Quantitative Analysis

of Interictal
Behavior in
Temporal
Lobe
Epilepsy
David M.
Bear, MD,
Paul
Fedio,
PhD
\s=b\
Patients with
unilateral temporal epi-
leptic
foci were contrasted with normal
subjects
and
patients
with neuromuscular
disorders in the evaluation of
specific
psychosocial aspects
of behavior.
Eigh-
teen traits were assessed in
equivalent
questionnaires
completed by
both sub-
jects
and
observers.
The
epileptic patients self-reported
a
distinctive
profile
of humorless
sobriety,
dependence,
and
obsessionalism; raters
discriminated
temporal
lobe
epileptics on
the basis of
circumstantiality, philosoph-
ical interests,
and
anger.
The
right tempo-
ral
epileptic displayed
emotional tenden-
cies in contrast to ideational traits of left
temporal epileptic. Right
temporal
epilep-
tics
exhibited "denial,"
while left
temporal
epileptics
demonstrated a
"catastrophic"
overemphasis
of dissocial
behavior.
The results
support
the
hypotheses
that
sensory-affective
associations are estab-
lished
within the
temporal
lobes,
and
that,
in
man,
there exists a
hemispheric asym-
metry
in the
expression
of
affect.
(Arch
Neurol
34:454-467,
1977)
Among neurologic
diseases with

confirmed anatomic
localization,
temporal
lobe
epilepsy
has been most
frequently
associated with
functional
psychiatric
disorders.1
-'
Despite
incon
sistencies in
sampling
of
temporal
epileptic patients
and the low inter-
rater
reliability
of
psychiatric diag
nosis
that
plague many studies,1
a
searching
review of the
epidemiologie
literature concluded that
"interictal
psychoses resembling schizophrenia
occur more often than
chance"
in
patients
with
temporal
lobe foci.3 This
and all
subsequent
studies discussed
are concerned with interictal
(be
tween
seizure)
behavior rather than
specific
ictal
(psychomotor) episodes.
While such observations
suggest
that
temporal
foci
produce
extensive
behavioral effects in some
individuals,
controversy
remains
concerning
the
frequency
of
"epileptic psychoses"
and the
specificity
of a causal rela
tionship.'
In
fact, only
a
minority
of
temporal epileptics
warrant the
diag
nosis of
schizophrenia,
and careful
descriptions
of such
patients
have
emphasized atypical
features like
deepened
affect and
preserved
social
relations.2 The
long
interval
(mean
of
14.1
years)
between seizure onset and
"schizophrenia-like psychosis"5 sug
gests
that the
psychiatric
disorder is a
secondary
and uncommon effect of an
underlying neuropsychologic process.
In
general,
there is no reason to
believe that
schizophrenia
or other
diagnostic categories
constructed
from observations of
psychiatric pa
tients should
accurately
describe the
behavioral
consequences
of a neuro
logic process
at a
specific
locus.
Perhaps
for similar
reasons, person
ality
tests standardized on
psychiatric
reference
groups
or based on
psycho-
dynamic postulates
have
yielded
no
consistent
description
of
temporal
epileptic patients.611
For
example,
the
Minnesota
Multiphasic Personality
Inventory (MMPI)
and Rorschach
Test have either failed to
support8
n
or
provided conflicting
accounts712 of an
interictal
"temporal epileptic person
ality."
In a recent
study,
the Reitan
battery
did not
reliably
differentiate
among patients
with
temporal epilep
sy, schizophrenia,
manic
depressive
disease,
and "brain
damage."13
Such evaluations of interictal be
havior have not furthered theoretical
understanding. By contrast,
the
study
of destructive anterior
temporal
le
sions in animals has identified
specific
changes
in
emotionality, fear, aggres
sion, sexuality, exploration,
and social
behavior."18 Similar
consequences
have been
reported
after bilateral
temporal-limbic injury
in man.1920
Attention to the nature of these
alterations has led to the testable
concept
that
sensory
limbic connec
tions
may
be
interrupted by
lesions
within the
temporal
lobe.2123
In this
study,
we have
attempted
to
determine the effects of a unilateral
temporal epileptic
focus on
specific
psychosocial aspects
of behavior.
Eighteen
traits
putatively
associated
with
interictal behavior were selected
on the basis of
prior reports
and
pilot
testing.24 Many
of these traits are
not,
in
themselves,
indicative of
psychopa-
Accepted for
publication
Feb
22,
1977.
From the Clinical Neurosciences
Branch,
National Institutes of
Neurological
and Commu-
nicative Disorders and
Stroke, Bethesda,
Md.
Since there is evidence to indicate that item
responses obtained to selected items isolated
from the context of a
personality inventory may
not be
comparable
to those obtained with the
context, the results of this research should not be
considered
applicable
to the standardized com-
plete form of the
inventory (Minnesota
Multi-$
phasic Personality Inventory).
Reprint requests
to Clinical Neurosciences
Branch, National Institutes of
Neurological
and
Communicative Disorders and
Stroke,
Rm 4N\x=req-\
232, Bldg 10,
National Institute of
Health,
Bethesda, MD 20014.
Downloaded From: http://archneur.jamanetwork.com/ on 06/19/2012
Table 1.Construction of Inventories
Trait Clinical Observations
Investigators
18 Characteristics Attributed to Interictal
Behavior in
Temporal Lobe
Epilepsy
Emotionality Deepening
of
all
emotions, sustained intense
affect
Davison and
Bagley,3
Glaser,'0 Hill,""
Slater," Slater and Beard,2 and Waxman
and Geschwind"
Elation,
euphoria Grandiosity,
exhilarated mood;
diagnosis
of
manic-depressive disease
Fior-Henry,36
30
and Slater and Beard2
Discouragement,
tearfulness,
self-depreciation;
diagnosis
of
depression, suicide
attempts
Sadness Glaser," Slater and
Moran,5 and Williams"
Increased temper, irritability Anger Falconer,"
Mclntyre
et al," Sweet et al,"
Taylor,"
and Treffert"
Aggression
Overt
hostility, rage attacks, violent crimes,
murder
Davidson,50 Mark and Ervin,5' Mark et al,"
and Serafetinides"
Altered sexual interest Loss of
libido,
hyposexualism;
fetishism,
transvestism, exhibitionism,
hypersexual
episodes
Blumer,5"55 Blumer and Walker,55 Davies and
Morgenstern,57
Gastaut and
Collomb,5*
Hierons,5" Hooshmand and Brawley,
and Mitchell et al8'
Guilt
Tendency
to
self-scrutiny
and self-recrimination Bear," Blumer,' Dominian et al,52 and
Waxman and Geschwind63
Hypermoralism Attention to rules with
inability
to
distinguish
significant
from
minor infraction; desire to
punish
offenders
Blumer,' Mark and Ervin,51 and Waxman
and Geschwind53
Obsessionalism Ritualism; orderliness; compulsive
attention to
detail
Bear,24 Blumer,' Bruens,84 and Waxman and
Geschwind63
Circumstantiality Loquacious, pedantic; overly
detailed,
peripheral
Bear,24 Slater and Beard,2 and Waxman and
Geschwind63
Viscosity Stickiness; tendency
to
repetition
Blumer1 and Glaser"
Sense of
personal
Events
given highly charged, personalized
significance;
divine
guidance
ascribed to
many features of
patient's
life.
Glaser,40 Slater and Beard,2 and Waxman
and Geschwind63
Hypergraphia Keeping
extensive diaries, detailed notes;
writing autobiography
or novel
Blumer' and Waxman and Geschwind"
Religiosity Holding deep religious beliefs, often
idiosyncratic; multiple
conversions,
mystical
states
Dewhurst and Beard,28 Ervin,65 Hill," Slater,"
and Slater and Beard2
Philosophical
interest
Nascent
metaphysical
or moral
speculations,
cosmologica!
theories
Bear," Slater and
Beard,2 and Waxman and
Geschwind83
Dependence, passivity
Cosmic
helplessness,
"at
hands
of
fate"
protestations
of
helplessness
Bear,24 Blumer,1 and Slater and Beard2
Humorlessness;
sobriety Overgeneralized ponderous concern; humor
lacking
or
idiosyncratic
Bear,24
Ferguson
et al,86 and Waxman and
Geschwind63
Paranoia
Suspicious, overinterpretative
of motives and
events; diagnosis
of
paranoid schizophrenia
Bruens,84 Hill," Pond,8'8S and Slater and
Beard2
thology:
for
example,
the
tendency
to
write
extensively,25 undergo religious
conversion,26
or feel
strongly
about
moral issues.1
Yet,
the
regular
oc
currence of such features in concert
might elucidate an interictal neuro-
psychologic process present
in
many
patients.
The traits were assessed in two
equivalent questionnaires,
one which
the
subject
answered about
himself
and a second
completed
about the
subject by
a close
observer.
Explicit
comparisons
between
patients'
self-
perceptions
and
raters' evaluations
have not
previously
been
reported,
and the
finding
of consistent
dis
crepancies
would
raise the
possibility
that
temporal
foci influence the
accuracy
of
self-description.
Effects of
laterality
of the
temporal
focus were
specifically
considered.
The human
temporal
lobes are ana-
tomically asymmetric,2728
and exten
sive
evidence, largely gathered
after
temporal
lobe
resection,
documents an
asymmetry
of
cognitive functioning
in which the left
temporal
lobe
is
specialized
for
linguistic, analytic pro
cessing,
the
right
for
spatial, synthet
ic
operations.2932
A
hemispheric asymmetry
in emo
tionality
and mood has also been
suggested
on the basis of reactions to
deficits
after lateralized
lesions,33
electroconvulsive
shock,34
and uni
lateral
intracarotid barbiturate.35-36
Leftward
gaze-shifts
to emotional
questions
have
recently
been cited as
evidence of a
right hemisphere
domi
nance for affect.37
An
epidemiologie
association of left
hemisphere temporal
lobe foci with
paranoid schizophrenia
and
right
tem
poral
foci with manic
depressive
psychosis has
been
reported.38
'"
How-
ever,
this observation was based on a
small
percentage
of
temporal epileptic
patients
who had received either of
these
psychiatric diagnoses,
and it has
not been
uniformly
confirmed
(W.
Weir, MD, unpublished data,
June
1976).
In the
present study,
in which
the
majority
of
epileptic patients
had
never received a
diagnosis
of
psycho
sis,
we wished to ascertain whether
distinct behavioral
profiles
character
ized
right
vs left
temporal epileptics.
Independent patient
and rater
ques
tionnaires allowed
separate compar
ison of
patient responses,
observed
behavior,
and
accuracy
of
patient
self-
description
between
right
and left
temporal epileptic groups.
SUBJECTS AND METHODS
Questionnaires
The 18 behavioral traits that were
assessed
by true-false
questionnaires
are
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summarized in Table 1. Each trait was
sampled by
five items
composed by
the two
investigators
and
judged representative by
three additional
professionals.
In addition
to these 90 trait-derived
items,
ten
ques
tions were modified from the Lie Scale of
the MMPI. These neutral items were
included with the
prediction that,
in
contrast to the trait
items, they
would not
discriminate
temporal epileptics from com
parison groups.
Two
equivalent 100-item
questionnaires
were
employed: a Personal
Inventory
that
the
subject completed about
himself, and a
Personal Behavior
Survey, consisting of
objectified, third-person versions of the
same items that a
long-time
observer
completed about the
subject. Sample items
in the two formats are
presented
in
Table 2.
Items were presented
in random order
within the
self-inventory
but
grouped by
trait for the rater
survey.
Each block of
questions,
in the
latter,
was introduced
by
a neutral
description
of the trait
(ie,
interest in details for circumstantiality).
Subjects
Four
groups totalling
48
subjects
were
tested.
Twenty-seven patients
with uni
lateral
spike
foci in the
temporal
lobe were
selected
according
to standard EEG crite
ria.70 All
patients
had
experienced psycho-
motor seizures
by
clinical
description.65
71
None had additional
neurologic
disease as
the
diagnosed cause of seizures or had
undergone temporal
lobe resection prior
to
testing.
The
epileptics
were chosen without
regard
to
psychiatric history; they
were
drawn from five
general epilepsy
clinics.
The
epileptic sample
consisted of 15
patients
with right temporal (RT)
and 12
with left
temporal
foci
(LT).
The minimum
age and education levels were 17
years and
eight completed grades.
None of the
patients was dyslexic.
A control
group
(C) was
composed
of 12
normal adults estimated to be
comparable
to the
epileptic patients
in age, education,
geographic distribution,
and socioeconomic
level. These included technical and clerical
employees
of the National Institutes of
Health
(NIH)
and of a midwestern state
agency. Nine
patients
under treatment at
the NIH for neuromuscular disorders
constituted a contrast
group
with neuro
logic
disease
(N).
This group included six
patients
with
progressive myopathie or
neuropathic weakness,
two with life-
threatening
motor
system
disease
(amyo-
trophic
lateral
sclerosis),
and one with a
peripheral sensory neuropathy requiring
multiple amputations.
A
description
of
subjects
and their raters
is
given
in Table 3. The two
groups of
Table
2.Sample
Items
Trait Personal
Inventory (Patient)
Personal Behavior Survey (Rater)
Aggression
I have a
tendency
to break
things
or hurt
people
when I
get angry.
Has a
tendency
to break
things
or hurt
people
when
angry.
Sadness I have often felt close to
ending my
life.
Has often felt close to
ending
his or her life.
Circumstantiality I have trouble
getting
to the
point
because of all the
details.
Has trouble
getting
to the
point
because of all the details.
I believe the Bible has
spe
cial
meaning
which I can
understand.
Religiosity
Believes the Bible has
special
meaning
which he or she can
understand.
Table
3Description
of
Subjects
and Raters
Temporal
Lobe
Epileptics
Right
Left
Contrast
Group
Neurologic
Control
Subjects
Number 15 12 12
Age, yr
(mean [range])
32.8
(20-54) 31.7(17-46) 46.0(26-64) 33.7(20-48)
Sex, M/F 6/9 9/3
6/3 7/5
Education:
highest
grade completed
(mean [range])
12.1
(8-18) 12.6(9-18)
12.7
(9-17) 14.3(12-18)
Age
at onset
of Illness,
yr
(mean [range]) 13.9(2-31)
12.2
(1-32)
33.6
(6-63)
Duration of
illness,
yr
(mean [range]) 18.7(6-35)
20.0
(8-35)
12.4
(1-48)
Seizure
frequency,
seizures per month
(mean [range])
6.1 (0-20) 3.8 (0-20)
Raters
Age, yr
(mean [range]) 45.7(18-61) 38.8(19-70) 45.9(26-68) 36.8(20-58)
Sex, M/F 4/11 1/11 2/7 5/7
Education:
highest
grade completed
(mean [range])
12.7
(9-20) 12.7(8-18) 12.9(12-16) 14.9(11-20)
Sex of
patient/sex
of rater
M/M
M/F
F/M
F/F
Relation of rater
to
patient:
Family
member
Spouse
Friend
Professional
temporal epileptics
were comparable
in all
sampled
characteristics. The neurologic
patients
were older
(P
<
.025)
and had a
later onset of illness
(P
<
.01)
but experi
enced similar durations of illness
compared
to the
epileptic groups.
The
patient groups
had achieved similar education
levels;
the
normal
subjects completed
more
schooling
(P
<
.05).
None of the rater characteristics
differed
significantly among groups.
Nonetheless, sampling
variations in sex of
subject, subject-rater
sex
pairing,
and
rater
relationship
to
patient
were explicitly
considered in
evaluating
behavioral dis
criminations between
groups.
Administration
Prior to
testing, social, medical,
and
psychiatric
information was
requested
of
each
subject.
For the
patient groups,
clinic
records were also utilized in
coding
epidemiologie
variables.
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Subjects and raters then
independently
completed
the Personal
Inventory
or Per
sonal Behavior
Survey, respectively,
check
ing every item "true" or "false."
Covering
instructions on both forms
requested
an
"immediate,
honest
response"
to each
statement about
"personal habits, prefer
ences, feelings,
and
beliefs"; it was
empha
sized that "there are no
right
or
wrong
answers." To
encourage candor,
all
subjects
were assured that
scoring
and
processing
would be
computerized
with
anonymity
preserved.
No
patient was tested while
hospitalized
for
psychiatric illness;
the
majority
com
pleted questionnaires during
routine out
patient
visits. No
epileptic patient was
tested within 24 hours of a clinical seizure.
This was a precaution
to assure assessment
of
stable,
interictal characteristics of
behavior rather than transient features of
a
peri-ictal
confusional state.
RESULTS
Characterization
of
Temporal
Lobe
Epileptics
Total
Scores.Figures
1 and 2 sum
marize the
performance
of all
groups
as
self-reported (1)
or evaluated
by
observer
(2).
Since each trait was
assessed
by
five
items, possible
scores
ranged
from 0 to
5,
the most extreme
degree
of the trait. Scores on the ten
MMPI-derived items are illustrated
separately;
these have been halved to
fall within the same
range.
The
grand
means over all traits are illustrated to
the
right
in both
figures.
Scores were
evaluated
by two-way analysis
of vari
ance with
repeated measures; specific
differences were tested
by
the
Scheffe
multiple comparison proce
dure.72
Temporal epileptics assigned
them
selves
higher
scores
(Fig 1)
and were
rated more severe overall
(Fig 2)
than
the
nonepileptic comparison groups.
Self-description (P
<
.0001)
and rater
evaluation
(P
<
.0005)
differentiated
both
right
and left
temporal epileptic
groups
from the
neurologic patients.
There were no
significant
differences
in
patient
or observer mean scores
between the two
epileptic groups
or
between the
neurologic
and control
group.
Trait Profiles.-Traits differed in the
capacity
to differentiate
groups
(P
<
.004).
To
identify
the character
istics most
discriminating
of
temporal
epileptics, one-way analysis
of vari-
ance was
performed
on each set of
trait scores. Traits are ranked
by
univariate F value on the horizontal
axis of
Fig
1 and 2. For each data
set,
the most discriminant traits
appear
to
the left. The
significance
of
epileptic
vs
nonepileptic, right temporal
vs left
temporal,
and
neurologic
vs control
differences are summarized for each
trait above the
profiles.
On the Personal
Inventory, epilep
tics scored
significantly higher
than
the contrast
groups
for each of the 18
traits,
while MMPI-derived items did
not discriminate the
epileptic patients
(Fig 1).
Observers identified
epileptic
patients by
14 traits.
Again,
MMPI
items did not differentiate
epileptic
from contrast
subjects (Fig 2).
In
contrast to the
specificity
of most
traits for
epileptic patients, only
three
differences between
neurologic pa
tients and controls were
significant,
which is within chance
expectation
for
multiple comparisons.
There were both similarities and
differences
between traits
empha
sized
by epileptic patients
and their
raters.
Thus, circumstantiality
and
dependence
were
extensively
self-
reported
and described.
However,
the
most discriminant
self-reported
ten
dencyhumorlessnessappeared only
ninth
among
characteristics noted
by
raters. On
the other
hand,
sadness
(including
features of
depression)
was
more
emphasized by
observers
(fourth)
than
patients (14th).
The most discriminant individual
traits
suggest
both a
profile
of
temporal epileptic patients
and a basis
for their identification. In self-
descriptions, they
were
subjects
who
emphasized
humorless
sobriety,
de
pendence, circumstantiality,
and
per
sonal
destiny. They
were seen
by
others as
circumstantial, obsessional,
dependent,
and
sad.
Profiles based on the
analysis
of
variance would involve
many traits,
some
tapping highly
similar behav
iors. To
develop
a more concise
account of
temporal epileptic patients,
trait scores were submitted to
step-
wise discriminant
analysis.73
This
multivariate
procedure, starting
with
the most discriminant
characteristic,
incorporates
each additional trait to
further the identification of
epileptic
patients.
The
algorithm yields
a short
ened list of traits that nonredun-
dantly
characterizes the
temporal
sub
jects.
The
accuracy
of the
description
is
reflected
in a
percentage
of
accurate identification.
A discriminant combination
of self-
reported humorlessness, dependence,
and obsessionalism
correctly assigned
90% of
subjects
to the
epileptic
or
contrast
group.
These three
traits,
listed in order of
decreasing
discrimi
nation,
were selected to
identify
inde
pendent aspects
of the
temporal
epileptic profile.
From the observations
by raters,
circumstantiality, philosophical
inter
est,
and
anger comprised
a discrimi
nant
profile
of the
temporal epileptics.
Based on these
traits,
92% of the
subjects
were
correctly
identified
by
diagnosis.
Item
Analysis.To
increase the
spe
cificity
of
description
of
temporal
epileptics,
we
sought
to
identify
the
source and nature of individual items
that
effectively
discriminated
these
patients. One-way analyses
of vari
ance were
performed
on each of the
100
patient
and rater items. Based on
this
procedure,
Table 4 summarizes
the
capacity
of trait items to
identify
temporal subjects.
The
majority
of
trait items were
individually
effec
tive. At least one item from each of
the 18 traits was discriminant in self-
reports;
from rater
responses, only
hypergraphia
lacked a discriminant
item.
By contrast,
items derived from
the MMPI Lie Scale were
equivalently
answered
by
and
applied
to
epileptics
and
nonepileptics.
This differential
discrimination
(P
<
.001)
is evidence
for the
specificity
of the trait
descriptions.
Profiles of
temporal subjects
de
rived
from
stepwise
discriminant
analysis
of item
responses
are summa
rized in Table 5.
By utilizing
the most
effective individual
items,
the
preci
sion of discrimination was
improved
so
that,
from either
patient
or rater
scores,
47 of 48
subjects
were
correctly
classified.
These
profiles complement
and ex
tend those
developed
from trait
scores. Items from each trait of the
discriminant three-trait clusters were
included in the
corresponding
seven-
Downloaded From: http://archneur.jamanetwork.com/ on 06/19/2012
item
patient
or rater
profile;
these are
noted in Table 5.
Additional items selected were
closely
related to the
original
clusters
as indicated
by
the
groupings
of the
Table. Obsessional
and circumstantial
items dealt with attention to details.
Questions
from
personal destiny, hy-
pergraphia,
and humorlessness em
phasized
sober reflection on and
recording
of minor events to which
patients
attributed covert
signifi
cance.
Religious
and
philosophical
items involved a search for
underlying
meaning
in the Bible or
philosophical
texts. The rater items from emotion
ality, anger,
and sadness were similar
in
stressing
overt
displays
of
strong
affect.
The discriminant
profiles identify
features of behavior
(obsessionalism,
circumstantiality,
and
dependence),
thought (philosophical
and
religious
interests,
sense of
personal destiny,
hypergraphia,
and
humorlessness),
and emotion
(mood swings, anger,
and
sadness)
that
distinguished temporal
epileptic patients
from either contrast
group.
Differentiation of
Right
From Left
Temporal Epileptics
Differences in
Profile.Although
right
and left
temporal epileptics
did
not differ in overall mean
scores,
significant
differences were observed
at the trait level.
Right temporal
epileptics reported
more
elation;
left
temporal epileptics
described more
anger, paranoia,
and
dependence
(P
<
.05; Fig 1). Right temporal
epileptics
were rated
higher
in obses
sionalism
(P
<
.05), viscosity,
emo
tionality,
and sadness
(.5
< <
.1);
left
temporal epileptics
were seen to
demonstrate the
greater
sense of
personal destiny (P
< .05; Fig 2).
To increase the
precision
of
right-
left
differentiation,
we
employed
the
analysis
of variance to
identify
those
individual items that
significantly
differentiated the two
epileptic
groups (P
<
.05).
This was done
sepa
rately
for
patient
and rater
responses.
From
patient responses,
nine dis
criminant
items were identified.
Ranked in order to
decreasing
dis
crimination, paranoia (1), anger (2, 8),
COMPARISON
Epileptic
vs o o o o

- 2 S S

Q
Nonepileptic
o o o
p o o o o o o
TRAITS (Order
of
Decreasing
Discrimination!
Fig 1.Self-reported
behavioral
profiles.
Traits are ordered
by decreasing ability
to
separate epileptic
from
nonepileptic subjects (analysis
of
variance).
Mean scores over all
traits are shown at
right.
LT indicates
left
temporal epileptics;
RT,
right temporal
epileptics; N,
contrast
group
with
neurologic
disease; and C, control
group.
COMPARISON
Epileptic
vsgggssss^^,.^,.,-^
Nonepileptic
Q
S
p
S S S S
ppppppp
TRAITS (Order
of
Decreasing Discrimination)
Fig
2.Rater
profiles.
Traits are in order of
decreasing
discrimination (analysis
of
variance).
Mean scores are shown at
right.
LT indicates left
temporal epileptics;
RT,
right
temporal epileptics;
N,
contrast
group
with
neurologic
disease;
and C,
control
group.
Downloaded From: http://archneur.jamanetwork.com/ on 06/19/2012
Table
4.Identification
of
Temporal Epileptics:
Trait vs Minnesota
Multiphasic
Personality Inventory
Derived Items
Responses
Source
of Items
No.
Discriminant'1'
No. Non-
discriminant
%
Discriminant
Selff
Traits 64 26
MMPI-Ue Scalei
10
71
Ratert Traits 58 32
MMPI-Lie Scale 10
64
" <
.05.
tP< .001.
JMMPI
indicates Minnesota
Multiphasic Personality Inventory.
Table 5.Profile of
Temporal Epileptic
Patients Based on Item
Responses*
Source
Order of Item
Incorporation
Trait
Item
Self-report
1,7
Personal
destiny
Humorlessnesst
Hypergraphia
Obsessionalismt
Circumstantiality
Dependencet
Rater
report
Circumstantialityt
Obsessionalism
Emotionality
Angerf
Sadness
Religiosity
Philosophical interest!"
*ln the
self-report,
26 actual
epileptics
were classified
epileptic
and one was classified
nonepilep-
tic. Of the actual
nonepileptics,
none was classified
epileptic
and 21
patients
were
correctly
classified
nonepilepfic (classification accuracy, 98%).
In
the rater
report,
27
actual epileptics
were classified
epileptic
and none was
categorized nonepilepfic.
Of the actual
nonepileptics,
one
patient
was
classified
epileptic
and 20,
nonepilepfic (classification accuracy, 98%).
tThese traits were included
in
the discriminant
profiles
derived from trait scores.
dependence (3, 9), religiosity (4),
sadness
(5), philosophy (6),
and humor
lessness
(7)
were
represented.
In each
case,
the nature of the discrimination
was a
higher
score for left than
right
temporal epileptics.
There was thus a
significant tendency
for left
temporal
epileptic patients
to describe them
selves more
severely (P
<
.004).
A
stepwise
discriminant
analysis
identi
fied six items on the basis of which all
epileptic subjects (15/15, 12/12)
were
accurately
lateralized. While the
sepa
ration showed left
temporal epileptics
exceeding right temporal epileptics
in
reporting multiple traits,
the initial
(most powerful)
discriminations re
flected the
greater reporting
of social
ly disapproved traits-anger
and
para
noiaby
left
temporal epileptics.
Observers also discriminated
be
tween
right
and left
temporal epilep
tics,
but on a different
basis,
as
summarized in Table 6.
Significant
qualitative
differences between the
groups
were reflected
by
the number
and discriminative
power
of listed
items
(P
<
.001).
The
right group
was
distinguished
by
items
stressing externally
demon
strated affect. This was manifested in
unusual sexual
attractions,
remon-
strations of
helplessness, periods
of
sadness,
emotional
arousability,
or
moralistic fervor. A second
type
of
item
involving
overconcern
with de
tails and orderliness also character
ized the
right temporal epileptic group
more than the left.
Left
temporal patients
were identi
fied with a sense of
personal destiny
and a concern for
meaning
and
signif
icance behind events. Related
items
emphasized powerful
forces
working
with one's
life
(paranoia)
and the need
for sober intellectual and moral self-
scrutiny (humorlessness,
conscien
tiousness).
To determine the most concise
combination of items that would
differentiate
right
from left
temporal
epileptics, stepwise
discriminant anal
ysis
was
performed (Table 7).
Four
items,
all
previously
selected
by
uni-
variate
analysis
of
variance,
were
able,
in
combination,
to
classify
26 of
27
patients by laterality. Consistently,
right temporal epileptics
were identi
fied with
changes
in affective drive or
behavior,
left
temporal epileptics
with
intellectual and moral
contemplation.
Factor
Analysis.To codify
the dis
tinctions between
group profiles,
we
sought
to
identify underlying
rela
tionships
within the set of traits.
Inspection
of trait correlation ma
trices for
each
of
the
groups justified
pooling
the 48
subjects
to extract
prin
cipal component factors.
Factor anal
ysis
was
performed separately
with
subject
and rater scores to assess the
generality
of the
underlying
factors.
In either
subject
or rater
analysis,
the first two
principal components
accounted for a
large percentage
(60.3%, 56.3%)
of
the total variance.
Their factor structures are
presented
in Table 8.
Subject
and rater factor
structures were
highly similar, sup
porting
the
generality
of the under
lying
association of traits. Factor 2 as
well as factor 1 was
strongly repli
cated,
since the inversion of
polarity
between
subject
and rater forms has
no
empirical significance.
Factor 1
appeared
to be a
general
factor, establishing
that all 18 traits
shared a familial
relationship
of inter-
correlation. The entire cluster tended
to
appear
in the
temporal epileptic
groups, accounting
for variance be
tween
patients
and contrast
subjects.
The MMPI-derived
items did not load
significantly
on this
factor, which,
with the results of Table
4,
excluded
the
interpretation
of a
nonspecific
response tendency.
Since all traits
loaded in the same
direction, principal
component
scores on this factor would
represent
a
weighted
sum of trait
scores 74 and constitute a measure of
quantitative severity.
In contrast to the unidirectional
factor
1,
factor 2 had a bivalent struc
ture of
loadings.
This factor identified
two
qualitatively
different
clusters of
traits that had a
negative
intercorre-
Downloaded From: http://archneur.jamanetwork.com/ on 06/19/2012
lation.
Overtly
emotive
(anger, ag
gression,
and
emotionality)
vs idea-
tional,
ruminative
(religiosity,
humor
lessness, personal destiny,
and
philos
ophy)
traits defined the
bipolar
ends
of the factor. The modified MMPI
items loaded
strongly
at the ideative
end of the continuum. While unin
tended,
this result was understand
able since
many
Lie items
probed
extremes of
sober, intellectually
rumi
native behavior: "I read
every
edito
rial in the
newspaper;
At
elections,
I
never vote for men about whom I
know little."
Thus,
each score on this
factor would
represent
the net
posi
tion,
calculated as a
weighted alge
braic
sum,
of a
subject
on the emotive-
ideative
qualitative
axis.
Scores derived from these factors74
are
plotted
in
Fig 3;
these were evalu
ated
by analysis
of variance. From
subjects' self-descriptions, epileptic
groups
were
easily distinguished
from
nonepileptics
on factor 1
(P
<
.001).
However, subject
scores did not
differentiate
groups along
the emo-
tive-ideative axis.
Specifically, right
and left
temporal epileptics gave qual
itatively
similar accounts of them
selves.
The raters
presented
a different
account.
Again,
scores on factor 1
allowed identification of
epileptics
(P
<
.001). However,
raters distin
guished
left
temporal epileptics
as
qualitatively
different from
any
other
group
in the ideative
emphasis
of
their
responses (P
<
.05).
This allowed
a
separation
from
right temporal
epileptics
on factor 1
(P
< .025). Right
temporal epileptics
were
unique
in
profile (P
<
.05); judged
most severe
overall,
the character of their
responses
had an emotive
emphasis.
Although
their mean score on factor 2
was less than the
control,
the five
subjects
with the
highest
emotive
scores in the total
sample
were
right
temporal epileptics.
To evaluate the
specificity
of an
emotive-ideative classification in dis
tinguishing right
from left
temporal
epileptics, principal component
scores
were derived for each
subject
from
responses
to the
discriminating
items.
These were calculated
by multiplying
the relevant
factor
matrix, using
the
loadings
of Table
8, by
the data
Table 6Observed Differentiation
of
Right
From Left
Temporal Epileptics
Differentiation
Univariate
Rank Trait
Membership
Items
Individually
Discriminant:
Univariate-Analysis
of Variance
Right temporal epileptics
characterized more than left
Sexual
alteration
Dependence
Sadness
Viscosity
Circumstantiality
Emotionality
11
Hypermoralism
12 Obsessionalism
14 Obsessionalism
16 Obsessionalism
13.50
< .001
12.74 <
.001
7.67
6.14
5.52
5.34
5.06
5.01
4.79
4.38
< .01
<
.05
<
.05
< .05
< .05
< .05
<
.05
< .05
Left
temporal epileptics
char
acterized more than
right
Personal
destiny
Personal
destiny
Personal destiny
10 Paranoia
13 Humorlessness
15
Conscientiousness
(MMPI)'
13.72 <
.001
8.08
5.75
5.07
4.88
4.56
< .01
<
.05
< .05
<
.05
<
.05
*MMPI indicates Minnesota
Multiphasic Personality Inventory.
Table 7.Observed Differentiation of
Right
From Left
Temporal Epileptics*
Order of
Incorporation
Trait
Membership
Unlvariate
Rank Differentiation
Stepwise
Discriminant
Analysis
1 Personal
destiny
LT > RTt
Conscientiousness
15 LT
> RT
Obsessionalism 16
RT > LT
Sexual alteration RT > LT
"Of the actual
right temporal epileptics,
14
patients
were classified as
right temporal
and one,
left
temporal.
Of the actual left
temporal epileptics,
none was classified
right temporal
and 12
patients
were classified as left
temporal.
tLT
> RT indicates that
personal destiny
characterized left
temporal epileptics
more than
right
temporal epileptics.
matrix of rater
responses
to differen
tiating
items.74 Standardized mean
scores are
plotted
in
Fig 4A; signifi
cance was assessed
by analysis
of vari
ance.
The
severity
factor
distinguished
either
epileptic group
from
the con
trast
patients (P
<
.001). Right
tem
poral epileptics
were evaluated as
significantly
more severe than left
temporal epileptics (P
<
.05),
in con
trast to the
greater severity
self-
reported by
left
temporal patients.
(This
difference must be
interpreted
in the
light
of sex effects
presented
below.)
Based on factor
2,
there was a
double dissociation
of
right
and left
temporal epileptics
from the contrast
groups.
The
right temporal epileptics
were rated more emotive
(P
<
.001),
the left
temporal epileptics
more idea
tive
(P
<
.005)
than either of the
control
groups,
which did not differ
significantly. Right
and left
temporal
epileptics
were
clearly separated
on
this dimension
(P
<
.001).
These differences in
profile
(P
<
.001)
are reflected in the two-
dimensional
scattergram
of
Fig
4B.
The ordinate
separates
all
right (emo
tive)
from left
(ideative) temporal
epileptics;
the most extreme emotive
or ideative
subjects belong respec
tively
to
right
or left
temporal groups.
On
the
severity axis, epileptics
are
generally
located above contrast sub
jects; neurologic patients extensively
Downloaded From: http://archneur.jamanetwork.com/ on 06/19/2012
Table
8.Principal Components
Factor
Analysis
Trait
Rater
Factor
Loading
Patient
Factor
Loading
Factor 1:
Severity*
Obsessionalism 848
-.735
Emotionality .828 -.849
Dependence -.808 -.762
Paranoia -.801
-.788
Sadness -.797 -.615
Viscosity -.788 843
Guilt -.776 -.806
Circumstantiality -.768 -.835
Aggression
-.699 .672
Anger -.663 698
Humorlessness -.648
.716
Hypermoralism
-.636 -.566
Religiosity -.634 -.600
Elation -.589 -.482
Sexual alteration -.582
.637
Personal
destiny
-.562 .730
Hypergraphia
-.516 .713
Philosophical
interest -.352
-.592
MMPI-Lie Scalet .108 -.113
Factor 2: Emotive-ldeativet
Anger .338 -.388
Aggression .295 -.477
Emotionality
.274 -.039
Obsessionalism .211
-.291
Hypermoralism .129 .025
Sadness .114 -.466
Viscosity
.104
-.148
Dependence
.086 -.072
Elation .077 .288
Sexual alteration .072 -.160
Guilt -.003 -.200
Circumstantiality -.039 .020
Paranoia -.076 -.074
Hypergraphia -.235 .280
Religiosity -.325 .430
Humorlessness
(sobriety) .332 .323
Personal
destiny
-.471 .457
MMPI-Lie Scale: conscientiousness -.733 .747
Philosophical interest -.756 .540
"Factor 1:
r,,,,
=
0.822
(P
<
.001).
tMMPI indicates Minnesota
Multiphasic Personality Inventory.
Factor
2:
r,,,
=
-0.883
(P
<
.001).
overlap
normal
subjects. Thus,
the
upper
two
quadrants,
severe-emotive
and
severe-ideative,
concentrate
right
and left
temporal epileptics, respec
tively.
Differences in Patient-Rater
Agreement
Between
Right
and Left
Temporal Epileptics
Right temporal epileptics
were dis
tinguished
from left both in self-
report
and rater evaluation. As
noted,
the bases of
separation
were differ
ent. This
suggested
that the
epileptic
groups gave
a different
profile
of
themselves from that
supplied by
raters
(Fig
1 and
2).
Figure
3 allows direct
comparison
of
patient
vs rater assessment of each
group.
The relative
severity
of
right
and left
temporal epileptic groups
is
reversed between
patient
and rater
accounts
(.05
< <
.1),
while con
trast
groups
maintained similar val
ues. On factor
2, right temporal
epileptics reported
themselves
signifi
cantly
more ideative than did raters
(P
<
.05);
left
temporal epileptics
overemphasized
emotive
qualities
(P
<
.02).
Neither of the contrast
groups
differed
significantly
from
their raters
(P>.1).
Patient-rater
disagreements
were
significantly
dif
ferent in
right
and left
temporal
epileptics (P
<
.005).
To
identify specific discrepancies
between
patient
and rater
accounts,
difference scores were constructed for
subjects by subtracting
each rater
response
from the
corresponding
sub
ject
item. Patient-rater
agreement
then
produced
a difference score of
0;
positive
differences indicated
patient
overreport,
and
negative
differences
showed
under-report
of a rated vari
able.
Averaged
over all
traits,
the left
temporal epileptics consistently gave
more severe self- than rater-evalua
tions. The left mean difference score
was
greater
than that of
any
of the
other
groups (P
< .01),
which did not
differ
significantly.
The
right tempo
ral
group
was
distinguished by
its
variability
over traits
(P
<
.01); right
temporal epileptics strongly
underre-
ported
some
qualities
and overre-
ported
others
compared
to raters'
accounts.
The most
significant
difference
among
traits was in the
reporting
of
sadness,
which included
signs
of clin
ical
depression (P
<
.001).
The
right
temporal patients
minimized or de
nied these tendencies
compared
to
raters'
observations,
while the left
temporal patients emphasized
them.
Thus,
left
temporal epileptics
self-
reported
more sadness than
right
temporal epileptics (Fig 1),
but
right
temporal patients
were evaluated as
the more
depressed (Fig 2).
A similar
pattern
of
underreporting by right
temporal epileptics
and
overreporting
by
left
temporal patients separated
groups
on
obsessionalism, dependence
(P
< .05), anger,
and the tenden
cy
to
punitive hypermoralism
(.05
< <
.1).
A different
profile
of
subject-rater
disagreement
differentiated
groups
on
personal destiny, guilt (evaluated
as
personalized
moral concern and
self-scrutiny),
and conscientious be
havior
(.05
< <
.1). Right temporal
epileptics
tended to
exaggerate
these
qualities.
The MMPI items showed a
specific discrepancy
in the left
tempo
ral
group,
for which raters acknowl
edged substantially
more conscien
tious behavior
(good
table
manners,
Downloaded From: http://archneur.jamanetwork.com/ on 06/19/2012
polite language, etc)
than
patients
self-reported.
On the basis of
patient-rater
dis
crepancies,
left and
right temporal
groups
differed on three traits at
< .05 and on an additional five
traits at < .1;
this is
significantly
greater
than chance
expectation
(P
<
.001).
The difference between
the
neurologic
and control
groups
approached significance
on
only
one
trait,
which is within
expectation.
Their scores were
generally
interme
diate between left and
right values,
close to zero over all traits
(Fig
5
and
6).
Trait difference scores were sub
jected
to a
stepwise
discriminant anal
ysis
to evaluate the
consistency
of
right-left temporal epileptic
differ
ences. Three traits were included in
the discriminant function: sadness
(denied by right temporal epileptics,
emphasized by
left
temporal epilep
tics), guilt
reflected as
self-scrutiny
(exaggerated by right temporal pa
tients),
and concern for
personal
destiny (exaggerated by right tempo
ral
epileptics).
Based on this
profile,
all 15
right temporal epileptics
and ten
of 12 left
temporal patients
could be
correctly
classified
by laterality.
When item scores were
similarly
analyzed,
a four-item
profile
was
developed
that
produced perfect
right-left temporal epileptic
differen
tiation. In the
discrimination,
sadness
and
aggression
were minimized
by
right temporal patients
and
exagger
ated
by
left
temporal patients;
con
scientious behavior was
emphasized
by right temporal epileptics
and
minimized
by
left
temporal epileptics.
Thus,
a
pattern
of trait
specific
denial
or
exaggeration
was a reliable feature
differentiating right
from left
tempo
ral
epileptics.
To
generalize
the basis of this
discrimination,
we utilized the anal
ysis
of variance and identified 12
items that
by patient-rater
differ
ences
separated right
from left tem
poral epileptics (.01
< <
.05).
In
general,
the items selected were not
those
discriminating
in the
previous
analyses
of
patient
or rater
profiles.
This
supported
an
independent
differ
entiation,
based on
patient-rater
dis
crepancies,
between the
epileptic
SELF
REPORT RATER REPORT
Severe Ideative
Normal
Emotive
-1.0
o-o RT
-
LT
g-ON
-*
C
+
1.0
-
Severe Ideative
Normal Emotive
Factor 1 Factor 2
Factor
1 Factor 2
Fig
3.Factor
profiles
derived from trait scores. Factor 1 :
severity.
Factor 2: emotive-
ideative. LT indicates left
temporal epileptics;
RT,
right temporal
epileptics; N, contrast
group
with
neurologic
disease;
and
C,
control
group.
Severe
Normal
Factor 2
- 1.0
Emotive
1.0
Severe
-2r*
D-o RT
- LT
3-
-a
C
~
2L
Normal
Factor
1

+
1
+ 2
Factor 2
Fig
4.Factor scores derived from discriminative items.
A,
Mean factor scores. Factor 1 :
severity.
Factor 2:
emotive-ideative. B,
Scattergram
of all
subjects by
factor scores.
Circled
symbols
indicate mean coordinates for
groups.
LT indicates left
temporal
epileptics;
RT,
right
temporal epileptics; N, contrast group with
neurologic
disease;
and
C, control
group.
groups (
<
.001).
Responses
of all
subjects
were used
to
group
the items
by
cluster
analysis
(McKeon
hierarchical cluster
algo
rithm)
and
by principal component
analysis.74
The
procedures
were con
gruent, yielding
two distinct clusters
of items that
segregated
at
opposite
polarities
of the first
principal compo
nent.
The
negative loading
cluster
(1)
included items from
sadness,
obses
sionalism, dependence, anger,
and
aggression.
These involved
depres
sion,
suicidal
feelings, explosive
tem
per, peevish
irritation to
disturbance,
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0.4
r
+0.3
+
0.2
a +0.1
-0.1
-
-0.2
-0.3
Cluster 1
Disapproved
Items
Cluster 2
Approved
Items
Fig 5.Patient-rater discrepancies. Mean
scores for cluster 1
(socially disapproved
items)
and cluster
2
(socially approved
items).
RT
indicates
right temporal epilep
tics; LT, left
temporal epileptics; N,
contrast
group
with
neurologic
disease;
and
C, control
group.
and
inappropriate dependence
on oth
er
people.
This was a cluster of
dysphoric, socially unacceptable
ten
dencies.
In
contrast,
the
positive
cluster
(2)
stressed
self-worth,
the
ability
to see
meaning
behind
suffering (personal
destiny), exceptional personal
eti
quette, prompt
attention to
obliga
tions
(conscientiousness),
and minimal
sexual needs
(sexual alteration).
These
qualities
were
socially
valued.
Group responses
to the clusters are
shown in
Fig
5. Vis--vis raters'
assessments,
left
subjects exagger
ated
negative qualities (P
<
.001).
Right patients
exhibited the
opposite
inclination:
compared
to control
sub
jects
who
agreed closely
with
raters,
they
denied the
dysphoric
tendencies
(P
<
.05). Right
and left
temporal
epileptics
were thus
sharply separated
(P
<
.001).
The
configuration
was reversed
for
positively
valued items.
Right tempo
ral
epileptics exaggerated
their
pos
session of desired
qualities (P
<
.05)
while left
temporal patients
tended to
minimize
positive
behavioral features
that raters
perceived (.05
< <
.1).
The
profile
difference between
right
+ 1.0
-1.0
-
Fig
6.Distortions of
self-image.
Compar
ison of
groups
based on principal compo
nent scores. LT indicates
left
temporal
epileptics; RT,
right temporal epileptics; N,
contrast
group
with
neurologic
disease; C,
control
group.
and left
temporal epileptics
was
high
ly significant (P
<
.0001).
The
classification of items
by
social
desirability,
which was derived from
patient-rater discrepancies,
could be
distinguished
from the
prior separa
tion of
ideative vs emotive
qualities.
For
example,
an item
indicating
lack
of a sense of humor fell in the
nega
tive
cluster,
consistent with its disso
cial
implications.
Other items from
humorlessness,
which stressed intel
lectual
probity,
sorted
positively.
An
item
exploring
unusual sexual
prac
tices loaded
strongly
in the
negative
sense;
this was denied
by
all
right
temporal patients
but affirmed
by
one
third of their raters.
However,
a de-
emphasis
of
sexual needs clustered
with
positive items;
its extent was
exaggerated by right temporal pa
tients.
Thus,
items from the same
trait
category
sorted
differently,
de
pending
on
acceptability. Disapproved
affects
(anger, aggression,
and sad
ness)
clustered
negatively;
items
sug
gesting
elation and
appropriate
emo
tionality
sorted with
positive quali
ties.
In
principal component analysis,
items of clusters 1 and 2 were
sepa
rated at their
respective polarities
of
the first
principal component.74
The
score on this
component
thus reflects
the
algebraic
sum of a
subject's exag
geration
of
positive (
+
)
and denial of
negative () qualities.
Extreme scores
of either
sign
indicate distortion of
the
subject's image
relative to rater
evaluation; scores near 0 are consis
tent with close
patient-rater agree
ment.
A
positive
score connotes
image
"polishing,"
since
it resulted when a
subject exaggerated
desired
qualities
and denied
disapproved
ones.
Nega
tive scores
express "self-tarnish,"
since such a
subject
had both
exagger
ated weaknesses and minimized
strengths.
Figure
6 summarizes these tenden
cies
among
the four
groups.
There was
a double
dissociation,
since the
right
temporal patients significantly "pol
ished"
(P
<
.005)
and the left
tempo
ral
patients
"tarnished"
(P
<
.005)
relative to either contrast
group.
The
epileptic groups
were
maximally sepa
rated
by
this dimension
(P
< .001).
Additional
Differentiating
Variables
Additional variables that
might
dif
ferentiate
groups
or bias the
interpre
tation of test scores were considered.
Table 9 summarizes
aspects
of
psy
chiatric and social
history. Although
no
patient
was tested in a
psychiatric
hospital
or while
judged psychotic, by
history,
one third of the
temporal
epileptic patients
had
undergone psy
chiatric
hospitalization.
This was a
significant prevalence (P
<
.02)
and
agreed closely
with a recent
survey
of
psychiatric
hospitalization among
temporal epileptics attending
a
gener
al
epilepsy
clinic
(W. Weir, MD,
unpublished data,
June
1976).
Within the
right temporal group,
patients previously hospitalized
ob
tained more severe self or rater scores
(P
<
.05).
In the
left
temporal group,
hospitalized patients
scored
higher
(P
<
.05)
but were not rated more
severe.
After deletion of
patients
with a
history
of
psychiatric hospitalization,
analysis
of variance was
repeated
on
both
subject
and rater scores. In both
analyses,
the
remaining epileptic pa
tients were
readily distinguished
from the contrast
subjects
(P
<
.001).
Although
the
type
of
psychiatric
disease
(schizophrenia
vs affective
disorder)
did not differ between
right
and left
temporal groups,
the
only
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patient
with a
history
of manic
episodes
had a
right temporal
focus.38
Suicide attempts
were
frequent
in
both
epileptic groups (P
<
.01),
often
in a
setting
of
depression.
Two
right
temporal epileptics
and one left tem
poral patient
had been convicted of
violent crimes
(P
<
.1); equal
numbers
(2)
of
neurologic
and
epileptic patients
had committed nonviolent crimes.
Sexual differences were evaluated
by analysis
of variance. Patient scores
did not reflect sex or sex interaction
effects.
Among
rater
scores,
female
subjects
received
higher
scores overall
than males
(P
<
.02).
This was true
for both
epileptic
and the normal
groups,
and
may
reflect cultural
assumptions. However,
within
groups,
the sex effect
only
reached
signifi
cance
among
left
temporal subjects
(P
<
.05).
Two left
temporal epileptic
women had been
hospitalized
with the
diagnosis
of
paranoid schizophrenia,
and another had
attempted
suicide.
While this
sample
is
small,
the results
are in
harmony
with
previous
observa
tions of severe
psychiatric pathologic
conditions
among
left
temporal epi
leptic
women.75
Since the
right temporal group
contained a
(nonsignificantly) higher
percentage
of women than the
left,
it
was
necessary
to exclude sex differ
ences as a contaminant in
right-left
temporal patient
behavioral discrimi
nations. Sex was never a
significant
factor in
analyses
of
patient
scores.
However,
women were rated more
severe than men on factor 1
(Fig 4).
Thus,
the
right-left temporal patient
severity
difference
may
have been
influenced
by
the
greater
number of
women in the
right group.
More
critically,
the emotive-idea-
tive scores on factor 2 were not
influenced
by
sex
(P
<
.5),
and none
of the
items selected for the
stepwise
discriminant function was
sexually
differentiating (Table 6).
There was
no sex effect on
patient-rater
differ
ence scores. The differentiations be
tween the
right
and left
temporal
groups
could
not, therefore,
be conse
quences
of sexual distribution.
Differences
among
raters were also
considered as
possible
distortions in
group
differentiation.
Specific
anal
yses
excluded sex of
rater, patient-
Table
9.Psychiatrie
and
Dysocial
Disorders in
Temporal Epileptic
Patients*
Right
Temporal Epileptics
No.
(%)
Left
Temporal
Epileptics
No.
(%)
Psychiatric hospitalization
5
(33) 4(33)
Type
of
psychiatric diagnosis
Thought
disorder
3
(20) 2(16)
Affective disorder
2(13)
20
(16)
Suicide
attempt
3
(20) 4(33)
Violent crime
2(13)
1
(8)
There was no
history
of
psychiatric
or
dysocial
disorder for the control and
neurologic
contrast
subjects.
rater sex
pairing,
and relation of rater
to
patient (family
member vs
spouse)
as
biasing
factors.
To evaluate the
consequences
of
sampling
variations
among groups
(Table 3), age,
education
level, age
at
onset of
illness,
and seizure
frequency
were correlated with behavioral
variables. Neither the
greater age
of
neurologic patients
nor the
higher
education level of control
subjects
accounted for
significant
variation in
trait scores.
Among patient groups,
the neuro
logic subjects
suffered illness with
later onset. Within this
group, ratings
on three traits correlated
positively
with
age
of onset. This contrasted
with
negative
correlations in both
epileptic groups
on six variables.
Thus, early
onset of
temporal epilepsy
but late onset of neuromuscular
disease were associated with more
extensive behavioral
effects, suggest
ing
different
underlying processes.
The later
average
onset of the neuro
logical group supplied
a conservative
bias, exacerbating apparent
behav
ioral
changes
in this
group.
Seizure
frequencies
were
compa
rable in
right
and left
temporal
epileptic groups.
There
was, however,
wide variation in
degree
of
seizure
control
(0
to 20
per month) among
epileptic patients.
It was therefore
striking
that seizure
frequency
showed no consistent correlation with
tabulated behavioral variables.
COMMENT
The
present study
identifies
psy
chological features, self-reported
or
observed,
which
reliably distinguished
patients
with
temporal
lobe foci.
These features did not
appear signifi
cantly
in
patients
with
other,
more
socially limiting
and
debilitating
neu
rologic
illnesses.
Although
unexam-
ined in the current
study, patients
with localized
epileptic
foci outside the
temporal
lobes do not
generally pre
sent abnormalities of emotion and
behavior.7"77 A consistent
profile
of
changes
in behavior
(obsessionalism,
circumstantiality), thought (religious
and
philosophical interest),
and affect
(anger, emotionality,
and
sadness)
thus
appears
to be the
specific
conse
quence
of a
temporal epileptic
focus.
It has been
possible
to
specify
discriminant
psychological
features
and to
distinguish
between those that
patients emphasize
in
self-report
and
those
conspicuous
on observation. This
results in considerable
descriptive
precision compared
to
epidemiologie
associations based on
psychiatric
diagnoses.
In
fact,
the most
power
fully
discriminant traits
(humorless
ness, dependence, circumstantiality,
and
philosophical interest)
do not
necessarily
connote
psychosis
or cor
respond
to
any
standard
psychiatric
descriptor.
Whereas all the
temporal
lobe
patients
were identified
by
the
discriminant
profile
above
(Table 5),
two thirds had never been described
as
psychotic.
Since
virtually
no correlation be
tween seizure
frequency
and behav
ioral variables was
significant,
it is
improbable
that the
psychological pro
file is a direct
consequence
of seizures.
By contrast,
duration of illness did
correlate with most behavioral
param
eters,
in
agreement
with
prior
find
ings
that
psychological changes
devel
op progressively
over
years
after
seizure onset.125 This
latency,
and the
stable, dispositional
character of
many
rated behaviors
(obsessional
ism, humorlessness,
and
dependence)
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also
argue against
the
possibility
that
tabulated
psychological changes
are
expressions
of
paroxysmal
subclinical
seizures.
Rather,
the behavioral
profile may
reflect
progressive changes
in limbic
structure
secondary
to a
temporal
lobe
focus. We have
previously suggested
that the set of 18 behavioral charac
teristics are related
by
an
underlying
mechanism: enhanced
affective asso
ciation to
previously
neutral
stimuli,
events,
or
concepts.24 Thus, experienc
ing objects
and events shot
through
with affective coloration
engenders
a
mystically religious
world
view;
if a
patient's
immediate
actions and
thoughts
are so
cathected,
the result is
an
augmented
sense of
personal
desti
ny.
A felt
significance
behind events
that others dismiss constitutes a seed
bed for
paranoia
or
may
confirm the
feeling
that the
patient
is a
passive
pawn
in the hands of
powerful
forces
that structure the world.
Feeling
fervently
about rules
and
laws
may
lead to action in which the
patient
"takes the law into his own hands."
Sensing
emotional
importance
in even
the smallest
acts,
he
performs
these
ritualistically
and
repetitively.
Since
details bear the
imprimatur
of affec
tive
significance, many
will be men
tioned in
lengthy,
circumstantial
speech
or
writing.
The
proposal
that an
epileptic
focus
in the
limbic system brings
about
enhanced affective associations
per
mits correlation with
theoretical2122
and
experimental2'
accounts that
anatomical connections
between sen
sory
and limbic structures are estab
lished within the
temporal
lobe.
Whereas destructive lesions
appears
to
produce sensory
limbic
dissociation
through disconnection,
it is our
sug
gestion
that the
epileptic process
brings
about functional
hyperconnec-
tion, leading
to a suffusion of
experi
ence with emotional coloration. The
effect of a
temporal
focus
may
be to
establish new functional connections
between neocortical and limbic struc
tures or to
disrupt
mechanisms that
normally
inhibit
fortuitous
sensory-
Iimbic associations.-1
Recent evidence
from
commissurectomized
monkeys
supports
the
possibility
that a cortical
epileptic
focus facilitates additional
functional connections.79
If enhanced affective association is
brought
about
by
a
temporal focus,
the
expression
of increased
affectivity
appears
to reflect a form of hemi
spheric asymmetry. Right temporal
foci led to external emotive or behav
ioral manifestions:
anger, sadness,
elation, circumstantiality, viscosity,
and
hypermoralism. By contrast,
left
hemisphere patients
had
ruminative,
intellectual tendencies:
religiosity,
philosophical interests,
and sense of
personal destiny.
Foci in either
hemisphere
thus
appear
to influence affective associa
tions. This is consistent with observa
tions of human
split-brain subjects
who demonstrate
familiarities, pref
erences,
and aversionsaffective
responsesto photographed objects
presented
to either isolated hemi
sphere (D. Zaidel, PhD, personal
communication, August 1974).8"
The
simple concept
of
right hemisphere
dominance for emotion
requires qual
ification.
However,
the nature of affective
association and
response
does
suggest
distinctive
hemispheric styles.
The
right hemisphere apparently
utilized
nonverbal reactions:
emotive, impul
sive,
and
dispositional.
The left
hemi
sphere
showed a
predilection
for idea
tive, contemplative,
and
perhaps
verbal
expressions
of affect as
repre
sented in
cosmologie
or
religious
conceptualizing.
The statistical asso
ciation of
right temporal
foci with
disorders of mood and of left foci with
thought
disturbance
supports
this dif
ferentiation.39 As
well,
a recent neu-
ropsychological study
identified
right
temporal epileptic patients
with an
impulsive
and left
temporal patients
with a reflective
"conceptual
tem
po."46
Comparison
of self and rater
responses
showed another distinction
between
right
and left
temporal
groups.
We have
interpreted patient-
rater
disagreement
in these
groups
to
reflect
contrasting
distortions
by pa
tients. This seems
justifiable
for
several reasons. There was no intrin
sic
feature of the
questionnaires
that
produced disagreements,
since self
and rater
profiles
coincided
closely
among
control and
neurologic
sub-
jects.
Cultural biases of raters con
cerning epilepsy
could not account for
the
opposing
nature of
discrepancies
in
right
and left
temporal groups.
Raters were
comparable among
groups,
and there were no consistent
variations in
profile
attributable to
rater characteristics. Since the observ
er
profiles
lack
apparent bias,
the
variable that best accounts for the
discrepancies
of
Fig
5 and 6 is
patient
self-perception.
These are
post
hoc conclusions from
the current
study.
In
fact,
the decision
to obtain
independent
rater evalua
tions came from
prior
clinical observa
tions of
temporal epileptic patients
who had distorted accounts of
objec
tively
verified
aggressive
tendencies.
The minimization or denial of
nega
tive behavior
among patients
with a
right temporal
focus was most strik
ing,
but a
tendency
of left
temporal
patients
to
overly
harsh
self-descrip
tion was also noted.24
Independent
clinical observations of
patient
bias
thus
prompted
the
quantitative
evalu
ation of
patient-rater discrepancies,
which confirmed the distortions.
The
present
results establish that
patients
with
right temporal
foci
deny
dysphoric, socially disapproved
behav
ior while
exaggerating
valued
quali
ties
("polishing").
Left
temporal pa
tients demonstrate an
opposite
distor
tion.
By emphasizing negative
behav
ioral
qualities
and
minimizing
their
extraordinary
conscientious
behavior,
they
"tarnished" their
images
relative
to observer evaluations.
These
contrasting
biases in self-
profile, dependent
on
laterality
of the
epileptic focus, parallel
observations
concerning
reaction to deficits after
unilateral cerebral lesions. The most
dramatic denial of
illnessanosog-
nosia for
hemiplegia-is strongly
asso
ciated with
right hemisphere
localiza
tion.8182 More
generally,
the reactions
of
patients
with
right hemisphere
injury
have been characterized as
facetious and
inappropriately
indif
ferent." Like the dissocial behavior of
right temporal epileptics,
deficits
demonstrated in
testing
of
right
brain
damaged patients
were
significantly
minimized or denied.33
Patients with left
hemisphere
dam
age
have been associated with cata-
Downloaded From: http://archneur.jamanetwork.com/ on 06/19/2012
strophic
reactions: outbursts of anxie
ty
and
despair
in the face of demon
strated failures.83
Intense,
often ex
cessive reaction to
shortcomings
whether
perceived
behavioral flaws or
cognitive impairmentsseems
a
spe
cific hallmark of left
hemisphere
involvement."
Thus,
the
lateralized
patterns
of
reaction to behavioral
consequences
of
a
temporal
focus are consistent with
prior
demonstrations of emotional
differences between
patients
with
right
and left
hemisphere
lesions.
Several
explanations
have been
pro
posed
for these
differences, including
the intactness of
metaphorical
speech,84 opposing
mood biases ex
erted
by
each
hemisphere34311
and a
dominant role of the
right hemisphere
in
emotionality.8586
However,
in
assessing hemispheric
roles in affective
distortion,
an addi
tional factor
may
be considered. Clin
ical
interrogations
and
questionnaire
completion
involve verbal
reports
from the
patient.
Conscious self-
awareness has been
equated
with the
potential
for verbal
expression,87
88
an
activity usually
confined to the left
hemisphere
in adult man.3289 An
intact left
hemisphere may
receive no
report
of associations established in
the
right hemisphere
if there has been
intrahemispheric damage (anosogno-
sia
following right hemisphere inju
ry),81
disconnection
(sense
of well-
being
after
commissurotomy32
or le
sion of the
genu
of the
corpus
callo-
sum9"),
or if newlimbic associations are
established
exclusively
and nonverb-
ally
within the
right hemisphere
(right temporal epileptic focus).
The
denial of
physical
or emotional defi
cits in
patients
with
right hemisphere
lesions
may
then reflect a confabula-
tory response
of the left
hemisphere
in the absence of
reportssensory
or
affectivefrom
right hemisphere
structures. There
is,
in
fact,
consid
erable evidence of confabulation
by
the isolated left
hemisphere among
patients
with
split
forebrain commis
sures.32
By contrast, cognitive
deficits in
left
hemisphere
functions
(calcula
tions and
language)
or verbal emo
tional associations established within
the
hemisphere
will be
readily appar-
ent to "conscious verbal"
injury.
In
the case of emotional
tendencies,
the
immediacy
of
verbally expressible
affect
may
lead
the left
temporal
epileptic
to
exaggerate
the behavioral
severity
of his emotions.
He
may
be
"hyperconscious"
of
such
feelings.
Norman
Geschwind, MD, supplied
advice and
encouragement
in these studies. Edith
Kaplan,
PhD,
and Kenneth Reich, Aphasia
Research
Unit,
Boston Veteran's
Hospital, Boston,
were
involved in the original planning
of the temporal
lobe behavior
inventory.
Several physicians
cooperated
in
allowing us to
study patients
under
their care. These include Lydia Pauli, MD,
and
Samuel
Livingston, MD, Livingston Epilepsy
Center, Baltimore;
Ernest
Rodin, MD, Epilepsy
Center of
Michigan, Detroit;
John Van
Buren,
MD,
and
King Engel, MD,
National Institute of
Neurological
and Communicative Disorders and
Stroke. John Bartko, PhD, and David Van Sant of
the National Institutes of Health
supplied
statis
tical and
computational
assistance.
The
Psychological Corporation permitted
us to
incorporate
items modified from the Lie Scale of
the Minnesota
Multiphasic Personality Inventory
(MMPI).
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