J Med Humanit DOI 10.1007/s10912-014-9294-4
Exaltation in Temporal Lobe Epilepsy: Neuropsychiatric Symptom or Portal to the Divine? Niall McCrae & Rob Whitley
# Springer Science+Business Media New York 2014
Abstract Religiosity is a prominent feature of the Geschwind syndrome, a behavioural pattern found in some cases of temporal lobe epilepsy. Since the 1950s, when Wilder Penfield induced spiritual feelings by experimental manipulation of the temporal lobes, development of brain imaging technology has revealed neural correlates of intense emotional states, spurring the growth of neurotheology. In their secular empiricism, psychiatry, neurology and psychology are inclined to pathologise deviant religious expression, thereby reinforcing the dualism of objective and phenomenal worlds. Considering theological perspectives and the idea of cosmic consciousness, the authors urge a holistic approach to the spiritual events of epileptic aura, potentially leading to a deeper understanding of the mind and its transcendent potential. Keywords Epilepsy . Religion . Spirituality . Consciousness . Geschwind syndrome
Introduction An intriguing phenomenon in some cases of epilepsy is the occurrence of spiritual experiences around the time of seizure, typically sensed as enlightenment to an expansive, timeless reality infused with deep meaning or of liberation of the soul from earthly constraint (Bear and Fedio 1977; Devinsky and Lai 2008). Fjodor Dostoyevsky described unsurpassable ecstasy during epileptic aura (Gastaut 1978), as conveyed vividly in the character of Prince Myshkin in The Idiot: Suddenly amidst the sadness, mental darkness, and depression, his brain seemed to burst into flame at brief moments, all his doubts and worries seemed composed in a twinkling, culminating in a great calm, full of sense and harmonious joy and hope…a blinding inner light flooded his soul. (1868/2004, 263) N. McCrae (*) Florence Nightingale School of Nursing & Midwifery, James Clerk Maxwell Building, King’s College London, 57 Waterloo Road, London SE1 8WA, UK e-mail:
[email protected] R. Whitley Douglas Mental Health University Institute, Department of Psychiatry, McGill University, 6875 LaSalle Boulevard, Montreal, Quebec H4H 1R3, Canada e-mail:
[email protected]
J Med Humanit
The content of spiritual experiences may be deistic, coloured by cultural and religious norms. Transient visions of angels, God or Heaven can have profound and enduring impact, in some cases leading to messianic zeal. Religiosity in epilepsy has attracted scientific interest since the beginnings of neurology in the nineteenth century and was well known in the mental institutions of that era (Temkin 1971). Visionary revelation was foundational to belief systems as major as Buddhism and Islam as well as various Christian sects. Medico-psychological retrospect has indicated psychiatric or neurological morbidity in the intense spiritual experiences of prophets and gurus, which have commonly been attributed to partial complex seizures of temporal lobe1 focus (e.g. Landtblom 2004; Freemon 1976; Foote-Smith and Bayne 1991; Landsborough 1987). Such fits typically last 2 or 3 min; the person remains awake but loses touch with reality, staring ahead while motionless or performing automatisms such as repetitive gesturing; in the postictal2 phase there is drowsiness and confusion. Sudden conversion has followed temporal lobe seizures in people of no prior religious interest beforehand (Dewhurst and Beard 1970). In his classic text The Varieties of Religious Experience, psychologist William James (1842–1910) challenged materialistic interpretation of events such as St Paul’s conversion. Son of a liberal theologian, James was much influenced by Richard Maurice Bucke (1837– 1902), an asylum superintendent in Ontario. Bucke formulated a hierarchy of consciousness with the highest level attained by very few people; cosmic consciousness brings fleeting awareness of the Universe in its entirety and of the immortality of soul. Despite prominence in his day, Bucke was forgotten in the literature of psychology, his mysticism eschewed in a culture of scientism (May 1993). Unlike Bucke, James never experienced a spiritual event, but his analysis was insightful. Differentiating personal experience from normative practice, James described cases of genius in which religion exists ‘not as a dull habit, but as an acute fever’ (1902/2002, 11). An altered state of mind, he thought, could be a doorway to a higher plane. Religious behaviour,3 a broad interest of psychologists, has drawn attention from neurologists and neuropsychiatrists in specific conditions such as epilepsy. In the 1970s, Harvard behavioural neurologist Norman Geschwind (1926–1984) described a syndrome of temporal lobe epilepsy featuring religiosity, hypergraphia (compulsive writing) and hyposexuality. Technological progress has enabled neurologists to link intense spiritual feelings to brain activity including epileptic seizures. However, there is a danger that disciplines operating in a culture of secular empiricism take the reductionist approach avoided so cogently by William James. Let us review in turn the contributions of psychiatry, psychology and neurology to understanding transcendental experiences in epilepsy.
Religiosity as psychotic interlude Observing a tendency for religious expression around the time of seizures, ancient Greek and Hebrew physicians described epilepsy as ‘the sacred disease’. Despite the pathological treatise of Hippocrates, religious associations persisted. In the witchcraft panic of the sixteenth and seventeenth centuries across Christendom, people with epilepsy were particularly prone to persecution; bizarre or unintelligible utterances, falling to the ground and frothing at the mouth suggested diabolical possession. Generally, physicians did not deny demonology, but many lives were saved by diagnosis of deviant behaviour as illness (Hunter and Macalpine 1963). In the nineteenth century, people with epilepsy were confined alongside the insane. This was not just for administrative convenience but because their behavioural symptoms were deemed primarily mental. The first studies of epilepsy were conducted in the Paris lunatic asylums la Salpêtrière and la Bicêtre where Jean Esquirol defined grand mal and petit mal
J Med Humanit
seizures. In his manual of mental disorder, Esquirol (1845) reported that of 385 consecutive cases in a female epileptic ward, after omitting 46 with feigned epilepsy or hysteria, almost 80 % had coexisting insanity of some form. By the mid-nineteenth century, it was accepted that asylum cases were unrepresentative of epilepsy generally: in France, Théodore Herpin found that of 300 private patients with epilepsy, only a few cases became insane; judging by his outpatients in London, JR Reynolds concluded that insanity was not a normal complication of epilepsy (Berrios 1979). Yet there was no doubt among asylum physicians that mental disturbance was common in epileptic inmates who were particularly difficult to manage. The epileptic ward was a volatile environment with fights as frequent as fits (Barham 1907). Two seminal texts on psychiatric disorder in epilepsy emerged from the Paris asylums in 1860. Jules Falret described an interictal condition folie epileptique, while Benedict Morel graded three stages of epileptic insanity: the first featuring irritability and sexual or hypochondriacal preoccupations; a second stage with violence (often leading to incarceration) and religious melancholy; and a final stage of dementia. Morel also introduced the concept of épilepsie larvée (masked epilepsy), with seizures substituted by behavioural excitation. However, few psychiatrists would diagnose epileptic insanity in the absence of seizures, and the concept of epileptic equivalents faded from psychiatric discourse. Instead, Richard von KrafftEbing and fellow German psychiatrists referred to composite psychosis (Berrios 1979). In Berlin in the 1870s, Peter Samt observed delusional religiosity as a common feature in the epileptic insane, such patients repeatedly consulting their pocket prayer books for comfort (Temkin 1971). James Howden (1872) of Montrose Asylum described several cases of religious sentiment in epilepsy, attributing the phenomenon to social isolation and an egotistic personality. In one young man’s account of visiting Heaven, Howden recognised the sylvan imagery of the part of Canada where the patient had spent his boyhood. The piety of such patients contrasted sharply with their tendency for wicked and unprovoked violence. Italian psychiatrist Cesare Lombroso (1835–1909), infamous for his physiognomy of the ‘born criminal’, considered epilepsy as the root of both crime and creative genius, which he saw as related forms of degeneracy. In the biographies of Napoleon, Julius Caesar, Mohammed, Flaubert and Dostoyevsky, Lombroso conceived a psychic form of epilepsy, whereby altered consciousness leads not to tonic-clonic crisis but to paroxysms of anger or moments of inspiration. Although Lombroso’s thesis was not accepted by peers, his construct of epilepsy and extraordinary mental powers has lingered at the margins of neuropsychiatric discourse (Granieri and Fazio 2011). Emil Kraepelin, in later versions of his psychiatric nosology, placed epileptic insanity alongside dementia praecox and manic-depressive psychosis in a trinity of severe mental diseases. A meticulous observer, Kraepelin noted the tendency of patients with epilepsy to perceive a personal relationship with God, interpreting religious rapture as the sufferer’s appeal for salvation. Debate continued over whether psychiatric symptoms were primarily ictal, features of an epileptic temperament, or an iatrogenic effect of crude bromides. While colonised by neurology in the twentieth century, epilepsy remained an issue in the mental hospitals. In the 1930s, mutual exclusivity of psychosis and epilepsy was the assumed rationale for convulsive treatment of schizophrenia—although as clarified by Wolf and Trimble (1985), its originator Ladislaus von Meduna actually meant symptomatic antagonism within syndromic affinity. Eventually, sober evaluation of the corrective efficacy of induced seizures led psychiatrists to conclude that schizophrenia and epilepsy were entirely independent. Reviewing monozygotic twin studies, Paul Hoch (1943) found epilepsy neither disproportionately common in the kin of people with schizophrenia nor vice versa. In the manual of psychiatry by Henderson and Gillespie (1950), an epileptic personality was no longer regarded as secondary to seizures but as preceding the development of epilepsy. However, the succeeding standard textbook by
J Med Humanit
Mayer-Gross, Slater and Roth (1955) described cases of enduring twilight states and personality changes and retained the concept of epileptic dementia. The introduction of Hans Berger’s electroencephelography (EEG) was a boon to the study of the psychiatric disorder in epilepsy, and it became apparent that the proportion of patients with epilepsy in mental hospitals with seizures of temporal lobe origin was much higher than in the overall epileptic population. Gibbs (1951) found delusions and hallucinations three times more frequent in temporal lobe cases. A combination of temporal lobe focus, mental disturbance and religiosity was illustrated in Bartlet’s (1957) case reports from the Bethlem Royal and Maudsley hospitals: Mr JMC. Aged 45 years. Chronic hypomanic state with religiose and messianic delusions commencing soon after the onset of epilepsy when he was 36 years old. EEG evidence points to the epilepsy originating in the temporal lobe. Miss BL. Aged 36 years. Symptomatic epilepsy following an undiagnosed organic lesion of the right side of the brain, aged 18 months, developing an affective psychosis mainly hypomanic, the delusions and hallucinations being mainly concerned with a religious theme and including the idea that she had a divine message which it was her duty to impart to the world. (343) Although epilepsy has been colonised by neurology, psychiatrists have contributed to the demarcation of interictal psychoses (Slater and Beard 1963; Betts 1981). However, patients are not routinely referred by neurologists for treatment of seizure-related mental disturbance; in rare instances where psychiatric consultation is sought, spiritual experience may be overlooked by clinicians immersed in standardised diagnosis and treatment. As some psychotic or drug-induced delusions and hallucinations have religious content, psychiatrists may be inclined to interpret extreme or culturally-divergent expression as symptomatic; as Thomas Szasz (1974, 113) remarked: ‘if you talk to God, you are praying; if God talks to you, you have schizophrenia’. Mystical experiences can be likened to psychosis as deviations from normal mental life, often entailing dissociative states with loss of identity and agency (Bartocci and Dein 2005). Raymond Prince (1979) considered religion and psychotic episodes as healing mechanisms of the psyche with the former more effective than the latter. Although religious beliefs sometimes contribute to distress, people who have had spiritual experiences score better than average on mental well-being scales (Hood 1996). Generally, religion appears to be salutogenic, with evidence of a positive (albeit modest) effect on mental health (Koenig 2009). Despite a burgeoning psychiatric literature on spirituality, in practice religion is commonly regarded as a private matter, and its therapeutic value has been neglected in core textbooks (Galanter, 2005). The item ‘religious or spiritual problem’ was added to the fourth edition of the Diagnostic & Statistical Manual (American Psychiatric Association 1994), which includes a cultural formulation to elicit contextual knowledge that can inform diagnosis and treatment. However, this instrument has been used primarily for understanding culture and ethnicity rather than religion (Lewis-Fernández and Díaz 2002). Psychiatrists have limited guidance for assessing religious expression with no objective differentiation from psychopathology (Ng, 2007). Arguably, a discipline that pretends to value-free rationality (Jackson and Fulford 1997) is not best placed to set criteria for the validity of religious experience. Moreover, psychiatry has been described as institutionally atheist (Whitley 2010). Lukoff and colleagues (1992) reported that 30–40 % of mental health practitioners in the U.S. believe in God, compared to 90–95 % of the general population; Curlin and colleagues (2007) found atheism more prevalent among psychiatrists than in other physicians. Such surveys may be criticised for narrow definitions of spirituality, but it appears that many psychiatrists practise in a different reality from that of patients with potentially adverse impact on therapeutic engagement (Kleinman, 2006). Psychiatry
J Med Humanit
has an important role in assessing (not necessarily pathologising) abnormal mentation such as the mystical experiences of people with neurological conditions such as epilepsy.
Conflicted personality William James (1902/2002) noted among founders of new religions a struggle to overcome psychic conflict, relieved only by spontaneous spiritual enlightenment. While not writing specifically on epilepsy, James was aware that paroxysmal images or thoughts, sometimes unrelated to a person’s normal beliefs or practices, could provoke character change. In a psychoanalytic formulation, Wilhelm Stekel explained epilepsy as a battle of the conscience against criminal impulsiveness with seizures arising from dread of divine retribution. Fits symbolised cleansing of sins and rebirth. Stekel argued that whereas ego conflict in hysteria is near the surface of consciousness, in epilepsy it has regressed to deeper layers (Edelston 1949). Despite his behavioural empiricism, James made a stand for consciousness as the focus of psychology, regarding the mind as a teleological entity. While acknowledging that the authenticity of experience is not dependent on objective investigation, he considered spiritual expression as amenable to scientific study as any other phenomena. Although he placed psychology on a proper scientific footing, James became disillusioned in later years by the narrowing positivism of peers. Academic psychology abandoned the abstract mind to focus on directly observable behaviour, and in its pursuit of scientific prestige, there has been little room for God or spirituality in understanding the human condition, as Robert May commented: It was truly tragic that psychology in the ensuing twentieth century failed to follow James’ own lead in studying altered states of consciousness, inner phenomena, and religious experience, and opted instead for a simplistic imitation of nineteenth century physical science. (1993, 94) Disparaged by psychologists on both sides of the analytical-empiricist divide, faith was regression to Sigmund Freud (1934), fear of punishment to BF Skinner (1987), and irrational thinking to progenitor of cognitive behaviour therapy Albert Ellis (1980). Even ‘scientist of the soul’ Carl Gustav Jung (1885–1961) saw God not as external being, but as inner Imago Dei. Jung denied transcendence, believing that mystical experiences arise from archetypal beliefs in the timeless, holistic and divine (May 1993). Until old age Jung remained evasive on the existence of God to whom he continued to act as unsolicited psychiatrist (Browne 1978). Selfdetermination, the goal of humanistic psychology, contrasts sharply with the collective submission in doctrines of major faiths. According to American social survey data (Iannoccone et al. 1998), over half of mathematicians and physical scientists are religious but only a third of psychologists. As in psychiatry, scholarly interest in spirituality is increasing with several journals emerging on the psychology of religion, and a flurry of books published by the American Psychological Association on integrating spirituality in therapeutic practice (e.g. Plante 2009). Bridges are being built, but until this is reflected in the practice of clinical psychologists, opportunities to understand spiritual experiences arising in neurological or psychiatric conditions will be missed.
Cortical fault The emergence of neurology as a clinical specialty coincided with the rising tide of insanity and the search for its putative somatic root. Laboratories were established at many asylums,
J Med Humanit
most notably at West Riding in Yorkshire where John Hughlings Jackson (1835–1911) produced a widely disseminated series of reports. In 1859 the first neurological hospital in the world, the National Hospital for the Paralysed & the Epileptic, opened at Queen’s Square, London, spurred by the presence of epilepsy in the Royal Family. Appointed as director of this novel institution, Jackson was instrumental in establishing epilepsy as an organic condition (Temkin 1971). Explaining seizures as the product of explosive neuronal discharge, he demonstrated that attacks arise focally rather than throughout the cortex. He described postictal mental disturbances ranging from slight confusion to maniacal frenzy and a dreamy state with a sense of déjà vu (Jackson and Stewart 1899). Jackson suggested that the combination of loss of consciousness and excitation of lower nervous function facilitates peri-ictal religious experience. After the false start of phrenology, localisation of cerebral function gained impetus after French surgeon Pierre Broca isolated the motor speech area in 1861. While great strides were made by the nascent specialty in deciphering the hidden workings of the brain, neurologists did not unanimously accept epilepsy as a primarily neurological affliction. Seizures were considered to represent a generalised impact of extreme emotional stimulation on the nervous system. As a neurotic, paroxysmal disorder, epilepsy was often conflated with hysteria. Indeed, the first anticonvulsant drug, announced in 1857 by Charles Locock, arose from experimental use of bromides in women with hysteria. Eventually, Parisian neurologist Jean Charcot (1825– 1893) clarified the distinction between organic epilepsy and the psychogenic seizures of hystero-epilepsy. Meanwhile Jackson, driven by his desire for order and precision, was a catalyst for the divergence of neurology and psychiatry. He attributed all mental features of epilepsy to neuropathology. While it is now known that psychogenic seizures often occur in true epilepsy, Jacksonian psycho-parallelism persists with emotionally intense experiences restricted to the status of epiphenomena. Knowledge of epilepsy and related experience and behaviour has accumulated steadily through technological advances from EEG to functional magnetic resonance imaging. Combined with the adjacent limbic structures of the amygdala and hippocampus,4 the inner temporal lobe has been implicated in our sense of self. Its high electromagnetic sensitivity was exploited in the 1950s by Canadian neurosurgeon Wilder Penfield, Nobel Laureate for research on epilepsy, who stimulated spiritual sensations in patients by applying electrodes to the temporal lobes. Much publicised research three decades later by Michael Persinger of Laurentian University indicated that anyone is amenable to mystical experiences through transcranial magnetic stimulation. His ‘God Helmet’ creates an artificial electromagnetic field from which impulses penetrate deeply into the brain. By targeting the temporal lobes, Persinger found that the resulting micro-seizures could produce spiritual experiences in people of no religious beliefs. Consequently, Persinger (1987) claimed that God resides not in heaven but in neural networks. He speculated that spiritual feelings arise in people with temporal lobe epilepsy from their sensitivity to environmental electromagnetic fluctuation. As well as its involvement in longterm memory, the temporal lobe mediates states of consciousness; Persinger believed that childhood fantasy or religious imagery aroused in ‘temporal lobe transients’ become profoundly meaningful. Spurred by such findings, a new school of ‘neurotheology’ emerged. However, neurological correlates of thoughts or behaviour do not refute the ontological basis of faith. Persinger’s effects appear superficial compared to spontaneous mystical occurrences, and the validity of his findings was challenged by Pehr Granqvist and colleagues (2005) who suspected suggestibility. In their double-blind study, randomising theology and psychology students to magnetic or sham field, differences in psychological reactions correlated less to exposure than to personality features.
J Med Humanit
In the Geschwind syndrome, an interictal behavioural pattern found in some cases of temporal lobe epilepsy, patients display ‘increased concern with philosophical, moral or religious issues, often in striking contrast to the patient’s educational background’ (Geschwind 1979). Bear and Fedio (1977), who devised an 18-item instrument to measure this syndrome, did not confirm religiosity as a distinct feature. Instead, they attributed the heightened emotional intensity of spiritual experiences in epilepsy (as in irritability, sorrow and elation) to kindling of limbic-cortical connections through repeated aura experiences. The validity of the religiosity feature was challenged by other studies. Mungas (1982) concluded that spiritual phenomena arise from psychiatric comorbidity. Tucker and colleagues (1987) found no differences in frequency of spiritual events between temporal lobe epilepsy, or between people with epilepsy and the general population. However, Mungas studied a small sample, and the Tucker study measured overt behaviour only. While the Geschwind syndrome has been observed in around 7 % of people with temporal lobe epilepsy (Trimble 1991), religiosity could be more common, because neurologists do not routinely enquire into such beliefs or experiences (Devinsky and Lai 2008). Technological advances have facilitated major developments in knowledge of the neural correlates of spiritual experience. Neurologist Andrew Newberg and psychiatrist Eugene d’Aquili (2000) of the University of Pennsylvania conducted functional brain scans on Tibetan monks and Franciscan nuns during meditation. When the participant entered a deep meditative state, a radioactive substance was injected via catheter to illuminate brain activity. Newberg and d’Aquili observed a reduction in blood flow to the parietal lobe and an increase to the frontal lobe. The findings suggested that spiritual experiences occur when the sense of self, which emanates from the parietal lobe, is overridden by a feeling of unity, which may result from increased attentiveness indicated by frontal lobe activity. This study also undermined the search for a ‘God spot’, as spiritual sensations involve various parts of the brain beyond the temporal lobe and adjacent structures. Basically, the neurophysiological explanation is that spiritual feelings arise from false signal sent by the limbic system during stress or seizure to the temporal lobe and other sensory areas of the cerebral cortex. Constraint should be exercised by researchers in expanding findings beyond the specific variables observed. Causal direction could be inverted. For example, magnetic resonance imaging by Wuerfal and colleagues (2004) revealed in religiose cases of refractory epilepsy an abnormally small right hippocampus, implying that this structure has a critical role in spiritual delusions. However, this is possibly not cause but effect; perhaps a rigid character or faithful certainty reduces hippocampal demand. Research findings have too readily become building blocks of grand somaticist theories of religion. Inspired by their observations of brain activity during transcendental experiences, Newberg and d’Aquili inferred biological causation of myth and religion, but in a review of books on the neurology of spirituality, Alasdair Coles (2008), was scornful of such findings: “Without careful interpretation, this contributes as much to the study of religious experience as a Chicago city plan does to an analysis of American culture” (1956). Against such reasoning, Coles argued that ‘neurotheology has become—not to put too fine a point on it—an embarrassment’. Just as religion asserts certainties beyond empirical verification, eminent neurologist and atheist Raymond Tallis (2011) rejects the notion that neuroscience can explain all human meaning. In accord with Auguste Comte, many neuroscientists consider religious belief as a prolonged but passing stage of human development. By contrast, spirituality was considered as a culmination of evolutionary progress by zoologist Alister Hardy (1965). This biological thesis was presented at The Gifford Lectures, a prestigious series initiated at University of Edinburgh in 1885 by Lord Gifford to advance the scientific study of religion; it was here that
J Med Humanit
William James presented his Varieties of Religious Experience. Referring to anthropological findings, Hardy argued that evolution is not a purely mechanical adaptation to the environment but is also a conscious behavioural process. Innate capacity for transcendent awareness, according to Hardy, is unique to Homo sapiens, favouring those who cope with adversity by engaging in a broader meaning of life. Atheist scientists such as Richard Dawkins would need more persuasion that spirituality has survival value for the human species. The true scientific attitude is doubt, as reflected in the puzzle set by Fingelkurts and Fingelkurts (2009): ‘is our brain hardwired to produce God, or is our brain hardwired to perceive God?’ Religious beliefs cannot be pinpointed to a single structure, and it would be recklessly reductionist to ignore the unique personal and psychosocial context of visions. Therefore, knowledge of epileptic variants such as the Geschwind syndrome would be enhanced by rapprochement between neurology and psychiatry. While their branches of medicine have developed in Cartesian parallel, biologically-orientated psychiatrists and behavioural neurologists accept that as all mental symptoms have associated neurological action, and vice versa, much may be gained from combined expertise. As Henningsen and Kirmayer (2000) emphasised, mystical events should be investigated not only as causa materialis but also causa efficiens, the latter concerned not with physical process but with the precipitating factors for altered states of mind. Thus we should not expect answers from medical science alone.
Spirits having flown Among the inspirational religious figures whose behaviour has been suspected as symptomatic of epilepsy are Buddha (c563-483 BC), Mohammed (569–623), Hildegaard of Bingen (1098– 1179), St Birgitta of Vadstena (1303–1373), St Teresa of Avila (1515–1582), George Fox (founder of the Quakers, 1624–1691), Ann Lee (originator of the Shakers, 1736–1784), and Mormon founder Joseph Smith (1805–1844). Swedish scientific genius Emmanuel Swedenborg (1688–1772) had his first spiritual experience in 1744 when aged 56, subsequently offering a revised Christian theology with himself as prophet. Reviewing the case, Henry Maudsley (1869) likened the sensations described by Swedenborg around the time of his visions to an epileptic attack. Other cases include Joan of Arc (1412–1431), Søren Kierkegaard (father of existentialist philosophy, 1813–1855), and the aforementioned Dostoyevsky (1812– 1881). Religious ecstasy was experienced by artist Vincent van Gogh (1853–1890), who was admitted to an asylum with epilepsy, probably of temporal focus (Blumer 2002). Composer Frédéric Chopin (1810–1849) was tormented by visions of creatures calling from his piano. Although at the time doctors believed that Chopin suffered from severe depression, a recent diagnostic review attributed his complex visual hallucinations to temporal lobe epilepsy (Caruncho and Fernández 2011). Popular theologian Karen Armstrong experienced mystical ecstasy as a teenager at a Catholic convent and was later diagnosed with epilepsy (Coles 2008). Neuropathiography of historical cases relies on incomplete information, and other diagnoses have been considered. Exaltation occurs in mania, and the mood swings of bipolar affective disorder could explain the intense emotional experiences of Joseph Smith, Ann Lee, George Fox and others (Foster 1993). The behaviour of Saint Teresa of Avila during divine inspiration was explained as epileptic symptoms by biographer Vita Sackville-West (1943), but as hysteria by other writers. A contentious case is that of Mohammed, prophet of Islam. At the age of 40, when a merchant in Mecca, Mohammed began to have visions in which a figure approached him, sometimes preceded by ringing bells. Convinced that this was Archangel Gabriel conveying messages from the God of the Christians and Jews, Mohammed realised his mission to cleanse the people of sin and guide them to a virtuous life. Ostracised as a madman,
J Med Humanit
Mohammed took his small band of followers to the rival city of Medina where a receptive audience embraced the new faith of Islam. On resolving their conflict with Medina, the citizens of Mecca converted, and Islam was thereafter propagated by Mohammed across the Middle East. The divine visions and dreams, collated posthumously to form the Koran, have been interpreted by some writers as paroxysmal phenomena. Mohammed was described as epileptic by Theophanes, Byzantine scholar of the eighth century, based on alleged testimony of his wife Ayesha and follower Zeid—although this story was dismissed as calumny by historian Edward Gibbon (Temkin 1971). Christian propagandists used the charge of epilepsy to discredit Islam in the Middle Ages, claiming that Mohammed had feigned trance to mask his embarrassing seizures or that he had been possessed by demons. Unlike in Christendom, mentally imbalanced persons were regarded as special to Allah and treated benevolently. However, the Koran alternates between compassionate and castigatory tones, which may reflect the character of its visionary. As reviewed by Frank Freemon (1976), factors supporting a diagnosis of temporal lobe epilepsy are rapid onset of mystical events followed by complete resumption of normal mental function, recurrences over a long time, and symptoms of complex partial seizures including hallucinatory imagery. Referring to his own experiences, Dostoyesky was convinced that Mohammed’s visions emanated from pre-ictal exaltation. Contrary evidence is that epilepsy was not diagnosed at the time despite the condition being well known to Arab physicians; temporal lobe epilepsy normally has younger onset, and the visions and messages appear too highly organised for random epileptic origin. Modern biographers have doubted an epileptic medium for Mohammed’s visions, such as Owsei Temkin arguing in his classic history of epilepsy that ‘it is hard to imagine that the Koran, a body of religious, legal, and social instruction should largely be the product of a succession of hallucinatory epileptic attacks’ (1971, 373). Others such as Karen Armstrong omit mention of epilepsy, but this may be undue sensitivity. As Freemon explained, ictal timing of visions would not necessarily negate the revelation. Perhaps the surreal or ecstatic experiences of prophets are only possible in an extreme emotional state or in epileptic aura, which may be potentiates not only of extraordinary powers of imagination but also of deep spiritual experience. It is often suggested that madness enhances creative talent by enabling the author to see the world differently: evidently, mental disorder is much more common in authors and artists than in the general population (Jamison 1989). William James believed that spiritual revelations originate in the mind, but he afforded the possibility that divine visions emanate from a surge of superconsciousness: If there be higher spiritual agencies that can directly touch us, the psychological condition of their doing so might be our possession of a subconscious region which alone should yield access to them. The hubbub of the waking life might close a door which in the dreamy subliminal might remain ajar. (1902/2002, 195) Cases of sudden religious conversion have been reported in temporal lobe epilepsy, sometimes in people of no premorbid spiritual interest. A legendary instance was on the road to Damascus where Paul, hitherto tormentor of Christians, was arrested by a vision; medical historians have explained this as a hallucinatory event preceding seizure. Dewhurst and Beard (1970) reviewed six cases of conversion in interictal psychoses of temporal lobe epilepsy, including this medical school dropout with schizophreniform episodes: Aged 33, he stopped taking his anticonvulsants; within 6 weeks he was having fits every few hours; he had become confused and forgetful. At this point he suddenly realised that he was the Son of God; he possessed special powers of healing and could abolish cancer
J Med Humanit
from the world… ‘It was a beautiful morning and God was with me…God isn’t something hard looking down on us, God is trees and flowers and beauty and love. God was telling me to carry on and help the doctors here’. (500) Three years later this patient still believed that he was under the influence of a strange electrical medium through which God was revealing a virtuous path. Conversion has been described (Christensen 1963) as an acute hallucinatory experience typically resulting from unconscious conflict in adolescence, influenced by childhood religious background and provoked by the psychic stress that can overwhelm the ego in a transitional stage of life. Indeed, conversions in epilepsy are a phenomenon of youth: in a survey of 700 instances (Brandon 1960), 84 % occurred before 21 years of age. Yet some of the most influential mystics and prophets were spiritually entranced in later life.
Theology and phenomenal truth A wealth of literature has accumulated on faith and reason. In Alone in the World?, based on his Gifford Lectures, Princeton theologian Wentzel van Huyssteen (2006) straddled disciplinary boundaries in considering the theological, anthropological and neurological basis of religion. Yet scholarly treatises provide little practical guidance for the clinical frontline where doctors have limited skills and resources to engage in the spiritual world of a patient reporting a mystical experience. For holistic assessment, theological consultation should be available in the psychiatric or neurological clinic. Health service providers usually have a dedicated chaplaincy trained to consider patients’ personal spiritual perspectives in coping with illness. Patients should have access to clergy of their own faith, but paradoxically here may be found another obstacle to understanding spiritual experiences. Among a flock shepherded within the enclosure of codification, claims of direct communication from God may be taken as errant or symptomatic. Neurologist Michael Trimble’s thesis in The Soul in the Brain (2007) is that the ascendancy of the rational left hemisphere over the creative right has served the conservative forces of religious orthodoxy. The term ‘religious enthusiasm’, initially applied by the Church to disarm radical preachers such as George Fox and John Wesley, featured prominently in early textbooks on insanity (MacDonald 1990). Religious practice is highly normative; Jung’s therapeutic goal of individuation was for the ego to be freed from the confines of collective consciousness. On examining official documentation on hundreds of claimed cases of divine communication, Swiss supernaturalist Erich von Däniken remarked: It becomes clear that the Catholic Church claims the exclusive right to recognise or reject these phenomena, regardless of the fact that these visions have been seen by people of all races and religions. But according to its decree neither the Blessed Virgin, nor the Lord Jesus Christ, nor the archangels are free to appear to anyone they want. Even the visionaries themselves are not allowed to judge of the authenticity of what they have observed. (1977, 35) Yet the Christian establishment cannot be expected to accept uncritically each claim of divine communication. Consider the visionary basis of the Mormon sect. In 1823, an angel appeared in the domicile of Joseph Smith, delivering a message from the Saviour. In later visions Smith was guided to a hilltop where lay a set of gold tablets, containing the complete gospel, which he transcribed to form the Mormon bible. Rather than bowing to ecclesiastical scrutiny, authors of such tangential religious experience have founded new denominations. In
J Med Humanit
1848, Smith’s followers settled in what would later be known as Utah, which was declared a Mormon state. Since the nineteenth century, disproportionate psychopathology has been observed in affiliates of minority sects, possibly reflecting nonconformative personality traits. It also suggests limits to anthropological explanation of spiritual events. Intriguingly, there is a tendency for hyperreligiosity in temporal lobe epilepsy to deviate from prevailing belief and practice (Waxman and Geschwind 1975). In a study by Trimble and Freeman (2006) of religiosity in temporal lobe epilepsy, 18 of the 28 cases were affiliated to denominations other than Anglican or Roman Catholic. A study by Dolgoff-Kaspar and colleagues (2011) showed that in patients with high frequency of spiritual auras, there were few instances of deistic religious content, while paranormal beliefs were disproportionately common. The authors suggested renaming the trait of hyperreligiosity as ‘cosmic spirituality’. However, scientific researchers may not always appreciate the breadth of theological interpretations of the spiritual domain, and may therefore apply simplistic distinctions between experiential and conventional religious phenomena. The religious component of Geschwind syndrome requires further examination, and this would be an opportunity to develop collaboration between experts of brain, mind and spirit. For clinical and clerical experts to work together, paradigmatic compromises must be made. To understand a mystical event is not to accept its truth beyond the individual level, and practitioners do not need to be spiritual themselves to engage in the patient’s world. Furthermore, it must be emphasised that spiritual aura experiences in temporal lobe epilepsy would not be a justification for avoiding treatment; seizures have a sclerotic impact on brain tissue and without anticonvulsant medication this could lead to neurodegenerative disease. However, the medical model or esotericism of any discipline should not override the phenomenal essence of being human. As psychiatrist-philosopher Karl Jaspers (1883–1969) urged, clinicians should be equally concerned with Erklären (applying general theory to the case) and Verstehen (understanding the unique narrative). To be humane, healthcare is a subjective endeavour (Evans 2008). William James, in respecting spiritual revelation as personal truth, was an early exponent of the phenomenological approach, now an established methodology in psychology and social science. Rediscovery of the individual has been encouraged by postmodern ethics and critique of scientific epistemology. Free from restriction to a priori variables, case study methodology provides a valuable heuristic primer to developing theory in poorly understood phenomena. The case study researcher is not simply telling a story but generating concepts from unique data with a theoretical perspective guiding the investigation (Yin 1994). However, instead of deductive testing of a top-down hypothesis, the researcher works upwards from individual experiences. Contrasting with the realism of medicine and empirical psychology, phenomenology elevates content over form, but there is a fundamental problem of generalizability in an experiential ontology. From a scientific or transcendentalist perspective, something ‘out there’ must be perceivable by others. As explained by New York neurologists Orrin Devinsky and George Lai (2008) in their review of religiosity in temporal lobe epilepsy, ‘spiritual and religious experiences are deeply personal and verbally inexpressible’. Nonetheless, it is impossible to understand spiritual events without hearing the individual perspective. For all its flaws, mind trumps brain as informant.
Cosmic consciousness revived Without a recursive relationship between subject and object, dualism persists. From the materialist stance, the mind is Gilbert Ryle’s ‘ghost in the machine’, being merely a figure
J Med Humanit
of speech for our cognitive processes. The spiritual concept of the soul is anathema to scientific episteme (Walach 2007), but such belief is not necessarily deistic or anthropocentric. Humanistic psychologist Abraham Maslow (1908–1970) regarded spiritual events not as supernatural but ‘within the jurisdiction of a suitably enlarged science’ (1964, 19), and religious ecstasy as a variety of ‘peak experience’ in which ultimate self-actualisation is attained. In a refinement to his hierarchy of needs, Maslow placed transcendence atop the pyramid. Current application of mindfulness in Western psychology, albeit in secularised form, is based on Buddhist meditative pursuit of a higher plane of consciousness. Many brilliant scientific discoveries have arisen from visionary dreams, Einstein suggesting that scientific genius draws on cosmic energy enabling insight beyond the reach of the normal range of intellect (May 1993). Temporal lobe epilepsy is but one condition in which spiritual phenomena are reported. We know from Persinger’s experiments and from David Hay’s (2006) qualitative research, that transcendental experiences occur in people with neither faith nor neuropsychiatric morbidity. However, it seems that insult to brain tissue may be an abrupt means of access to a world unseen in normal conscious life. In his provocatively-titled Proof of Heaven, neurosurgeon Eben Alexander (2012) described his surreal experience while in a coma caused by a severe form of meningitis, which effectively closed down his cerebral cortex. Previously sceptical of patients’ reports of out-of-body experiences, Alexander had vivid and dramatic visions of the universe as a whole, sensing that he had been close to entering a realm of consciousness beyond the body. His book was being attacked by the medical and scientific commentators before its release. From a theological perspective, mystical events are a manifestation of pure consciousness, overriding learned responses to profane surroundings (Forman 1998). Perhaps the spontaneous aura experiences of temporal lobe seizures are a portal to a holistic reality, as in the implicate order described by physicist David Bohm (1980)—or the cosmic consciousness of Bucke.
Conclusion As can be seen, the paradigms of psychiatry, psychology and neurology have eschewed extracerebral explanations for spiritual events in epilepsy. William James was writing at a time of spiritual awakening, and after a twentieth century of neglect, there are strong signs of revived interest in spirituality in society, reflected in the literature of psychology and medicine. Atheist polemics such as Richard Dawkins’ God Delusion (2007) have put faith back on the agenda. Despite apparent incompatibility, the goal of science and religion is fundamentally the same: both are concerned with ultimate reality. This may not be found by delving deeper in the atomist tradition of Democritus but by gazing higher, as in the idealism of Plato. In an inclusive paradigm, accounts of visionary experiences should be judged on individual merit, not by symptomatology or religious creed. We urge a broader, interdisciplinary perspective from a starting point that the ‘truth’ of visions is doubted rather than denied. Without a spiritual perspective, it is difficult to see how the phenomenon of transcendental experience in epileptic aura can be understood beyond descriptive enquiry. Refined empirical and phenomenological research may help to explain whether the complex, partial seizures of temporal lobe epilepsy are a cause of spiritual feelings, or an accessory to individual and universal enlightenment.
Endnotes 1 Temporal lobe: a division of the cerebral cortex, which is the grey matter responsible for intellectual function. Located at the temple on either side, the temporal lobe is involved in perception, speech and memory.
J Med Humanit 2
Ictal: pertaining to seizure (ictus). The boundaries between spirituality and religion are debatable. In this paper, religion is considered as a subset of spirituality, which in turn belongs to the broader metaphysical domain (which would include, for example, a sense of transcendence of no teleological implication). 4 Limbic system: complex network of structures including the hippocampus and amygdala. The hippocampus, enclosed within the temporal lobe, is involved in the forming, organisation and storage of memory. The adjacent amygdala produces emotional reactions and activates the ‘fight or flight’ mechanism. 3
References Alexander, E. 2012. “Heaven is Real: a Doctor’s Experience of the Afterlife.” Newsweek 15 October. American Psychiatric Association. 1994. Diagnostic & Statistical Manual of Mental Disorders IV. Washington, DC: American Psychiatric Association. Barham, G.F. 1907. “Notes on the Management and Treatment of the Epileptic Insane with Special Reference to the NaCl-Free (or Hypochlorination) Diet.” Journal of Mental Science 53:361–367. Bartlet, J.E.A. 1957. “Chronic Psychosis Following Epilepsy.” American Journal of Psychiatry 114:338–343. Bartocci, G., and S. Dein. 2005. “Detachment: Gateway to the World of Spirituality.” Transcultural Psychiatry 42:545–569. Bear, D.M., and Fedio, P. 1977. “Quantitative Analysis of Interictal Behaviour in Temporal Lobe Epilepsy.” Archives of Neurology 34:454–467. Berrios, G.E. 1979. “Insanity and Epilepsy in the Nineteenth Century.” In Psychiatry, Genetics and Pathography: a Tribute to Eliot Slater, edited by M. Roth and V. Cowie, 161–171. London: Gaskell. Betts, T.A. 1981. “Epilepsy and the Mental Hospital” . In Epilepsy and Psychiatry, edited by E.H. Reynolds and M.R. Trimble, 175–184. Edinburgh: Churchill Livingstone. Bohm, D. 1980. Wholeness and the Implicate Order. London: Ark. Brandon, O. 1960. The Battle for the Soul: Aspects of Religious Conversion. London: Hodder & Stoughton. Browne, V. 1978. Jung: Man and Myth. London: Macmillan. Caruncho, M.V., and F.B. Fernández. 2011. “The Hallucinations of Frédéric Chopin.” Medical Humanities 37:5– 8. Christensen, C.W. 1963. “Religious Conversion.” Archives of General Psychiatry, 9:207–216. Coles, A. 2008. “God, Theologian and Humble Neurologist.” Brain 131:1953–1959. Curlin, F.A., Odell, S.V., Lawrence, R.E., Chin, M.H., Lantos, J.D., Meador, K.G., and H.G. Koenig. 2007. “The Relationship between Psychiatry and Religion among U.S. Physicians.” Psychiatric Service 58:1193–1198. Dawkins, R. 2007. The God Delusion. London: Black Swan. Devinsky, O., and G. Lai. 2008. “Spirituality and Religion in Epilepsy.” Epilepsy & Behaviour 12:636–643. Dewhurst, K., and A.W. & Beard. 1970. “Sudden Religious Conversions in Temporal Lobe Epilepsy.” British Journal of Psychiatry, 117:497–507. Dolgoff-Kaspar, R., Ettinger, A.B.., Golub, S.A., Perrine, K., Harden, C., and S.D. Croll. 2011. “Numinous-Like Auras and Spirituality in Persons with Partial Seizures.” Epilepsia 52:640–644. Dostoyevsky, F. 1869/2004. The Idiot, translated by D. McDuff. London: Penguin. Edelston, H. 1949. “A Case of Hystero-Epilepsy Successfully Treated by Deep Analytic Psychotherapy.” Journal of Mental Science 95:388–402. Ellis, A. 1980. “Psychotherapy and Aesthetic Values: a Response to AE Bergin’s ‘Psychotherapy and Religious Values.’” Journal of Consultative Clinical Psychology 48:635–639. Esquirol, J.D. 1837/1845. Mental Maladies: Treatise on Insanity, translated by E.K. Hunt. Philadelphia: Lea & Blanchard. Evans, H.M. 2008. “Affirming the Existential Within Medicine: Medical Humanities, Governance, and Imaginative Understanding.” Journal of Medical Humanities 29: 55–59. Fingelkurts, A.A., and A.A. Fingelkurts. 2009. “Is our Brain Hardwired to Produce God, or is our Brain Hardwired to Perceive God? A Systematic Review on the Role of the Brain in Mediating Religious Experience.” Cognitive Process 10:293–326. Foote-Smith E., and L. Bayne. 1991. “Joan of Arc.” Epilepsia 32:810–815. Forman, R. 1998. “What Does Mysticism Have to Teach us About Consciousness?” Journal of Consciousness Studies 5:185–201. Foster, L. 1993. “The Psychology of Religious Genius: Joseph Smith and the Origins of New Religious Movements.” Dialog: a Journal of Mormon Thought 26:1–22. Freemon, F.R. 1976. “A Differential Diagnosis of the Inspirational Spells of Muhammad the Prophet of Islam.” Epilepsia 17:423–427.
J Med Humanit Freud, S. 1934. The Future of an Illusion. London: Leonard & Virginia Woolf at the Hogarth Press. Galanter, M. 2005. Spirituality and the Healthy Mind: Science, Therapy and the Need for Personal Meaning. Oxford: Oxford University Press. Gastaut, H. 1978. “Fyodor Mikhailovitch Dostoevski’s Involuntary Contribution to the Symptomatology and Prognosis of Epilepsy.” Epilepsia 19:186–201. Geschwind, N. 1979. “ Behavioural Changes in Temporal Lobe Epilepsy.” Psychological Medicine 9:217–219. Gibbs, F.A. 1951. “Ictal and Nonictal Psychiatric Disorders in Temporal Lobe Epilepsy.” Journal of Nervous & Mental Disease 113:522–528. Granieri, E., and P. Fazio. 2011. “The Lombrosian Prejudice in Medicine: the Case of Epilepsy; Epileptic Psychosis; Epilepsy and Aggressiveness.” Neurological Sciences. Accessed October 24, 2011. www. springerlink.com/content/kh63041g33m3n418/fulltext.pdf Granqvist, P., Fredrikson, M., Unge, P., Hagenfeldt, A., Valind, S., Larhammar, D., and M. Larsson. 2005. “Sensed Presence and Mystical Experiences are Predicted by Suggestibility, Not By the Application of Transcranial Weak Complex Magnetic Fields.” Neuroscience Letters 379:1–6. Hardy, A. 1965. The Living Stream: a Restatement of Evolution Theory and its Relation to the Spirit of Man. London: Collins. Hay, D. 2006. Something There: the Biology of the Human Spirit. London: Darton, Longman & Todd. Henderson, D.K., and R.D. Gillespie. 1950. Textbook of Psychiatry, 7th edition. London: Oxford University Press. Henningsen, P., and L.J. Kirmayer. 2000. “Mind Beyond the Net: Implications of Cognitive Neuroscience for Cultural Psychiatry.” Transcultural Psychiatry 37:467–494. Hoch, P.H. 1943. “Clinical and Biological Interrelations Between Schizophrenia and Epilepsy.” American Journal of Psychiatry 99:507–512. Hood, R. 1996. The Psychology of Religion, 2nd edition. New York: Guilford Press. Howden, J.C. 1872. “The Religious Sentiment in Epileptics.” Journal of Mental Science 18: 82–497. Hunter, R., and I. Macalpine. 1963. Three Hundred Years of Psychiatry 1535–1860. London: Oxford University Press. Iannaccone, L., Stark, R., and R. Finke. 1998. “Rationality and the ‘Religious Mind.’” Economic Inquiry 36: 373–389. Jackson, J.H.. and P. Stewart. 1899. “Epileptic Attack With a Warning of a Crude Sensation of Smell and Intellectual Aura (Dreamy State) in a Patient who has Symptoms Pointing to Gross Organic Disease of Right Tempero-Sphenoidal Lobe.” Brain 22: 534–549. James, W. 1902/2002. The Varieties of Religious Experience: a Study in Human Nature. London: Routledge. Jamison, K.R. 1989. “Mood Disorders and Patterns of Creativity in British Writers and Artists.” Psychiatry 52: 125–134. Kleinman, A. 2006. What Really Matters? New York: Oxford University Press. Koenig, H.G. 2009. “Research on Religion, Spirituality and Mental Health: A Review.” Canadian Journal of Psychiatry 54:283–291. Landsborough, D. 1987. “St. Paul and Temporal Lobe Epilepsy.” Journal of Neurology, Neurosurgery & Psychiatry 50:659–664. Landtblom, A. 2004. “Did Sts Birgitta Suffer from Epilepsy? A Neuropathography.” Seizure 13:161–167. Lewis-Fernández, R., and N. Díaz. 2002. “The Cultural Formulation: A Method for Assessing Cultural Factors Affecting the Clinical Encounter.” Psychiatric Quarterly 73:271–295. Lukoff, D., Lu, F., and R. Turner. 1992. “Toward a More Culturally Sensitive DSM-IV.” Journal of Nervous &Mental Disease 180:673–682. MacDonald, M. 1990. “Insanity and the Realities of History in Early Modern England.” In Lectures on the History of Psychiatry, edited by R.M. Murray and T.H. Turner, 60–81. London: Gaskell. Maslow, A.H. 1964. Religion, Values and Peak Experience. New York: Penguin. Maudsley, H. 1869. “Emanuel Swedenborg.” Journal of Mental Science 15:169–198. May, R.M. 1993. Cosmic Consciousness Revisited: the Modern Origins and Development of a Western Spiritual Psychology. Rockport: Element. Mayer-Gross, W., Slater, E., and M. Roth. 1955. Clinical Psychiatry. London: Cassell & Company. Mungas, D. 1982. “Interictal Behaviour Abnormality in Temporal Lobe Epilepsy: A Specific Syndrome or Nonspecific Psychopathology.” Archives of General Psychiatry 39:108–111. Newberg, A.B.., and E.G. d’Aquili. 2000. “The Neuropsychology of Religious and Spiritual Experience.” Journal of Consciousness Studies 7:251–266. Ng, F. 2007. “The Interface Between Religion and Psychosis.” Australasian Psychiatry 15: 62–66. Persinger, M.A. 1987. Neuropsychological Bases of God Beliefs. New York: Praeger. Plante, T.G. 2009. Spiritual Practices in Psychotherapy: Thirteen Tools for Enhancing Psychological Health. Washington DC: American Psychological Association.
J Med Humanit Prince, R. 1979. “Religious Experience and Psychosis.” Journal of Altered States of Consciousness 5:167–181. Skinner, B.F. 1987. “What Religion Means to Me.” Free Inquiry 7:12–13. Slater, E., and A.W. Beard. 1963. “The Schizophrenia-Like Psychoses of Epilepsy.” British Journal of Psychiatry 109:95–150. Szasz, T. 1974. The Second Sin. Garden City: Doubleday. Tallis, R. 2011. The Aping of Mankind: Neuromania, Darwinitis and the Misrepresentation of Humanity. Acumen. Temkin, O. 1971. The Falling Sickness: a History of Epilepsy from the Greeks to the Beginnings of Modern Neurology, 2nd edition. Baltimore: Johns Hopkins University Press. Trimble, M. 1991. The Psychoses of Epilepsy. New York: Raven. ———. 2007. The Soul in the Brain: the Cerebral Basis of Language, Art and Belief. Baltimore: Johns Hopskins University Press. Trimble, M., and A. Freeman. 2006. “An Investigation of Religiosity and the Gastaut-Geschwind Syndrome in Patients with Temporal Lobe Epilepsy.” Epilepsy & Behaviour 9:407–414. Tucker, D.M., Novelly R.A., and P.J. Walker. 1987. “Hyperreligiosity in Temporal Lobe Epilepsy: Redefining the Relationship.” Journal of Nervous & Mental Disease 175: 181–184. van Huyssteen, J.W. 2006. Alone in the World: Human Uniqueness in Science and Theology. Grand Rapids: Eerdmans. von Dänicken, E. 1977. Miracles of the Gods: a Hard Look at the Supernatural. London: Corgi. Walach, H. 2007. “Mind-Body-Spirituality.” Mind & Matter 5:215–240. Waxman, S.G., and N. Geschwind. 1975. “The Interictal Behaviour Syndrome of Temporal Lobe Epilepsy.” Archives of General Psychiatry 32:1580–1586. Whitley, R. 2010. “Atheism and Mental Health.” Harvard Review of Psychiatry 18:190–194. Wolf, P., and M.R. Trimble. 1985. “Biological Anatagonism and Epileptic Psychosis.” British Journal of Psychiatry 146:272–276. Wuerfel, J., Krishnamoorthy E.S., Brown R.J., Lemieux L., Koepp M., Tebartz van Elst L., and M.R. Trimble. 2004. “Religiosity is Associated with Hippocampal but not Amygdala Volumes in Patients with Refractory Epilepsy.” Journal of Neurology & Neurosurgical Psychiatry 75:640–642. Yin, R.K. 1994. Case Study Research: Design and Methods, 2nd edition. Thousand Oaks, California: Sage.
