By: Annemarie DeChellis
Ecstatic seizures are a rare form of focal seizure that occur without the impairment of a person’s awareness or consciousness. During an ecstatic seizure, a person typically experiences a feeling of intense positive emotions, enhanced physical wellbeing, and enhanced self-awareness or perception of the external world. Other symptoms may include altered sense of time, increased self-world clarity, feelings related to spiritual and religious experiences, bodily sensations (e.g., floating)
, and sensory fullness (Gschwind & Picard, 2016; Picard & Kurth, 2014). Laryngeal constriction and speech impairment may occur during ecstatic seizures as well (Gschwind & Picard, 2016; Roodakker et al., 2020). Additionally, ecstatic seizures may evolve into a secondary seizure, impairing consciousness such as a tonic-clonic seizure. Occasionally, ecstatic seizures may occur alongside gelastic seizures (Gschwing & Picard, 2016; Picard & Craig, 2009; Roodakker et al., 2020).
Causes and Origin
Ecstatic seizures are thought to originate within the insular cortex. The insular cortex lies deep within the brain and is divided into posterior and anterior lobes. Functionally, the insular cortex plays a role in bodily and sensation awareness, pain perception, emotions, decision-making, and self-awareness (Benarroch, 2019; Craig, 2009; Dougherty, 2019). Epilepsy of the insular cortex is rare; during a seizure patients remain conscious and experience somatosensory symptoms (e.g., unpleasant bodily sensations), difficulty with speech and laryngeal constrictions or discomfort. Many of these symptoms are similarly reported with ecstatic seizures (Dougherty, 2019; Isnard et al., 2004; Landtblom et al., 2011).
Specifically for ecstatic seizures, the left anterior insular cortex is referenced most often as the potential origin. The anterior insular cortex plays a significant role in self-awareness, “present-moment awareness,” and positive feelings. The functional role of the anterior insular cortex aligns closely with characteristics of ecstatic seizures, such as heightened self-awareness and feelings of bliss (Benarroch, 2019; Craig, 2009; Gschwind & Picard, 2016; Landtblom et al., 2011; Picard & Craig; 2009; Picard & Kurth, 2014).
Diagnosis
Electroencephalograms (EEG) and magnetic resonance imaging (MRI) can be used to diagnose ecstatic epilepsy. EEG reports have shown abnormalities in the temporopolar region, notably left anterior slow theta waves. MRI scans may reveal a tumor relating to seizure activity. However, not all who experience ecstatic seizures show neuroanatomical abnormalities such as a tumoral mass (Picard & Craig, 2009).
Treatment
For some patients surgery has successfully resolved ecstatic seizures. However, there is the possibility that ecstatic seizures may return after surgery despite initially resolving the seizures (Picard & Craig, 2009; Roodakker et al., 2020). For example, one patient who experienced ecstatic and gelastic seizures underwent surgery to remove a hypothalamic hamartoma. After removal, the patient did not experience an ecstatic seizure until several years later when they reappeared possibly due to a neural network reactivating within the insular cortex (Roodakker et al., 2020). In addition, antiepileptic drugs, such as levetiracetam, can help treat ecstatic seizures (Picard & Craig, 2009).
Historical Significance
One of the earliest descriptions of ecstatic seizures is found in Fyodor Dostoevsky’s novels.Dostoevsky (1821-1881) was a Russian philosopher and novelist, who is hypothesized to have had a form of temporolimbic epilepsy and ecstatic seizures (Picard & Kurth, 2014; Rayport, Rayport, & Schell, 2011). Dostoevsky’s talent for writing enabled him to create a detailed description of a complex phenomena that many patients struggle to describe themselves. Dostoevsky’s writing became a source for ecstatic epilepsy research, providing a greater understanding of the nature of ecstatic seizures. Even today many patients describe their ecstatic seizures similar to Dostoevsky’s (Picard & Craig, 2009).
Patients Descriptions of Ecstatic Seizures
- “Feelings in the head, a happy feeling without a cause, a pleasant feeling, a dream about something wonderful, a feeling of hearing and understanding everything, like when a dark sky is being lit up by the sun. Words cannot describe it. No other life experience is comparable” (Roodakker et al., 2020).
- “During the seizure it is as if I were very, very conscious, more aware, and the sensations, everything, seems bigger, overwhelming me.” (Case 1, Picard & Craig, 2009).
- “My head fills with feelings and emotions… I feel more conscious of myself, more concentrated on myself. I feel more present from a psychological point of view, with more sensations…” (Case 4, Picard & Craig, 2009).
Conclusion
Rare forms of epilepsy can be challenging to diagnose and adequately treat. In the case of ecstatic seizures, patients may be reluctant to discuss symptoms with healthcare providers, have difficulty finding the words to describe an ecstatic seizure, or may have other secondary seizures that overshadow the presence of ecstatic seizures (Picard & Craig, 2009). However, the information which patients have provided has significantly contributed to the advancement of understanding and treating epilepsy while also providing crucial insight to the functional role of different areas of the brain (Benarroch, 2019).
References
Benarroch, E.E. (2019). Insular cortex: Functional complexity and clinical correlations. Neurology, 93(21), 932-938.
Craig, A. (2009). How do you feel — now? The anterior insula and human awareness. Nat Rev Neurosci, 10, 59–70.
Dougherty, M. L. (2019). Epilepsy essentials: Insular epilepsy. Practical Neurology, 22-23.
Gschwind, M., & Picard, F. (2016). Ecstatic Epileptic Seizures: A Glimpse into the Multiple Roles of the Insula. Frontiers in behavioral neuroscience, 10, 21.
Isnard, J., Guénot, M., Sindou, M. and Mauguière, F. (2004). Clinical manifestations of insular lobe seizures: A stereo-electroencephalographic study. Epilepsia, 45(9),1079-1090.
Landtblom, A.M., Lindehammar, H., Karlsson, H., & Craig, A. D. (2011). Insular cortex activation in a patient with “sensed presence”/ecstatic seizures. Epilepsy & Behavior, 20(4), 714–718.
Picard, F., & Craig, A. (2009). Ecstatic epileptic seizures: A potential window on the neural basis for human self-awareness. Epilepsy & Behavior, 16(3), 539–546.
Picard, F. & Kurth, F. (2014). Ictal alterations of consciousness during ecstatic seizures. Epilepsy & Behavior, 30, 58-61.
Rayport, S. M. F., Rayport, M., & Schell, C. A. (2011). Dostoevsky’s epilepsy: A new approach to retrospective diagnosis. Epilepsy & Behavior, 22(3), 557–570.
Roodakker, K.R., Ezra, B., Gauffin, H., Latini, F., Zetterling, M., Berntsson, S., & Landtblom, A. (2020). Ecstatic and gelastic seizures related to the hypothalamus, Epilepsy & Behavior Reports, 14, 1-5.
