Auditory hallucinations are infrequent as an initial manifestation of a seizure and usually represent a psychotic disorder or one of several more benign conditions. Occasionally, a patient with a focus in one superior temporal convolution will report a buzzing or roaring in the ears. A human voice, sometimes repeating unrecognizable words, or the sound of music has been noted a few times with lesions in the more posterior part of one temporal lobe. Some people with epilepsy and a strong family history of seizures with auditory auras, may have normal imaging but turn out to have mutations in the LGI1 gene.
Vertiginous sensations of a type suggesting a vestibular origin may on rare occasions be the first symptom of a seizure. The lesion is usually located in the superoposterior temporal region or the junction between parietal and temporal lobes. In one of the cases reported by Penfield and Jasper, a sensation of vertigo was evoked by stimulating the cortex at the junction of the parietal and occipital lobes. Occasionally with a temporal focus, the vertigo is followed by an auditory sensation. Giddiness, or light-headedness, is a frequent prelude to a seizure, but this symptom, as discussed in Chap. 14, has so many different connotations that it is of little diagnostic value.
Vague and often indefinable visceral sensations arising in the thorax, epigastrium, and abdomen are among the most frequent of auras, as already indicated. Most often they have a temporal lobe origin, although in several such cases the seizure discharge has been localized to the upper bank of the sylvian fissure, in the upper or middle frontal gyrus, or in the medial frontal area near the cingulate gyrus. Palpitation and acceleration of the heart rate at the beginning of the attack have also been related mainly to a temporal lobe focus.
Temporal Lobe Seizures (Characterized by Altered Responsiveness, Complex Partial Seizures, Psychomotor Seizures)
These differ from the major generalized and absence seizures discussed above in that (1) they signify a focal onset in the temporal lobe as reflected by an aura that may be a hallucination or perceptual illusion, or (2) a period of altered behavior and incomplete impairment of consciousness, a dyscognitive state, in contrast to the loss of connection to the environment typical of absence epilepsy.
Although it is difficult to enumerate all the psychic experiences that may occur during these types of seizures, they may be categorized as illusions, hallucinations, depersonalization states, and affective experiences. Among the altered psychic states are a feeling of intense perception of familiarity in an unfamiliar circumstance or place (déjà vu) or, conversely, of strangeness or unfamiliarity (jamais vu) in a previously known place or circumstance. There may be the experience of autoscopy, a type of depersonalization, or dream-like state in which the patient views himself as an external observer. Fragments of certain old memories or scenes may insert themselves into the patient’s mind and recur with striking clarity, or there may be an abrupt interruption of memory. (See Gloor for a more detailed description of the experiential phenomena of temporal lobe epilepsy.) Sensory illusions, or distortions of ongoing perceptions, are the most common. Objects or persons in the environment may shrink or recede into the distance, or they may enlarge (micropsia and macropsia), or perseverate as the head is moved (palinopsia). Tilting of the visual environment has been reported. Hallucinations are most often visual or auditory, consisting of formed or unformed visual images, sounds, and voices; less frequently, they may be olfactory (usually unpleasant, unidentifiable sensations of smell), gustatory, or vertiginous. Associated epigastric and abdominal sensations have been alluded to above and likely have their origin in autonomic and limbic structures.