Epileptic equivalents in psychiatry:
Some 19thcentury views
B. Schmitz, M. Trimble
Department of Neuropsychiatry
Instituteof Neurology, London
Introduction
In this paper, some of the important contributions of 19th
century neuropsychiatrists to an understanding of the links
between epilepsy and psychopathology, namely the idea of
epileptic equivalents, are reviewed.
The English Contribution
The possibility that patients with epilepsy could show
behaviour disturbances rather than convulsions, as part of
their epileptic condition was well established by the turn of
the 19th century. Willis in 1667 (1) had noted that:
epilepsy is sometimes cured by the help of medicines,
experience doth testify ... in the meantime, as to what
further belongs to the prognostication of this disease, if it
ends not about the time of ripe age, neither can be driven
away by the use of remedies, there happens a diverse event
in several sick patients, for it ends immediately in death, or
is changed into some other disease, to wit, the palsie,
stupidity, or melancholy, for the most part incurable.
George Man Burrows practised general medicine, but
from 1815 devoted himself to insanity. He travelled
widely, especially seeking evidence of cure of mental
illness, and spent some time in Paris, being acquainted with
the latest ideas and developments there. Burrows noted of
epilepsy that, if an early death do not supervene, the
malady induces demency, idotism or incurable insanity
(2). These ideas were expanded in his commentaries (3).
Closely aligned to the clinical picture are symptoms,
Address:
B. Schmitz
Departmentof Neuropsychiatry
Institute of Neurology
Queen Square
London WC13BG
U.K.
122
referred to as maniacal, which include severe violence. For
example, he states: Of all the modifications of mental
derangement, there are none so terrible as that complicated
with epilepsy. Maniacal epilepsy is usually characterised
by the most ferocious, malign, and often murderous
paroxysms; and often it is as instantaneous as it is violent.
These pejorative associations had been recognised over
the centuries, for example, epilepsy being referred to as
The disease of Hercules, the mythological character that
killed his family in a paroxysm of rage, supposedly due to
a seizure (4).They are themes revived by several European
authors, for example, Morel (see below).
Burrows also opened the way for the development of two
separate associations between epilepsy and insanity, the
strands of which are still with us today, Thus, he recognised
that epilepsy could lead to insanity, but also noted: The
epileptic attack may be preceded by a furious paroxysm, or
merely by elevated ideas, by great depression of spirits, or
by mental imbecility, forgetfulness, etc; or the reverse may
obtain, and the sequel of the epileptic fit may exhibit these
morbid conditions of the mental functions. ...in other cases,
the disease is either preceded or succeeded by violent
paroxysms of mania. ...it appears as if the epileptic impulse
when not ending in convulsion, acts on the brain in a
peculiar mode, and imparts to it that particular action
denominated epileptic mania.
Burrows, in the fxst quoted section seems to be referring
to what we would now refer to as pen-ictal changes of the
mental state, associated with prodromata, auras, and the
post-ictal phase. However, the later quotes clearly imply
the potential for epilepsy to present, in the absence of
convulsions with a manic episode. He went on to quote the
case of a 30 year old man, subject to occasional fits of
epilepsy, who had become lately much inclined to
religious devotion, who suddenly and violently attacked
a neighbour, an episode for which the next day he was
amnestic.

Epileptic Equivalents in Psychiatry Some 19IhCentury Views
The suggestion that one pattern of a disease could
replace another had already developed, via the concept of
sympathy. Burrows was a somatist, exclaiming that mental
symptoms should be examined in the same way as a
clinical examination of the symptoms of bodily diseases.
He was familiar with the writings of Mead who put forward
the theory that mental illness was incompatible with bodily
disease (5),and had observed cases of the interchangeable
relation between lunacy and phthisis pulmonalis. This
was intertwined with the concept of sympathy, one
explanation of why symptoms might occur distant from an
impaired body part, the sympathetic nerves being given a
central role in this process, and conversion. Femar (6),
summed this up as: a disease is said to be converted, when
new symptoms arise in its progress, which require a
different designation, and which either put a period to the
original disorder, or combining with is, alter the
physicians views reflecting the prognostics or the method
of cure.
Thus, Burrows separated two concepts. That of the
development of insanity as a direct complication of
epilepsy, and that of paroxysmal episodes of disturbed
behaviour that were not associated with a convulsion, but
were nevertheless a part of the epilepsy. He speculated on
the reasons for these events, citing increased vascular
action and fullness of the blood vessels as common to both
epilepsy and mania.
Another English author to discuss epilepsy was Henry
Maudsley (7). Although mostly interested in the forensic
aspects of mental disease, he recognised epileptic mania,
a most dangerous form of insanity, but also recognised
the concept of masked epilepsy, and that changes of
character and temperament could occur months or even
years after the epileptic seizures were manifest. Masked
epilepsy was a transitory mania occumng in lieu of the
usual convulsions. He went on to speculate on the
mechanism:
Instead of the morbid action affecting the motor centres
and issuing in a paroxysm of convulsions, it fixes upon the
mindcentres and issues in a paroxysm of mania, which is,
so to speak, an epilepsy of the mind.
Thus, English neuropsychiatrists in the 19th century
recognised the interplay between epilepsy and
psychopathology, hinting at several relationships, one of
which was the development of alteration of the mental
state, not directly related to the ictus, which often had a
characteristic form. Interestingly, these early
developments were not followed up and it was
developments on the continent, especially in France and
Germany, that clarified some of these concepts, and led to
the development of two intertwined concepts, namely that
of interictal personality disorders, and that of epileptic
equivalents.
-
The French Contribution
Pine1 (8), physician in chief at the Bicstre and the
Salp2trikre, recognised insanity complicated with
epilepsy, a subject taken up for study by several of his
pupils. Notable amongst them was Esquirol (9), whose
main contribution was in delineating the more chronic
interictal states, which included mania, monomania and
dementia. A little later Delasiauve (10) observed that mood
changes were seen in epilepsy, including mania, which
could become la forme furieuse. He described case
histories without obvious convulsions, but thought that the
attacks generally were more associated with increasing
seizure frequency. It was however J.P.J. Falret, son of J.P.
Falret, a student of the Esquirol circle, and Morel, himself
a student of J.P. Falret, who made the psychiatric aspects
of epilepsy a special study.
Falrets (1 1-13) main contributions are contained in
three papers published in 1860 and 1861. He noted that
patients with epilepsy could have attacks of mania which
succeed or alternate with seizures, but that only a few
authors had written on this subject. He quotes Cavalier,
Morel, Delasiauve, Aubanel and Guillermin as authorities.
In his classification of the psychiatric states of epilepsy
he has three categories. The frst occur before, during or
following the seizure, the second are those in the interval
between attacks, and the third are those of long duration,
which constitute real madness. Here he obviously
distinguishes ictal, and interictal disorders, a classification
still used today, and recognises the chronic interictal
syndrome.
The second category, the attacks in the intervals between
seizures, Falret said needed a special name, and he called
them folie tpileptique. They consisted of mood and
intellectual changes, such as imtability, suspiciousness,
and outbursts of violence, rather than psychoses, although
he commented on the sentiments religieux which often
coloured the mental state. The important thing for Falret
was the intermittent nature of the psychic phenomena.
The disorders of the third group he divided into two, the
petit mal and the grand ma1 intellectuel, noting the
close relation between the physical and mental aspects of
the disease. The former present with early mood changes,
memory difficulties, attacks of violence and impulsivity,
feelings of persecution with suicidal ideas and acts, He
stated: The essentially impulsive and instant character of
the epileptic delirium is really very remarkable.
The grand mal type were more likely found in asylums,
and were known as mania with fury. He went on to
describe a manic state with rapid ideas, pressure of speech,
variable mood, agitation and excessive violence.
Hallucinations might occur, they often ended abruptly.
Importantly, there was no clear relationship of these
episodes, which were a rapid explosion which often
ended abruptly, to the seizures. In some patients seizures
were not observed, in others he thought that subtle seizure
123
Schmitz, Trimble
manifestations, or nocturnal seizures might have been
missed. However, his point was that the epileptic delirium
substitutes in some manner epileptic seizures. It is a
manifestation of the same illness in a different form.
Attention to the clinical characteristics of the attack would
reveal the essential underlying epileptic nature, and he
quoted a case of Delasiauve, in which the history of
epilepsy was only revealed later, and in one of his own
cases, no epileptic attacks had occurred for two years. He
also identified long term remission as a risk factor for the
development of the psychiatric symptoms in epilepsy,
especially if the epileptic seizures returned and were
repetitive.
Falret recognised the controversial nature of this
findings, especially the transformation of epilepsy into
madness. This touched on the transformation of one disease
into another, but he cautioned against this interpretation.
Essentially the convulsions and the madness should be
viewed as two manifestations of the same disease.
For Falret therefore, the psychiatric states in epilepsy
always implicated the epilepsy, and a history of seizures
was always to be found, at some stage. The clinical
characteristics of the insanity were also important in giving
it a particular stamp, identifiable as folie epileptique.
Morels concept was epilepsie larvCe (14, 15). He being epileptic. This was taken up by Griesinger and then
referred to this as a special form of delirium, characteristic
of the neurosis of epilepsy. He quoted Burrows with
approval and then went on to describe three types or stages
of the insanity. Early on these included irritabilities and
preoccupations, either sexual or hypochondriacal. In the
second period the behaviour was more violent, and patients
often needed asylum confinement. Religious melancholy
was noted. The third period was characterised by dementia
and general paralysis. He described the personality
changes of epileptic patients, essentially interictal, and not
associated in any direct way with the ictus.
The German Contribution
The writings of Hemming (16) were representative of
German psychiatry in the early 19th century. He was a
somaticist and played an important role in the development
of the German asylum system. He was one of three editors
who founded the journal Allgemeine Zeitschrift f i r
Psychiatrie in an attempt to unify German psychiatric
thinking which was split between the philosophically
orientated psychics and the asylum somaticists (17).
In this textbook on pathology and therapy of psychoses
(1859), Hemming developed a pathophysiological
concept of the relationship between epilepsy and insanity,
and described four different modes. First, epilepsy as a
iransient symptom of the same general excitation of
nervous centres which cause the mental disorder, in this
case epilepsy usually proceeds and introduces the insanity.
Second, a seizure of an established periodic epilepsy fails
to appear and is replaced by a paroxysm of madness, which
either presents in the form of melancholia or mania, both
usually accompanied by major precordial anxiety. Third,
established epilepsy directly causes the mental disorder in
that the initation of the whole nervous system due to long
repetitive seizures also damaged the central organs of
thinking. In this case mental disorder and epilepsy exist in
parallel. Fourth, epilepsy follows insanity and then
accompanies insanity with the sporadic seizures. In this
case an organic cause which initially only involves sensory
nervous centres expands into the motoric system.
Although Flemmings pathophysiological concepts
surpassed most of his comtemporaries in terms of clarity
and complexity, his hypotheses were largely neglected
because his writings lacked psychopathological details,
which were more popular than pathophysiological
concepts at that time ( I 8). It is his second category in which
the concept of epileptic equivalents emerges.
This term seems to be used for the first time by Hoffmann
(19). He noted that: eventually epileptic seizures may be
missed completely, but the mental disease can reveal
through its particular symptoms and signs thzt it is an
equivalent of epilepsy, especially of convulsions and
coma. Crucial to this statement is the idea that the clinical
features of the psychopathology identify the events as
Samt.
Griesinger broadened the concepts of the mental
changes associated with epilepsy. When Griesinger went
to the Charit6 in Berlin, he was relatively inexperience in
clinical psychiatry. He was a believer in identifying
psychopathology as a diagnostic tool to later reveal
neuropathology. He acknowledged that one of his tasks
was to combine neurology and psychiatry.
In his textbook, the first edition in English being in 1867
(20), he made passing reference to the problem of insanity
and epilepsy, noting psychical symptoms that precede, or
occur with the ictus. He also accepted chronic mental
disease even during the intervals between the attacks. He
quoted Esquirols figures with approval, and emphasised
a spectrum of presentations from hypochondriasis to
dementia.
He expanded on these ideas in his paper of 1869 iiber
einiger epileptoide Zust;inde (21). In this he wrote about
epileptoid symptoms, wishing to expand these to include
a wide variety of psychosensitive and psychomotor
symptoms. He also described interval symptoms. In some
patients these are the main problem, and the actual epilepsy
may be missed.
In this paper, Griesinger was developing his ideas on
epilepsy and insanity, and recognised that his broadening
of the concept was controversial. It seems that he intended
to write further papers on the subject, but he died before the
project was complete.
The person who developed these ideas more extensively
was Peter Samt. He had worked with Griesinger as a
 Epileptic Equivalents in Psychiatry - Some 19hCentury Views
younger man when doing his doctoral thesis, and in 1873
became frst assistant to the department of insanity.
Griesinger had by now died, and Westphal was the chief.
Although his career was tragically short, he died from an
infection contacted at a post-mortem examination, he
wrote two substantial papers (22, 23) on the subject of
epileptic insanity (Epileptische Irreseinsformen). These
were published in 1875 and 1876, in the journal which
Griesinger had inaugurated. He was first and foremost
interested in the nosology of mental illness. It was, he felt,
important to classify clinical entities, especially of patients
sharing a similar course and development of illness.
Classification could not be based on pathological entities,
as so little was known, and the clinical method was
paramount.
He quoted with much approval the writings of Morel and
Falret, especially the latter, stating that his observations are
supportive of Falrets ideas.
He noted that epileptic insanities were by that time a well
recognised clinical group, a specific form of insanity, and
distinguished sub-groups. These were 1. The psychic
epileptic equivalent, 2. the protracted psychic epileptic
equivalent, 3. acute post epileptic insanity, 4. the chronic
protracted epileptic insanity and 5. the cycling epileptic
insanity.
In these papers, Samt clearly described patients with
acute behaviour disorders, but no seizures. The patterns of
the behaviour however resembled that of seizures, with a
herald, an acute crisis, and a post-paroxysmal phase. The
episodes themselves were often of an aggressive nature,
and were accompanied by amnesia. Thus, it was the form
of the insanity, not the associated seizures that lead to the
diagnosis of epileptic insanity. He stated that he called
them equivalents in order to characterise the attack-like
and paroxysmal nature. In his discussion of more
prolonged states, he introduced the term transformed
epilepsy (transformierte Epilepsie) prefemng such
expression to the term Epilepsie larvte of Morel. He
considered larval epilepsy inappropriate in the sense that
the symptoms were either epileptic or not, but could not be
larval.
In his final classification of epilepsy he distinguished 12
diagnostic categories, which included three types of
seizures and nine psychopathological states.
These views of Samt were highly controversial, and
evoked comments over the next half a century. One aspect
was to further specify the psychopathology of the
epileptisches Irresein in terms of consciousness (24),
speech (26) and gender differences (27). However most
authors (24, 28, 29) insisted on the occurrence of seizures
as a prerequisite for diagnosis, some even requiring a close
temporal relationship between seizures and the insanity
(30).
Sommer (31) criticised the amount of attention paid to
epileptic equivalents, and suggested that in his clinical
experience there were more psychic disorders directly
related to epilepsy than had yet been systematised. In a
comprehensive paper, he clearly distinguished personality
changes, neuropsychological deficits, dementia and
psychoses. While accepting the possibility of transient
psychoses without related epileptic seizures in the form of
an epileptic rudiment, he rejected this idea for clinical use
because of its hypothetical nature.
Kraepelin (32) supported some of Samts ideas,
suggesting that crucial to the diagnosis of epilepsy was not
the demonstration of a specific form of seizure, but the
existence of an independent periodicity of the disorder
form the onset of the illness.
By the end of the century, Samts broad spectrum of
epileptic insanity forms had been significantly reduced,
and psychiatry became influenced by Bonhoeffer (33), and
his exogenous reaction types, which were independent of
the underlying pathology. Epileptic equivalents largely
disappeared from the literature and from the conceptual
framework of those writing about epilepsy. Psychiatry and
neurology were going their own separate ways and fertility
of the earlier neuropsychiatric pastures gave way to the
circumscribed disciplines that dominated and restricted
20th century thought.
Conclusions
Table I shows the development of the various concepts that
are discussed in this paper. Essentially, the European
authors of the 19c recognised that epilepsy was strongly
associated with insanity, and struggled to understand the
relationship. In the early part of the century, Pine1 and his
followers such as Esquirol, Calmeil, and Georget
recognised that chronic epilepsy could lead to mental
illness, and represented a problem for asylum
management. Burrows was the first to coherently express
the possibility of transformations of the illness pattern, and
that epileptic insanity could occur on occasions without
manifest seizures. These ideas were taken up in France and
Germany, and lead to concepts such as the epileptic
character, epilepsie larvte and the epileptic equivalent.
Table I. Terminolcgyofepileptjcpsychosesinthel!3hcerduty
Morel1860 Hoffmann1872
Epilepsiehk Epikpkddquient
Wlirekpilepbque
Falret1861 Samt 1875
Folie$ileptique Epileplischeslmin
Petmalintellectuel Psychis& Epilepsie
Grandmalintellectuel TransfomierteEpilepie
Griesinger 1869 Sommer 1881
EpileptoideZustihde EpilepdschesRudiment
Psychomotorischeund PsychisdlerStatus
psychosensitveeZ. Epllepbbx
125
Schmitz, Trimble
These developments were highly controversial, and
remain so today. Towards the end of the 19th century, the
idea that some kind of antagonism existed between mental
illness and epilepsy became prevalent, or more specifically
dementia praecox, and epilepsy, and the literature on
equivalents and its variants virtually ceased. As Wolf and
Trimble (34) pointed out, some of the antagonism
literature has been misinterpreted, and if viewed as an
antagonism of symptoms, rather than diseases, then it
forms a continuous thread with some of the concepts
discussed here.
These ideas are reviewed, not only for their historical
interest, but because they are, in a revised form also
currency today. The whole concept was revived with the
description of nonconvulsive status epilepticus by ~ M O X
(33, the phenomenon of forced normalisation by Landolt
(36), the concept of episodic dyscontrol (37), and the
persistent use of such terms as epileptoid or epileptiform in
clinical practice.
It is not our intention to suggest that all the states we have
been discussing are epilepsy, or necessarily are
pathogenetically linked to it. However, patients with such
conditions have fascinated clinicians for nearly two
centuries, continue to present to our clinics, and continue
to disturb, both those around them and our cosy concepts
of what is epilepsy.
References
1. Willis T. Pathologiae cerebri et nervosi generis specimen, 1667,
translated by S. Pordage. London: Dring, 1681.
2. Burrows GM. Inquiry into certain errors relative to insanity and their
consequences. London: Thomas and George Underwood, 1820.
3. Burrows GM. Commentaries on the causes, forms, symptoms, and
treatment, moral and medical, of insanity. London, 1828.
4. Temkin 0. The falling sickness. Baltimore: John Hopkins
University Press, 1971.
5. Mead R. De imperio solis ac lunae in corpora humani, et morbis inde
oriundis. London, 1746.
6. Feniar J. Medical histories and relections. London: Cadell and
Davies, 1795.
7. Maudsley H. Responsibility in mental disease. London: Henry King,
1874.
8. Pinel P. A treatise on insanity. Translated by D.D. Davis. Sheffield
W. Todd, 1806.
9. Esquirol J. Mental maladies: A treatise on insanity. Translated by
E.K. Hunt. Philadelphia: Lea and Blanchard, 1845.
10. Delasiauve. Trait6 de ICpilepsie. Paris: Victor Masson, 1854.
126
11. Falret J. De lttat mental des Cpileptiques. Archives gCnirales de
medicines 1860: 16: 661-79.
12. Falret J. De ICtat mental des Cpileptiques. Archives gintrales de
mtdicines 1861: 17: 661-91.
13. Falret J. De 1Ctat mental des Cpileptiques. Archives gtnirales de
midicines 1861: 18: 42343.
14. Morel BA. Maladies mentales. Paris: Masson, 1860.
15. Morel B. Dune forme de dtlire, suite dune surexcitation nerveuse
se rattachent a une variett non encore dCcrite dtpilepsie. Gaz hebd
med chir 1860: 7: 773-75.
16. Flemming CF. Pathologie und Therapie der Psychosen. Berlin:
August Hirschwald, 1859.
17. Darner K. Burger und h e . Frankfurt: Europaische Verlagsanstalt
GmbH, 1984.
18. Wolf P. Psychosen bei Epilepsie. Ihre Bedingungen und
Wechselbeziehungen zu Anfillen (Thesis). Berlin: Freie
Universitat, 1976.
19. Hoffman F. h r die Eintheilung der Geisteskrankheiten in
Siegbug. Allg Zschr Psychiat 1872: 19: 367-91.
20. Griesinger W. Mental pathology and therapeutics. London: New
Sydenham Society, 1857.
21. Griesinger W. iiber einige epileptoide Zustande. Archiv fur
Psychiatrie und Nervenkrankheiten 1868: 1: 320-33.
22. Samt P. Epileptische Irreseinsformen. Archiv f i r Psychiatrie und
Nervenheikunde 1875: 5: 393-444.
23. Samt P. Epileptische Irreseinsformen. Archiv f i r Psychiatrie und
Nervenkrankheiten 1876: 6: 110-216.
24. Gnauck R. Uber die Entwicklung von Geisteskrankheiten aus
Epilepsie. Archiv fur Psychiatrie und Nervenkrankheiten 1882: 12:
337-58
25. Krafft-Ebing R. Uber epileptische Dammer- und Traumzustibde.
Allg Zschr Psychiat 1877: 33: 547-86.
26. Raecke J. Zur Symptomatologie des epileptischen Irreseins,
imsbesondere uber die Beziehungen zwischen Aphasie und
Perseveration. Archiv fur Psychiatrie und Nervenkrankheiten 1906:
41: 1-28.
27. Fischer F. Zur Lehre vom epileptischen Irresein. Archiv fur
Psychiatrie und Nervenkrankheiten 1884: 15: 741-76.
28. Raecke J. Die transitorischen Bewusstseinsstorungen der
Epileptiker. Halle a. S., 1903.
29. Leidesdorf. Uber die sogenannten epileptische Aquivalente. Wiener
medizinische Wochenschrift, 1887.
30. Christian J. Epilepsie - Folie Cpileptique. Brussels: Hayez, 1890.
31. Sommer W. Postepileptisches Irresein. Archiv fur Psychiatrie und
Nervenkrankheiten 1881: 11: 550-612.
32. Kraepelin E. Psychiatrie - Ein Lehrbuch fur Studierende und h t e .
Leipzig: J.A. Barth, 1903.
33. Bonhoeffer K. Zur Frage der exogenen Psychosen. Neurologisches
Zentralblatt 1909: 32: 499-505.
34. Wolf P. Trimble MR. Biological antagonism and epileptic
psychosis. Br J Psychiat 1985: 46: 272-76.
35. Lennox WG. The treatment of epilepsy. Medical clinics of North
America 1945: 29: 1114-28.
36. Landholt H. Serial electroencephalographic investigations during
psychotic episodes in epileptic patients and during schizophrenic
attacks. In: Lorentz de Haas AM, ed. Lectures on epilepsy.
Amsterdam: Elsevier, 1953: 91.
37. Monroe RR. Episodic dyscontrol. Harvard: Harvard University
Press, 1960.