The Schizophrenia-like Psychoses of Epilepsy: i.

Psychiatric
Aspects
ELIOT SLATER and A. W. BEARD

The British Journal of Psychiatry 1963 109: 95-112

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Brit. 3. Psychiat. (1963), 109, 95-150

The Schizophrenia.-like Psychoses of Epilepsy

i. Psychiatric Aspects

By ELIOT SLATER and A. W. BEARD*

INTRODUCTION This is the first explicit recognition of the

In 1953, in an article intended for the general syndrome which is discussed in detail in the
practitioner, Denis Hill made a brief reference paper which .follows ; but the occurrence of
to the chronic paranoid psychoses which may schizophrenia-like psychoses in association with
develop in association with temporal lobe epilepsy has been reported again and again
epilepsy. He described the condition as likely over the last half-century, usually with a good
to come on when the seizures were diminishing deal of bewilderment on the side of the author.
in frequency, as appearing gradually with onset In his excellent review (I 936), Gruhle quotes
in middle age, and as resembling a paranoid a total of 23 authors, most of them describing
schizophrenic state. In 1957, D. A. Pond, from cases in ones and twos, going back to Giese who
the same department of applied electro reported six cases in 1914. Gruhle remarks that
physiology at the Maudsley Hospital, gave a to report further cases would only have a
more detailed account of the clinical features. purpose if this were done from a new view
He described the psychotic states as closely point. The particular form of association between
resembling schizophrenia, with paranoid ideas epilepsy and schizophrenia which struck him
which might become systematized, ideas of with great force was that in which patients who
influence, auditory hallucinations often of a had been observed for years or decades as
menacing quality; and occasional frank thought undoubted epileptics then developed chronic
disorder with neologisms, condensed words and paranoid psychoses. In his own material there
inconsequential sentences. There were, how was one case in which the psychosis antedated
ever, also some points of difference, of a quanti the epilepsy, and in seven others a schizophrenic
tative rather than qualitative kind: a religious psychosis followed the onset of epilepsy at
colouring of the paranoid ideas was common; intervals of i, 6, 10, i8, 19 and 38 years,
the affect tended to remain warm and appro with one case not known.
priate; and there was no typical deterioration Gruhle, who was one of the pioneers of
to the hebephrenic state. All the patients had phenomenological analysis of the symptomato
epilepsy arising from the temporal lobe region logy of schizophrenia and an observer of
with complex auras; occasional major seizures outstanding sensitivity and acumen, said that
occurred in sleep only. EEG foci, always the form of delusional experience in these
present, were sometimes only to be demon schizophrenic epileptics was not clinically dis
strated in sleep-sphenoidal records. The epilepsy tinguishable from the true schizophrenic delu
began some years before the psychotic symp sion. Delusions were mostly of a simple
toms, usually in the late teens or the twenties; persecutory kind, lacking a paraphrenic fan
and the latter often seemed to begin as the tastic quality; they were mostly expressed in
epileptic attacks were diminishing in frequency, statesof alteredmood, but they could be
either spontaneously or with drug treatment. elicited
by questioningat alltimes.They bore
* With the support of the Mental Health Research no relationto epileptic
personality
change,by
Fund. degree or quality.Finallyhe formulatedhis
95
96 THE SCHIZOPHRENIA-LIKE PSYCHOSES OF EPILEPSY [Jan.
own opinion, that these cases did not constitute there was one case, and one case only, in which
a combination of two diseases, but were all the schizophrenia antedated the epilepsy. In the
symptomatic schizophrenias. “¿Es
liegt also nur remainder, the onset of epilepsy was in the
em Grundleiden vor : eine toxisch endogene age range 6—35,with mean of i 7 years, the
Epilepsie.― schizophrenia appeared between the 22nd and
In reviewing past work, we propose to confine 42nd year, with mean of 3 I years, the mean
ourselves to the more important Contributions duration of epilepsy before onset of schizo
of an observational kind. Reviews of the litera phrenia being 14 years, with extremes of 5
ture, and discussions on such points as whether and 36 years. In these cases schizophrenia had
or not the combination of epilepsy and schizo been diagnosed by clinicians of Bleuler's clinic,
phrenia occurs with more than random ftc some of them by Eugen Bleuler personally.
quency, will be ignored. Papers reporting EEG Again the cases bear a strong resemblance to
abnormalities of an epileptic type occurring in our own, with paranoid syndromes pre
schizophrenics, or noting without adequate dominating. A marked deficiency of the report,
description the occurrence of abnormal mental judged by present-day standards, is the lack of
states in association with an EEG focus, will information bearing on the possibility of a focal
not be reviewed here. origin of the epilepsy. There are, however,
Of the early reports, those by Krapf (i 928) indications of a focal origin in several cases,
and Glaus ( i 93 I ) are the most interesting. in which an aura of vertigo or of an olfactory
Krapf reviewed the cases described in the kind, or the occurrence of automatisms are
literature before that time in a critical or even mentioned. Like Krapf, Glans attempts to
hypercritical spirit. As an example he abstracts evade where he can the necessity of making a
Giese's fourth case, in which a man who had double diagnosis. Thus his first case is one in
epilepsy from the twenties first became psychotic which a man, who had had grand mal attacks
at the age of 53; but while he admits the diag from the age of I 2, at the age of 23 entered on
nosis of schizophrenia he throws doubt on the a chronic paranoid psychosis in which he
epilepsy. He emphasizes the similarity of the believed that he was the creator of the world,
experiences of the epileptic twilight state with had been twice born, and had a ring of electri
those of schizophrenia; here too one may see city around his head; on grounds which are
withdrawal of thought, imposition of thoughts, obscure to us, this is interpreted as an un
thoughts heard aloud, feelings of being hypno complicated epileptic psychosis without even
tized, etc. In other cases, he thinks, schizo schizophrenic colouring. Three other cases
phrenic-like symptoms may be interpreted as are regarded as epileptic only, though showing
reactive delusion-formation on the basis of an some schizophrenic colouring to the picture.
epileptic personality change. He himself reports In the remaining cases, however, the combina
six cases, of which five are very similar to the tion of epilepsy and schizophrenia, either
cases which are the subject of the present paper; simultaneously or successively, is accepted. In
in his fourth case, however, overt epileptic one of these cases there was a schizophrenic
symptoms were first shown only after the onset mother, and in another a schizophrenic father.
of a schizophrenic-like personality change. In The classic paper by Feuchtwanger and
these cases he succeeds in rejecting the double Mayer-Gross on brain injury and schizophrenia
diagnosis by arguments along the lines men (1938) also contains relevant material. This
tioned. Where such an argument is not possible consists of 23 patients who before the onset of
he proposes the alternative of a latent pre their schizophrenic illnesses had all had open
disposition to schizophrenia which is tem head injuries, mainly penetratingshrapnel
porarily mobilized during the psychosis; in two wounds, all but two sustained during the ‘¿914—
of the cases reported, the existence of schizo i8 war. The first nine patients described all
phrenic relatives in the families is noted. developed epilepsy within one to three years
The paper by Glaus is a better documented after the injury. The “¿schizophrenic―
psychosis
one, and 12 cases are described in detail. Again was predominantly paranoid in seven cases,
1963] BY ELIOT SLATER AND A. W. BEARD 97
predominantly catatonic in two. In these cases five of them paranoid and one predominantly
the injuries were either frontal or temporal. hebephrenic, is provided by Rodin et at. (i@@7).
Other papers may be more briefly discussed. In the hebephrenic case onset was at the age
That by Jasper et al. (1939) is principally of i I ; in the remainder it was in the span I 6 to
concerned with EEG abnormalities discovered 42, the epilepsy having antedated the schizo
in 82 patients with typically schizophrenic phrema by many years in every case.
psychoses. One case is described of an in In his monograph on 415 cases of brain
gravescent paranoid state in a woman subject injury Hillbom (i 960) reports II psychoses
to myoclonic epileptic attacks. Rey et al. (1949) diagnosed as schizophreniform. Of these only
in a paper on 82 cases of temporal lobe dis two patients were subject to epilepsy, and in
turbance mention that there was a schizophrenic both of them there had been a penetrating
impression in 14 cases, and one patient had been wound in the right temporal or fronto-temporal
diagnosed as schizophrenic. Ervin et at. (I 955) region. It is interesting that, as in the material
found that 81 per cent. of 42 patients with of Feuchtwanger and Mayer-Gross, there is no
temporal spikes on the EEG were schizophrenic. great difference between the schizophrenia-like
However, transient psychotic episodes, which psychoses of the head injury patients, whether
may well have been epileptic twilight states, these patients had epilepsy or did not. In his
were so diagnosed. Karagulla and Robertson comments Hillbom says that in nine of the
(I 955) have discussed in detail the schizophrenic cases there was a chronic disturbance reminding
like symptoms which may appear in association one of schizophrenic paranoid-hallucinatory
with a temporal lobe attack, with a number of psychoses, while in two the picture was more
striking illustrations; but the chronic paranoid reminiscent of the defect state left behind by
psychosis of epilepsy, with its similarity to such a psychosis. When there were such
paranoid schizophrenia, is not referred to. psychotic symptoms as primary delusions and
This is the subject explicitly dealt with by hallucinations, which might appear even in a
Bartlet (1957). Examining the literature, he quite clear state of consciousness, there was
found no evidence to support the hypothesis always a lesional cause, most likely an irritation
that schizophrenia was more or less likely to caused by the injury in temporal, frontal or
occur in epileptics than in the general popula parietal lobes, most frequently the temporal
tion. He examined the records of all patients lobe.
with a diagnosis of psychosis following epilepsy From this review it may be seen that the
and those with a combined diagnosis of psychosis appearance of psychoses resembling schizo
and epilepsy attending the Bethlem and phrenia during the course of a chronic epilepsy
Maudsley Hospitals, 1949—53,in which epilepsy has been a phenomenon which has repeatedly
antedated the onset of psychosis and the patient attracted psychiatric attention. Those who have
continued to suffer from delusions for a year. observed them have described these illnesses in
He concluded that the eight schizophrenics so much the same terms; and the duration of the
found were not a larger number than could be epilepsy before the onset of the schizophrenia
accounted for by chance, since they constituted like psychosis has tended towards the same mean
0@75 per cent. of the total material. The figure in a number of reports. It has, in fact,
argument is fallacious, since the concepts of long been recognized that we have here an
prevalence and incidence are confused; the important problem for which no generally
o@8per cent. risk of schizophrenia which applies acceptable solution has yet been proposed.
to the general population refers to the whole
life-time, and not to a single delimited year.
More interesting is the short clinical description EPILEPSY AND SCHIZOPHRENIA A5 A CHANCE
which is provided for each of these eight cases; COMBINATION
seven of them had clinical or EEG evidence of It has been argued that, as neither schizo
a temporal lobe lesion. phrenia nor epilepsy are excessively rare, the
A somewhat fuller description of six cases, appearance of both conditions in one individual
5*
 98 THE SCHIZOPHRENIA-LIKE PSYCHOSES OF EPILEPSY [Jan.
should at least be sufficiently frequent to account year 1957 given by the Registrar General's
for the cases which have been reported in the Statistical Review, we may calculate that in
literature. This argument has never been backed the 36,733,000 individuals over the age of i 2,
by any adequate statistical reasoning. In the 22,209,000 risk-lifetimes will have been survived,
attempt to account for our collection of 6g with the expected appearance of 666 ES indivi
epileptics who developed schizophrenic-like duals. Of the 45 million population of England
psychoses, we may consider the matter as and Wales we may suppose that two-ninths, or
follows. approximately I0 million, live in Greater
For a member of the general population the London, or rather in the area served by the
expectation of schizophrenia is approximately Maudsley and National Hospitals. In this area
@ 0 oo8 and the expectation of epilepsy is o 005. accordingly we estimate that 148 ES individuals
The expectation of a combination of both dis will be living ; and that fresh cases will be
orders on the basis of chance coincidence is appearing at the rate of about one-fiftieth of
@ therefore 0 00004. Forty per miffion of the this number per annum, i.e. three per annum.
population can expect over the course of their Ordinary clinical considerations suggest that of
lives, provided they live through the entire risk the standing ES population the great majority
period, to become either schizophrenic epileptics will be living as chronic patients in mental
or epileptic schizophrenics. As epilepsy has an hospitals.
earlier age of onset than schizophrenia, though Alternatively we may look at the matter in
the ranges of age of onset largely overlap, the the following way. The mean age of our pro
former of these two combinations will be bands at the time of onset of psychosis was
commoner. We may make the rough guess 29 years. Twenty-nine years before the time of
thattherewillbe threeepileptics who become our enquiry, in the year 1928, 660,267 persons
schizophrenicfor every schizophrenicwho were born. If we suppose that this was the
becomes epileptic. If this is accepted, the expec number of personsborn yearlyon the average
tation for the development of first epilepsy then from 1900 onwards, and that all individuals
schizophrenia, a process we shall call ES, will destined to become ES survived until their
be O@OOOO3. twenty-ninth birthday, and then became psy
The ages of our probands at the time of onset chotic, there would be 20 fresh ES cases every
of psychosis lay between the limits of i 2 and 59. year in the totalpopulationof England and
We shall assume Wales. Two-ninths of these would be appearing
in the London area, i.e. four to five fresh cases
I. that there is zero probability of becoming
per annum.
ES under theage of 12;
The National Hospitaland the Maudsley
@ 2. that between the ages of 12 and the
Hospital are, of course, hospitals to which
probability of ES havingoccurredincreases
psychotic epileptics might well be preferentially
arithmetically from year to year;
referred. But it is inconceivable, if such an
3. thatafterthe age of 6o thereisno further
exiguous supply of cases was the only source to
riskofES;
be drawn on, that we could so easilyhave
4. that,although thisis very unlikely,ES
ascertained asmany as69 freshcasesintwo only
individuals have thesame expectation of life
of all the neurological and psychiatric clinics,
as other members of the population,this
the observation wards, the psychiatric wards of
assumptionbeing one that maximizes the
general hospitals and the mental hospitals which
number of ES individuals one might find in
serve the London area.
thepopulation.
On the basis of these considerations we con
Other more complex assumptionscould be cluded that patients suffering from epilepsy
made, but would make little difference to the develop schizophrenia-like psychoseswith a
result ofthecalculation thatfollows. frequency much greater than chance expecta
From the estimated age distribution of the tionswould permit.The suggestion which then
totalpopulationofEngland and Wales formid arises, that a schizophrenia-like psychosis may
1963] BY ELIOT SLATER AND A. W. BEARD 99
be the consequence of epilepsy, was greatly the Maudsley Hospital, and saw the patients
fortified in our minds by clinical observations being investigated there, and was able to select
which were made quite early in the enquiry. those who came within our terms of reference.
These were special features, both of the epilepsy In this way it was possible to reach approxi
and of the psychosis, and of the way in which mately the same standard of neurological and
they were combined, which could not be psychiatric investigation in both series of
accounted for, except on the basis of a causal patients.
relationship. Although we were looking for The case material from which the selection
“¿schizophrenics―
with a past history of epilepsy, was made was the intake of the two hospitals
without being too particular about time rela between the years 1948 and iç@ç, and the
tionships, in all our cases the epilepsy was study itself extended from March I 957 to
continuing at the time of the onset of the August 1959. It is certain that not all the patients
“¿schizophrenia―.
Although any type of epilepsy who attended the two hospitals from i 948 to
would have satisfied our criteria, focal epilepsy ‘¿959,and who would have fulfilled our criteria,
was very much commoner in our group than have fallen into our net. The ascertainment, in
petit mal and centrencephalic epilepsy. While fact, was not fully systematic. In brief, all the
any psychosis which, in the absence of epilepsy, patients whom we got to hear of were included
would have been diagnosedas schizophrenicwho fulfilled the criteria :—(i ) that the diag
was admitted to the series, paranoid schizo nosis of epilepsy was supported by EEG or
phrenic pictures greatly preponderated, and unequivocal clinical evidence ; and (2a) that
even considered as such were anomalous for the diagnosis of schizophrenia had been made
relatively good preservation of affective respon by psychiatrists of experience ; or (2b) that, in
siveness. The extent to which these early our opinion, the diagnosis of schizophrenia
impressions were borne out as the series grew to would have been the diagnosis of choice in the
completion, and the other clinical findings of a absence of a history of epilepsy. From this it
specific kind which were later made, will appear will be seen that we took only a narrow selection
from the account which follows. Table A of epileptic psychoses, and excluded all those
summarizes the information in detail as it was in which psychotic symptoms had been confined
obtainedin everycase. to episodes in which confusion or some altera
tion of consciousness could have been regarded
as playing some part. We were interested only
COLLECTION OF DATA in patients whose schizophrenia-like state had
The work of the presentauthors,though it persisted for weeks or months in a setting of
came to be intimately connected with the work apparently complete mental lucidity. When the
proceeding at the Maudsley Hospital, was collection of material was closed, we had
independently inspired; cases of the type accumulated a total of 83 cases, of which 14
described here were being demonstrated as had subsequently to be excluded, either because
epileptic psychoses atleast by 1952.The motiva it was not certain that the patient had at some
tionfortheinvestigation and theway in which time suffered from epilepsy, or because the
itwas conductedhave been described elsewhere mental disorder, out of context with the
(Beard and Slater,1962).At thispoint it is epilepsy, might have failed to pass muster as
sufficient to say that 31 of the casesto be schizophrenic in the judgment of a competent
describedwere ascertainedin the courseof psychiatrist. When the list was closed 47 of our
routineclinical work at the NationalHospital, 6g patients, or more than two-thirds, had been
where both authors were working in the givena diagnosis ofschizophrenia atsome other
psychiatric department.The largernumber of psychiatric centre.
38 caseswere made available at the Maudsley One of the purposes of the survey was, of
Hospital, where Professor (thenDr.)DenisHill course, to see whether a definite clinical syn
and Dr. D. A. Pond gave thisinvestigationdrome could be delineated. First impressions
everyfacility and support.A.W.B. attendedat suggested the formation of four groups :—(i) a
@
@
@ .@ ..@ .@ @C .@ .@
.@

I00 THE SCHIZOPHRENIA-LIKE PSYCHOSES OF EPILEPSY [Jan.

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A
6N 23i@ 5+0+ +A IMN +++ E C 31 +
9 M 00345 m 375'1740++ ++6 2 TL A + AV M + + E C oi + +
i6 M M1473 A2229
2847+++0 2RCeii GenN + i: B
22 M Fitp6 m 0 0 + + A nof.u.
@oN i@om A2335++
1928+ ++o ITL TBA +A + S B ii +
32 M Go@6@ in 3+TLA+ 2 + A B or +
@ 48 M Ho442 m 5 2+ +v I A B @r+
49 M Gog46 m N727++
1044 + 2 4TB TBA + + E F or
51 M E1467 in 2Nnd2944++i 5 + AV E F is
@N 62413m 3+TLA1919 +A + + E C 2i +
6o M 00398 f 1RTLnd1423 + 0 +A ILM + E B ir
B
I M Hog45 in 2RTRN3345++ +0 + A N ++ B Ir+
2 M Hz@io in @TBAII 0+2 + E C is
3N 77808in 3 2 + A LM + B 2r
4N 72f ‘¿Iii
28 4+2 R TL N ± GO LM ++ C Is +
S M Gi666 f A1113+
720++
25+++4+4+ LTR TBA ± A LM + F 23 + +
8 M GiSog f 1TBA21‘+0 0 + + C ii + +
10 M A1662 f + A L C ii
Ii M C@6i4 f nd24 22+ +0 3 TBN
@Can + A M + + F or
12 N 21217 f +0+0 + ASV M + ++ C is
i3N 679o4m 13 21 +0 0 N nd + A IL + C is +
I4N g48m 3949 +0 1+ TL T + + died
i5N @o83f 3946 +0 3+ TL N + AS F is +
17 M B3o95 f 726 +2 1 GenA + A C ii
i8 M Ko82o f 11 20 ++O 3 TR N + AOSV LM + + C is +
39 N iiio in NII4047+
1052 34+++5+0LTR GenN + A L ± Cii
20 M Ko3o3 in +6 o + + + C is
24N 77298f A3638
28 3 + 2 +TL TBA + AO M + ++ C nof.u.
25 M J2261 in @+o+ + A ± E C nol.u.
27 N 54768 in 3939+ +0+1 N A + C Ir+
28 N 43316 m 1743 +1 3 TB A + G 51 + C Ii +
3' N @3O78in nd183113
1631 1+1RTB TBA + 0 + B ii +
33 M H1193 f +4 0 + A M A F Ii
MN 16871m A19 22+ +6+oFR TBA + AV IM + + E F ii
@6 M J1582 f . +0 0 + V ++ + A F ii
37 M Hri@6 f 1014+ +2 4+ TB A + B IE
39 N 11114 1 33+ +2 0 TL nd + B i,
40 M Bong I 1836++ 3 I TR nd + AV A C
41 N @9295 I 12 12+++2 3+ TL N + AV IM ++ B or + +
42 M Jo776 m 1945+ +0 2 FR A + A B ir+ S

43 M B6@i6 f 1421+ 2 0 TL rid + A ++ C Ir+

45 51 B2649 in 1636 ++@ 3 TR A + A + + F oi
46 M G1955 in 15 27+++4+I TB A + A F nof.u.
50 M Hig@@ I 415+++1 0 RC A + ILMN + ++ A B ii
52 N 73526 1 11 59 +4+3 TR A + AV + + S B Ir
53 M J2o46 in 434 ++6+2 TR T + S B is +
55 M JIMS in 333 ++5 0 TB A + A M + ++ F IS
@8M Do152 in 11 39+ 2 1 R TB nd + A + + B 21 +
59 M B2173 in 229+ I 0 RC TB A + A M C 2 5 +
6i M Ho529 I 1030 1+1 TL A + AS ++ F os +
62 M K1376 in 4955+ +1+2 TB A + M ++ B died
64M 01671 1422 +0 3+ TL N + AV LM ++ B or +
65 M A@i6i I ‘¿4 24+++2 I Gen nd + AV L + E F si +
66N 536331 ‘¿515 ++2+4 Gm N + AV ILM + E C ir+
67N 8@i62I 15 25+ 2+2 TL nd + A M + ++ E C 01 +
68N 82627in 31+++5±0
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1019 1 0+R TLN
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C
7 M J2137 I +3+2 AV LMN +++ I B ir+
21 N 63268 in 2 24+ 3+0+ TB A + S C died
s3N 2258m 1721 +3±1+ RC TR N A M + + E B ii + +
26 N 82640 1 1/11 17 +4 1 TR A 1@ A ILM +++ A C oi + +
29 N 62352 1 515 I 0 C A + GO LMN +++ S C ss +
35 N 67756 in 712 + 5+' Sec N A ILM +++ A F 2T +
@8N 22821 728 +3 2+ TL A + A LM +++ I Cis+
@N 13o78m 1533 + 3+1+ TL A + AS +++ I C 25
47N 6@@8gf 13 @8 ++5+O C nd + LM ++ I C si
@6N 13027 in 17 i8 0+0 C N + A IM +++ S F Ir+
57N 22971 424 1+1+ TB A + AV IM +++ S C died
63N 595961 II19 i6 4+1R CA rid + ASV M ++ S B
 1963] BY ELIOT SLATER AND A. W. BEARD 101
group of i I patients whose chronic psychosis PAST PSYCHIATRIC HISTORY;
had been preceded by the repeated recurrence PREvious PERSONALITY
ofshort-lived confusional episodes;(2)a group The family histories of these patients were
of 46 whose psychosis was highly typical of a subjected to a special investigation, which will
paranoid schizophrenia; (3) eight patients with be reported in the third paper of this series by
a picture resembling hebephrenic schizophrenia; Slater @and Glithero ; and the past medical
and (i.) four patients whose epilepsy was of the history, and the history relating to the epilepsy,
petit ma! type. On further investigation, the are reported in the second paper by A. W.
distinctions between these groups became some Beard. The previous personalities of these
patients may be discussed here.
If there were a common aetiological basis for
T@rn.a I the schizophrenia-like psychoses of epilepsy and
for other types of schizophrenia, one would
ClinicalClasszficationand Provenanceof Cases expect to find evidence of it in the prepsychotic
personality, e.g. in “¿schizoid―
traits. This would
Hospital be true whether one supposed that the epilepsy
Group
Maudsley NationalTotal had releaseda latentpredisposition or that
epilepsy and schizophrenia co-existed intheone
A. Chronic psychosis patient as a result of chance. The recorded
with recurrent con accountofthepatient's prepsychotic personality
fusional episodes...
B. Chronic paranoid 8 3 U was therefore examined with thisin mind.
states ... Examination of the pre-morbid personality, i.e.
29 17 46
C. Hebephrenic
states I II 12 thepersonality
beforeonsetofepilepsy,was not
possible
in thelargemajorityof casesin which
Totals 38 31 6g
______________________ epilepsy
had come on beforethepersonalityhad
fully matured.
what blurred, no one group having a monopoly In Table II the relevant observations are
of any single symptom, and the differences entered, and in reading it it must be borne in
between the groups being quantitative rather mind that the majority of case records will
than qualitative. In the following pages, how contain no statement in respect of any single
ever, we have retained a part of this c!assifica named trait. The psychiatrist describes the
tion. The first and second groups are retained personality by noting salient features, and does
as Groups A and B ; but the third and fourth not mention character traits in which the
groups are combined in Group C which, as will patientdifferslittle from the generalityof
later be seen, shows points of difference from mankind.
the others. The clinical classification and the An examinationof thesefiguresshows no
provenanceof our casesare shown in Table I. excess of schizoid traits of personality. Of the

T*st@ A. This shows individualcase data, with the patientsclassified consciousness, (i 8) hallucinations in clear consciousness, A = auditory,
into three Groups, A, B and C. The data are shown in six blocks. G = gustatory, 0 = olfactory, S = somatic, V = visual, (is) cata.
The first block shows (i) the series number, (2) whether the case tonic symptoms, I = impulsive and bizarre acts, L = loss of mobility
was first ascertained at the National or Maudsley Hospital, (@) hospital and volition, M = manneristic behaviour, N —¿
negativism, (so) pre
case numberS (@) sex. sence of schizophrenic thought disorder, (si) affective flattening,
The second block shows (@) age of onset of epilepsy, (6) age of (ss) cases where a diagnosis of schizophrenia had been formally
onset of psychosis, (7) cases in which there was a history suggesting made in another hospital.
brain damage, (8) history of confusional episodes, (9) history of mood
disturbances, (io) the number of signs of organic personality change, The fifthblock shows data about course and outcome, (23) onset
(ii) inspairrnent of memory, (is) the nuinber of different symptoms
of psychosis,A = acute, E = episodic,I = insidious,S = subacute,
(24) course of the schizophrenia-like psychosis, B = in the direction
of teinporal lobe disturbance shown in the history, (i 3) dysphasic
of improvement, C = towards chronicity, F —¿fluctuating, (25) out.
symptoms.
The third block shows neurological findings on examination, come o the epilepsy,o —¿no fitsin the last 12 months before the
(‘4)neurological lateralization right or left, (15) EEG findings, follow-up report, i = fitsrare and constitutingno problem, 2 —¿
fits
@ moderately troublesome, = fits a severe problem, (s6) outcome of
(i6) AEG findings. Under (is) N normal, Gen = @eneraUy
abnormal, C —¿ centrencephalic, Sec secondary subcortscal ab. the schizophrenia.likepsychosis,r = recovered or passed off, i
normality, F = frontal focus, T —¿ temporal locus, B = bilateral, improved, s —¿
persisted unchanged, (s@) presence of disability from
deterioration of personality of organic type. no f.u. no follow up.
R right, L = left.Under (s6) nd = not done, N = normal,
A —¿signsof an atrophic process,T —¿ signssuggestinga tumour. The lastcolumn indicateswith + the ii casesin which a temporal
The fourth block shows the psychiatricfindingson examination lobectomy was carried out and with ‘¿
the case in which a frontal
indicating a schizophrenic psychosis, (17) delusions persisting in clear lobectomy was performed.
 102 THE SCHIZOPHRENIA-LIKE PSYCHOSES OF EPILEPSY [Jan.
TAaut II changes, and not as signifying any pre-existing
Distribution of Personality Trails constitutional deviation.
Affective traits show no deviation from
0@lu::@tr@5 expectation, but there is a high proportion of
SchizoidTraits p patients with obsessional traits. Pedantry, cir
20 cumstantiality, rigidity and other obsessional
i . Outgoing, sociable, good mixer
Shy, withdrawn, unsociable, seclusive 23 phenomena are commonly seen in patients who
have suffered some organic impairment of
2. Affectionate, kind, considerate
Cold, selfish .. .. I@ central nervous function, and as an. epileptic
personality change ; and of the I 9 patients
3. Easy to get on with ... 3 showing such traits 14 had an early epilepsy
Touchy,sensitive, paranoid,
@ suspi- with onset not later than 15.
cious ..
. . We conclude that the premorbid personality
4. “¿Not
schizoid― . . . . . . I was of a normal type, with a normal amount of
“¿Schizoid―
. . . . . . 2 variation ; but that when the onset of epilepsy

Epileptic Traits was early, epileptic personality changes could

5. Placid, good-tempered . . . . S be found in the prepsychotic personality. There

Irritable, bad-tempered . . . . 14 is no evidence of an unusual abundance of

I personality traits of a kind which might indicate

@ 6. Unaggressive..
Aggressive :: :: :: apredisposition
toschizophrenia.
7. (a) Stubborn, obstinate .. 4
(b) Impulsive, improvident.. 5 THE ONSET OF MENTAL ILLNESS
(c) History of delinquency .. 2
(d) Religious interests .. 8 As will be shown in the paper by A.W.B., the
age of onset of psychosis was related to the age
Affective Traits ofonset ofepilepsy and the duration of epilepsy.
8. Cheerful, happy disposition.. . . 25 The mean age of onset of psychosis was at
Moody, liable to depression..
. . @4 29 . 8i years of age, after the epilepsy had lasted
Anxious .. .. ..
@ . . 5 for a mean duration of i 4 I 0 years. There was
9. Hardworking, energetic .. . . ‘¿5 a highly significant correlation coefficient
Lacking energy or initiative..
. . 9 between ages of onset of epilepsy and “¿schizo

Obsessional Traits phrenia― of +0 ‘¿

6, indicating that the duration
I0. Perfectionist, very tidy, obsessional.. ‘¿9 ofthe epilepsy is likely to be one ofthe causative
factors. Exceptionally, the psychotic symptoms
began very soon after the first recognizable
two patients recorded as “¿schizoid―,
one (26) epileptic fits :—in less than one year in four
was a girl who had had epileptic attacks from cases (27, 41, 6o, 66) , and in less than two years
the age of three months, and the other (69) in two cases(ii,56).
was a woman who had had fits from the age In some of these six cases the relationship
of I 0 years. Paranoid traits also are associated between the onset of epilepsy and of psychosis
with early onset of epilepsy, none of the nine is dubious. Thus in Case ii, the patient was
patients recorded having an onset later than first admitted to hospital at the age of 32 with
the age of i8. It is reasonable to suppose that a historyof having had both fitsand ideasof
where these traits were shown they were in part reference
forthepast10 years.In Case 27,the
caused by an epileptic personality change. patient came under observation at the age of 53,
The same is true of the epileptic personality with a history of having had a fracture of the
traits ; irritability, aggressiveness, stubbornness skull in an explosion at Woolwich Arsenal at
were noted in a total of I 3 patients, all of them the age of 38; within a year his eventual
with onset of epilepsy not later than i 7. They epilepsy was showing itself in periodic nocturnal
too can be regarded as the result of personality incontinenceand automatisms,and his psy
1963] BY ELIOT SLATER AND A. W. BEARD 103
chosis in suspicions of his wife's fidelity. In improvement in the psychosis followed on the
Case 4' it is impossible to date the onset of the occurrence of two spontaneous grand ma!
epilepsy with certainty. At the age of i 2 the attacks. In the other (36), after a year of freedom
patient began to have inexplicable attacks of from fits, the patient became depressed, made a
temper which would end in a deep sleep, and suicidal attempt, and on recovery from this
also at times to fall from her pony. In one of depression began to suffer from auditory hal
these falls at the age of i 5 she sustained a sub lucinations. In two other patients (28, 31) the
dural haematoma ; and after this came attacks mental state improved every time a fit occurred;
of unconsciousness without convulsion, and in the second of these the patient would begin
periodic rages and moods of depression. to get olfactory hallucinations if for a time there
In Case 6o, at the age of ‘¿9
the patient had a had been no fits.
single convulsion which passed off into a pro
longed confusional episode with disorientation
and hallucination. She misidentified people, MODE OF ONSET
was emotionally labile, noisy and aggressive. Data relating to mode of onset and course
The psychotic state persisting,shewas eventually of the psychosis are shown inTable III. The most
diagnosed as suffering from schizophrenia, and
given electro-shock and insulin coma treatments. T@rn@xIII
In the remaining cases (56, 66) the epilepsy Onset and Course of Schizophrenia-like illness
and the psychosis can be dated more accurately.
Group Group Group Total
A B C
Onset
RELATION BETWEEN FREQUENCY OF Frrs
Acute 3 6 2 II
AND PSYCHOSIS Episodic.. 52 I 20
7
In all cases epileptic fits persisted up to the Subacute I 3 5 9
Insidious 25 4 29
onset of the psychosis, with the exception of Course
Case 36, mentioned below. In the great majority Towards
it was not possible to relate the onset of the improvement.. 5 ‘¿3 3 21
mental illness to any change in the quality Fluctuating 2 II 2 15
or frequency of the fits. In some cases, however, Towards
chronicity 3 25 7 3!
some such relationship was at least suggested. Not observed I —¿ 2
In two cases (g, 48), there was an increase in
the frequency of the fits shortly before the Totals II 46 12 69
appearance of psychotic symptoms ; but in a
larger number the reverse was true.
Thus in six cases (i@', 19, 30, 38, 43, 44) the usual onset was very insidious ; and as a rule
psychotic symptoms appeared at a time when there was the gradual appearance of delusions
the fitfrequencywas fallingor was being as a first symptom. The following case is
successfully controlled by medication. In four representative.

cases(27,6z,65,68) the fluctuating coursesof

both the epilepsy and the psychosis showed a Case 19
relationship, in that paranoid symptoms were This man had had epilepsy since the age of io. At 38,
more prominent when the fitswere fewer.In when he was having one major attack a month, he began
to complain of depression. He told the psychiatrist he
anotherpatient(,5o) therewas a suggestion of didn't know whether he was coming or going. Someone
an inverserelationship between the psychotic had told him he was being a Billy Muggins. For six months
episodes and the amount of subcortical epileptic he had had the idea he was being followed ; people had
brain activityshown on the EEG. In two followed him round who looked like foreigners. At a tea
bar the man who served him had said “¿thankyou very
patients, bom with a centrencephalic petit ma!, much, your Majesty―; and he was only a plain mister
therehad been no epileptic fitsfora yearbefore as far as he knew. These vague ideas in course of time
the onsetof the psychosis. In one of them (p') became systematized into the delusion that he was a scion
104 THE SCHIZOPHRENIA-LIKE PSYCHOSES OF EPILEPSY [Jan.

ofa noble family, and could expect a vast sum from a will. nocturnal, without convulsion, and followed by
He became auditorily hallucinated, and heard voices in a period of confusion. At the age of 40 he had
his head which said “¿Duke of York―, “¿Duke of Cam
bridge― (the names ofpubs in his neighbourhood), “¿Duke attacks on three successive days. On the two
of Salisbury―and “¿Squire―.
The voices knew everything intervening days he was normal, but on the
he had done, and they must have recordings of his entire third day his behaviour changed. He got up
life. There was a pick-up in his body, “¿a
pin in my body and went to his work as a gardener as usual;
to pick up the nerve vibrations―,which transmitted but there he felt that all his friends were plotting
thoughts from the brain, and also made the brain receive.
against him. After that he began to get suspi
In i8 patients the first psychotic symptoms cious of his wife. He refused to drink his tea,
took the form of apathy, depression, lassitude saying she had poisoned the sugar. On attending
and forgetfulness. In these cases the psychosis at the hospital, he felt that the magazines in the
manifested as the culmination of epileptic per out-patient department had been specially
sonality changes. The following may be cited chosen to test patients. The delusional state
as an example. persisted for more than three years, before it
Case 47 gradually began to fade.
This patient had had screaming attacks as a little girl, An episodic mode of onset was shown by
and grand mal attacks without aura or focal signs since 53. 20 patients, the following being a well-marked
Her attacks practically ceased at the age of 32. From this example.
time on there was a progressive personality change. From
being normally affectionate and active, she became Case 6
unaffectionate, sulkyand aggressive, and lost all her interests. This man was subject to epileptic attacks from the age
When admitted to hospital at the age of 38, she was of i 7. There were short-lived psychotic episodes of i i days
becoming more and more difficult, refusing her food, in 1950, 14 days in 1951 with a second episode lasting
refusing her tablets, refusing to get out of bed or to wash 26 days in the same year, 38 days in 5957, and s6 days
herselL In hospital she showed thought blocking, in in 5958. Most of these started with a confusional state, in
congruities of thought and affect, grimacing and frag which he would be shouting in the street. In 1950 he was
mentary delusional ideas. The state persisted even when described as excited, talking about Christ, deluded,
the possibility of drug intoxication, which had first been manneristic and confused. In i g@I he was regarded as
thought of, had been eliminated ; and she was then found showing epileptic dementia, and was agitated, hilarious,
to be also auditorily hallucinated. excited, uncontrollable, grandiose. In 5957 he was sus
picious and secretive, said he had been in touch with
In four patients auditory hallucinations in a Scotland Yard about a woman across the way, and thought
clear state of consciousness were the first that people wanted to kill him. His speech was vague and
psychotic symptom. Thus one patient (23), incomprehensible; he smiled at times for no apparent
who had been epileptic since i 7, had nervous reason. In his illness in 5958 catatonic signs were shown,
sitting up in bed with arms flexed in a boxing stance,
breakdowns at 2 I and 23, on the latter occasion
sitting up and lying down, posturing ; he was auditorily and
receiving deep insulin treatment. He was first visually hallucinated, his talk jerky, rapid, incoherent.
seen by us at the age of 3 I , and had then been
almost continuously auditorily hallucinated for Acute and subacute modes of onset were
10 years, hearing women's voices that constantly shown by a total of 20 patients. This most
questioned him, leaving him only for a few usually took the form of the more or less rapid
hours at a time. During the past seven years appearances of paranoid ideas over the course
they had become quieter and quieter till they ofdays or weeks, accompanied by corresponding
were now little more than a distant mumble. anomalies of behaviour. However there were
Delusional ideas were restricted to a few ideas examples of other modes of onset, e.g. with
of reference. He was first regarded as a burnt sudden acute excitement or religious ecstatic
out schizophrenic, and only under investigation psychosis (22, 32), with an attempt at suicide
showed the signs which led in the end to a (33, 36), and on recovery from status epilep
temporal lobectomy. ticus (48). An onset taking the form of an acute
In 17 casesthe chronicpsychosisappeared catatonic state was shown in the following case:
as a sequela after a series of epileptic confusional Case @6
episodes. Thus one patient (28) was subject to This girl, who had had fits since infancy, at the age of
epileptic
attackssincethe age of I7, mostly 17 went into a psychotic state which developed rapidly
 1963] BY ELIOT SLATER AND A. W. BEARD 105
in the course of a few days. There were first a tendency to tends to go on. The best chances of improvement
make odd and inappropriate remarks, and bizarre or recovery are found in patients with an acute
behaviour such as sitting the whole of a morning with a
newspaper, apparently reading it but in answer to ques
or subacute onset (observed I 0, expected 5 . 96),
tions being unable to say even what was in the headlines. patients with an episodic onset tended to a
She then kept her eyes closed, her mouth in a fixed smile; fluctuating course (observed 8, expected 4 . 48)
in the night she was found kneeling naked in a position of and those with an insidious onset tended towards
prayer, apparently having been there for some time, as
@ chronicity (observed I 8, expected I 2 96). These
she was very cold. Admitted to hospital she remained
@ negativistic and catatonic. At times she would eat if a differences are statistically significant I 2 I 9,
piece of bread was put into her hand ; at other times the 4d.f.,•¿o2>p>•oI).
food had to be put into her mouth. She had to be taken
to the toilet, but would walk with assistance; if pushed
SYMPTOMATOLOGY
too hard she would become aggressive. Investigations
showed a focus in the right temporal lobe, and in due The schizophrenic symptomatology shown by
course a lobectomy was carried out with removal of a these patients is schematically described in
neoplastic lesion. Table V. The more detailed description which
If we compare the modes of onset of psychosis follows relies not only on anamnestic data but
in the three groups, we note that an episodic also on the findings made during hospital
mode of onset was predominant in Group A, observation.
an insidious onset in Group B, and either a
T@asi V
subacute or an insidious onset in Group C.
Differences between the groups in these respects &hizophrenicSymptomatology,from541-descriptionor
Observed in Hospital
are statistically significant ; but they may well
have been determined in part by the principles Group
on which the cases were classified, and if so CTotalsDelusions AGroupBGroup
would not be very meaningful.
in clear conscious
The different types of course which the illness ness .. ..
II461067sciousnessauditory ..
took are also shown in Table III. The commonest Hallucinations in clear con
development was towards chronicity, or even to
deterioration (46 per cent.) ; but in 3 I per cent. .63!946gustatory
.. .. .
.. .. .. —¿
of cases there was a tendency to improve, even olfactory .. .. .. —¿
4 I 5
to the point of recovery from the psychosis. A somatic .. .. .. —¿
5 2 7
fluctuating course was observed in 22 per cent. visual .. .. .. 3 10 3 i6
of cases. In respect of these characteristics there total patients affected
52haviourimpulsive .. 72 351 103

are no significant differences between the three Catatonic disorders of be

Groups A, B and C. Nevertheless, course and and bizarre acts
mode of onset are themselves correlated, as is loss ofmobility and volition i 52 6 ig
shown in Table IV. As the illness began, so it manneristic behaviour .. 3 25 10 34
negativism. . .. .. I 2 2 5
T@ust.x
IV total patients affected .. 4 26 10 40
Correlation of Mode of Onset with Type ofCourse of Thought disorder, schizo.
the Schizophrenic-like Psychosis phrenictype .. .. 4 i6 Ii 31
Course Loss of affective responsive
B F C ness .. .. . .3 I6 174 5053 28
Mode of towards fluctu- towards Total
onset improve ating chroni I . Delurional symptoms
ment city
Delusion formation was shown by all our
Acute
andsubacute. patients with the exception of two (26, 35),
.104519Episodic. both of them in Group C, i.e. suffering from
.48820Insidious.
hebephrenic-like states. The second of these
.73i828Totals.
suffered from auditory hallucinations, and
.21153167
believed in the objective reality of his cx
periences.
106 THE SCHIZOPHRENIA-LIKE PSYCHOSES OF EPILEPSY [Jan.
The primary delusional experience, which is might be based on a feeling of depersonalization.
supposed to be very characteristic of schizo One patient (@) felt filled with a radioactive
phrenia, can seldom be directly observed, but fluid ; another (ç@)could feel light playing
was reported by a few of our patients. Thus one through his eyes into his skull, which was empty;
man (9) said that after three fits on successive another (i8) said that her womb had been
days he had a sudden abnormal clarity of destroyed ; another (29) that her veins had gone
thought, “¿I
had two thoughts side by side―, back on her, her heart had shifted ; another (32)
and he then realised the untruth of Christianity. that half his head had been eaten away;
Another patient (‘3)on a bus journey suddenly another (47) that she was turning into a
realised the conductor was whistling because he diamond ; another (57) that she was changing
thought the patient was queer. Another (20) into a man.
had a sudden awareness of the power of the Derealization experiences might be the basis
love of God, and realised he had a special of other delusional ideas. One patient (2)
mission. Another patient (@u), during the doubted the paternity of his children ; another
interview, suddenly thought the examiner had (7) thought her father was not her father, her
“¿summedup― against her. Another (@@) mother not her mother, her birthday presents
dropped something to the floor by accident, and were not hers ; another (29) said that her father
instantaneously found that this meant that had lines on his face, her mother was wearing
everything would be all right. It suddenly came a mask, her clothes were not her own ; another
to another (5') that he was God, and his (5) that her clothes were mildewed ; another
fiancéethe Virgin Mary. man (48) said that he was God, and was
Mystical delusional experiences are remark crucified, his mother was not his mother. Other
ably common. Apart from those already patients say that everything that is cooked is
mentioned, the following may be cited. One dirty, the patients are not patients but medical
patient (34) said that “¿God,
or an electrical staff, the doctor is not the doctor but the Devil,
power― was making him do things ; he was people in the street look like foreigners, every
Christ, the Son of God. Another (53) said that body is dressing up as in a pantomime.
he felt God working a miracle on him. Another Passivity feelings are prominent, and are
(54) felt that God and the Devil were fighting closely connected with systematized ideas of
within him, and God was winning. Another (68) persecution. One patient (3) is under the control
claimed, “¿All
life comes from radioactivity in of a machine ; another (12) feels things moved
space. All this goes into one vast electronic under her hand, and feels she is photographed
brain, which gives God the power to give you and spied on all the time ; another (ii) said
life and individuality. I am the Ark of God―. the neighbours influenced the quality of her
Another man (@@)said that because his name voice, she could feel the drawing of the rays,
was John, he was like John the Baptist and was drawing her towards her kitchen ; another (i')
to make known the Second Coming ; the patient felt an external force, possibly the Devil, was
in the next bed was the reincarnation of the taking over her brain ; another (i8) that sexual
Messiah. Two of the women (38, 50) believed feelings were being forced on her ; another (24)
they were pregnant and would be the mother of that people were reading her thoughts and
God. A good description of visionary experience “¿diggingat her privacy― ; another (6i) could
was given by a patient feel people looking at her as she undressed.
(@j@)who said that an
instant came when everything all of a sudden Into these delusions enter a number of bizarre
made sense.“¿The next thingI was aware of features : rays, thought-reading, telegraphic
was the earthrevolvingon itsaxis.I saw the sense, hypnosis, being filmed, being judged,
mass of the earth, under the earth, and sort of electronic wires, magnetic powers.
in thesky.I seethesymbolization of God, and Some of the most characteristically schizo
God says to me ‘¿Thereis no such thing as phrenic ideas which are met with in these
nothing' “¿. patients are the feelings of special significance
Related to these are the delusions which which may attachtocommonplace events. Two
 1963] BY ELIOT SLATER AND A. W. BEARD 107

parked cars are seen, which mean that the the world ; this may have been a seagull.
patient is being watched. The colour green is Another said he saw the roof-tops painted gold
of evil omen, so that green foods must not be under the sun. Another saw colour everywhere,
touched. Other people's actions take on a red on all the shops, put there to send her mad.
special meaning; all the patient's past life is What appear to be visceral hallucinations are
appearing in the office letters. There is a strange not infrequent ; vaginal sensations (two
significance to events ; it all falls into a pattern. patients) ; a feeling inside as if the bladder was
Things have “¿some
kind of connection―. “¿It
is full, the organs being touched, the devil having
all a put up affair.― “¿Something'sgoing on, sexual intercourse with her ; stomach sensa
I don't know what.― People's Christian names tions ; a sensation of the body being shrivelled
have a significance. Things are said which the and constricted ; the tongue being moved ; the
patient has heard before. The cars hoot in code. strength draining out of the head into the
Special powers are claimed by many :—being abdomen. Auditory hallucinations are also
able to heal people by looking at them (48), sometimes associated with particular parts of
having a telegraphic sense (67), being able to the body. One patient heard his stomach and
see through walls (i), being able to split the his intestines speaking to him, and also parts
atom (68), being able to read the thoughts of of his mind, such as his “¿common
sense―.Two
others and foretell the future (25) . One woman other patients heard voices coming from the
(52) said she was magnetic, and could draw the stomach or abdomen, and another said the
beauty out of anything, it was the crystals in voice came from the abdomen and from the
her eyes that gave her the power. This delusion top part of the head, and his left eye would tell
appeared to be derived from the illusion one him what he was reading.
has of rays of light proceeding from a source, Olfactory and gustatory hallucinations were
such as a street-lamp, seen through the window experienced by six patients : tea tasting like hair
or through the eye-lashes. One patient (53) shampoo ; saliva poisoned, gas in the throat;
said he could pick up people's thoughts, he had bread soapy ; scent being thrown on her ; “¿a
a strange power coming down from the Lord, holy smell―.
and it opened to him certain scriptures. Another Visual hallucinations were most commonly
patient (20), who had had an AEG examina experienced in what was probably a dream
tion, said that a fluid had been taken from him like state, although one in which there was no
at operation which would provide a strong confusion and a subsequent clear recollection
power, if brought into contact with a female was retained. These hallucinations were often
fluid of the same amount and standard. extremely complex, and were usually full of
Persecution of an extreme kind is a dominant meaning, often of a mystical type. Nearly
feeling in the minds of many. Not only are they always there was auditory hallucination at the
watched, followed, made fun of, controlled from same time. One patient saw God, heard voices
outside, but they are also poisoned, starved, and music, and received a message that he was
raped, enveloped in poison clouds, they are going to heaven. Another had a vision of Christ
being driven mad, and are on the point of on the Cross in the sky, and heard the voice
beingdone in. of God saying “¿You
will be healed, your tears
have been seen―.No fewer than eight patients
2. Hallucinations
(@,32,34,40,41,48,51,63)had thesecomplex
Only I i of our patients had, as far as is mystical experiences, half of them being in
known, no hallucinatory experiences.at all; and Group A. Visual hallucinations, also of a com
in a further 6 cases, though hallucination was plex kind, were experienced by other patients
probable it was not certain. A few had experi without any mystical affect. One patient saw
ences of an illusional type, or transitional visions of friends and acquaintances, often for
between illusion and hallucination. Thus one as long as fifteen minutes at a time, projected,
patient said she had seen a white dove flying as she thought, in a three-dimensional picture
round the square, which betokened the end of in her room. She would hear the figures
 io8 THE SCHIZOPHRENIA-LIKE PSYCHOSES OF EPILEPSY [Jan.
recounting conversations on sexual topics which action ; another took orders from voices to do
she could not understand, so that they would the most ordinary things, e.g. to pull the chain
laugh at her naivety. Other patients saw a cross after going to the lavatory. Particularly interest
in the sky and birds that flew through her, ing are the hallucinated remarks which also
visions of faces in the sky, a star and an arm show thought disorder : “¿That's human nature;
with lights coming out of the fingers, visions of the old voicing is too much for you―, “¿you
male genitalia with a voice that called her a should live up to the voices never―, “¿truthor
whore who was always “¿wanting it―,horrible horribility―.
frightening things with glaring eyes and
monkeys climbing up the walls of her room, 3. Thought disorder
visions of mice, crocodiles, giant legs walking This symptom was shown by about half the
with a lady in Victorian dress. The simpler patients, and then most commonly in a relative
hallucinations were often experienced in what incapacity to handle abstract concepts, and
appears to have been a state of complete tendencies to be rambling, one-idea'd, long
lucidity, without any dream-like quality. winded, inconsequential, repetitive, mono
The commonest type of hallucination was in tonous, circumstantial. These are qualities
the auditory field. Such hallucination might go which one may find in both the organic and
on continuously and without limit, provoking the schizophrenic patient, and are not con
some emotional reaction but without any sidered further here ; they have not been
observable effect on consciousness. Thus one included in Table V. More characteristically
patient said she heard innumerable voices from schizophrenic are answers beside the point,
everywhere, from the very walls of the house, answers interrupted by thought-blocking,
only passing off when she fell asleep, friendly answers never finished or with disturbed syntax,
Norfolk voices, all female. Much commoner are or containing neologisms : “¿The spirit of God
the persecutory voices. Another female patient is too great in men and therefore I have
heard the neighbours reporting on what she was epilepsy―, “¿Regardingmy permissible entry
doing all day long ; there was much sexual talk, into the Maudsley, I place all confidence thus:
and the voices would say “¿communistpig―, I choose favourably―, “¿The strange thing is
“¿the
old cat―,“¿she
is listening―, and sometimes you can't make up your mind what religion
meaningless phrases. This patient was subject you are going to be ; every religion you think
to multiple hallucination. She felt pricking and of is different, and so is life itself―, “¿I am not
pulling sensations in her eyes due to electricity, going to be transfigured, so that my face can
she felt a vibration in the lower limbs, needles be altered, by giving away my family history―.
and electricity being put into her, and saw the Neologisms used by patients include “¿frauding―,
lights flashing as cameras went off. Other“¿nones―,
“¿insentiment―,
things ‘¿
‘¿antaggered―,
“¿bleed
the voices say are “¿We'll get him―, “¿He's ant―.
natural, I mustn't do that to him―, “¿Isuppose The allusive answer, which seems to be
he will be using his bodily organ in Piccadilly hinting at abnormal experience without explicit
tonight―, “¿Give
him double now―, “¿shedoes, statement, is particularly characteristic of
she doesn't―, “¿come
down to earth―. Both God sch@.zophrenia ; it was shown by a number of
and the Devil are among those who speak, as patients : “¿I am not where you see me, but
also relatives, neighbours, and unknown per somewhere secret― ; “¿It's
the modern world I
sons. Voices that comment on the patient's don't understand, I don't mix with the modern
actions, repeat his own thoughts and otherwise people, it's the modern speech as far as I can
directly interfere are relatively common. Some tell―; “¿I'mdefinite it's a religion and I'm
give orders, which may or not be obeyed. One almost certain it's God because I try to act
patient repeatedly smashed the furniture at natural―. Incoherence to the point where what
home under such commands; another was emergesisa word-saladwas shown by a handful
constantly urged by the voice of her mother to of patients, but on occasion only. Thus one
kill herself or kill her sister, but took no such patient was speaking of being “¿put inside Cam
1963] BY ELIOT SLATER AND A. W. BEARD 109

bridge―. When asked whether he meant 5. Disturbances ofvolition and catatonic

“¿Claybury―(Hospital), he replied : “¿It
is just phenomena
a different university principle. It is just a These are best considered together, since the
different regard in dress, isn't it ? Two gentle distinction between them is in any case rather
men, both been in the same places and they've vague. Impairment of volition, shown in reduc
got different ways about them, isn't it ? High tion of energy, interest and initiative, was shown
temperamental or egg-timing―. at times by i g patients. Activity might sink to a
The subjective experience of thought disorder very low level, or take on a bizarre quality. One
was reported by several patients. One said: patient (26) would sit the whole morning with
“¿It's
very difficult ; you see, everything has a a newspaper open in front of her ; she would
double meaning―, another “¿my mind keeps only walk if assisted, and only eat if the food
dotting about all over the place―, another com were put into her hand. This inactivity would
plained that his thoughts stuck and he was be at times interrupted by a sudden wild dash,
unable to get rid of them, and several more or a peal oflaughter. Another patient (7) began
that their thoughts could be read and thoughts to slow up in all movements, took to walking
were put into the mind or their thoughts inter only on the pattern ofthe carpet, and eventually
rupted. Some of these patients thought the retired to bed, where she lay answering ques
external thoughts were coming from God. tions only with a puzzled look or an incongruous
smile. This patient also showed characteristic
4. Emotional disturbance schizophrenic ambivalence : when the doctor on
Affective disturbance ofsome kind was shown the round left her side, she called him back,
by all patients, if only in the form of periodic but when he turned to her again was unable
moods of depression or irritability. Moods of to say anything. Of other patients, one would
irritability and aggressiveness were in fact shown sit looking at her wrists for hours, another would
by 34 of the patients, and moods of depression hold his hand in front of his mouth when
by 33. The most typical form of the depressive speaking, or whistle instead of answering,
mood was short-lived but frequently severe; another kept her hand pressed to her abdomen,
I 7 of these patients made one or more attempts another was constantly looking round at the
at suicide. The converse mood of exaltation or door. Withdrawal from family life, going out
ecstasy was experienced at times by I 2 patients, to sit on the stairs, retiring to the bedroom to
most typically as a semi-mystical experience, sit with drawn curtains, sitting for hours listen
such as has already been referred to. The ing or staring into space were other typical
paranoid mood, in which there is a feeling of manifestations.
something mysterious going on, without specific Some degree of manneristic behaviour was
delusional idea, has also been discussed. Single shown by 34 patients :—smihng, frowning, a
patients also described sudden unmotivated foolish giggle, talking to oneself, screwing up of
feelings of intense fear and of a devastating the eyes, banging of the head, clapping hands
loneliness and bewilderment. and slapping the floor with the feet, a statuesque
The schizophrenic defect symptom of flatness posture, or mincing or stilted gait, holding the
of affect was exhibited to some degree, at least fingers twisted, etc. Sudden impulsive acts,
at times, by 28 of the patients. The more aggressive or bizarre, motivated in some cases
communicative patients described loss of interest, by hallucinations, e.g. a dash into the garden
incapacity to find any enjoyment, the lack of to fetch in a brick, suddenly putting the hand
warmth in their feelings for relatives. More through a pane of glass, were shown by i3
commonly there was no such complaint, but the patients. One patient spent the better part of
patient showed flat, silly or inappropriate 24 hours in stereotyped repetitive exercises, as
emotional responses, would smile without reason he believed under the influence of an external
in a fatuous or in a secretive or superior way, control. Resistiveness and negativism of a
or, especially in cases of Group C, show an schizophrenic kind were shown by five patients.
unrelieved hebetude. Some of the patients were able to describe
110 THE SCHIZOPHRENIA-LIKE PSYCHOSES OF EPILEPSY [Jan.
the subjective experience of disturbance of the schizoid predisposition, the past personalities
ego : “¿I
keep finding myself with various per of these patients were examined. It was con
sonalities―, the body feeling as if it were moved cluded that the premorbid personality was of
around under external control, feeling drugged, normal type, but that when the onset of epilepsy
the mind revolving under the control of a was early, epileptic personality changes could
machine, being told what to do. be found in the prepsychotic personality. There
was no evidence of schizoid traits in excess.
6. Clinical summa,y 3. The mean age of onset of the psychosis
In summary one may say that there is not was 29 . 8 years, after the epilepsy had lasted for
one of the cardinal symptoms of schizophrenia a mean duration of I4 I years. There was a
which has not been at some time exhibited by significant correlation coefficient between the
these patients. However, the combination of ages of onset of epilepsy and ofschizophrenia of
symptoms shown by individuals differs slightly +0 . 6, indicating that the duration of the
from the most usual schizophrenic patterns. epilepsy was likely to be one of the causative
Although they are seen, catatonic phenomena factors. There was no close relationship between
of any gross degree are unusual, and loss of the frequency of fits and the onset of psychosis;
affective response does not occur so early or but in some instances there was a suggestion of
become so marked in the great majority of these an inverse relationship, e.g. psychotic symptoms
patients as in the typical schizophrenic. By and first appearing when the fit frequency was
large they are friendlier and more co-operative, falling.
and less suspicious of hospital staff, so that only 4. The modes of onset of the psychosis could
very rarely do they cause a serious nursing be classified into acute, episodic, subacute and
problem. In a ward with mentally normal insidious. The last of these was the commonest
patients they are usually able to keep their (29 patients), with onset of an episodic kind
symptoms to themselves and to spare the feelings the next most frequent (20 patients) . The course
of other patients. of the psychosis was similarly classified into
one with tendency to improve, a fluctuating
SUMMARY AND CONCLUSIONS
course, and a course tending to chronicity. Of
The appearance of chronic psychotic states, these the last was the most frequent (@I patients).
clinically closely resembling schizophrenia, in 5. A phenomenological analysis of the schizo
epileptic patients has been recorded from time phrenic symptoms shown by our patients
to time by many authors. The more significant showed delusion-formation of a typically schizo
of these papers are here reviewed. Most recently phrenic kind in all but two of the patients.
Pond has associated chronic paranoid psychoses Typically schizophrenic hallucinatory experi
resembling schizophrenia with temporal lobe ences in clear consciousness occurred in 52
epilepsy. patients, auditory hallucinations predominating.
Patients of this type have been collected, as Affective disturbances of a great variety of kinds
systematically •¿
as circumstances permitted, at were experienced by these patients, depressions
the National Hospital, Queen Square, and at and ecstasies being not infrequent. The most
the Maudsley Hospital ; 69 such patients were typically schizophrenic affective symptom of
found, and have been investigated. flatness of emotional response was observed, at
i. The question is examined whether the least to some degree, in 28 patients. Disturb
purely coincidental combination of epilepsy and ances ofvolition and catatonic phenomena were
schizophrenia, each of them relatively common shown by 40 patients. The commonest form of
disorders, would be sufficiently frequent to make thought disorder shown was ofa type compatible
such a collection possible. It is concluded that with organic states, e.g. deficiency of conceptual
this is not so, and that in the bulk of cases the thinking, circumstantiality, etc. Thought dis
combination cannot be randomly determined. order of a specifically schizophrenic kind was
2. As the appearance of a schizophrenic-like shown to some degree by 3! patients. It is con
psychosis in an epileptic might be aided by a cluded that there is not one of the cardinal
1963] BY ELIOT SLATER AND A. W. BEARD III

symptoms of schizophrenia which has not been tive, would sit picking her nails ; answered beside the
point : (What are you doing ?) “¿I wanted to know her
exhibited at some time by these patients. It
address.― (Whose ?) “¿Teresa.―
(Who is Teresa ?) “¿I
don't
would not be possible to diagnose these patients, know.―
on psychological symptomatology alone, as
suffering from anything other than a schizo Case 36
phrenic psychosis; the recognition of the At the age of 25 after influenza became dreamy,
psychosis as essentially epileptic in origin solitary, visually hallucinated, would sit laughing to her
self and believed she could be heard on the wireless;
requires consideration of all the available
made an attempt at suicide. In hospital she was hallu
information. cinated and hostile, with inappropriate affect, ideas of
reference and influence, inappropriate giggling. Intimated
APPENDIX that what she thinks is repeated on the street ; people can
read her thoughts and she can read theirs. Everyone was
The Centrencephalic Epileptics talking about her : “¿When
I look at them I hear one thing,
when I look away I hear another. It's done to annoy me.―
A few words should be said about the patients Voices came from her abdomen, accusing her of immoral
with centrencephalic epilepsy. There were seven behaviour.
of them (Cases 7, 29, 36, 47, 50, 56, 63), and
five of them are in Group C, two in Group B Case 47
and none in Group A. They suffered in fact Onset of psychosis at 38 ; bit by bit she had become a
predominantly from a hebephrenic type of serious problem to her parents, lying in bed unless pushed
to get up. In hospital a facile laugh and smile, some bizarre
psychosis. The family history is negative in all postures ; at times thought blocking, gaps and pauses in
but one ; in Case 50, the mother was in a mental conversation. Auditory hallucinations eventually elicited,
hospital for twelve months with a puerperal “¿I
have an idea that doctors are about at night saying
confusional psychosis. The personal history is things . . .“No spontaneous speech ; would sit with her
negative in all cases but two ; in Case 50 there head in her hand looking vaguely about, rarely at the
questioner, smiling vacantly. Said she thought she was
was a forceps delivery, and in Case 63 there turning into a diamond, and would be presented to her
was premature birth. In these cases onset of mother in this form ; the world would come to an end;
epilepsy tended to be early, ranging from four the new world would be like a diamond.
to I 7, with a mean of I I . The onset of psychosis
was also relatively early, ranging from i 5 to 38 Case 50
with a mean of 2 I . Brief synopses may be given: Liable to confusional episodes, and onset of psychosis
at 15. In hospital, disturbed, noisy, destructive, abusive,
Case 7 negativistic, giggled foolishly, wrote rubbish on pieces of
At 19 she developed the belief that her boy friend had paper. Felt her father was saying things she had heard
had sex relations with her. She saw a cross in the sky and before ; her tablets had been substituted ; she might be
birds which flew through her. She began to slow up, didn't pregnant ; the nurses were there to look at her.
seem able to grasp things, began to walk only on the
pattern of the carpet. She became superstitious about Case56
green, wouldn't even eat peas ; she said her food was Developed depressive symptoms at i 7 ; had idea that
poisoned, scrutinized it minutely, said it was dirty. She
people's eyes were made ofglass ; in hospital for six months,
told her father he wasn't her father. There was little then came home and sat around brooding, doing nothing.
affective display. In hospital she was negativistic, affec In hospital, auditorily hallucinated, very manneristic,
tively flat, with silly emotional responses ; when the thought blocking, talking to sell When asked a question,
doctor left her on a round she would call him back, then would sometimes whistle instead of answering it ; would
not say anything. Admitted hearing voices, could give hold his hand in front of his mouth when speaking.
no further information, “¿It'svery difficult ; you see, Paranoid ideas vague, other patients against him, worried
everything has a double meaning.― about the whole human race, especially the Jews.
Case 29
At i@ she began to get the idea her mother was putting Case 63
tablets into her tea; the bread was soapy; people were Admitted to hospital at i6, having behaved strangely
throwing funny scent over her in the bus. She would sit for three months ; would avoid going into the sitting room
and look at her wrists for long periods; said her veins had with no reason given ; would refuse to do things she was
gone back on her, her heart had shifted. She told her bidden, saying she was ordered not to, there was someone
father he had lines on his face, her mother that she had a standing beside her. and would glance over her shoulder
mask on her face. In hospital withdrawn, uncommunica when she explained to her mother. Said the devil had been
 I 12 THE SCHIZOPHRENIA-LIKE PSYCHOSES OF EPILEPSY

commanding her to do evil things. Whenever she prayed, GRUHLE, H. W. (1936). “¿Ueber den Wahn bei Epilepsie―,
she saw two persons, one like the Virgin Mary and another Zeitschr. ges. Xeur. Psychiat., 154, 395.
@ a man. Would go out of the room when her father came HILL, D. “¿Psychiatric
disorders of epilepsy―, Med.
in. In hospital, unresponsive, sat with hand pressed to Press, 20, 473.
abdomen. Said she had a feeling inside as if the bladder HILLBOM, E. (i@6o). “¿After-effects of brain injuries―,
was full; she felt that her organs were being touched; as Acta psychiat. neurol. Scand., suppi. 142.
if the devil was having intercourse with her. Affect flat, J ASPER,H. H., FITZPATRICK,
C. P., and SOLOMON,
P.
no spontaneity, sudden silences and facial twitchings, (i@@g). “¿Analogiesand opposites in schizophrenia
paucity of ideas and vagueness. and epilepsy―, Am. 3. Psychiat., 95, 834.
KARAGULLA, S., and ROBERTSON, E. E. (1955). “¿Psychical
phenomena in temporal lobe epilepsy and the
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