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Epileptic equivalents in psychiatry:

Some 19thcentury views

B. Schmitz, M. Trimble

Department of Neuropsychiatry
Instituteof Neurology, London

Introduction referred to as maniacal, which include severe violence. For


In this paper, some of the important contributions of 19th example, he states: Of all the modifications of mental
century neuropsychiatrists to an understanding of the links derangement, there are none so terrible as that complicated
between epilepsy and psychopathology, namely the idea of with epilepsy. Maniacal epilepsy is usually characterised
epileptic equivalents, are reviewed. by the most ferocious, malign, and often murderous
paroxysms; and often it is as instantaneous as it is violent.
These pejorative associations had been recognised over
The English Contribution the centuries, for example, epilepsy being referred to as
The possibility that patients with epilepsy could show The disease of Hercules, the mythological character that
behaviour disturbances rather than convulsions, as part of killed his family in a paroxysm of rage, supposedly due to
their epileptic condition was well established by the turn of a seizure (4).They are themes revived by several European
the 19th century. Willis in 1667 (1) had noted that: authors, for example, Morel (see below).
epilepsy is sometimes cured by the help of medicines, Burrows also opened the way for the development of two
experience doth testify ... in the meantime, as to what separate associations between epilepsy and insanity, the
further belongs to the prognostication of this disease, if it strands of which are still with us today, Thus, he recognised
ends not about the time of ripe age, neither can be driven that epilepsy could lead to insanity, but also noted: The
away by the use of remedies, there happens a diverse event epileptic attack may be preceded by a furious paroxysm, or
in several sick patients, for it ends immediately in death, or merely by elevated ideas, by great depression of spirits, or
is changed into some other disease, to wit, the palsie, by mental imbecility, forgetfulness, etc; or the reverse may
stupidity, or melancholy, for the most part incurable. obtain, and the sequel of the epileptic fit may exhibit these
George Man Burrows practised general medicine, but morbid conditions of the mental functions. ...in other cases,
from 1815 devoted himself to insanity. He travelled the disease is either preceded or succeeded by violent
widely, especially seeking evidence of cure of mental paroxysms of mania. ...it appears as if the epileptic impulse
illness, and spent some time in Paris, being acquainted with when not ending in convulsion, acts on the brain in a
the latest ideas and developments there. Burrows noted of peculiar mode, and imparts to it that particular action
epilepsy that, if an early death do not supervene, the denominated epileptic mania.
malady induces demency, idotism or incurable insanity Burrows, in the fxst quoted section seems to be referring
(2). These ideas were expanded in his commentaries (3). to what we would now refer to as pen-ictal changes of the
Closely aligned to the clinical picture are symptoms, mental state, associated with prodromata, auras, and the
post-ictal phase. However, the later quotes clearly imply
the potential for epilepsy to present, in the absence of
Address: convulsions with a manic episode. He went on to quote the
B. Schmitz case of a 30 year old man, subject to occasional fits of
Departmentof Neuropsychiatry
epilepsy, who had become lately much inclined to
Institute of Neurology
Queen Square religious devotion, who suddenly and violently attacked
London WC13BG a neighbour, an episode for which the next day he was
U.K. amnestic.

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Epileptic Equivalents in Psychiatry Some 19IhCentury Views

The suggestion that one pattern of a disease could The French Contribution
replace another had already developed, via the concept of Pine1 (8), physician in chief at the Bicstre and the
sympathy. Burrows was a somatist, exclaiming that mental Salp2trikre, recognised insanity complicated with
symptoms should be examined in the same way as a epilepsy, a subject taken up for study by several of his
clinical examination of the symptoms of bodily diseases. pupils. Notable amongst them was Esquirol (9), whose
He was familiar with the writings of Mead who put forward main contribution was in delineating the more chronic
the theory that mental illness was incompatible with bodily interictal states, which included mania, monomania and
disease (5),and had observed cases of the interchangeable dementia. A little later Delasiauve (10) observed that mood
relation between lunacy and phthisis pulmonalis. This changes were seen in epilepsy, including mania, which
was intertwined with the concept of sympathy, one could become la forme furieuse. He described case
explanation of why symptoms might occur distant from an histories without obvious convulsions, but thought that the
impaired body part, the sympathetic nerves being given a attacks generally were more associated with increasing
central role in this process, and conversion. Femar (6), seizure frequency. It was however J.P.J. Falret, son of J.P.
summed this up as: a disease is said to be converted, when Falret, a student of the Esquirol circle, and Morel, himself
new symptoms arise in its progress, which require a a student of J.P. Falret, who made the psychiatric aspects
different designation, and which either put a period to the of epilepsy a special study.
original disorder, or combining with is, alter the Falrets (1 1-13) main contributions are contained in
physicians views reflecting the prognostics or the method three papers published in 1860 and 1861. He noted that
of cure. patients with epilepsy could have attacks of mania which
Thus, Burrows separated two concepts. That of the succeed or alternate with seizures, but that only a few
development of insanity as a direct complication of authors had written on this subject. He quotes Cavalier,
epilepsy, and that of paroxysmal episodes of disturbed Morel, Delasiauve, Aubanel and Guillermin as authorities.
behaviour that were not associated with a convulsion, but In his classification of the psychiatric states of epilepsy
were nevertheless a part of the epilepsy. He speculated on he has three categories. The frst occur before, during or
the reasons for these events, citing increased vascular following the seizure, the second are those in the interval
action and fullness of the blood vessels as common to both between attacks, and the third are those of long duration,
epilepsy and mania. which constitute real madness. Here he obviously
Another English author to discuss epilepsy was Henry distinguishes ictal, and interictal disorders, a classification
Maudsley (7). Although mostly interested in the forensic still used today, and recognises the chronic interictal
aspects of mental disease, he recognised epileptic mania, syndrome.
a most dangerous form of insanity, but also recognised The second category, the attacks in the intervals between
the concept of masked epilepsy, and that changes of seizures, Falret said needed a special name, and he called
character and temperament could occur months or even them folie tpileptique. They consisted of mood and
years after the epileptic seizures were manifest. Masked intellectual changes, such as imtability, suspiciousness,
epilepsy was a transitory mania occumng in lieu of the and outbursts of violence, rather than psychoses, although
usual convulsions. He went on to speculate on the he commented on the sentiments religieux which often
mechanism: coloured the mental state. The important thing for Falret
Instead of the morbid action affecting the motor centres was the intermittent nature of the psychic phenomena.
and issuing in a paroxysm of convulsions, it fixes upon the The disorders of the third group he divided into two, the
mindcentres and issues in a paroxysm of mania, which is, petit mal and the grand ma1 intellectuel, noting the
so to speak, an epilepsy of the mind. close relation between the physical and mental aspects of
Thus, English neuropsychiatrists in the 19th century the disease. The former present with early mood changes,
recognised the interplay between epilepsy and memory difficulties, attacks of violence and impulsivity,
psychopathology, hinting at several relationships, one of feelings of persecution with suicidal ideas and acts, He
which was the development of alteration of the mental stated: The essentially impulsive and instant character of
state, not directly related to the ictus, which often had a the epileptic delirium is really very remarkable.
characteristic form. Interestingly, these early The grand mal type were more likely found in asylums,
developments were not followed up and it was and were known as mania with fury. He went on to
developments on the continent, especially in France and describe a manic state with rapid ideas, pressure of speech,
Germany, that clarified some of these concepts, and led to variable mood, agitation and excessive violence.
the development of two intertwined concepts, namely that Hallucinations might occur, they often ended abruptly.
of interictal personality disorders, and that of epileptic Importantly, there was no clear relationship of these
equivalents. episodes, which were a rapid explosion which often
ended abruptly, to the seizures. In some patients seizures
were not observed, in others he thought that subtle seizure

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Schmitz, Trimble

manifestations, or nocturnal seizures might have been either presents in the form of melancholia or mania, both
missed. However, his point was that the epileptic delirium usually accompanied by major precordial anxiety. Third,
substitutes in some manner epileptic seizures. It is a established epilepsy directly causes the mental disorder in
manifestation of the same illness in a different form. that the initation of the whole nervous system due to long
Attention to the clinical characteristics of the attack would repetitive seizures also damaged the central organs of
reveal the essential underlying epileptic nature, and he thinking. In this case mental disorder and epilepsy exist in
quoted a case of Delasiauve, in which the history of parallel. Fourth, epilepsy follows insanity and then
epilepsy was only revealed later, and in one of his own accompanies insanity with the sporadic seizures. In this
cases, no epileptic attacks had occurred for two years. He case an organic cause which initially only involves sensory
also identified long term remission as a risk factor for the nervous centres expands into the motoric system.
development of the psychiatric symptoms in epilepsy, Although Flemmings pathophysiological concepts
especially if the epileptic seizures returned and were surpassed most of his comtemporaries in terms of clarity
repetitive. and complexity, his hypotheses were largely neglected
Falret recognised the controversial nature of this because his writings lacked psychopathological details,
findings, especially the transformation of epilepsy into which were more popular than pathophysiological
madness. This touched on the transformation of one disease concepts at that time ( I 8). It is his second category in which
into another, but he cautioned against this interpretation. the concept of epileptic equivalents emerges.
Essentially the convulsions and the madness should be This term seems to be used for the first time by Hoffmann
viewed as two manifestations of the same disease. (19). He noted that: eventually epileptic seizures may be
For Falret therefore, the psychiatric states in epilepsy missed completely, but the mental disease can reveal
always implicated the epilepsy, and a history of seizures through its particular symptoms and signs thzt it is an
was always to be found, at some stage. The clinical equivalent of epilepsy, especially of convulsions and
characteristics of the insanity were also important in giving coma. Crucial to this statement is the idea that the clinical
it a particular stamp, identifiable as folie epileptique. features of the psychopathology identify the events as
Morels concept was epilepsie larvCe (14, 15). He being epileptic. This was taken up by Griesinger and then
referred to this as a special form of delirium, characteristic Samt.
of the neurosis of epilepsy. He quoted Burrows with Griesinger broadened the concepts of the mental
approval and then went on to describe three types or stages changes associated with epilepsy. When Griesinger went
of the insanity. Early on these included irritabilities and to the Charit6 in Berlin, he was relatively inexperience in
preoccupations, either sexual or hypochondriacal. In the clinical psychiatry. He was a believer in identifying
second period the behaviour was more violent, and patients psychopathology as a diagnostic tool to later reveal
often needed asylum confinement. Religious melancholy neuropathology. He acknowledged that one of his tasks
was noted. The third period was characterised by dementia was to combine neurology and psychiatry.
and general paralysis. He described the personality In his textbook, the first edition in English being in 1867
changes of epileptic patients, essentially interictal, and not (20), he made passing reference to the problem of insanity
associated in any direct way with the ictus. and epilepsy, noting psychical symptoms that precede, or
occur with the ictus. He also accepted chronic mental
The German Contribution disease even during the intervals between the attacks. He
The writings of Hemming (16) were representative of quoted Esquirols figures with approval, and emphasised
German psychiatry in the early 19th century. He was a a spectrum of presentations from hypochondriasis to
somaticist and played an important role in the development dementia.
of the German asylum system. He was one of three editors He expanded on these ideas in his paper of 1869 iiber
who founded the journal Allgemeine Zeitschrift f i r einiger epileptoide Zust;inde (21). In this he wrote about
Psychiatrie in an attempt to unify German psychiatric epileptoid symptoms, wishing to expand these to include
thinking which was split between the philosophically a wide variety of psychosensitive and psychomotor
orientated psychics and the asylum somaticists (17). symptoms. He also described interval symptoms. In some
In this textbook on pathology and therapy of psychoses patients these are the main problem, and the actual epilepsy
(1859), Hemming developed a pathophysiological may be missed.
concept of the relationship between epilepsy and insanity, In this paper, Griesinger was developing his ideas on
and described four different modes. First, epilepsy as a epilepsy and insanity, and recognised that his broadening
iransient symptom of the same general excitation of of the concept was controversial. It seems that he intended
nervous centres which cause the mental disorder, in this to write further papers on the subject, but he died before the
case epilepsy usually proceeds and introduces the insanity. project was complete.
Second, a seizure of an established periodic epilepsy fails The person who developed these ideas more extensively
to appear and is replaced by a paroxysm of madness, which was Peter Samt. He had worked with Griesinger as a
Epileptic Equivalents in Psychiatry - Some 19hCentury Views

younger man when doing his doctoral thesis, and in 1873 experience there were more psychic disorders directly
became frst assistant to the department of insanity. related to epilepsy than had yet been systematised. In a
Griesinger had by now died, and Westphal was the chief. comprehensive paper, he clearly distinguished personality
Although his career was tragically short, he died from an changes, neuropsychological deficits, dementia and
infection contacted at a post-mortem examination, he psychoses. While accepting the possibility of transient
wrote two substantial papers (22, 23) on the subject of psychoses without related epileptic seizures in the form of
epileptic insanity (Epileptische Irreseinsformen). These an epileptic rudiment, he rejected this idea for clinical use
were published in 1875 and 1876, in the journal which because of its hypothetical nature.
Griesinger had inaugurated. He was first and foremost Kraepelin (32) supported some of Samts ideas,
interested in the nosology of mental illness. It was, he felt, suggesting that crucial to the diagnosis of epilepsy was not
important to classify clinical entities, especially of patients the demonstration of a specific form of seizure, but the
sharing a similar course and development of illness. existence of an independent periodicity of the disorder
Classification could not be based on pathological entities, form the onset of the illness.
as so little was known, and the clinical method was By the end of the century, Samts broad spectrum of
paramount. epileptic insanity forms had been significantly reduced,
He quoted with much approval the writings of Morel and and psychiatry became influenced by Bonhoeffer (33), and
Falret, especially the latter, stating that his observations are his exogenous reaction types, which were independent of
supportive of Falrets ideas. the underlying pathology. Epileptic equivalents largely
He noted that epileptic insanities were by that time a well disappeared from the literature and from the conceptual
recognised clinical group, a specific form of insanity, and framework of those writing about epilepsy. Psychiatry and
distinguished sub-groups. These were 1. The psychic neurology were going their own separate ways and fertility
epileptic equivalent, 2. the protracted psychic epileptic of the earlier neuropsychiatric pastures gave way to the
equivalent, 3. acute post epileptic insanity, 4. the chronic circumscribed disciplines that dominated and restricted
protracted epileptic insanity and 5. the cycling epileptic 20th century thought.
insanity.
In these papers, Samt clearly described patients with Conclusions
acute behaviour disorders, but no seizures. The patterns of Table I shows the development of the various concepts that
the behaviour however resembled that of seizures, with a are discussed in this paper. Essentially, the European
herald, an acute crisis, and a post-paroxysmal phase. The authors of the 19c recognised that epilepsy was strongly
episodes themselves were often of an aggressive nature, associated with insanity, and struggled to understand the
and were accompanied by amnesia. Thus, it was the form relationship. In the early part of the century, Pine1 and his
of the insanity, not the associated seizures that lead to the followers such as Esquirol, Calmeil, and Georget
diagnosis of epileptic insanity. He stated that he called recognised that chronic epilepsy could lead to mental
them equivalents in order to characterise the attack-like illness, and represented a problem for asylum
and paroxysmal nature. In his discussion of more management. Burrows was the first to coherently express
prolonged states, he introduced the term transformed the possibility of transformations of the illness pattern, and
epilepsy (transformierte Epilepsie) prefemng such that epileptic insanity could occur on occasions without
expression to the term Epilepsie larvte of Morel. He manifest seizures. These ideas were taken up in France and
considered larval epilepsy inappropriate in the sense that Germany, and lead to concepts such as the epileptic
the symptoms were either epileptic or not, but could not be character, epilepsie larvte and the epileptic equivalent.
larval.
In his final classification of epilepsy he distinguished 12 Table I. Terminolcgyofepileptjcpsychosesinthel!3hcerduty
diagnostic categories, which included three types of
seizures and nine psychopathological states. Morel1860 Hoffmann1872
These views of Samt were highly controversial, and Epilepsiehk Epikpkddquient
evoked comments over the next half a century. One aspect Wlirekpilepbque
was to further specify the psychopathology of the
Falret1861 Samt 1875
epileptisches Irresein in terms of consciousness (24), Folie$ileptique Epileplischeslmin
speech (26) and gender differences (27). However most Petmalintellectuel Psychis& Epilepsie
authors (24, 28, 29) insisted on the occurrence of seizures Grandmalintellectuel TransfomierteEpilepie
as a prerequisite for diagnosis, some even requiring a close
temporal relationship between seizures and the insanity Griesinger 1869 Sommer 1881
EpileptoideZustihde EpilepdschesRudiment
(30). Psychomotorischeund PsychisdlerStatus
Sommer (31) criticised the amount of attention paid to psychosensitveeZ. Epllepbbx
epileptic equivalents, and suggested that in his clinical

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Schmitz, Trimble 11. Falret J. De lttat mental des Cpileptiques. Archives gCnirales de
medicines 1860: 16: 661-79.
12. Falret J. De ICtat mental des Cpileptiques. Archives gintrales de
These developments were highly controversial, and mtdicines 1861: 17: 661-91.
remain so today. Towards the end of the 19th century, the 13. Falret J. De 1Ctat mental des Cpileptiques. Archives gtnirales de
idea that some kind of antagonism existed between mental midicines 1861: 18: 42343.
illness and epilepsy became prevalent, or more specifically 14. Morel BA. Maladies mentales. Paris: Masson, 1860.
15. Morel B. Dune forme de dtlire, suite dune surexcitation nerveuse
dementia praecox, and epilepsy, and the literature on se rattachent a une variett non encore dCcrite dtpilepsie. Gaz hebd
equivalents and its variants virtually ceased. As Wolf and med chir 1860: 7: 773-75.
Trimble (34) pointed out, some of the antagonism 16. Flemming CF. Pathologie und Therapie der Psychosen. Berlin:
literature has been misinterpreted, and if viewed as an August Hirschwald, 1859.
antagonism of symptoms, rather than diseases, then it 17. Darner K. Burger und h e . Frankfurt: Europaische Verlagsanstalt
GmbH, 1984.
forms a continuous thread with some of the concepts 18. Wolf P. Psychosen bei Epilepsie. Ihre Bedingungen und
discussed here. Wechselbeziehungen zu Anfillen (Thesis). Berlin: Freie
These ideas are reviewed, not only for their historical Universitat, 1976.
interest, but because they are, in a revised form also 19. Hoffman F. h r die Eintheilung der Geisteskrankheiten in
currency today. The whole concept was revived with the Siegbug. Allg Zschr Psychiat 1872: 19: 367-91.
20. Griesinger W. Mental pathology and therapeutics. London: New
description of nonconvulsive status epilepticus by ~ M O X Sydenham Society, 1857.
(33, the phenomenon of forced normalisation by Landolt 21. Griesinger W. iiber einige epileptoide Zustande. Archiv fur
(36), the concept of episodic dyscontrol (37), and the Psychiatrie und Nervenkrankheiten 1868: 1: 320-33.
persistent use of such terms as epileptoid or epileptiform in 22. Samt P. Epileptische Irreseinsformen. Archiv f i r Psychiatrie und
clinical practice. Nervenheikunde 1875: 5: 393-444.
23. Samt P. Epileptische Irreseinsformen. Archiv f i r Psychiatrie und
It is not our intention to suggest that all the states we have
Nervenkrankheiten 1876: 6: 110-216.
been discussing are epilepsy, or necessarily are 24. Gnauck R. Uber die Entwicklung von Geisteskrankheiten aus
pathogenetically linked to it. However, patients with such Epilepsie. Archiv fur Psychiatrie und Nervenkrankheiten 1882: 12:
conditions have fascinated clinicians for nearly two 337-58
centuries, continue to present to our clinics, and continue 25. Krafft-Ebing R. Uber epileptische Dammer- und Traumzustibde.
Allg Zschr Psychiat 1877: 33: 547-86.
to disturb, both those around them and our cosy concepts
26. Raecke J. Zur Symptomatologie des epileptischen Irreseins,
of what is epilepsy. imsbesondere uber die Beziehungen zwischen Aphasie und
Perseveration. Archiv fur Psychiatrie und Nervenkrankheiten 1906:
41: 1-28.
27. Fischer F. Zur Lehre vom epileptischen Irresein. Archiv fur
Psychiatrie und Nervenkrankheiten 1884: 15: 741-76.
28. Raecke J. Die transitorischen Bewusstseinsstorungen der
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