, feelings, and ideas and that sometimes it did not. We did not tell the patient which were stimulation or nonstimulation interviews, nor the sites or times of stimulations. The EEG recorders, stimulator, one tape recorder, and the members of the research team concerned mainly with neurophysiological factors (J.D., H.H.) were in an observation room adjacent to the patient's room during the interviews. This tape recorder recorded the interviews and signals
Time of Him.
INTRACEREBRAL ELECTRICAL STIMULATION TABLE 2. STIMULATION SCHEDULES OF INTERVIEWS
Electrode point *
Volt* 5 10
Time of Him.
Volts 10 10 7 10 5 5 10 10 10 10 5 5 10 7 10 10
15'30" 18'18" 22'31" 25'50" 30-56" 35'51" 40'58" 48'25" 53'32" 57'12" 60-43" 64'42" 69-07" 72'31" 80-16" 85'41" 93'42" 98'35" 101'37" 8'13" 11'47" 15-41" 19'39" 24'19" 27'47" 31-20" 35'13" 39'52" 44-03" 47'34" 54'37" 58'33" 62'28"
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 1 2 3 4 5 6 7 8 9 10 11 12 13 14
Ant. Ndl. 1-2 Ant. Ndl. 1-2 Ant. Ndl. 3-4 Ant. Ndl. 3-4 Ant. Ndl. 5-6 Ant. Ndl. 5-6 Post. Ndl. 1-2 Post. Ndl. 3-4 Post. Ndl. 5-6 Plate 3-5 Plate 6-7 Plate 6-7 Plate 3-5 Post. Ndl. 5-6 Post. Ndl. 3-4 Post. Ndl. 1-2 Ant. Ndl. 5-6 Ant. Ndl. 3-4 Ant. Ndl. 1-2 Plate 6-7 Plate 3-5 Post Ndl. 5-6 Post. Ndl. 3-4 Ant. Ndl. 5-6 Ant. Ndl. 3-4 Ant. Ndl. 1-2 Ant. Ndl. 1-2 Ant. Ndl. 3-4 Ant. Ndl. 5-6 Post. Ndl. 3-4 Past. Ndl. 5-6 Plate 3-5 Plate 6-7
10 5 7 5 5 5 5
5 5 5 5 5 5 5 5 5
5'13" 10'14" 14-51" 20-50" 25'35" 29'57" 37'46" 39'54" 43'55" 48'05" 51'46" 55'19" 59'48" 68-09" 72'27" 76'47"
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Ant. Ndl. 1-2 Ant. Ndl. 3-4 Ant. Ndl. 5-6 Post. Ndl. 1-2 Post. Ndl. 3-4 Post. Ndl. 5-6 Plate 3-4 Plate 6-7 Plate 5-6 Plate 3-5 Post Ndl. 5-6 Post. Ndl. 3-4 Post. Ndl. 1-2 Ant. Ndl. 5-6 Ant. Ndl. 3-4 Ant. Ndl. 1-2
5 5 5
5 5 5 5 5 5 5 5
7'28" 13'36" 19-31" 28'11" 33-12" 37'55" 42'57" 47-40" 53'30"
1 2 3 4 5 6 7 8 9
Post. Ndl. 5-6 Post. Ndl. 3-4 Ant. Ndl. 5-6 Ant. Ndl. 3-4 Ant. Ndl. 1-2 Ant. Ndl. 1-2 Ant. Ndl. 3-4 Ant. Ndl. 5-6 Post. Ndl. 3-4
7 7 10 10 10 10 10 10 7
indicating the onset and termination of the stimulations. The latter could also be determined directly from EEG recordings. A second recorder taped the interviews but no signals indicating stimulation. These provisions made it possible to study the interviews repeatedly and to collate the exact moment of stimulation, interview changes, and the EEG recordings. Methods of Study The
All interviews were transcribed.
times, site, and voltage of each stimulation were noted in the typescript. Two of us then joined forces for the study of the interview recordings and typescripts, one (A.R.) entering the work at this point for the first time, with no preconceptions as to the effects of stimulation. Working together, and using both the recordings and typescripts, we first studied the entire series of interviews several times to identify possible stimulation effects. At this phase we were guided by the following: 1. Any perceptual, ideational, affective
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The neurophysiologist independently examined all EEG recordings and identified all seizure activity, its duration, its locus, and whether it was spontaneous or evoked by stimulation. Results Illustrative Interview Summaries Summaries of the first, third, fourth, seventh, and eighth interviews are presented below so as to give first a general impression of the interaction with the patient before electrode implantation, after operation but without stimulation, during stimulation interviews, and finally, without stimulation but with other conditions continuing unchanged. Interview 1 (Preoperative, no EEG tracings, face to face, patient in street clothes) Within the first few minutes, the patient begins asking about the forthcoming operation (i.e., electrode implantation) and openly acknowledges her anxiety about it. When asked about her understanding of the procedure, she says, T i n supposed to have these things put in and they're supposed to find where the difficulty is." She then asks a flood of detailed questions about the operation and subsequent diagnostic study and frequently intersperses a reference to the fact that she has had a headache all day because she is so nervous about what is facing her. After the interviewer indicates that he considers her anxiety natural, she relaxes somewhat and is able to give a fairly detailed description of her characteristic seizure patterns. She reveals that she has been seizure-free for the 8 days immediately preceding her entry into the hospital. Although the interviewer indicates that such a short seizure-free period has no special significance, she becomes pre. occupied about this and wonders whether her seizures could have been products of her imagination. The interviewer re-
or other event that was not obviously accounted for by the interaction was to be regarded as a possible response to stimulation. 2. This was especially so if the event occurred simultaneously with, or shortly after, stimulation. This preliminary screening resulted in the following potential response categories: 1. References to 12. Sensations of head pain coldness 2. Jaw sensations 13. Urination 3. Tongue sensa- 14. Grasps intertions viewer 4. Eye sensations 15. Praying 5. Skin sensations 16. Dizziness 6. Olfactory sen- 17. Dissociated resations sponse 7. Respiratory sen- 18. Pressured sations speech 8. Thirst sensa- 19. Extrinsic ideational response* tions 9. Hunger sensa- 20. Intrinsic ideations tional response* 10. Genital refer- 21. Reduced interences action 11. Sensations of 22 Increased manwarmth ifest anxiety 23. Defensiveness of report We then carefully reexamined the stimulation interview records several times and tabulated, by stimulation sites, all the occurrences of Categories 1-20, inclusive. A category was judged to be a possible response to the last stimulation that occurred and was tabulated only if both judges agreed on its occurrence. We again listened to the recordings of the stimulation interviews and independently rated categories 21, 22, and 23 for the intervals following each stimulation, using three scales: For "Interaction," zero designated no change, with reduced interaction progressing from zero to —2 (markedly reduced) and increased interaction progressing from zero to +2 (markedly increased). "Manifest Anxiety" and "Defensiveness" were rated from 1 (low) to 3 (high). We determined the reliability and computed the means of the ratings by the two judges for each stimulation interval. The mean ratings were then tabulated by stimulation sites.
*The meaning of these categories is clarified under Results. VOL. XXVI, NO. 4. 1964
assures her that this is unlikely and she becomes concerned with trying to find an explanation of her illness. In a bemused, sometimes almost hopeful way, she asks whether her seizures could be caused by an allergy to chemicals she handles at work. She wonders, too, whether arising very early in the morning to go to work or falling and hitting her head at age 17 could have produced the condition. Approximately halfway through the interview the patient reveals some concern about being in a psychiatric hospital and then asks the interviewer directly what he thinks about her now that he has talked with her. When the interviewer responds noncommittally by talking about her clinical condition, there is a change in the patient's affect and the quality of her interaction which persists more or less throughout the remainder of the interview. First, there is a short silence and a reduction in the patient's high level of participation and her spontaneous verbal productions. The interviewer asks her what she is thinking about. Then, in a somewhat sad and decidedly intimate way, she says that she is concerned about what the interviewer thinks of her and the fact that he seems to be staring at her. She labels this concern an "inferiority complex" and says that generally she feels that people do not like her and talk about her. She feels the interviewer believes there is really something wrong with her. There is more discussion of her seizure patterns and the specifics of the operative procedure. Repeatedly, she asks for reassurance that she can be helped, that she will not have a convulsion during the tests (EEG recordings) and that her anxiety is normal. She tends to believe that she can't be helped and seems to have a negative outlook. Finally, toward the end of the interview, she becomes manifestly tearful and reveals that she is preoccupied with the idea that she might die. She is reluctant to have the
INTRACEREBRAL ELECTRICAL STIMULATION
interview terminate and engages him with a fresh series of questions at the end. The most striking features of the interview are the patient's understandable anxiety, her openness in acknowledging the anxiety, and her attempts to handle her feelings by asking numerous questions and trying to find an explanation for her illness. She participates actively in the discussion and is fairly intimate, almost seductive, in her relationship to the interviewer at several points. Interview 3 (First postoperative day; EEG tracings from intracerebral electrodes; no stimulations; patient in bed) The interview begins with a detailed discussion of the operative experience. The patient minimizes being disturbed by the procedure, but says she is disappointed that she did not receive gas anesthesia and was aware of everything that happened. She tells of difficulty sleeping afterward because of head pain and general discomfort. Throughout the interview she complains of head pain in the areas of electrode implantation, abdominal distention, eructation, and back pains. She is restless and, from time to time, she reports that she is sweating. After the discussion of the operation, the patient presses the interviewer for some statement about what the procedure has shown so far and when she can go home. When he indicates that this has not been decided, she becomes somewhat subdued and unspontaneous. As before, however, she responds to the interviewer's questions and the discussion turns to some factual material about her living conditions, her daughter and her work historv. At one point, she describes temper outbursts at work and the interviewer asks her if she has gotten mad during her stay at the hospital. Although she flatly denies having been mad, a change in the qualitv of her interaction with the interviewer ensues. First, she asks him if she "talks puzzled" (i.e.,
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presses irritation freely and laughs a good deal. Although this irritation and laughter is certainly partly a function of her anxiety, the free expression of these feelings seems to represent for this woman a growing sense of comfort and intimacy with the interviewer. Unlike the case in previous interviews, there is little discussion of seizure history and only brief recounting of material about her family. Interview 4 (First postoperative day, 5 hr. later; intracerebral EEG tracings; stimulations; patient in bed) The patient spontaneously reports, for the first time, sudden and discrete ideational experiences and sudden, at times painful, sensations in her jaw and wetness on her tongue. Characteristically, these experiences and sensations interrupt the conversation and do not appear to be related to any specific type of subject, quality of interaction or external stimulus within the room. The interview begins with the patient's report that she felt nauseous and on the verge of fainting during a skull X-ray procedure that was carried out after the last interview. After describing this discomfort in some detail she says she is feeling much better now and she does appear to be fairly relaxed. The interviewer then asks the patient to tell him a little more about herself, what she was like as a little girl, for example. She responds openly with the remark that "I was my mother's pet," and in a freely-flowing exchange speaks briefly of her adolescent datings, marriage, her husband, and her concern that people don't like her, mentioning her specific concern about what the interviewer and his colleagues think of her. She spontaneously speaks of how close she feels to her mother. She then tells of how she worried about past illnesses of her mother: a broken leg and a uterine cyst, for example. She worries about the fact that her mother is old and won't
seem confused). When he reassures her that she does not, she complains of the monotony and the heat and then begins smiling and laughing in a provocative, slightly coquettish way. Although she attributes this laughter to concern about the interviewer studying her, she admits that she feels "less nervous" now after laughing. During the remainder of the interview, she returns to many of the concerns in the first two interviews. She wonders if her illness is imagined and if she is insane and will have to stay in the hospital. At one point, she reveals a specific concern that she might have cancer. In distinction to previous interviews, she frequently becomes overtly irritated with the interviewer. She complains that he asks too many questions and accuses him of knowing what's wrong with her but not telling her. Then, when the interviewer tries to explain that he is merely trying to get to know her better, she becomes argumentative. This irritation alternates with short spontaneous bursts of laughter. The laughter seems to function primarily as a release of her anxietv about the test procedure, her illness and, at times, her interaction with the interviewer. However, it also has a friendly sometimes coquettish quality. She herself attributes her bursts of laughter to concern about the interviewer looking at her with her "head all shaved off." Toward the end of the interview, she becomes preoccupied with a swelling under her eye and a sensation of muscle twitching in the eye itself. She complains that the interviewer's tobacco smells funny. The interview differs mainly from the two previous ones in her many physical complaints and her preoccupation with her physical sensations. At the same time she appears more relaxed and seems relieved that the operation is over. She continues to talk about her concerns openly and reveals a previously unspoken fear of having cancer. She exVOL. XXVI, NO. 4, 1964
always be alive. She tells how she has called her mother on the phone every day since she's been married and of how her mother took care of "the baby," i.e., the patient's daughter. She goes on to describe her daughter in some detail and expresses regret that she had to work instead of staying home with her daughter. However, she says, she always tried to take good care of her daughter; she saw that she had prompt medical care, for example. (During the segment of the interview summarized in this paragraph the first three stimulations occurred, the first two at Ant. Ndl. 1-2 and the third at Ant. Ndl. 3-4). The interview then turns to a discussion of working. They needed the money she earned. Her husband works on "findings," which she explains means unfinished jewelry. At this point, Stim. 4 at Ant. Ndl. 3-4 occurs and the patient spontaneously reports the first of the intrusive ideational experiences. When she said "findings" she heard a fellow "saying some word silly." (All ideational responses are described in detail in the Appendix. The patient tells the interviewer about this experience and mentions that the wife of the fellow she heard just lost a baby and that he was a "hot sketch" (i.e., a joker, a "card"). The patient then wonders what the interviewer's colleagues are doing in the next room and starts to speak about her seizures. She tries to recall how long ago they started and is associating them with her pregnancy when Stim. 5 at Ant. Ndl. 5-6 occurs. She sounds startled and says, "My mind just went off again . . . (to) . . . the fellow's wife . . . I don't know what she said." The patient says that she spoke to this woman on the phone just after she had lost her baby. The patient then becomes subdued and quiet. The interviewer interrupts a very long pause by asking what she is thinking about. While the patient answers that she was thinking of how she has not had a seizure for 10 days up to then, but that
INTRACEREBRAL ELECTRICAL STIMULATION
her mind has "gone off' in this interview, Stim. 6 at Ant. Ndl. 5-6, is administered and she immediately says, "See that girl came again" and ". . . all of a sudden it seems like she was saying, like a saying. . . . It's somethin' that she says to me a long time ago." Spontaneously, the patient resumes the topic of her husband's work but then becomes quiet. Stim. 7 at Post. Ndl. 1-2 occurs and causes the patient to startle and say that "oh boy, I opened my mouth too much." She describes her sensation: "Like a snap . . . like a wire to my tongue." She says she felt frightened and asks the interviewer to look at her tongue for it feels "like a little wet . . . I thought maybe I was bleeding." At the patient's request the interview is then interrupted so she can urinate. When the interviewer returns to the patient's room, Stim. 8 at Post. Ndl. 3-4 takes place and she says the word "kerchief intruded into her thoughts. The patient then becomes particularly subdued. The next half hour she is generally quiet, interacting episodically with the interviewer as she comments intermittently and briefly about how strong his tobacco smells; the possibility she might vomit again when skull X-rays are taken; her physical discomfort from the operation; the heat; her anxiety over the present hospital admission; an anticipated visit of her family; and an incident in which a young woman made fun of the way she talked. During this uneventful half-hour period, Stims. 9, 10, 11, 12, 13 and 14 occur and are seemingly unrelated to the transient episodes of interaction. Following Stim. 15 at Post. Ndl. 3-4 the patient says "a word came" to her but does not elaborate when the interviewer questions her about it. She seems to be especially defensive and then starts a rapid, unconnected discourse on difficulties she has had with underarm boils. Conversation about this is suddenly disPSYCHOSOMATIC MEDICINE
MAHL ET AL.
silent prayers while in the hospital. Briefly then, the conversation turns to her plans to quit work. Again she wonders about the causes of her illness. There is a short pause following Stim. 2 at Post. Ndl. 3-4, and she says, "Ooh, a crazy word just came to me." As the interviewer tries to elicit clarification of the experience, she begins to wonder if these words that come to her are products of her imagination just as she wondered previously whether her spells were due to her imagination. She becomes quiet and appears thoughtful. When the interviewer inquires if she is worried about anything, she replies that she guesses she isn't. Stimulation 3 at Ant. Ndl. 5-6 occurs as the interviewer asks what she means by that. After a short pause, she states: "You says that and something came to me. . . . Seemed like somebody else said somethin'. I don't know what it was now." She becomes quite subdued and highly anxious. She says that she is scared and is sweating. After Stim. 4, Ant. Ndl. 3-4, she is subdued and startles when the clock marks the quarter hour. She then becomes very quiet remarking finally that her head is throbbing because she is so nervous. After a short silence, suddenly she startles, grasps the interviewer' arm, and utters a sharp, high-pitched gasp—all with Stim. 5 at Ant. Ndl. 1-2. When the interviewer asks what happened, she replies "nothing." He persists and finally she tells him only that she is saying prayers, Hail Marys. (While something obviously had happened, this could not be counted as an ideational response in our data.) A few minutes later she suddenly gasps and grasps the interviewer's arm again when Stim. 6, at the same site, occurs. At first, she will not tell the interviewer what happened. Finally, she tells him: "I think it wasn't nice . . . it musta been dirty . . . maybe a word . . . it wasn't a swear word." The patient thinks she said the word. She resumed praying silently, explaining "just saying my pray-
rupted by another jaw and tongue sensation upon Stim. 16 at Post. Ndl. 1-2. The patient seems overtly anxious and after a few more remarks about her past boils she becomes subdued again and continues so, increasingly, until the end of the interview some 15 min. later. In the meantime Stim. 17, 18, and 19 in the Ant. Ndl. occur. Interview 7 (Second postoperative day, 2 hr. after Interview 6; intracerebral EEG tracings; stimulations; patient in bed) This interview is a little more than half as long as Interview 4. Also, the stimulation schedule differs in the several respects mentioned earlier. One important difference is that only stimulation sites that have been associated with the ideational experiences are used and these stimulations are all at the higher 7- and 10-v levels. The major features of the interview are the high concentration of ideational experiences (five over a relatively short period of time), the patient's high level of anxiety, and her defensiveness in reporting what she is experiencing. She brings up little spontaneously, except for the sudden ideational experiences, and her general evasiveness is marked, in contrast to the openness of the early interviews. When questioned in detail about the ideational experiences, the patient cannot decide whether she actually heard people saying words to her or whether she thought about the words. However, she does say that they are not merely words which she associates with past events; the words, sentences, and conversations occur at the time she reports them. The interview opens with some discussion of her husband's visit that afternoon and she talks again about her daughter. She knows that her daughter is concerned about her and wonders if the girl says prayers for her every night. She admits that she, herself, has said
VOL. XXVI. NO. 4, 1944
ers so my mind won't drift some place." Twice more she reports the sudden onset of ideational experiences. One of these occurs with Stim. 8, Ant. Ndl. 5-6. It consists of a conversation between two people and seems of hallucinatory intensity. She resumes saying Hail Marys to herself. With the final stimulation at Post. Ndl. 3-4, she whispers "Purse onto school." She thinks she said "Pake into school." At the end of the interview there is a brief discussion of the prayers and she reveals that she has often said this particular prayer in the past when she has been concerned that she is about to have an episode. Interview 8 (Second postoperative day, 3 hr. later; intracerebral EEG tracings; no stimulations; patient in bed) During the interval between this interview and the previous one, the patient had an episode in which objects seemed dull to her. This occurred while she was alone in the room, and seemed to last about a half hour. When it terminated, she thought of her family and everything seemed clear all at once. At the beginning of this interview, she reports feeling tired and nervous and complains of a headache again. She becomes more relaxed, however, as the interview progresses and returns to the high level of spontaneous interaction with the interviewer which she manifested in the preoperative interviews. There is only one brief reduction of verbal interaction during this interview. It occurs after a discussion of her forthcoming operation (in which the tip of the left temporal lobe will be amputated.) The tone of the interview is friendly. Discussion of the patient's early life and her family predominates. Also, the patient asks the interviewer some questions about himself and his training. There are no sudden psychological experiences. Occasionally, the patient wonders why she is not having them. She becomes worried at times when she
INTRACEREBRAL ELECTRICAL STIMULATION
moves too much and seems to be momentarily expecting something to happen. Several times during the interview she complains that her nose itches and occasionally reports that her head hurts, but no other physical sensations are reported. Towards the end of the interview, she becomes teasing and somewhat verbally seductive to the interviewer. She apologizes for having gotten angry at him on occasion and reports feeling much more relaxed at the end. Analysis of the Effects of Stimulation The jaw and tongue sensations and the unusual ideational experiences were clearly results of stimulation. Table 3 presents the frequency of these reactions at the various stimulation sites. The remainder of Categories 1-20 either showed no consistent relation to specific stimulations or were not unique to the stimulation interviews. The categories Manifest Anxiety, Interaction, and Defensiveness will be considered later. Jaw and Tongue Sensations Table 3 shows that these sensations occurred each time Post. Ndl. 1-2 was stimulated, once out of the 8 Post. Ndl. 3-4 stimulations, and once in the 7 Post. Ndl. 5-6 stimulations. The sensations never occurred with the 27 Ant. Ndl. or 12 Plate stimulations, nor did the sensations occur in any nonstimulation interview. The following summaries, consisting of condensed verbatim interview excerpts, illustrate the nature of the jaw and tongue sensations. The interviewer did not observe any unusual facial movements during these responses.
INTERVIEW 4 (Stim. 7, Post. Ndl. 1-2, 5 v.). Immediately upon stimulation the patient said, "Oooh," and then described her experience in the following words: "Oh. boy, I opened my mouth too much—like a snap—like a wire to my tongue—I musta opened my mouth too much—As I went to talk to you, I opened by mouth, like. Over here it hurts. I just felt like a snap—look on
MAHL ET AL TABLE 3.
FREQUENCY OF OCCURRENCE OF JAW AND TONGUE SENSATIONS AND UNUSUAL IDEATIONAL EXPERIENCES ACCORDING TO STIMULATION POINTS
Stimulation points Ant. Ndl.
Post. Post. Post. Ndl. Ndl. Ndl.
1-2 3-4 5-6
No. OF SENSATIONS OR EXPERIENCES
Jaw Sens. Tongue Sens. "Extrinsic" ideational experience!: "Intrinsic" ideational experience I I
0 0 8 0
4 4 0 0
I" 0 1 6
0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
No. OF STIMULATIONS 5v 7v lOv 4 0 5 4 0 5 4 3 2 2 0 2 6 2 0 6 1 0 0 0 1 4 0 1 0 0 1 4 0 1
*Only with 5-v stimulations. tQuestionable response. tldeational experience in which someone other than the patient speaks. SOnly with 10-v stimulations. I I Ideational experience in which a word "comes to" patient or she actually speaks.
lows: "Oh, did I feel it—Oooh, I'm afraid —Ohhh, right in my ear—into my tongue. It felt like water—I don't know—hope I don't get it again—Today's been a helluva day—[It felt as if] my jaw cracked—was sharp through there—and then—like it went on my tongue—like on top of my tongue—or is there water. My eve is sore." It was obvious that pain and fear accompanied the complex of sensations evoked by Post. Ndl. 1-2 stimulations INTERVIEW 5 (Stitn. 4, Post. Ndl. 1-2, 10 and that the pain and fear increased with v.). With stimulation, the patient ex- the change from 5 v to 10 v. We decided claimed as if in pain and said, "Oh, right in to omit any further stimulations at these my ear and then my mouth again—Oh, I electrode points. got like a shock then. Through my ear, and Extrinsic and Intrinsic Ideational through my jaw again. And, I didn't move my mouth—It felt like water or something Experiences wet on my tongue—[It was like] a sharp These terms refer to two distinct types pain—Tastes funny. I feel as though my of events evoked by stimulations in two mouth smells or something." distinct areas. LATENCY. The experiences apparINTERVIEW 5 (Stitn. 12, Post. Ndl. 1-2,10 «.). With stimulation the patient ently occurred simultaneously with stimscreamed and moaned, "I'm afraid." She ulation. At times this was obviously so then described what had happened as fol- for the patient often verbalized them
VOL. XXVI, NO. 4, 1964
my hand—I got like perspiration. [I'm] frightened. Is there anything on my tongue? —I felt, you know, like a little wet on my tongue. I thought maybe I was bleeding—" —"Yeah [it frightened me]. Did you see me jump? I think I have to pass my water." (The interview is interrupted while patient urinates. Comments to nurse included: "I'm so warm. I'm sweating somethin' awful. Still going. Boy, I can't stop. Boy, I'm still going.")
immediately. On other occasions, it could be definitely inferred that the experiences coincided with stimulation for she often thereupon fell silent and thoughtful, or startled and grasped the interviewer's arm, etc. When asked what she was thinking of, the patient would then give some indication of the unusual ideational experiences.
GENERAL NATURE OF EXPERIENCES.
INTRACEREBRAL ELECTRICAL STIMULATION
with stimulation: "Purse into school." This description never applied to the extrinsic responses. Furthermore, the mention of another person entered into only two descriptions of the intrinsic experiences. She did not identify those people and their role in the experience was ambiguous.
DEPENDENCE OF IDEATIONAL EXPERIENCES ON LOCUS OF STIMULATION. At
The nature of the experiences can best be realized by examining the summaries of them contained in the Appendix. These summaries, consisting of condensed verbatim excerpts from the interviews, reflect the paucity and sketchiness of the patient's descriptions. Sometimes the patient seemed to be trying very hard to tell us all she could, but at others she appeared to be concealing intentionally the content of the experiences. The experiences are complex in nature, but all have one thing in common: a sudden ego-alien intrusion of "words," "expressions," or "sayings" into the patient's awareness. To varied degrees, at various times, the experiences have the qualities of peremptoriness, memory, hallucination, illusion, and active motor expression in speech.
DISTINCTION BETWEEN 'EXTRINSIC' AND
'INTRINSIC'. Careful examination of the patient's description of the ideational experiences suggests that they were of two general kinds. In "extrinsic" responses the patient readily and unambiguously attributed the "word," "expression," or "saying" to someone else. In most instances she gave some identifying characteristic of the person—name, sex, traits, etc. Further, there was a distinct auditory quality to the experiences; at times they appeared to be hallucinatory. The patient's spontaneous report of what we have called "intrinsic" experiences always included a statement that "a word came to me." In one instance, she actually uttered "nonsense" words
no time in any of the nonstimulation interviews did the patient report or give indirect evidence that ideational experiences had occurred. When they did occur in the stimulation interviews they were associated with stimulation at specific sites. Tables 3 and 4 demonstrate the localization phenomenon. In Table 4 the N's in the cells are too small for meaningful use of a statistical test of significance, such as Chi-square, but the tabulation shows the following: 1. Ideational experiences occurred with stimulation in the needle electrodes, but never with plate stimulation. 2. There was a very marked association of extrinsic responses with Ant. Ndl. stimulations and of intrinsic responses with Post. Ndl. 3-4 stimulations. The tabulation for the 19 ideational responses shows this relationship (Table 5). Even within each needle area, the localization was narrowly prescribed. Thus, intrinsic responses were associated with only Post. Ndl. 3-4 stimulations, and extrinsic reTABLE 4. IDEATIONAL RESPONSES
ACCORDING TO STIMULATION POINT
No ideational response* ExIn2 trinsir trinsic Neither Him.
1 3 8 0 1 0 0 13 0 0 0 0 6 0 0 6 6 1 4 1 7 12 39
Ant. Ndl. 1-2 Ant. Ndl. 3-4 Ant. Ndl. 5-6 Post. Ndl. 1-2 Post. Ndl. 3-4 Post. Ndl. 5-6
Plate, all points
9 9 9 4 8 7 12 58
MAHL ET AL TABLE 5. DISTRIBUTION OF IDEATIONAL RESPONSES Kind of response Extrinsic Intrinsic Ant.Ndl. points Post. Ndt.
TABLE 6. IDEATIONAL EXPERIENCES WITH ALL STIMULATIONS IN RELATION TO EVOCATION OF SEIZURE No. of stimulations Seizure evoked Yes No 2 15 13 28 4 26 30 19 39 58
12 0 12
1 6 7
13 6 19
p < .003 (ti), Fisher's Exact Test.
Evoking ideational experiences Not evoking ideational experiences
sponses were most strongly related to Ant. Ndl. 5-6 stimulations. 3. The effects of the Ant. Ndl. stimulations suggest a "gradient." The only stimulations at Ant. Ndl. 1-2 and 3-4 producing ideational responses were those of 10-v intensity. Further, the closer the site of the 10-v stimulation to Ant. Ndl. 5-6, the more likely were these responses to occur. These findings may represent a difference in "thresholds" at the various points in the Ant. Ndl., or they may indicate a transmission of the higher voltage excitations from Ant. Ndl. 1-2 and 3-4 to Ant. Ndl. 5-6 loci. 4. The one anomalous extrinsic experience with Post. Ndl. 3-4 stimulation posed a difficulty in classification. The subject provided few cues for us. It actually resembles an intrinsic response in that the patient seemed to speak automatically. The attribution of a word to the interviewer was the deciding factor in classifying this experience in the extrinsic category. Yet such attribution may in this case have resulted from her attempts to integrate the experience. Stimulus localization for the ideational experiences appeared consistently in all four stimulation interviews.
RELATIONSHIP OF IDEATIONAL EXPERIENCES AND ELECTRICAL SEIZURE ACnVITY.
porally with any of the ideational experiences. There was, however, an association between evoked after-discharge and the ideational experiences. Table 6, covering all stimulations, shows the nature of this relationship. Considering all electrode points, there were many evoked electrical seizures without ideational experiences, but if there was an ideational experience it was very likely to have been associated with evoked seizure activity. The tabulation in Table 7 is limited to the Ant. Ndl. and Post. Ndl. 3-4 stimulations—i.e., those sites that evoked the ideational experiences. The comparison of the two tabulations shows that there were 10 out of 23 stimulations at points other than Ant. Ndl. points and the Post. Ndl. 3-4 points that evoked seizure activity without evoking an ideational response, but there were
TABLE 7. IDEATIONAL EXPERIENCES WITH ANTERIOR NEEDLE AND POSTERIOR NEEDLE 3-4 STIMULATIONS IN RELATION TO EVOCATION OF SEIZURE No. of stimulations With ideational experience Without ideational experience Yes Seizure evoked No 4
There was no relationship between the ideational experiences and the patient's spontaneous electrical seizure activity. A great many instances of spontaneous electrical seizure activity occurred in the EEG records and none was related temVOL. XXVI, NO. 4, 1964
3 13 16 18 17 35 2 X = 10 p <.OO5
only 3 of 35 such stimulations in the Ant. Ndl. and at Post. Ndl. 3-4. All four ideational experiences not associated with evoked electrical seizure activity were extrinsic ones, and were among 9 such experiences elicited by 7and 10-v stimulations. Furthermore, three of these four extrinsic experiences resulted from stimulation at Ant. Ndl. 1-2 and 3-4—i.e., the less sensitive of the extrinsic response points of the anterior electrode. We cannot interpret these data at present.
RELATIONSHIP BETWEEN IDEATIONAL EXPERIENCES AND INTERVIEW CONTENT AND
INTRACEREBRAL ELECTRICAL STIMULATION
To study this relation-
ship, one must make more complex assumptions than are required for the observations presented so far. If not, the relationship appears to be minimal or nonexistent. In the following analysis we assumed, as a working hypothesis, that the ideational experiences are related to the interview content and interaction in the same manner as Freud 7 assumed the manifest dream content was related to the dream associations. Our premises included a specific assumption that comments made by the patient as she elaborated about her experiences referred to "intermediate ideas" linking the experiences to interview content or interaction. Viewed within this general framework, 8 of the 19 ideational experiences appear related to the immediate interview content or interaction, arbitrarily defined as that occurring within 2 min. before the stimulus onset. Five of these 8 experiences seem to be also associatively connected to more remote interview material —i.e., that occurring any time in the same interview earlier than 2 min. before stimulation. The following summaries show the nature of these apparent relationships. Italicized words indicate elements common to the experiences and the interview content and "intermediate ideas."
(1) STIMULATION Ant. Ndl. 3-4, 10 v, Stim. 4, Interview 4. IDEATIONAL EXPERIENCE Experience concerned "the way this person talked." The patient consistently related the experience to her utterance of the word "findings" a few seconds before stimulation. She heard a man "sayin some word silly." The man is one of a "married couple," the "wife just lost a baby." "He was a hot sketch . . . he was like a—a laugh." Later in the interview the patient mentioned that she had spoken with the man's wife over the telephone. RELATED INTERVIEW MATERIAL Immediate The interaction at the time of stimulation included a lack of understanding by the interviewer of the patient's vernacular. The following is a verbatim record of this interaction. P: The three fellas are partners. (I.e., her brother and two other men.) I: I see. And what do they do with that? P: Findings. My husband works there. I: What do they do? P. Findings. I: What does that mean? P: It's unfinished jewelry. (Onset of stimulus ) Just before the preceding interchange the interviewer had not understood the patient when she mentioned her brother's unusual first name. And 80 sec. before this (100 sec. before stimulation) the interviewer had laughed quietly when the patient said her husband suffered from a "sa-psy-chrtiioliac." These interchanges must have been affect-laden for the patient, for later in the interview she spontaneously told of a time someone had "made fun of the way I talk." Remote In the first 5 min. of the interview, the patient had told how she met her husband on a double date involving another couple and married shortly. There were several references to "baby" and her mother's pet. "My mother figured to have me for old age—instead I got married." She later spoke of the closeness between herself and her mother, of how she has worried about her mother's illnesses, and how she is concerned that her mother will die some day. She said she has called her mother on the phone every day since her marriage and
MAW. ET AL.
mentioned that her mother took care of the "baby" (i.e., patient's daughter) while she herself worked. She went on to describe her daughter fondly and expressed regret that she had to work instead of caring for her. She said she took good care of her anyway for she called the doctor right away whenever her daughter had a cold—"no matter what she had."
RELATED INTERVIEW MATERIAL Immediate When stimulation occurred, the patient was speaking of the length of time she had been seizure-free: P: I's just thinkin'—ah—today's the tenth day I don't feel nothin'. I: Mhm. P: And then like, you know, like I told you, my mind just went off for a minute. I: Yeah. P: But th's—that's not like—ah— (2) I: That's not like the beginning of the STIMULATION spell. Ant. Ndl. 5-6, 5 v, Stim. 5, Interview 4. P: Oh, no-ooo (onset of stimulus). IDEATIONAL EXPERIENCE The experience concerned the wife of the I: Mhm. "fella" of the "married couple" who ap- P: I mean it jus'—See, that girl came to me again. peared in the experience described above. Remote Before the previous stimulus, The patient heard the woman say somethe patient had wondered "how long ago" thing. The patient told of talking to the woman her seizures had started and had associated on the phone one day. "She just had lost them with her pregnancy and the birth of her baby." Later the patient added that her baby. The previous ideational responses this had been a miscarriage—i.e., before the had involved, first indirectly and then directly, the woman appearing in the present baby was born. one. RELATED INTERVIEW MATERIAL Immediate Just before stimulation the (4) patient was speaking as follows: "How long have I been gettin' those feelings [i.e., STIMULATION Post. Ndl. 3-4, 5 v, Stim. 8, Interview 4. seizures]? Gee, if I could only remember how long ago it started. I know I had them IDEATIONAL EXPERIENCE A word, possibly "kerchief" occurred to when the baby was born—even before the baby was—ooh (sounds startled—onset of the patient. stimulus)—even before the baby was RELATED INTERVIEW MATERIAL born." Immediate One minute before stimulaRemote Patient had been talking and tion the patient had told the interviewer: thinking about this woman, her husband, "I'm all wet—I mean I'm sweatin—warm and the fact she had lost her baby in the —." (At a later time in the study when she course of describing the preceding ideation- complained of sweating and the heat, the al experience. All of the interview material patient asked the interviewer to get her a regarded as remotely related to that experi- handkerchief from the drawer of her bedence may also be regarded as remotely re- side table.) lated to this one, especially that involving Remote Just before these remarks the references to couple, marriage, baby, illness interview had been disrupted because of and death, separation between mother and the patient's urge to urinate. She comchild, telephoning. plained to the nurse who came in to assist her of "sweatin somethin awfuf and also asked the nurse for toilet tissue and later to (3) be dried after urinating. The last stimulus STIMULATION Ant. Ndl. 5-6, 7 v, Stim. 6, Interview 4. (not included here) had produced a senIDEATIONAL EXPERIENCE sation that her tongue was wet and bleedThe same woman who appeared in the ing. preceding experience now reappeared and All of these immediate and remote refersaid something that she had said to the ences concern body functions often, or pospatient "a long time ago." sibly, involving the use of a handkerchief.
VOL. XXVI, NO. 4, 1964
(5) STIMULATION Post. Ndl. 3-4, 5 v, Stim. 12, Interview 5. IDEATIONAL EXPERIENCE Upon cessation of the stimulus, the patient mumbled in an automatic way ". . . feel better tomorrow," She went on to say ". . . seemed like you said another word— like another word. I don't know the name of the word." RELATED INTERVIEW MATERIAL Immediate When stimulus occurred, interviewer was saying, "It'll feel better tomorrow." (6) STIMULATION Ant. Ndl. 5-6, 5 v, Stim. 5, Interview 6. IDEATIONAL EXPERIENCE Patient heard someone saying "Don't be like this one. . ." RELATED INTERVIEW MATERIAL Immediate In the minute preceding stimulation the patient was comparing the ideational experiences with her seizures and was trying to explain the nature of the ideational experiences. Remote The previous stimulus (not included here) had caused the words "floats in the tide" to come to her. This, her first ideational experience of this interview, led her to express concern over why she was having such experiences. After the present experience she again wondered why she was having them and related them to fears of being insane. "The nut house always comes to my head."
INTRACEREBRAL ELECTRICAL STIMULATION
P: "?? a baby sister" she keeps saying thai all the time. I: Mhm. How about you? P: Hum. I: How about you—do you want to have another child? P. Oh—ah (clears throat—stimulus occurs) something just came to me right then, etc. After describing the resulting ideational experience, the patient says: "I wouldn't mind bein'—you know, having another baby—I was thinking about it before." (8) STIMULATION Ant. Ndl. 5-6, 10 v, Stim. 8, Interview 7. IDEATIONAL EXPERIENCE The patient heard the voice of a girl who worked with her speaking to her: "A (patients name), that guy is—tough." The patient added: "The girl says to me that her brother-in-law says something about someone's gotta go to work—." RELATED INTERVIEW MATERIAL Immediate Stimulation occurred as the patient was speaking of her "spells" at work and of actual operations performed at work: P: Like—ah—when I used to get those— ah—like I'd be workin— I: Mhm. P: and I'd have the tool in my hand, and wrap it up in a direction sheet, you know? I: Yeah. P: And—ah—sometimes the object would seem strange. I. Mhm. P. Like—ah—(onset of stimulus) — I: Yeah? P: Seemed like somebody just came to me. Etc. The patient identified either the people or the words, or both, in the preceding eight ideational experiences. She also did this for three other ideational experiences, but it was impossible to see any obvious relationship between them and the interview content or interaction. The following was specified about these three experiences: 1. A girl named "Jeannette," who worked with the patient, said something.
STIMULATION Ant. Ndl. 5-6, 5 v, Stim. 10, Interview 6. IDEATIONAL EXPERIENCE The patient heard a female voice, perhaps a girl, saying something about a baby. Perhaps it was "/ got a baby . . . sister." RELATED INTERVIEW MATERIAL Immediate At the time of stimulation the patient was speaking about her daughter's wish that the patient have a baby so she could have a baby sister or brother. The patient was also wishing this herself: P: (speaking spontaneously of the topic) She (i.e., her daughter) wants a baby sister or baby brother so bad. I: Does she?
MAHL ET AL
TABLE 8. RELIABILITY OF JUDGES' RATINGS Agreement betwee n % ratert (%) Variable Anxiety level Defensiveness of report Interaction level Obtained Chance expectation P
2. The words "floats in the tide" came to the patient. 3. The words "purse into school" and "pake into school" came to the patient. She uttered the first phrase, apparently when it "came to her." There were eight additional ideational experiences that could not be related easily to the interview content or interaction. In none did the patient specify the person or the words involved. The following statements represent what she conveyed about these eight responses. 1. A word came to her. 2. A "person said a saying." 3. "Some girl" said "something true." 4. Somebody said something. 5. A word came to her. 6. A "crazy" word came to her. 7. Somebody said something. 8. Somebody said a "dirty" word
PATIENT'S REACTION TO IDEATIONAL EX-
72 78 63
33.3 33.3 25.
<.001 <.001 <.001
PERIENCES. The patient's descriptions of the experiences show that they seemed intrusive, and were nearly always completely out of context and of strange— often disorganized—content. She desired an explanation for them, apparently for both their occurrence per se and their content. In general the experiences frightened her. At various times she gave the following manifest signs of her anxiety: 1. A startled response in which she gasped "Oh" or suddenly grasped the interviewer's arm 2. Perspiring 3. Spontaneous statements that she was "scared" or "nervous" and statements that the experiences made her think of "the nut house" 4. Uncontrollable laughter 5. Concern about anticipated experiences ("God knows what word is gonna come to me next.") 6. Silent praving—"Hail Marys" ("Just saying mv pravers so my mind won't drift someplace.") 7. Reduced communication and what appeared to be attempts to conceal the
VOL. XXVI, NO. 4. 1964
content of the experiences from the interviewer (Long silences, monosyllabic comments, changing the subject: "Don't ask me." Telling the interviewer that something came to her, but then saying nothing but "I don't know" when asked about it.) For systematic observations we used the crude rating scales of the patient's anxiety level, defensiveness of reporting, and level of interaction and independently rated each stimulation interval on the three variables. The data of Table 8 show that the two judges were able to make reliable ratings. The average of the ratings by the two observers was used for subsequent analysis. The ideational responses were accompanied by increased manifest anxiety 2 ( x = 4.176, p < .05) and increased defensiveness of report (x2 = 3.183; p = .05). The level of interaction did not change consistently with the occurrence of ideational responses.* Discussion The presentation of our results has answered the questions posed in the introduction. Here we wish to relate certain of our limited observations to the very extensive ones of Penfield and his associates which have been described and conceptualized over the last 25
*The only other positive finding concerning the three rated variables was the very high anxiety level accompaning the painful jaw and tongue sensations. The ratings did not vary directly with point or voltage of stimulation, or with interviews.
years. ' ~ ' Where comparable, our observations are similar to those of Penfield. The use of the interview situation and of verbatim recordings for subsequent study provided us the opportunity, however, to observe certain events which Penfield has not reported. These empirical extensions suggest a qualification in Penfield's interpretation of some of the effects of temporal-lobe stimulation and an alternative interpretation of the observable phenomena. Electrical stimulation of the epileptogenic, left temporal lobe of our patient evoked "psychical"* responses. Even within the limited range of loci made available by the needle electrodes, these effects were dependent upon the specific location of stimulation within the temporal lobe. Furthermore, stimulation of the inferolateral cortex of the left frontal lobe, by means of the plate electrode, did not elicit psychical responses, nor any other observable ones. In their general outline, these findings are consistent with Penfield's observations that psychical responses may follow stimulation of specific areas in the pathological temporal lobe of patients with psychomotor epilepsy.
•Penfteld uses this term to distinguish temporal-lobe cognitive and perceptual responses from the simple sensory and motor effects i>f stimulation in the other regions of the cerebrum. Stimulation at the very tip of the posterior needle produced pinful jaw and tongue sensations. The lack of adequate X-rays precludes exact interpretation of these responses. Penfleld has never observed such sensations upon stimulation of the temporal lobe. Phanor Perot, M.D., Montreal Neurological Institute, a colleague of Penfleld, wrote us in a personal communication: "From the description given of the posterior needle, it seems fairly clear that the responses of sensation in the law and tongue were due to stimulation of the third division of the trigeminal nerve and/or the dura around it. We have often seen this kind of response with stimulation at operation where the dura was stimulated or manipulation was carried out around the nerve in the middle part of the floor of the middle fossa." We are excluding the jaw and tontrue sensations from our discussion of temporal-lobe responses.
18 20 27 s0
INTRACEREBRAL ELECTRICAL STIMULATION
Our "extrinsic" responses appear to be identical with Penfield's category of hallucinatory or experiential responses. Our "intrinsic" responses seem most similar to Penfield's category of automatism, for they included nonsensical and unrelated speech and "forced thinking" and occurred with stimulation of deep structures in the temporal lobe. The latter might very well be included in the periamygdaloid region reported to be the place of origin for such responses.30 Our patient did not, however, seem amnesic for her intrinsic responses which is characteristic for the automatisms observed by Penfield. With the present patient, in contrast to the one described previously,14 there were no clear-cut instances of Penfield's interpretive response category. This is a category of a variety of illusory experiences such as deja vu, depersonalization, illusory emotional perceptions of the environment, and changes in apparent magnitude or proximity of sounds or visual stimuli. Once, remarks by the interviewer sounded altered, and there was a vague d£ja vu quality in the patient's description of some of her extrinsic experiences (Stim. 6, Interview 4; and Stim. 5, Interview 6). These seemed to be the closest aproximations to the interpretive response category, if indeed they are that. Since Penfield has found that certain of the interpretive responses are limited to the nondominant hemisphere, the fact that we stimulated in only one side mav account for these negative findings. The patient's left side may actually have been dominant for some functions even though she was left-handed. Dominances may shift independently for different functions.27 We are more interested in the interpretation of the nature of the extrinsic responses, which as we have mentioned are identical with Penfield's experiential responses. Penfield22"2* interprets these responses as the detailed re-enactments of previous experiences, the hallucinaPSYCHOSOMATIC MEDICINE
MAHL £7" AL
occurrence is vivid and impressive, the descriptions of the experiences are too fragmentary ever to determine if they were, in all respects, the actual reliving of previous experiences. Our data seem to justify a more conservative conclusion. Stimulation produced hallucinatory experiences containing perceptions from the past, but it is not known if their organization into the hallucinatory experiences replicated any actual previous experience. In other words, we cannot tell whether the hallucinatory experiences were the equivalent of dreams or psychotic hallucinations or the equivalent of an exact "playback." These considerations led us to review the basis upon which Penfield concluded that stimulation resulted in the exact "flash-back" activation of memories. A large number, if not the majority, of the response protocols Penfield has published resemble our patient's descriptions in their sketchiness. He has obtained more complete reports on some occasions, but he has not provided in any detail the kind of evidence, and the technique for obtaining it, that was taken as proof that the patients were actually reliving the past on these occasions. That his patients were having experiences involving past perceptions seems indisputable. But here too we can see no basis for making a final judgment as to whether the hallucinatory experiences were essentially new creations based on memories, analogous to dreams, or simply playbacks. Evidence pertaining to this issue of the essential nature of the hallucinatory experiences will be extremely valuable. It will also be very difficult to obtain. At the outset it will be necessary to have adequately detailed descriptions of the experiences, undistor^ed by defensive and synthetic trends in the patient's reports. These are clearly discernible in the protocols of the Appendix. And then, when determining if an experience is an exact playback of previous events, it will be necessary to control carefully for
tory evocation of memories by the stimulus activation of their neuronal counterpart recorded in a part of the brain that is outside of, but intimately connected with, the temporal lobe. Do the extrinsic responses of our patient fit this formulation? It is important to realize at the outset that the sketchy, fragmentary nature of our patient's reports about these experiences do not convey, when reduced to written, paraphrased, and excerpted presentation, the full impact of the patient's actual behavior during the interview or during the replaying of the taperecordings. Her manifestations of surprise, as well as her verbal descriptions, leave little doubt that she experienced auditory hallucinations upon stimulation in the anterior needle. Possibly she was reliving past experiences in these hallucinatory episodes, but the available evidence is inconclusive. In five of the 13 extrinsic experiences, the patient identified the people she heard as being ones she knew and thus heard in the past. In one of these five experiences, a man was talking "silly," as he often had in the past, and in three more of the five experiences the patient identified the words spoken as actually having been said by these people in the past. We cannot say whether the content of the other eight extrinsic experiences referred to the patient's past or not. The patient made no reference to the past in describing them, a circumstance that could be due to a variety of factors. Defensiveness of reporting and instantaneous repression, arising from the fear of insanity as well as from other anxiety and guilt over the content of the experiences, could very well have prevented the patient from providing the missing memorial reference for these eight experiences. However, even if we simply do not concern ourselves with these eiffht experiences, we must still evaluate the five "positive" hallucinatory experiences. While the evidence of their
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similar defensive and synthetic trends, and other types of distortion, in the thinking of whatever witnesses are utilized. Our consideration of the exact nature of the hallucinatory experiences is related to our observations about the relationship between the interview content prior to stimulation and the content of the experiences themselves. Some of the observations about this relationship presented under Results are admittedly inferential, and some are equivocal as to the role of interview content with respect to repetitive stimulation at the same locus. But two of them show in a very obvious and unequivocal way that thoughts of the patient at the moment of stimulation may be related to the perceptual content evoked by the stimulation. These are the experiences elicited by Stim. 10, Interview 6, and Stim. 8, Interview 7, both at Ant. Ndl. 5-6. Immediately before the first of these two stimulations, the patient was talking about her daughter's desire for a baby sister and, if the patient is to be believed, she herself was then thinking that she would like to have another baby. With stimulation, the patient hears a female voice say "I got a baby . . . sister." Just before the other stimulation, the patient was speaking of her "spells" at work and of actual details of her work. Upon stimulation she hears the voice of a girl who used to work with her. And the words uttered by the girl include the phrase, "someone's gotta go to work." (Baldwin1 reports a very similar observation. The visual hallucinatory responses of a 28year-old man varied in content with the sex and identity of the observer seated before him in the operating room. One wonders if the same kind of thing has gone undetected in Penfield's studies. Could it have happened, for example, in the case of Penfield's young boy patient who, upon one stimulation, said, "my mother is telling my brother he has got his coat on backwards. I can just hear
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them."23 Had this boy thought to himself prior to stimulation that those in the operating room "had their clothes on backwards"?) The preceding observations suggest the following hypothesis: The patient's "mental content" at the time of stimulation is a determinant of the content of the resulting hallucinatory experiences." This hypothesis is testable and could open-up a new dimension in temporallobe stimulation studies. It modifies Penfield's interpretation-3'24 that the exact memorial material elicited by stimulation is primarily a random matter. According to the preceding hypothesis this could not be the case. The hypothesis also accounts for certain stimulation sequence effects. Penfield has observed that if stimulation at a point X elicits a particular hallucinatory response, additional stimulations at this or even at another "positive" point may elicit responses with related content if the stimulations occur at short time intervals, whereas the thematic content will be unrelated if the time intervals are long. Our own data confirm these observations. Thus, in Interview 4, there was a run of three hallucinatory responses with related content when stimulations were only 5 min. apart although at two different positive points; later stimulation at one of these points elicited quite different content:
Interview 4 Stim. 4, Ant. Ndl 3-4: A man says some word "silly." 5' Stim. 5, Ant Ndl. 5-6: The man's wife said something. 5' Stim. 6, Ant. Ndl. 5-6: The man's wife said something she had said a long time ago. Interview 7 Stim. 8, Ant. Ndl. 5-6: A girl the patient worked with said, "(Patient's name) that
•Anyone made uncomfortable by the term "mental content" can substitute for it more modern terms such as "cognitions," "cognitive structures," etc. PSYCHOSOMATIC MEDICINE
M A H L ET AL.
tual threshold. The trace that had the highest level of latent excitation before stimulation would form the content of the hallucinatory experience if this consisted of a single event or would be the most intense element of a complex hallucinatory response. When the conscious theme is a continuing one, the distribution of the unequal, subliminal excitations of associated memory traces might change, keeping pace with varying accents in the conscious mental content. Stimulations occurring under these conditions would then produce a series of thematically related hallucinatory experience, though the specific details need never be the same. This first hypothesis can be illustrated by the first three responses of our patient in Interview 4. Here one could assume that the overt interchanges concerning couples, babies, etc., and finally the patient's speech, was accompanied by subliminal excitation of a network of memory traces of experiences with the "hot sketch" couple. (We are making no assumption about the "direction of causality" here; only one of "association.") At the time of stimulation the excitation of traces of "silly speech" of the man in this pair would have been more intense than the excitation level of traces concerning the woman. Therefore, with stimulation, a trace of the man's "silly speech" was raised above perceptual threshold and the patient heard him say a "word silly." But by the time the next stimulus came, the patient had spoken of the man's wife. Now the excitation level was greatest on traces concerning her, so that with the next stimulation the patient heard the wife speak. If we include psychodynamic considerations, we increase the flexibility and explanatory power of this first hypothesis. We might then, for example, be able to account for the absence of response at positive electrode points on the grounds that the subliminal trace-excitations reach sufficient prestimulation intensity only when the conscious content
guy was tough," and apparently repeated statements made by her brother-in-law about "someone's gotta go to work." Penfield's interpretation24 of such a sequence is that the difference in content of the first and last experience was the result of "a random re-enactment," and that the thematic relatedness of the first three responses depended upon neuronal facilitation. According to our hypothesis, the first experience consisted of a man speaking in a silly fashion just because the patient was preoccupied with her own speech and the concern that she sounded silly to the male interviewer at the time of stimulation. Similarly, the content of the last experience pertained to work just because she was thinking and talking about work at the moment of that stimulation. But the same process seems to account for the relatedness of the first three experiences, for she was still thinking about the content and associated thoughts of the preceding experience when the next stimulation occurred. The same hypothesized determinant function of mental content present at the time of stimulation accounts for the selection of memory elements appearing in any one hallucination, and also for the similarities and disparities among the responses. There are at least two alternative hypotheses, related but differing in points of emphasis, concerning the process or mechanism that might mediate the relationship between prestimulation mental content and the hallucinatory responses. Both hypotheses assume that conscious mental content is always accompanied by unequal, subliminal excitation of associated memory traces. The first, or facilitation, hypothesis makes the additional assumption that excitation resulting from electrical stimulation summates with the background, latent excitation of the memory traces, thus raising the total excitation of the traces. The excitation level of one or more traces may thus reach the percepVOL. XXVI. NO. 4, 1964
is affect-laden or is sufficiently instinctualized in the psychoanalytic sense. Or the perceptual threshold might vary with the patient's strengh of defenses at the moment of stimulation. The hypothesis is also useful in that it yields predictions that are conceivably testable. Its basic prediction, and the one that sharply distinguishes it from the alternative hypothesis to be mentioned, is that the hallucinatory experiences are in fact the re-enactment of previous experiences—exact playbacks. The first hypothesis, even without the psychodynamic considerations, draws upon the thinking of both Penfield and Freud's topographic model.7 The second hypothesis rests almost completely on enduring concepts of Freud's early metapsychology. A striking resemblance exists between the relation of the hallucinatory responses to their prestimulation mental content and the relation of dreams to their dream thoughts. In our two clear examples ("I got a baby . . . sister" and ". . . someone's gotta go to work"), verbally expressed thoughts are followed, upon stimulation, by relevant concrete, sensory percepts with memorial qualities. If the patient had gone to bed preoccupied with thoughts of work or of her daughter's desire for a baby sister and dreamt, she might have hallucinated in her dreams exactly what she did upon electrical stimulation of her temporal lobe. Freud's explanation of such an event is indicated in the following quotations:7 . . . a dream is thinking that persists . . in the state of sleep, (p. 550). [some analysts] seek to find the essence of dreams in their latent content and in so doing they overlook the distinction between the latent dream-thoughts and the dreamwork. AT BOTTOM DREAMS ARE NOTHING OTHER THAN A PARTICULAR FORM OF THINKING. MADE POSSIBLE BY THE CONDITIONS OF THE STATE OF SLEEP. IT IS THE DREAM-
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WHICH CREATES THAT FORM, AND IT ALONE IS THE ESSENCE OF DREAMING—THE EXPLANATION OF ITS PECULIAR NATURE, (pp. 506-507: a footnote added by Freud in 1925—capitals, ours; italics, Freud's) But dreams differ from day-dreams in their second characteristic: namely, in the fact of their ideational content being transformed from thoughts into sensory images, to which belief is attached and which appear to be experienced . . . it is not only in dreams that such transformations of ideas into sensory images occur: they are also found in hallucinations and visions, which may appear as independent entities, so to say, in health or as symptoms in the psychoneuroses. In short, the relation which we are examining now is not in any respect an exclusive one. (p. 535, italics ours) If we said, "such transformations of ideas into sensory images are also found in the hallucinatory responses to electrical stimulation of the temporal lobe," we would be stating the essence of the second hypothesis about our observations. For this alternative conceptualization, which might be called the alteredstate hypothesis, is that the essenial effect of stimulation is to alter the state of consciousness of the patient in such a way that primary-process thinking replaces secondary-process thinking. In Freud's metapsychology, primary-process thinking is epitomized by the hallucinatory revival of memory traces achieved by the displacements and condensations of the memory-trace excitations so that they eventually reach perceptual threshold intensity. Since the displacements and condensations introduce varying degrees of distortion into the revival, it may range from relatively exact reproductions of the past to such extremely distorted revivals that strange "created" experiences occur. All are hallucinatory. In the normal adult this primary-process mode of thinking occurs most characteristically in sleep and similar states of consciousness such as occur in hypnaPSYCHOSOMATIC MEDICINE
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considerations discussed earlier in that connection, other questions originating in Freud's dream studies now naturally arise: Will hallucinatory responses occur with stimulation only if conflictful mental content—ideas, wishes, etc.—has been activated prior to stimulation? Does the seemingly frequent "trivial" content of the hallucinatory experiences, a matter often remarked by Penfield, merely serve as the cover for inhibited content? Some observations in this patient and the one previously reported14 suggest that the questions deal with possibilities. Some of the present patient's responses seemed to be related to affect-laden but inhibited thoughts. Thus, in the case of the first experience, where the man spoke in a silly fashion, the patient did not then speak of her concern over how she sounded to the interviewer in spite of the repeated transactions determined by her speech that occurred just before stimulation. Later, however, this concern was expressed in a derivative, affective fashion. In the case of her response, "I got a baby . . . sister," the patient did not voice her own desires to be pregnant at the time she spoke of her daughter's wish. Later she did. It is as though she hallucinated her own desires, adding the "sister" as an afterthought. Finally, we know that in the last stimulation interview on at least one occasion she heard a "dirty word," refused to speak of all her experiences, and reacted by praying. In our previous paper we reported that the boy patient said upon stimulation, "I'd like to be a girl." In a follow-up interview, he recalled this statement but negated it, and he disrupted the interview when thwarted in this defensive reaction. The altered-state hypothesis readily encompasses these observations. There is another implication of the altered-state hypothesis which speaks further in its favor. It can also account for many of the changes in perception of external events and in self-perception
gogic reverie upon falling asleep and in hypnosis.13 According to this second hypothesis, then, electrical stimulation of the temporal lobe does not directly activate memory traces in the ganglionic record. Instead it induces a state of consciousness which makes it more probable that primary-process modes of functioning will prevail. If there is a background of subliminally excited memory traces in the ganglionic record at the time of stimulation, then all the conditions exist for the occurrence of hallucinatory experiences, and the content of these experiences would necessarily be related to the prestimulation mental events, for it would be determined partly by them. According to this second hypothesis the hallucinatory experiences would be compounded of memory traces, but would not themselves necessarily be exact re-enactments of the past. There could be a range from exact revival to seemingly novel content. This prediction is conceivably testable. Since the first and second hypotheses make two different predictions on this matter, a critical test of them would be very important. * As with the facilitation hypothesis, the introduction of psychodynamic considerations might increase the predictive or explanatory power of the altered-state hypothesis. In addition to the kinds of
•In many of Penfleld's protocols the patients spontaneously describe their experiences as dreams or dreaming. And his patients, as our present one, often felt there was a similarity between the experiential responses and their aurae. Perhaps they sensed the similarity in the states themselves. Penfield frequently related the experiential responses to dreams in his earlier papers and once commented2* that: "Experience with cortical stimulation brings one to the conclusion that these induced mental states are like dreams." (p. 179) But he was explicitly referring to the memorial dimension of dreams and hallucinatory responses rather than to the states themselves and their basic attributes, such as modes of thinking.
which may occur with temporal-lobe stimulation. These consist of those changes which Penfield classifies as "interpretive illusions" and which are taken to indicate that temporal-lobe stimulation has not only activated ganglionic memory traces but has also interfered with the process of scanning traces and comparing present perceptions with them. In psychoanalytic theory, a change in state of consciousness is basically dependent upon a change in distribution of attention cathexes. And the distribution of attention is a fundamental determinant of perception.0"1- We are indebted to Rapaport2R for the systematizing and creative elaboration of this material. The theory directly implies that any change in consciousness characterized by a transition towards primary process modes of thought would also be accompanied by disturbances in perception of the self or the external world, or both. In our research we found the same kind of hallucinatory responses upon temporal-lobe stimulation as Penfield discovered. In this discussion we have questioned, however, whether the hallucinatory responses are typically exact reenactments of the past or are, to varying degrees, new creations compounded of memories of the past. Either interpretation seems possible in the light of present evidence. We then discussed our observations and hypothesis that the mental content at the time of stimulation was a determinant of the content of the hallucinatory responses. Next we suggested two alternative hypotheses to account for such a relationship. We also cited some observations suggesting that temporal-lobe stimulation may facilitate the expression of inhibited wishful or affective ideas. We have just speculated that the altered-state hypothesis could account for both the hallucinatory responses and the interpretive illusions. Each of these issues can be the subject
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of, and merits, further investigation in its own right. Taken as a whole, these considerations suggest a single unifying hypothesis: Electrical stimulation of the epihptogenic temporal lobe may induce a state of consciousness in which there is a shift towards primary-process organization and away from secondary-process organization of behavior. This state of affairs may have several consequences. The conscious and unconscious mental content present at the time of stimulation may be manifested in hallucinatory experiences. Disturbances in perception of the self or of the external world may occur. Finally, there may be a change in the drive-defense organization such that more direct drive manifestations are displayed or both drive and defense become more primitive and intense. According to this hypothesis, then, the effect of stimulation is to provide the general neural conditions in which the specific consequences may occur according to their own mechanisms. A discussion of how stimulation may do this is a major question in itself. Even if there were time and space to attempt it, we cannot improve upon the suggestions specifically concerned with the role of the temporal lobe in states of awareness which Kubie included in his brilliant paper.15 We share with Kubie and the psychoanalysts who discussed his paper—Kris, Lewin, Margolin, and Ostow—the belief and the hope that research on the effects of stimulation of the temporal lobe, pioneered by Penfield, provides one point of significant interaction between neurophysiology and psychoanalysis. The aspect of Penfield's work which excited the most interest among psychoanalysts was that dealing with memories. By and large it was granted that stimulation directly activated memories and produced re-enactments of the past. The question of interest became, "Are these repressed memories?" We believe these
MAHL ET M.
electrode was placed on the inferiorlateral surface of her left frontal lobe. EEG tracings were recorded from and electrical stimuli were administered, with certain controls, through these electrodes during four unstructured interviews. Nonstimulation interviews preceded and followed the stimulation interviews. All interviews were tape-recorded and transcribed for subsequent study. Stimulations in the plate electrode produced no observable responses. Stimulations at the tip of one depth electrode produced painful jaw and tongue sensations, indicating that the tip of this electrode was outside the temporal lobe. Stimulations at other points in both depth electrodes, within the temporal lobe, produced two distinct kinds of ideational experiences: (1) The subject said people "came to her mind" and seemed to be speaking. The experiences seemed to vary from thoughts, to vivid memories, to hallucinations. (2) A word or expression "came to her" but nobody was saying it. The words were sometimes remembered expressions, nonsense words, and "dirty" words and at times the subject could not or would not describe them. The ideational experiences resulted from sharply localized stimulation. They were associated with evoked, but not spontaneous, electrical seizure activity. The subject experienced them as ego-alien, with considerable overt anxiety, and was defensive in reporting them. The findings resemble and extend Penfield's observations obtained with a different procedure. The use of the interview and careful study of the recordings, however, permitted the discovery that the content of the ideational experiences was often related to the patient's mental content just before or at the time of stimulation. Minimally, this discovery requires certain modifications in Penfield's theoretical interpretations. Maximally, it leads
particular reactions were premature, the result of an enthusiastic reunion. We have also concluded, however, that there are many points at which psychoanalysis and this area of neurophysiology can have significant encounters. Our limited empirical observations and our theoretical consideration of the work in this area led us in a direction anticipated by Bertram Lewin16 in the following paraphrased remarks from his discussion of Kubie's paper:
The most interesting part of this paper is that which deals with the material produced by electric stimulation and the interpretation of this material. Here certainly we need much cautious and at the same time imaginative handling . . . the patient's productions should be treated with all the methods that we employ when confronted by the material of free association. . . . It would be wrong . . . to assume that electric stimulation provokes a direct catharsis. . . . We can find in all these productions a complicated structure, which should yield to ordinary analytic methods of approach. The appearance of visual representations and other states resembling dreaming needs handling more according to dream theorv . . .
Summary Two multilead needle electrodes were implanted within the left temporal lobe of a young woman with intractable psychomotor epilepsy. A multilead plate
*During our earlier collaboration with Dr. John Higgins, the possibility of interpreting stimulation effects in terms of primary process organization occurred to us. We did not pursue that line of thought at that time, however, possibly because the stimulus effects observed then did not include hallucinatory responses. These, after all, fit the simplest paradigm— dreams—of primary process thinking. Also, we were very fortunate subsequently to have the benefit of studying with Drs. William Pious and David Rapaport, who opened our eyes to the content and broad application of Freud's general metapsychology. VOL XXVI, NO. 4, 1944
to quite different interpretations. Certain alternative hypotheses, extensions of Freud's metapsychology, are discussed. The mutual implication of psychoanalysis and temporal-lobe stimulation studies for each other, emphasized by Kubie, is noted.
333 Cedar St. New Haven, Conn.
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1. BALDWIN, M. "Electrical Stimulation of the Mesial Temporal Region." Electrical Studies on the Unanesthetized Brain, Ramey, E. R. and O'Doherty, D. S. (EDS.) Hoeber, New York, I960. Pages 159-176. 2. DELGADO, J. M. R. Permanent implantation of multilead electrodes in the brain. Yale } . Biol, & Med. 24:351, 1952. 3 DELGADO, J. M. R. "Elektroenzephalographic der tieferen Zellmassen des Gehirns." (Electroencephalography of the deeper cell masses of the brain.) In Einftihrung in die Stereotaktischen Operationen mit einem Atlas des Menschlichen Gehirns. (Introduction to Stereotaxis with an Atlas of the Human Brain.) G. Schaltenbrand and P. Bailey. Thieme, Stuttgart, 1959. pp. 401-419.
4. DELGADO, J. M. R., ROBERTS, W. W.,
8. FREUD, S. (1911) Formulation on the Two Principles of Mental Functioning. Standard Edition of Complete Psychological Works of Sigmund Freud. Vol. 12, Hogarth Press, London, 1958, pp. 218-226. 9. FREUD, S. (1915) The Unconscious. Standard Edition of Complete Psychological Works of Sigmund Freud. Vol. 14, Hogarth Press, London, 1957, pp. 166-204. 10. FREUD, S. (1917) A Metapsychological Supplement to the Theory of Dreams. Standard Edition of Complete Psychological Works of Sigmund Freud. Vol. 14, Hogarth Press, London, 1957, pp. 222-235. 11. FREUD, S. (1925) A Note upon the 'Mystic Writing Pad." Standard Edition of Complete Psychological Works of Sigmund Freud. Vol. 19, Hogarth Press, London, 1961, pp. 227-232. 12. FREUD, S. (1925) Negation. Standard Edition of Complete Psychological Works of Sigmund Freud. Vol. 19, Hogarth Press, London, 1961, pp. 235239.
13. GILL, M., and BRENMAN, M. Hypnosis
and Related States. Internat. Univ. Press, New York, 1959.
14. HICGINS, J. W., MAHL, G. F., DELGADO,
and MILLEF, N. Learning motivated by electrical stimulation of the brain. Am. J. Physiol. 279:587, 1954.
5. DELGADO, J. M. R., ROSVOLD, H. E.,
and LOONEY, E. Evoking conditioned fear by electrical stimulation of subcortical structures in the monkey brain. /. Comp. <b Physiol. Psychol. 49:373, 1956. 6. FREUD, S. (1895) Project for a Scientific Psychology. In The Origins of Psychoanalysis. Bonaparte, M., Freud, A., and Kris, E., (EDS.). Basic, New York, 1954. 7. FREUD, S. (1900) The Interpretation of Dreams. Standard Edition of Complete Psychological Works of Sigmund Freud. Vol. 4 and 5. Hogarth Press, London, 1953.
J. M. R., and HAMLIN, H. Behavioral changes during intracerebral electrical stimulation. A.M.A. Arch. Neurol. b Psychiat. 76:399, 1956. 15. KUBIE, L. S. Some implications for psychoanalysis of modern concepts of the organization of the brain. Psychoanalyt. Quart. 22:21, 1953. 16. LEWIN, B. Discussion of "Some implications for psychoanalysis of modern concepts of the organization of the brain," by L. S. Kubie. Psychoanalyt. Quart. 22:61, 1953.
17. MACLEAN, P. D., and DELGADO, J.
M. R. Electrical and chemical stimulations of frontotemporal portion of the limbic system in the waking animal. Electroencephalog. Clin. Neurophysiol. 5:91, 1953.
18. MULLAN, S., and PENFIELD, W. Illu-
sions of comparative interpretation and emotion. A.M.A. Arch. Neurol. Psychiat. 81:269, 1959.
M A H L ET AL. 19. OLDS, J., and MILKER, P. Positive re26.
PENFIELD, W., and RASMUSSEN, T. The
inforcement produced by electrical stimulation of septal area and other regions of rat brain. / . Comp. <b Physiol. 27. Psychol. 47:419, 1954. 20. PENFIELD, W. The cerebral cortex in man. A.M.A. Arch. Neurol. Psychiat. 28. 40:417, 1938. 21. PENFIELD, W. Memory mechanisms. A.M.A. Arch. Neurol. Psychiat. 67: 29.
Cerebral Cortex of Man. Macmillan, New York, 1952.
PENFIELD, W., and ROBERTS, L. Speech
and Brain Mechanisms. Princeton Univ. Press, Princeton, N. J., 1959.
RAPAPOHT, D. Organization and Pa-
thology of Thought. York, 1951.
RAPAPORT, D. "On the Psychoanalytic
22. PENFIELD, W. The Excitable Cortex in Conscious Man. (The Sherrington Lectures V). Thomas, Springfield, 111., 1958. 30. 23. PENFIELD, W. The interpretive cortex. Science 129:1719, 1959. 24. PENFIELD, W. A surgeon's chance encounter with mechanisms related to consciousness. /. Roy. Coll. Surgeons 31. Edinburgh 5:173, 1960.
25. PENFIELD, W., and JASPEH, H. Epi-
Theory of Motivation." In Nebraska Symposium on Motivation, Jones, M. R. ( E D . ) . Univ. Nebraska Press, Lincoln, 1960, pp. 173-247. ROBERTS, L. "Activation and Interference of Cortical Functions." In Electrical Stimulation of the Brain, Sheer, D. E. ( E D . ) , Texas Press, 1961, pp. 533-553.
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Appendix A. Summaries of Extrinsic Ideational Experiences
Content of experience
Content of experience as though he said—and it seemed like he was coming out with some word—sayin' some word silly—"
No. 4 Ant. Ndl. 3-4, lOv
When stimulation ended, patient said: "You know, I just felt funny, just now—I told you they work on findings [at jewelry factory where husband works], right, then all of a sudden somethin' else came to me —these the people—the way this person talked. This married couple—as though the fellow came into my mind—as though like he was saying somethin'—like oh my mind drifted for a minute—to somethin foolish, I mean I wasn't even thinkin' of it—I just said some word to you, and it seemed like —he used to be a hot sketch—
No. 5 Ant. Ndl. 5-6, 5v
With stimulation patient said, "Ooh," and then described what happened in following terms: "My mind just went off again— [to] the fella's wife—I don't know what she said—I mean— just seemed a little strange for a minute—I was lookin', starin* —one day I was talking to her on the phone—the couple we know—she just had lost her baby. I don't know, I happened to just think of it." Immediately with cessation of stimulation patient said: "See, that girl came to me again." She described it as follows: ". . . just now, just as though she was gonna sav somethin'—isn't that
No. 6 Ant. Ndl. 5-6, 7v
VOL. XXVI, NO. 4, 1964
Stimulation Content of experience
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Content of experience
funny—all of a sudden it seems like she was saying—it's somethin that she says to me a long time ago—Gee, I can't remember the words."
No. 2 Ant. Ndl. 3-4, lOv
Immediately upon cessation of stimulation patient said: "It's as if my mind just went off again. I thought of somethin'." She described the experience as follows: "[I thought] of some girl who worked with me, I guess —somethin' just came to me— see, I forget it—was just a thought that comes to me—it's somebody else now—How come I've been thinkin' of people?— like a sayin that she said—some kind of a sayin' but I can't remember how it goes. I think it was Jeanette." With stimulation patient said: "I just thought of somethin' else —now I can't think of it." Her descriptive comments were: "Somethin else came to me, another saying and it went—I can't think of it now. How come these things are comin' like that —I mean all of a sudden— like, oh a person sayin—/ don't know who it was though." When stimulation occurred, interviewer was saying, "It'll feel better tomorrow." (i.e., her head). Upon cessation of stimulus patient mumbled in an automatic way: ". . . feel better tomorrow" and became thoughtful. She described her experience: "111 tell ya'—seemed like you said another word—like another word, I don't know the name of the word." With cessation of stimulus, patient said: "Another person came to me." Her descriptive remarks were: ". . . was just as
No. 15 Ant. Ndl. 3-4, lOv
though somebody was sayin' something—I don't know who it was—as though I could hear them saying something—like a saying—maybe something true —it must have been a girl." A few seconds after cessation of stimulation, patient said: ". . . somethin puzzled again," In remarking further, she said: "I can't explain it—like a puzzle— puzzled—as though somebody said somethin'—I can't remember—could I imagine it?—I know that they weren't here, they just came to my mind."
No. 5 Ant. Ndl. 5-6, 5v
No. 3 Ant. Ndl. 5-6, 7v
During stimulation, patient started following remarks: "See. Now look, I just got the—I just thought of somebody again." Her description was as follows: "Oh, I can't think of it now— somebody was thinking of s— I don't know, it's all mixed up— As though somebody was thinkin'—of how somebody used an expression—It just came to me that—someone was saying, like 'Don't be like this one'—and then how this person says an expression—I guess I'm mixed up—." Immediately after start of stimulation, patient said: "Something just came to me right then." She remarked about this experience as follows: "It musta been the same person [who said "Don't be like this one" some 20 min. earlier!]—seems like a g— it must be something about a baby—it comes to me fast and then it goes away—she says to me 7 got a baby . . . sister'—or something — she — something comes to me—someone says something—I don't know—I was thinkin' of—I wouldn't
No. 12 Ant. Ndl. 3-4, 5v
No. 10 Ant. Ndl. 5-6, 5v
No. 14 Ant. Ndl. 5-6, 7v
M A H L ET AL.
Content of experience Stimulation Content of experience brother-in-law says something about someone's gotta go to work—Oh, I don't know, I'm mixed up—a girl said it—somebody that worked with me—." B. Summaries of Intrinsic Ideational Experiences
mind—having another baby—I was thinkin' about it before . . ." [NOTE: Just prior to stimulation patient was talking about her daughter's wish to have a baby sister or brother.]
No. 3 Ant. Ndl. 5-6, lOv
Interviewer asked patient if she was worried about anything. She replied: "No, I guess not." Interviewer asked, "What do you mean, you guess not?" Then stimulation occurred. In a few seconds, patient commented: "You just says that and somethin" came to me—oh, I don't know [what]—what did you just say to me?—seemed like somebody else said somethnig. I don't know what it was now." Immediately upon stimulation. patient reached and grasped interviewer's arm. She remained silent and thoughtful. Upon prodding by interviewer as to what happened when she suddently grasped his arm, she said: "I felt the thing again, I guess," and continued: "Funny —trying to figure out what that was—/ think it wasn't nice—it must have been dirty—I don't know what it was—maybe a word—wasn't a swear word—I don't think—something foolish —somebody else might have said it—a saying—I don't know, I think it was dirty. . ." With stimulation, patient said, "Seemed like somebody just came to me—'[Patient's name] that guy is . . .'—a girl said it to me—[Patient's name]—I can't think of it now. See it goes right off—like the girl comes— somebody says to her '(Patient's name) the—that guy was tough' — The girl says to me, that her
No. 6 Ant. Ndl. 1-2, lOv
With stimulation, patient apNo. 8 Post. Ndl. peared to be uncomfortable. When interviewer asked if she 3-4, 5v was, patient said, "Funny word came to me and I don't know what it is—I don't know if it is 'kerchief or what—that word came to me when I—like I thought it—Well, before when I used to get these feelings— like I call funny feelings—if I kinda put my hand this way, depending like how I sat—a word would come to me—seemed like someone was makin' a comment when it occurred to me." No. 15 With stimulation patient felt she Post. Ndl. had "opened her mouth too hard again" and then said that 3-4, 5v when she felt this she had been thinking of " . . . a word, I don't know—tryin' to remember it—a word that came to me—nobody was saying it."
No. 4 Post. Ndl. 3-4, 5v
No. 8 Ant. Ndl. 5-6,10v
Patient fell silent for 20 sec. following stimulation and interrupted pause saying, "A word just came to me—like an expression—'Floats in the tide' I think—how come I've been getting expressions lately—you know, I was just staring over there and then seemed like I heard like, ah, like I remember that that somebody used that expression—as though somebody used that expression—
VOL. XXVI, NO. 4, 1964
Stimulation Content of experience
INTRACEREBRAL ELECTRICAL STIMULATION
Content of experience INTERVIEW 7
there's nobody here—as though I know that someone used that expression—it didn't sound like that expression—but like I remember, oh, like I keep saying the expression then it comes out to that—that's how I got those funny feelings." No. 11 Upon stimulation patient sudPost. Ndl. denly fell silent and looked 3-4, 5v thoughtful. She maintained this silence steadfastly for 40 sec. during which interviewer attempted to find out what she was thinking. Finally, she said, "A word musta come into my head, but I don't know what it is." She sparsely commented further: "I don't know what it really is—I don't know what the word is—I don't know the word. I'd tell you if I knew the word. I told you other words I could think of—suppose another word comes to me. God knows what word is gonna come to me next—I don't know what the word was. Now don't ask
With stimulation patient said:
"Ooh, a crazy word just came to
me." Her description of her experience: "I can't think of it now—I was trying to make out the word. It just came to me, just for a minute—all of a sudden—could that be my imagination—this word came to me and I was about to say it to you —I couldn't make it out now— it's coming to me, nobody was sayin'—sounded like a lotta words."
3-4,7v Immediately upon stimulation No. 9 patient broke a markedly unPost. Ndl. communicative period with a whispered nonsensical phrase: "Purse onto—" "What did I say?" She then went on to say for clarification: "Purse into school—see that just came to me—I think I says 'Pake into schooY—it doesn't make any sense—Did I say that?" [I.e., "Pake into school"].