Temporal+Lobe+Epilepsy

=Possible Causes = -Incisural hernation at the time of birth is a major cause of amygdala injury and hippocampal sclerosis -Head injuries also cause injuries to the temporal region due to contusion from the bony structures in which it is encased. -Middle ear infections are associated with disturbances involving the temporal lobe -Severe and repeated early emotional trauma can injure the immature hippocampus and temporal lobe, giving rise to a propensity to develop kindling as well as abnormal neural networks making these individuals are more likely to develop psychotic and severe emotional and dissociative disorders.

**Role of the Amygdala and Hippocampus **
Temporal lobe epilepsy is often associated with atrophy and sclerosis of the hippocampus in about 50% of such patients, with yet others demonstrating sclerosis in the amygdala. "studies on temporal lobe epilepsy provide evidence that the amygdala is involved inmany of the common symptoms and signs that occur in the course of temporal lobe seizures." "hippocampal sclerosis is most likely a consequence of prolonged seizures or status epilepticus, particularly when occurring in early childhood and can therefore be regarded as a lesion induced by seizures rather than a causative agent." it is suggested that the seizure is either produced by the amygdala, which then envelops the hippocampus, and/or that both must give rise to the seizure simultaneously. Removal of the amygdala and the hippocampus showed a favorable outcome, whereas an equal number showed a favorable outcome if just the amygdala was removed and the hippocampus was spared.

=**Objective Symptoms** = -Usually no abrupt and drastic alterations in motor activity such as tonic-clonic spasms -Some may simply cease to respond and stare blankly straight ahead -Make licking or smacking movements of the lips -Fiddle with their clothing, as if picking up pieces of lint -May appear awake and conscious, although unable to speak or respond to questions, and behaviorally their actions seem semi-purposeful

<span style="color: #000000; font-family: 'Times New Roman',serif;">Although conscious-awareness is lost, these patients are not unconscious. Rather, their mental state is one of absence. Sometimes it is extremely obvious that they are experiencing a seizure, whereas in some cases an inexperienced observor may only have the impression that the person is acting somewhat odd. <span style="color: #000000; font-family: 'Times New Roman',serif;">Nevertheless, unless the patient has several different seizure foci, the same characteristic behavioral manifestations are elicited every time a patient has a seizure. The patient does not simply stare on one occasion and on the next begin rolling his eyes and cry out.

=Subjective Symptoms=

**<span style="color: #000000; font-family: 'Times New Roman',serif;">Auras & Automatisms **
<span style="color: #000000; font-family: 'Times New Roman',serif;">Some individuals note an aura immediately prior to seizure onset. This may involve <span style="color: #000000; font-family: 'Times New Roman',serif;">-Feelings of fear or anxiety ( <span style="font-family: 'Times New Roman',serif;">panic, terror, or of someting horrible about to happen)

<span style="color: #000000; font-family: 'Times New Roman',serif;">-Alterations in gastric motility <span style="color: #000000; font-family: 'Times New Roman',serif;">-Unpleasant tastes or in particular, odors (e.g. burning rubber or feces), i.e. an olfactory aura <span style="color: #000000; font-family: 'Times New Roman',serif;">-Some may lick and repeatedly smack their lips.

<span style="color: #000000; font-family: 'Times New Roman',serif;">Presumably, the experience of olfactory hallucinations is due to abnormal activation of the rhinencephalon (the "nose brain") and thus limbic nuclei such as the amygdala. <span style="color: #000000; font-family: 'Times New Roman',serif;">Licking and smacking movements presumably are also due to activation of the amygdala and other limbic structures associated with food consumption. Changes in gastrict motility may be secondary to insular activation and/or limbic participation.

<span style="color: #000000; font-family: 'Times New Roman',serif;">Automatisms associated with TLE occur in up to 75-95% of patients which is twice what occurs with lesions outside the temporal lobe <span style="color: #000000; font-family: 'Times New Roman',serif;">-Feelings of a racing or flutering heart (pounding or throbbing) <span style="color: #000000; font-family: 'Times New Roman',serif;">-Feelings of smothering or chocking. <span style="color: #000000; font-family: 'Times New Roman',serif;">-Numbness <span style="color: #000000; font-family: 'Times New Roman',serif;">-Tenseness <span style="color: #000000; font-family: 'Times New Roman',serif;">-Pressure <span style="color: #000000; font-family: 'Times New Roman',serif;">-Heaviness. -V<span style="font-family: 'Times New Roman',serif;">isual sensations such as macro or micro or of things be very hear or far. -<span style="font-family: 'Times New Roman',serif;">Feelings of strangeness or familiarity are also common <span style="font-family: 'Times New Roman',serif;">-Deja vue occurs in up to 20% of such patients, usually with right cerebral seizures within the temporal lobe. <span style="font-family: 'Times New Roman',serif;">-Some claim to have feelings like a desire to ge alone, or of wanting something but not knowing what.
 * staring || searching || groping || lip smacking ||
 * spitting || salivation || laughing || crying ||
 * hissing || gritting/gnashing teeth || clenching fist || confused talking ||
 * screaming || shouting || standing || running ||
 * walking || kissing || etc. ||  ||
 * <span style="color: #000000; font-family: 'Times New Roman',serif;">Common visceral reactions **
 * <span style="color: #000000; font-family: 'Times New Roman',serif;">Body sensation include **

<span style="color: #000000; font-family: 'Times New Roman',serif;">Olfactory hallucinations are not uncommon and are usually quite disagreeable and include smells <span style="font-family: 'Times New Roman',serif;">like burning meat, fish, lime, acid fumes, burning feces. <span style="font-family: 'Times New Roman',serif;">There may also be gustatory sensations which are also usually disagreeable coupled with very bad and bitter or metalic and sour tastes.

<span style="color: #000000; font-family: 'Times New Roman',serif;">-Fear <span style="color: #000000; font-family: 'Times New Roman',serif;">-Remembrance of a fearful or traumatic memories <span style="color: #000000; font-family: 'Times New Roman',serif;">-Rising epigastric sensations <span style="color: #000000; font-family: 'Times New Roman',serif;">-Chest sensations <span style="color: #000000; font-family: 'Times New Roman',serif;">-Nausea <span style="color: #000000; font-family: 'Times New Roman',serif;">-Heart palpitations <span style="color: #000000; font-family: 'Times New Roman',serif;">-Feelings of cold or warmth <span style="color: #000000; font-family: 'Times New Roman',serif;">-Shivering <span style="color: #000000; font-family: 'Times New Roman',serif;">-Pallor or flushing of the face <span style="color: #000000; font-family: 'Times New Roman',serif;">-Respiratory changes inlcuding apnea <span style="color: #000000; font-family: 'Times New Roman',serif;">-Salivation <span style="color: #000000; font-family: 'Times New Roman',serif;">-Belching <span style="color: #000000; font-family: 'Times New Roman',serif;">-Farting <span style="color: #000000; font-family: 'Times New Roman',serif;">-Sweating <span style="color: #000000; font-family: 'Times New Roman',serif;">-Vaginal secretions in women which may be accompanied by sexual feelings or behaviors <span style="color: #000000; font-family: 'Times New Roman',serif;">Many of these same exact feelings & behaviors can be triggered by direct stimulation of the amygdala, including deja vu--the feeling of familiarity/reminiscence.
 * <span style="color: #000000; font-family: 'Times New Roman',serif;">Symptoms reflecting the possible activation of those structures innervated by the amygdala **

<span style="color: #000000; font-family: 'Times New Roman',serif;">Individuals may act out on these emotions and auras. There have been reported instances sudden lashing out and even attempting to attack those close by, while in the midst of a seizure, and/or attacking, kicking, and destroying furniture and other objects. <span style="color: #000000; font-family: 'Times New Roman',serif;">Patient's have also behaved violently with direct stimulation of the amygdala, as have a variety of animal subjects. <span style="color: #000000; font-family: 'Times New Roman',serif;">Others have responded with behaviors indicative of extreme fear, or conversely, extreme pleasure, including laughter and mirth. Moreover, some patients have acted out sexually during a seizure, such as by displaying their penis, or lying on the floor with legs spread and thrusting, even moaning with pleasure and experiencing libidinous feelings in the vagina and thighs, coupled with an orgasm. <span style="font-family: 'Times New Roman',serif;">to develop psychotic and severe emotional and dissociative disorders.

=<span style="color: #000000; font-family: 'Times New Roman',serif;">SEXUAL SEIZURES = <span style="color: #000000; font-family: 'Times New Roman',serif;">The amygdala in conjunction with the overlying temporal lobe, is capable of detecting sexually significant stimuli, and can determine and detect gender differences such as male and female faces and the emotions they convey. Activation of the amygdala can produce <span style="color: #000000; font-family: 'Times New Roman',serif;">-Penile erection <span style="color: #000000; font-family: 'Times New Roman',serif;">-Sexual feelings <span style="color: #000000; font-family: 'Times New Roman',serif;">-Sensations of extreme pleasure <span style="color: #000000; font-family: 'Times New Roman',serif;">-Memories of sexual intercourse <span style="color: #000000; font-family: 'Times New Roman',serif;">-Ovulation <span style="color: #000000; font-family: 'Times New Roman',serif;">-Uterine contractions <span style="color: #000000; font-family: 'Times New Roman',serif;">-Lactogenetic responses <span style="color: #000000; font-family: 'Times New Roman',serif;">-Orgasm

<span style="font-family: 'Times New Roman',serif;">-Continuous masturbation <span style="font-family: 'Times New Roman',serif;">-Indiscriminate, often hypersexual hetero- and homosexual behaviors including attempts at sex with inanimate objects <span style="font-family: 'Times New Roman',serif; line-height: 1.5;">-May expose and manipulate their genitals <span style="font-family: 'Times New Roman',serif; line-height: 1.5;">-Masturbate in public <span style="font-family: 'Times New Roman',serif; line-height: 1.5;">-Attempt to have sex with family members or individuals of the same sex
 * <span style="color: #000000; font-family: 'Times New Roman',serif;">Injuries/Seizure <span style="font-family: 'Times New Roman',serif;">within the amygdala/temporal lobe can elicit sexual changes **

<span style="font-family: 'Times New Roman',serif; line-height: 1.5;">Moreover, abnormal activity involving the amygdala and overlying temporal lobe has been associated with the the development of <span style="font-family: 'Times New Roman',serif; line-height: 1.5;">-Hyposexuality <span style="font-family: 'Times New Roman',serif; line-height: 1.5;">-Hypersexuality <span style="font-family: 'Times New Roman',serif; line-height: 1.5;">-Homosexuality <span style="font-family: 'Times New Roman',serif; line-height: 1.5;">-Transvestism <span style="font-family: 'Times New Roman',serif; line-height: 1.5;">-Confusion over sexual orientation <span style="font-family: 'Times New Roman',serif; line-height: 1.5;">-May even engage in "sexual intercourse" even in the absence of a partner.

=<span style="color: #000000; font-family: 'Times New Roman',serif;">RUNNING, LAUGHING & CRYING SEIZURES = <span style="color: #000000; font-family: 'Times New Roman',serif;">A number of authors have presented case reports of individuals who developed laughing (gelastic epilepsy), crying (dacrystic epilepsy), and/or running seizures (cursive epilepsy) -running apparently being triggered via amygdala-striatal activation.

<span style="color: #000000; font-family: 'Times New Roman',serif;">**Examples:** 1) suddenly bursting into laughter, rubbing his upper abdomen and running wildly about the room with an expression of fear on their face. <span style="color: #000000; font-family: 'Times New Roman',serif;">2) paroxysmal attacks of weeping, sobbing, and mournful moaning. <span style="color: #000000; font-family: 'Times New Roman',serif;">These behaviors were involuntary, however, and part of the seizure. Once consciousness returned, the patients would have no recollection of their actions.

=<span style="color: #000000; font-family: 'Times New Roman',serif;">EMOTION = <span style="color: #000000; font-family: 'Times New Roman',serif;">The most common emotional reactions/sensations which occur secondary to or during the course of a temporal lobe seizure include: <span style="color: #000000; font-family: 'Times New Roman',serif;">-Fear <span style="color: #000000; font-family: 'Times New Roman',serif;">-Anxiety <span style="color: #000000; font-family: 'Times New Roman',serif;">-Depression <span style="color: #000000; font-family: 'Times New Roman',serif;">-Depersonalization <span style="color: #000000; font-family: 'Times New Roman',serif;">-Pleasure <span style="color: #000000; font-family: 'Times New Roman',serif;">-Unpleasure <span style="color: #000000; font-family: 'Times New Roman',serif;">-Familiarity

<span style="color: #000000; font-family: 'Times New Roman',serif;">fear being the most frequently experienced. Many of these same feelings are also triggered by electrical stimulation of the temporal lobes, amygdala and hippocampus. <span style="font-family: 'Times New Roman',serif;">Some experience fear coupled with sexual sensations, including fear associated with a feeling of sexual climax, or feelings of being sexually penetrated following by orgasm then a loss of consciousness.

<span style="font-family: 'Times New Roman',serif; line-height: 1.5;">-Depression (lasting from hours to weeks) <span style="color: #000000; font-family: 'Times New Roman',serif;">-Confusion.
 * Sequela**

<span style="color: #000000; font-family: 'Times New Roman',serif;">A depressive aura may also precede and thus hearld the coming of a seizure by hours or even days. This may be due in part to the role of the temporal lobe (and amygdala) is storing emotional and personal memories, including those with are negative, depressing and traumatic such that when activated, depressive moods and memories may be provoked. Depressed patients demonstrated more right vs left temporal lobe electrophysiological activity and EEG abnormalities. Moreover, others have argued that ECT administered to the right vs left temporal lobe is more likely to alleviate depressive symptoms.

<span style="color: #000000; font-family: 'Times New Roman',serif;">Rather than increased emotionality, some patients complain of emotional blocking, and feelings of emptiness: "feelings don't reach me anymore". <span style="color: #000000; font-family: 'Times New Roman',serif;"> Presumably this is a consequence of limbic disconnection in which the siezure foci (or lesion) acts to deconnect the limbic areas from the temporal (or orbital frontal) lobes.

=<span style="color: #000000; font-family: 'Times New Roman',serif;">TEMPORAL LOBE EPILEPSY & RELIGIOUS EXPERIENCE = <span style="color: #000000; font-family: 'Times New Roman',serif;">sometimes people may experience very sexual as well as bizarre, unusual and fearful mental phenomenon including dissociative states, feelings of depersonalization, and hallucinogenic and dream-like recollections involving threatening men, naked women, sexual intercourse, religion, the experience of god, as well as demons and ghosts and pigs walking upright dressed as people. Some individuals report communing with spirits or receiving profound knowledge from the Hereafter, following temporal lobe activation.

<span style="color: #000000; font-family: 'Times New Roman',serif;">Intense activation of the temporal lobe, hippocampus, and amygdala has been repeatedly reported to give rise to a host of sexual, religious and spiritual experiences; and chronic hyperstimulation can induce an individual to become hyper-religious or visualize and experience ghosts, demons, angels, and even God, as well as claim demonic and angelic possession or the sensation of having left their body.

=<span style="color: #000000; font-family: 'Times New Roman',serif;">OUT OF BODY, HEAVENLY & "OTHERWORLDLY EXPERIENCES" = <span style="font-family: 'Times New Roman',serif; font-size: 13px; line-height: 1.5;">Between .5 and 20% of such patients claim such feelings <span style="font-family: 'Times New Roman',serif; line-height: 1.5;">-P <span style="font-family: 'Times New Roman',serif;">leasant auras and describe feelings such as <span style="font-family: 'Times New Roman',serif;">-Elation <span style="font-family: 'Times New Roman',serif;">-Security <span style="font-family: 'Times New Roman',serif;">-Eternal harmony <span style="font-family: 'Times New Roman',serif;">-Immense joy <span style="font-family: 'Times New Roman',serif;">-Paradisiacal happiness <span style="font-family: 'Times New Roman',serif;">-Euphoria <span style="font-family: 'Times New Roman',serif;">-"Completeness"

-"<span style="font-family: 'Times New Roman',serif;">As though I were two persons, one watching, and the other having this happen to me," <span style="font-family: 'Times New Roman',serif;">- "It was as though the person were attending a play and was both actor and audience." <span style="font-family: 'Times New Roman',serif;">-"Sudden feeling of extreme well being involving all my senses. I see a curtain of beautiful colors before my eyes and experience a pleasant but indescribable taste in my mouth. Objects feeling pleasurably warm. the room assumes vast proportions, and I feel as if in another world." <span style="color: #000000; font-family: 'Times New Roman',serif;">- "Like a sunny day when your friends are all around you." <span style="font-family: 'Times New Roman',serif;">-A feeling that she was being lifted up out of her body, coupled with a very pleasant sensation of elation and the sensation that she was "just about to find out knowledge no one else shares, something to do with the line between life and death." <span style="font-family: 'Times New Roman',serif; line-height: 1.5;">-Feelings and things suddenly become "crystal clear" or that they have a feeling of clairvoyance, or of having the truth revealed to them, or of having achieved a sense of greater awareness and of a new awareness such that sounds, smells and visual objects seemed to have a greater meaning and sensibility.
 * <span style="font-family: 'Times New Roman',serif;">Descriptions **

PERSONALITY & PSYCHIATRIC DISTURBANCES
Personality and psychiatric disorders have been frequently reported as a common associated complication among a small percentage of individuals (between 4.5 to 7%) with seizures-disorders localized to the temporal lobe.

It is argued that, like hallucinations, the nearer the seizure foci to the anterior temporal lobe, the greater the probability of significant psychiatric abnormality. Presumably this is a function of hyper-activation of underlying limbic structures and thus abnormal attribution of emotional significance to different afferent streams of perceptual experience.

They may appear -Depressed -Paranoid -Hysterical -Suffering from schizophrenic-like symptomology

SCHIZOPHRENIA & THE TEMPORAL LOBE
A significant minority (~3-7%) of individuals with temporal lobe epilepsy suffer from prolonged and/or repeated instances of major psychopathology Conversely, those with affective disturbances, e.g. mania, have been found to suffer from seizures involving the right temporal lobe or right frontal lobe, although depression may be more likely with left vs right hemisphere injuries.

Right hemisphere is dominant for most aspects of emotional functioning. When damaged or abnormally activated, such as from a seizure or chronic subclinical seizure activity, emotional functioning becomes altered and disturbed. Moreover, since the amygdala and hippocampus are often secondarily aroused (or hyperaroused), the possibility of abnormal emotionality is enhanced even further.
 * Explanations**

Some individuals with temporal lobe seizures may complain of emotional blunting resulting from limbic disconnection.

It has also been repeatedly demonstrated that the temporal lobe of schizophrenics are characterized by an excessive focal temporal lobe neuronal damage including gliosis. Hence, may experience -Auditory hallucinations -More likely to demonstrate formal thought disorders and aphasic thinking including the production of neologisms and syntactical speech errors -Emotional (or thought) blocking or blunting due to limbic system-temporal lobe disconnection -May be unaware of their illness -Certain subgroups display significant abnormalities in the semantic, temporal-sequential, and lexical aspects of speech organization -Speech comprehension disturbed and deviantly constructed or aphasic tendencies -Temporal-sequential (i.e. syntactical) abnormalities in ability to reason. e.g. "I am a virgin; the Virgin Mary was a virgin; therefore I am the Virgin Mary."

The left frontal region and medial frontal cortices are also implicated in the genesis of schizophrenic-like abnormalities including catatonia.
 * Differential Dx**

Frontal lobe schizophrenia who are more likely to present with "negative" symptoms and emotional blunting Temporal lobe schizophrenics are likely to present with "positive" symptoms, including retention of the capacity to experience and express "warmth". Emotional expression, however, tends to be abnormal, inappropriate or incongruent, and/or exaggerated.

Amygdala and hippocampus are involved: -Memory and emotional functioning may be most severely effected -May experience visual hallucinations. -May behave violently and aggressively -May also experience extreme feelings of religiousness, fear, paranoia, and depression

APHASIA & PSYCHOSIS
Since the left temporal lobe is intimately involved in all aspects of language comprehension and the organization of linguistic expression, altered neocortical activity involving this region is likely to result in significant disruptions in language functioning and the formulation of linguistic thought. Individuals with left temporal lobe damage and Wernicke's aphasia are likely to be diagnosed as suffering from a formal thought disorder due to their fluent aphasic language disturbances their failure to comprehend.

Several authors have noted significant similarities between schizophrenic discourse and aphasia. Similar findings have been reported for individuals developing post-traumatic schizophrenic-like symptoms following head injury and missile wounds. Just as some aphasic individuals may be unaware of their disorder, similar findings have been noted with schizophrenics and those with schizoaffective disorders.

TEMPORAL LOBE SEIZURES, PSYCHOSIS & APHASIA
-Commonly become globally aphasic during the course of their seizure. When spoken to or if their name is repeatedly called they may make only fleeting eye contact, grunt or utter partial words such as "huh?" Some individuals remain aphasic for seconds to minutes after seizure termination as well.

-Language impairments, verbal memory disorders and associated linguistic deficiencies are usually apparent even between seizures if adequately assessed. -Left sided foci tend to have lower (WAIS-R) Verbal IQ's as compared to their Performance IQ's compared to right sided foci. In some cases, excessive activity within the left (or right) temporal (or frontal) lobe can actually result in what appears to be enhanced functional activity.

-Possible abnormal activity in the left temporal lobe, and presence of an active lesion, can result in significant alterations in not only language, but the organization of linguistic thought such that the patient appears psychotic. In this regard, abnormal thought formation may become a characteristic pattern. If left temporal region is periodically disconnected from centers mediating emotion, patients may demonstrate what appears to be emotional blunting as well as a formal thought disorder.

BETWEEN SEIZURE PSYCHOSES
The range of disturbances among those with temporal lobe epilepsy includes -Strikingly high rate of sexual abberation as well as hyposexuality -Aggressiveness -Paranoia -Depression -Deepening of emotion -Intensification of religious concerns -Disorders of thought -Depersonalization -Hypergraphia -Complex visual and auditory halluciantions -Schizophrenia

Frequently the seizure related disturbances in emotional functioning waxe and wane, such that some patients experience islands of normality followed by islands of psychosis. Possibly these changes are a function in variations in subclinical seizure activity and kindling.

The psychiatric disturbance may develop over days as a prelude to the actual onset of a seizure, due presumably to increasing levels of abnormal activity until the seizure is triggered. Regarding depression, the alterations in personality and emotionality may occur following the seizure and may persist for weeks or even months

In yet other instances, patients may act increasingly bizarre for weeks, experience a seizure, and then behave in a normal fashion for some time, only to again begin acting increasingly bizzarre. This has been referred to as an inter-ictal (between seizure) psychosis and is possibly secondary to a build up of abnormal activity in the temporal lobes and limbic system.

Caveats
Some authors have argued that there is no significant relationship between these psychotic disorders and temporal lobe epilepsy, whereas others have drawn attention to possible social-developmental contributions. That is, growing up with a seizure disorder, feeling victimized, not knowing when a seizure may strike, loss of control over ones life, etc. can independently create significant emotional aberrations.

It is also important to emphasize that it is probably only a subpopulation of individuals with temporal lobe epilepsy who come to the attention of most researchers; e.g. those with the most serious or intractable problems. Thus one should not immediately view an individual with temporal lobe (or any type of epilepsy) as immediately suspect for emotional-psychotic abnormalities. Nevertheless, it is noteworthy that not only is there an association between the temporal lobe and certain forms of schizophrenia, but that temporal lobe abnormalities have been noted across generations of individuals and families afflicted with psychotic disturbances.