Epileptic States 癫痫状态 Particularly interesting under the heading of organic syndromes is the interaction between epileptic states and paranoid manifestations. From one point of view, one can point to significant psychogenic factors which might link epileptic states with paranoid manifestations. The child who suffers from convulsions is somehow regarded as different by his age-mates and by other significant figures in his environment. He may be treated in a special, careful or fragile manner. He comes to view himself consequently as different, and experience himself in terms of vulnerability and lack of control. Psychodynamic factors involving the guilt of parents and projective mechanisms, which we have described elsewhere in this study, can force on the epileptic child an introjected self-image of one who is somehow vulnerable, weak, and defective, and the object of hostile and demeaning treatment from important figures around him. 在器质性综合征的标题下，特别有趣的是癫痫状态和偏执表现之间的相互作用。从某种角度来看，人们可以指出一些重要的精神因素，这些因素可能把癫痫状态与偏执表现联系起来。患抽搐症的儿童在某种程度上被他的同龄人和环境中的其他重要人物视为与众不同。他可能会受到特殊的、谨慎的或脆弱的对待。因此，他认为自己与众不同，并在脆弱和缺乏控制方面体验到自己。涉及父母的内疚和投射机制的精神动力因素(我们在本研究报告的其他地方已描述过)﹐可迫使癫痫儿童有一种内摄的自我形象﹐即他在某种程度上是脆弱、软弱和有缺陷的﹐并且是他周围重要人物敌视和贬低的对象。 Psychomotor Epilepsy. Viewing the syndrome in this context establishes some continuity with the dynamics of the paranoid process as we have come to know it in the course of this study. But the further question which lurks in the background in cases of psychomotor epilepsy particularly, and which remains substantially unanswered, is the question as to whether the disorganization associated with psychomotor states contributes in some direct and/or casual manner to paranoid manifestations. 精神运动性癫痫. 从这个角度来看这个综合症，与我们在本研究过程中所了解的偏执过程的动态建立了某种连续性。但是，在精神运动性癫痫的病例中，潜伏在背景中的另一个问题是，与精神运动状态相关的混乱是否以某种直接和/或偶然的方式促成了偏执表现，这个问题在很大程度上仍未得到回答。 The frequency of paranoid manifestations in psychomotor epileptics has been frequently noted (Ervin, 1967). In a study, specifically of psychotic episodes occurring in known epileptic subjects, Dongier (1959) studied 516 epileptics with interseizure psychoses. He concluded that 44 percent of the psychotic occurrences took place in patients with psychomotor epilepsy—indicating a strong disposition for temporal lobe pathology to manifest itself in psychotic behavior. The characteristics of these psychotic episodes were described as including marked paranoid ideation along with anxiety and depression. By way of contrast, centrencephalic or generalized epilepsy seemed to show a more confused psychotic state with more consistently abnormal EEG patterns. 精神运动型癫痫患者的偏执表现的频率已被经常注意到(Ervin, 1967)。Dongier(1959)在一项研究中，特别是在已知的癫痫受试者中发生的精神病性发作，研究了516名患有发作间歇性精神病的癫痫患者。他的结论是，44%的精神病发作发生在精神运动型癫痫患者身上——这表明颞叶病理有很强的倾向性，可以表现为精神病行为。这些精神病性发作的特征被描述为包括明显的偏执思维以及焦虑和抑郁。相比之下，脑中风或全身性癫痫似乎表现出更混乱的精神病状态，并有更一致的异常脑电图模式。 In reviewing the disruption in limbic system functioning that takes place in temporal lobe seizures, the disruption of the integration between experiencing and recording mechanisms was a central aspect of the temporal lobe syndrome (Meissner, 1966). In addition to the frequently observed overlap of temporal lobe epilepsy with personality disorders and even psychosis, one must add the important observations of EEG abnormalities affecting the septal, hippocampal, and amygdaloid regions in certain types of schizophrenic patients during active psychotic episodes. In both conditions—temporal lobe epilepsy and schizophrenia—abnormal activity in limbic structures is associated with disturbances of consciousness and effective psychological functioning. This reflects the central role of these CNS structures in the integration of higher functions. It has been observed in addition that nonictal psychiatric symptoms often are exacerbated when psychomotor seizures are reduced by medical means—but that both seem to be eliminated after temporal lobe resection. Conversely, it has been observed in some cases that psychosis appeared in cases of psychomotor epilepsy with the diminution of seizures—a striking relationship in view of the fact that seizure activity and psychotic behavior are often correlated. 在回顾颞叶癫痫发作时发生的边缘系统功能的中断时，体验和记录机制之间的整合中断是颞叶综合征的一个核心方面（Meissner，1966）。除了经常观察到的颞叶癫痫与人格障碍甚至精神病的重叠外，还必须加上对某些类型的精神分裂症患者在活动性精神病发作时影响隔叶、海马和杏仁体区域的脑电图异常的重要观察。在这两种情况下——颞叶癫痫和精神分裂症——边缘结构的异常活动与意识和有效心理功能的干扰有关。这反映了这些中枢神经系统结构在整合高级功能方面的核心作用。此外还观察到，当通过医学手段减少精神运动性发作时，非发作性精神症状往往会加重——但在颞叶切除术后两者似乎都被消除了。相反，在一些病例中观察到，精神运动性癫痫的病例中，随着癫痫发作的减少而出现精神病——鉴于癫痫发作活动和精神病性行为常常是相关的，这种关系是惊人的。 On the opposite side of the coin, the association of personality disorder with psychomotor epilepsy is not accepted on all fronts. A comparison of matched groups of patients with focal temporal and frontal epilepsy with patients with nonfocal seizures indicates that nonfocal epileptics perform less well on tests of attention, but that they show no significant differences on tests of memory. Similar comparison of psychomotor against other forms of epilepsy has failed to demonstrate any significant differences on a variety of psychological and psychiatric measures. The argument has thus been presented by Stevens (1966), who argues that the psychomotor-temporal form of epilepsy is unique in that it also shows an age prevalence paralleling that of hospitalized psychosis in the general population. She suggests that the failure to control for this aspect accounts for the apparently increased incidence of the psychomotor syndrome in psychiatric populations, and conversely the high incidence of personality disorder in psychomotor epileptics. 在硬币的另一面，人格障碍与精神运动性癫痫的关联并不是所有方面都被接受。把局灶性颞部和额部癫痫患者与非局灶性发作的患者的匹配组进行比较,表明非局灶性癫痫患者在注意力测试中表现较差,但他们在记忆力测试中没有显示出明显的差异。将精神运动与其他形式的癫痫作类似的比较﹐在各种心理和精神测验上都没有显示出任何显著的差异。因此，Stevens(1966)提出了这一论点，她认为精神运动-颞形式的癫痫是独特的，因为它还显示出与一般人群中住院精神病的年龄流行率相当。她认为，未能控制这一方面是精神运动综合症在精神病人群中的发病率明显增加的原因，相反，精神运动型癫痫患者的人格障碍发病率很高。 One can suggest that the implication that temporal lobe disorder or psychomotor seizures have a causal influence in the production of paranoid symptomatology needs considerable proving. One distinct possibility that must be kept in mind is that subtle disruptions of the organization of internal experience, which might be associated with temporal lobe pathology, may serve as the precipitating basis for the organization of paranoid defenses. It has been observed, for example, that paranoid symptoms often precede or occur in the apparent absence of recognizable signs of an organic brain syndrome. It is possible in such cases that the paranoid behavior is an early indicator of organic difficulties, appearing in response to insidious or quite subtle organic disruptions, before any frank neurological impairment in memory functions or in the form of disorientation, delirium, or confusion might make itself known. Such impairments might serve to increase the subject's feelings of loss of control, of vulnerability and susceptibility, and thus increase fears of external threat or attack. The incipient organic deterioration may then serve to trigger previously existing paranoid trends or capacities. 可以说，颞叶病变或精神运动性癫痫发作对偏执症状的产生有因果影响的说法，还需要大量的证明。必须牢记的一个明显的可能性是，可能与颞叶病变有关的内部经验组织的微妙干扰，可能成为偏执防御组织的诱发基础。例如，有人观察到，偏执症状常常在明显没有可识别的脑部器质性综合征的征兆中或之前发生。在这种情况下，偏执行为有可能是器质性困难的早期指标，出现在对隐蔽的或相当微妙的器质性干扰的反应中，在 记忆功能 或 以迷惑、谵妄或混乱的形式出现的 任何明确的神经系统损害可能被察觉之前。这种损伤可能会增加受试者的失控感、脆弱感和易感性，从而增加对外部威胁或攻击的恐惧。初期的器质性恶化可能会引发以前存在的偏执倾向或能力。 The best evidence for anatomical and specifically neurological links between paranoid manifestations and physiological substrates is seen in the effects of the amphetamines and in lesions—either organic or epileptic—of the limbic system. This association, however, is by no means universal, and is certainly not exclusive. The disorders most commonly associated with paranoid manifestations are those involving distortion or disruption of perception and memory. If our analysis of the paranoid dynamics is correct, we can suggest that the deficit in these particular functions would be particularly closely linked to a need to reconstitute the realm of experience by the employment of paranoid mechanisms. 偏执表现和生理基质之间解剖学的和更具体地神经学的联系的最好证据见于安非他明的影响和边缘系统的病变--无论是器质性的还是癫痫性的。然而，这种关联绝不是普遍的，当然也不是唯一的。最常见的与偏执表现相关的疾病是那些涉及感知和记忆的扭曲或破坏的疾病。如果我们对偏执动力学的分析是正确的，我们可以认为，这些特定功能的缺失将 与 通过使用偏执机制来重建经验领域的需要特别密切相关。 One aspect of the overall problem of the relationship between temporal lobe seizures and the production of apparent functional pathology is that the limbic system structures in general are known to have an extremely low threshold of seizure discharge. Consequently epileptic focuses can produce seizure discharge in limbic structures without any apparent alteration in the surface EEG recordings. A number of cases of spiking discharges from limbic structures in a context of negative surface EEG findings have been documented. This raises the interesting possibility that a certain percentage of cases might be suffering from undetected limbic system disorganization which may serve as the triggering condition for eliciting psychotic or paranoid manifestations without detectable or identifiable organic findings using conventional techniques. 颞叶癫痫发作与产生明显的功能病变之间关系的总体问题的一个方面是，边缘系统结构在一般情况下具有极低的癫痫放电阈值。因此癫痫灶可在边缘结构中产生发作性放电，而表面脑电图记录无明显改变。有一些病例在表面脑电图结果为阴性的情况下，从边缘结构中产生尖峰放电，已经被记录下来。这就提出了一个有趣的可能性，即有一定比例的病例可能患有未被发现的边缘系统紊乱，这可能是诱发精神病或偏执表现的诱因，而使用常规技术却无法检测或识别器质性的发现。 Epilepsy and Violence. The whole question of violence—which we have discussed above—and the problem of the interaction of epileptic and paranoid phenomena fall together at this point. The question arises of the extent to which patients who manifest violent behavior may suffer concurrently from paranoid and epileptic disorders. A recent study of so-called episodic dyscontrol (Bach-y-Rita et al., 1971) carefully evaluated a sizeable group of 130 patients who presented with the complaint of explosive violent behavior. The patients were categorized into the following groups: those with temporal lobe epilepsy, those with seizurelike outbursts, those with diffuse patterns of violence, those suffering from pathological intoxication (see discussion under effects of alcohol), and finally, those patients with repetitive violence directed at specific individuals in their environments. 癫痫与暴力. 整个暴力问题──我们已在上面讨论过──以及癫痫和偏执现象的相互作用问题在这里是一起的。问题是出现了表现出暴力行为的病人在多大程度上可能同时患有偏执和癫痫病。最近一项关于所谓发作性控制障碍的研究(Bach-y-Rita等人，1971)仔细评估了一组规模相当大的130名患者，他们以爆发性暴力行为为诉求。这些病人被分为以下几组：那些患有颞叶癫痫的人，那些有癫痫样爆发的人，那些有弥漫性暴力模式的人，那些患有病理性中毒的人(见在酒精影响下的讨论)，以及最后，那些在其环境中对特定个人反复施暴的病人。 Psychosocial histories revealed a fair amount of childhood deprivation and social maladjustment—including work and family instability. The patients seemed to demonstrate a chronic lack of control resulting in innumerable life difficulties, including job loss, family disruption, and brushes with the law. There was a high incidence of abnormal EEG findings and episodes of unconsciousness and seizures, suggesting that the difficulties experienced by many of these patients were the effects of minimal brain dysfunction (MBD). Psychodynamically these patients are described as rather dependent men—usually dependent on a strong mothering female figure—and as men with a poor sense of masculine identity. They tended to be outwardly hypermasculine and extremely intent on defending their masculinity against any questioning or insult. They shared a sense of uselessness, impotence and inability to change the environment which they confronted. In individual episodes of violence, there was a total breakdown of ego functioning and a disorganization of thought processes accompanied by an outpouring of primary process thought. The striking thing about this group of patients and their description is that they seem to reveal a high incidence of paranoid dynamics, including displacement, denial, and projection as prominent defense mechanisms. And we can also ask the question, even though a minority of these patients had identifiable temporal lobe pathology, whether in fact the acute episodes of violence might not have been linked with limbic system pathology which created an episode of acute vulnerability and psychic decompensation in individuals with paranoid predispositions. At this point these questions as to the interlocking of organic and psychopathological phenomena must remain no more than intriguing speculations. 心理社会史显示，患者有相当多的童年被剥夺和社会不适应，包括工作和家庭不稳定。患者似乎表现出长期缺乏控制，导致无数的生活困难，包括失业、家庭破裂和与法律的冲突。异常的脑电图发现和无意识及癫痫发作的发生率很高，这表明许多患者所经历的困难是最小脑功能障碍（MBD）的影响。从心理动力学角度看，这些患者被描述为相当依赖性的男性——通常依赖一个强势的抚育的女性形象——并且是男性身份感差的男性。他们倾向于外在的低男性化，并极力捍卫自己的男性气质，以抵御任何质疑或侮辱。他们都有一种无用感、无能感和无力改变他们所面对的环境。在个别暴力事件中，自我功能完全崩溃，思维过程紊乱，同时伴有初级过程思维的涌现。这类患者及其描述的惊人之处在于，他们似乎透露出偏执动力学的高发生率，包括置换、否认、投射等突出的防御机制。而我们也可以提出这样一个问题，即使这些患者中少数人有可识别的颞叶病变，但事实上，暴力的急性发作是否可能与边缘系统病变有关，而这种病变造成了具有偏执倾向的个体的急性脆弱和心理失代偿的发作。在这一点上，这些关于器质性现象和精神病理现象相互交织的问题，只能是耐人寻味的猜测。