Epilepsy & Behavior 40 (2014) 49–51

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Epilepsy & Behavior

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Commentary

Comments on Devinsky O, Lai G. Spirituality and religion in epilepsy.Epilepsy & Behavior 2008;12:636–643

Bruce P. Hermann ⁎Department of Neurology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA

⁎ Tel.: +1 608 263 5430; fax: +1 608 265 0172.E-mail address: hermann@neurology.wisc.edu.

http://dx.doi.org/10.1016/j.yebeh.2014.10.0091525-5050/© 2014 Elsevier Inc. All rights reserved.

a r t i c l e i n f o

Article history:

Accepted 7 October 2014Available online 3 November 2014 This article is part of a special 15th Anniversary Issue

© 2014 Elsevier Inc. All rights reserved.

1. Review and gist of the article

The review by Devinsky and Lai [1] is a scholarly presentation of therelationship between epilepsy and spirituality and religiosity. There is along established view of a relationship between epilepsy, or specificepilepsy syndromes, and elevated spirituality and religiousness. Thetopic itself is not an easy ground for review. As Devinsky and Lai begin:

The more subjective the phenomenon, the less easily can sciencefocus on its image. Spiritual and religious experiences are deeplypersonal and verbally inexpressible. The scientific effort to dissectand define them may miss or destroy their essence. Yet, spiritualand religious thoughts are phenomena of the mind and brain withphysiologic and structural correlates. The presence of spiritualbeliefs among all cultures strongly suggests that the human brainis programmed to experience and explain parts of existence in spir-itual terms. Like language, spirituality develops in different forms indifferent cultures, yet the emotional–cognitive processes and under-lying anatomy probably share many elements. The aphasias helpedusher in modern neurology 150 years ago. Linguists and cognitiveneuroscientists actively study normal language function. In contrast,priests and, occasionally, psychiatrists focus on spiritual–religiousdisorders, but “normal” spirituality and religious experiences rarelyreach the fringes of science. (p. 637).

Devinsky and Lai review the origins of the belief between epilepsyand religiosity and, in so doing, mention 19 religious figures withalleged seizures or epilepsy (e.g., Ezekiel, Buddha, MuhammadSt. Paul, Joan of Arc, George Fox [founder of Quakers], Anna Lee [founderof Shakers], Joseph Smith [founder of Mormons], and Soren Kierkegaard[founder of existentialism]).

Hippocrates began his discourse on the “sacred disease” by refutingthe connection between epilepsy and the divine; he argued against

the widespread beliefs of prophetic and mystical powers attributedto personswith epilepsy and the disorder's divine causation.However,Hippocrates' attempt to dissociate epilepsy and religion was unsuc-cessful. Subsequent religious figures were asked to heal people withepilepsy. The New Testament gospels of Matthew (17:14–20), Mark(9:14–29), and Luke (9:37–43), who was a physician, recount howJesus cast out the evil spirit from a boy with epilepsy who had justhad a seizure, thereby curing him. Throughout the Middle Ages andthe Renaissance, religious and magical treatments of epilepsy pre-dominated, and in the nineteenth century the religiosity of personswith epilepsy was stressed by physicians such as Esquirol, Morel,and Maudsley. From ancient to modern times, many cultures viewedseizures as resulting from demonic or divine supernatural influences.Maudsley noted that Siberian medicine men of his day alwayspreferred epileptic pupils. Leuba's classic monograph on religiousmysticism noted that “among the dread diseases that afflict humanitythere is only one that interests us quite particularly; that disease isepilepsy.” Throughout the twentieth century, many anecdotal reportscontinued to associate epilepsy with heightened religious sentiment.(p. 637).

What can one make of such an ingrained and long-standing view ofepilepsy and religiosity in terms of our current understanding of theepilepsies? Devinsky and Lai review the literature regarding ictal reli-gious experiences, postictal religious experiences, the controversialtopic of interictal religiosity and epilepsy, and the relationship ofreligiosity with the indeterminate states between the periictal and theinterictal period. Useful case studies are included to elaborate andextend upon certain points. The descriptions of patient experiences,especially postictal experiences, are striking. In one case of postictalreligiosity, the following was described:

Iwas in bed and Iwas called out into the living room. I saw a vision ofChrist and I asked him what he wanted. He told me my time hadcome. I stepped into the kitchen and this strange feeling and visionleft me. I stood in between the living room and the kitchen and the

Table 1Interictal personality traits ascribed to temporal lobe epilepsy [6].

Trait Clinical observation

Viscosity Stickiness, tendency for repetitionHumorlessness Sobriety, overgeneralized ponderous concern,

lacking humorSadness/depression Discouragement, tearfulness, self-depreciationAnger Increased temper, irritabilityAggression Overt hostility, rage attacks, violent crimes, murderAltered sexual interest Loss of libido, hyposexualismCircumstantiality Loquacious, pedantic, overly detailedParanoia Suspicious, overinterpretative of motives and eventsGuilt Tendency toward self-scrutiny and self-recriminationHyperreligiosity Holding deep religious beliefsFeeling of personal destiny Egocentricity, personal events highly chargedHypergraphia Keeping extensive diaries, detailed notesPhilosophical interest Nascent metaphysical or moral speculations,

cosmological theoriesElation Euphoria, grandiosity, exhilarated moodHeightened emotionality Deepening of all emotions, sustained intense affectDependence, passivity Cosmic helplessness, “at hands of fate”Obsessiveness Ritualism, orderliness, compulsive attention to detailHypermorality Attention to rules with inability to distinguish

significant from minor infractions

50 B.P. Hermann / Epilepsy & Behavior 40 (2014) 49–51

strange feeling returned. I looked down the hallway and the voicesaid: whatever you do, do not wake your wife up. I did not knowwhat was going on. So I went into the bedroom and tappedmywifeon the shoulder and told her that Jesus is out in the living room. Helikes to talk to us. (p. 639).

The relationship between religiosity and the interictal state has beenespecially controversial:

While ictal and postictal religiosity are “religious fevers,” interictalreligiosity usually takes the form of a heightened state of religiousconviction. Unlike the “acute infections” of religious experience,interictal religiosity is a more continuous behavioral trait. Religi-osity is an uncommon personality feature among individuals withepilepsy. (p. 640).

All in all, this is an interesting review of a controversial topic, provid-ing a historical context and careful examination of the phenomenon inrelation to the ictus, providing pertinent case examples, with a tradi-tional review of the literature—all done in a measured and thoughtfultone.

2. The clinical and conceptual importance of this area of investigation

Investigations of the relationship between epilepsy, especially tem-poral lobe epilepsy, and features of abnormal and atypical behaviorhave typically focused on one of at least seven areas, and some mayargue more, characterized by the personality and/or behavior issueunder study: (1) psychosis, (2) aggression, (3) sexual dysfunction,(4) depression and anxiety, (5) general psychopathology as assessedby standardized personality tests or other measures of problem behav-ior (for example, rates of psychiatric hospitalization), (6) disruptions ofsocial/interpersonal behavior (social neuroscience) and theory of mind,and (7) nonpsychopathological behaviors and personality change.Issues in this last category attracted much attention and controversyin the past.

Although the concept of a global “epileptic personality” has general-ly fallen into disfavor, case studies and anecdotal observations raisedinterest in unusual personality and behavioral characteristics positedto hold a relationship with epilepsy or temporal lobe epilepsy in partic-ular, including sudden religious conversions, increased philosophicalinterest, humorlessness, and other traits. Waxman and Geschwind pro-posed the existence of a specific interictal behavioral syndrome associ-ated with temporal lobe epilepsy consisting primarily of alterations insexual behavior, increased religiosity, and a tendency toward extensiveand, oftentimes, compulsive writing (hypergraphia) [2–4]. Bear elabo-rated upon this syndrome and proposed the existence of 18 traits asso-ciated with temporal lobe epilepsy which reflected alterations inbehavior, thought, and affect [5] (Table 1). It was suggested that thesetraits were related to an underlyingmechanism, that is, enhanced affec-tive associations with previously neutral stimuli, events, or concepts,thought to be caused by a progressive change in limbic system structuresecondary to a temporal epileptic focus. Bear specifically argued that anepileptiform focus in the limbic system produced new functional con-nections between neocortical and limbic structures, and this processwas called sensory–limbic hyperconnection [5,6].

Geschwind [4] and Bear and Fedio [5,6] argued that as these behav-ioral changes were neither maladaptive nor psychopathologic in thetraditional sense, new and/or different assessment techniques wereneeded to demonstrate their existence. Studies of behavior change intemporal lobe epilepsy and of the proposed underlying mechanismsprogressed along different investigative lines which could be groupedaccording to the dependent measures used: (a) specially designedpersonality questionnaires designed to assess these traits in patientsthrough their own self-report or the observations of others, that is, thePersonal Inventory and Personal Behavior Survey [6–9]; (b) measures

of physiological responsivity to stimuli varying in nature and degree ofaffective content [10]; (c) specially developed semistructured psychiat-ric interview protocols [11]; and (d) direct measures of behavior [12].

In my own view, advances in this literature came when theindividual traits were examined in specific ways, for example, present-ing specific stimulus questions and prompting patients for a responseand then quantifying aspects of the verbal responses provided eitherorally (verbosity) or in writing (hypergraphia). This led to operationaldefinitions of the behavior under question, estimates of the ratesthat the target behavior occurred in the sample with epilepsy versusthe control population, and predictors of the target behavior. Focuson specific behaviors also pointed to the complexities involved, asthe Devinsky and Lai paper points out in regard to spirituality andreligiosity.

3. Why has this study been downloaded with such high frequency?

The paper of Devinsky and Lai [1] informed the controversial issue ofthe relationship between epilepsy and spirituality in a scholarly fashion.It broadened the historical time frame of discussion; reviewed the olderhistorical literature; considered the behavior in terms of prodromal,periictal, ictal, interictal, and postictal states of epilepsy; and placedthe behavior in a broad perspective. As such, it was and remains avery helpful as well as an interesting review of the topic.

4. What has changed in the field since publication of this paper?

Others may have a different view, but my own perspective is thatthere has been a decreasing number of papers devoted to personalitytraits and personality type ascribed to a particular epilepsy syndrome.This literature was most active, in a highly charged fashion, from thelate 1970s through the 1980s and dwindling into the 1990s.

Over time, there has been a corresponding increase in the investiga-tion of “traditional” psychopathologies, as defined by the DSM and ICD,such as depression; suicidal ideation, suicide attempts, and suicidecompletion; anxiety disorders; ADHD; and other categories of psycho-pathology including Axis 2 disorders (e.g., [12,13]). Correspondingly,there has been decreased attention to the notion of the behavioralchanges summarized in Table 1. If that literature was more active, theDevinsky and Lai paper would not be in the “most frequent download”category but would be listed in the “most frequently cited” category.

51B.P. Hermann / Epilepsy & Behavior 40 (2014) 49–51

Conflict of interest

The author declares that there are no conflicts of interest.

References

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[4] Geschwind N. Behavioral change in temporal lobe epilepsy. Arch Neurol 1977;34:453.

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[8] Nielsen H, Kristensen O. Personality correlates of sphenoidal EEG-foci in temporallobe epilepsy. Acta Neurol Scand 1981;64:289–300.

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[10] Bear D, Schenk L, Benson H. Autonomic responses to neutral and emotional stimuliin patients with temporal lobe epilepsy. Am J Psychiatry 1981;138:843–5.

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[12] Swinkels WA, Kuyk J, van Dyck R, Spinhoven P. Psychiatric comorbidity in epilepsy.Epilepsy Behav 2005;7(1):37–50.

[13] Swinkels WA, van Emde Boas W, Kuyk J, van Dyck R, Spinhoven P. Interictaldepression, anxiety, personality traits, and psychological dissociation in patientswith temporal lobe epilepsy (TLE) and extra-TLE. Epilepsia 2006;47(12):2092–103.