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(2) instead of a complete loss of control of thought and action, there is a period of altered behavior and consciousness, for which the patient is later found to be amnesic Although it is dif cult to enumerate all the psychic experiences that may occur during complex partial seizures, they may be categorized into a somewhat arbitrary hierarchy of illusions, hallucinations, dyscognitive states, and affective experiences 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, unidenti able sensations of smell), gustatory, or vertiginous The term dyscognitive state refers to feelings of increased reality or familiarity (deja vu) or of strangeness or un ` familiarity (jamais vu) or a sense of depersonalization 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) Associated epigastric and abdominal sensations have been alluded to above Emotional experiences, while less common, may be dramatic sadness, loneliness, anger, happiness, and sexual excitement have all been recorded Fear and anxiety are the most common affective experiences, while occasionally the patient describes a feeling of rage or intense anger as part of a complex partial seizure Ictal fear may have no apparent connection to objective experience and is generally not related to the situation in which the patient nds himself during the seizure Each of these subjective psychic states may constitute the entire seizure (simple partial seizure), or some combination may occur and proceed to a period of unresponsiveness Patients call these auras, but they represent electrical seizures and have the same signi cance as a motor convulsion The motor components of the seizure, if they occur, do so during the latter phase and take the form of automatisms such as lip-smacking, chewing or swallowing movements, salivation, fumbling of the hands, or shuf ing of the feet Patients may walk around in a daze or act inappropriately (undressing in public, speaking incoherently, etc) Certain complex acts that were initiated before the loss of consciousness such as walking, chewing food, turning the pages of a book, or even driving may continue However, when asked a speci c question or given a command, the patients are obviously out of contact with their surroundings There may be no response at all, or the patient may look toward the examiner in a perplexed way or utter a few stereotyped phrases In a very small number of patients with temporal lobe seizures (7 of 123 patients studied by Ebner et al), some degree of responsiveness (to simple questions and motor commands) is preserved in the presence of prominent automatisms such as lip-smacking and swallowing Interestingly, in this small group of partially responsive patients, the seizures originate in the right temporal lobe The patient, in a confused and irritable state, may resist or strike out at the examiner The violence and aggression that are said to characterize patients with temporal lobe seizures usually take this form of nondirected oppositional resistance in response to restraint during the period of automatic behavior (so called be-.

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cause the patient presumably acts like an automaton) or, more often, in the postictal period Unprovoked assault or outbursts of intense rage or blind fury are very unusual; Currie and associates found such outbursts in only 16 of 666 patients (24 percent) with temporal lobe epilepsy Pen eld once commented that he had never observed a rage state as a result of temporal lobe stimulation It is exceedingly unlikely that an organized violent act requiring several sequential steps in its performance, such as obtaining a gun and using it, could represent a temporal lobe seizure Rarely, laughter may be the most striking feature of an automatism (gelastic epilepsy) A particular combination of gelastic seizures and precocious puberty has been traced to a hamartoma of the hypothalamus Or the patient may walk repetitively in small circles (volvular epilepsy), run (epilepsia procursiva), or simply wander aimlessly, either as an ictal or postictal phenomenon (poriomania) These forms of seizure are actually more common with frontal lobe than with temporal lobe foci Dystonic posturing of the arm and leg contralateral to the seizure focus is found to be a frequent accompaniment if sought again, the origin is more often in the frontal than the temporal lobes, localizing particularly to the supplementary motor area After the attack, the patient usually has no memory or only fragments of recall for what was said or done Any type of complex partial seizures may proceed to other forms of secondary generalized seizures The tendency to generalization holds true for all types of partial or focal epilepsy The patient with temporal lobe seizures may exhibit only one of the foregoing manifestations of seizure activity or various combinations of them In a series of 414 patients studied by Lennox, 43 percent displayed some of the motor changes; 32 percent, automatic behavior; and 25 percent, alterations in psychic function Because of the frequent concurrence of these symptom complexes, he referred to them as the psychomotor triad Probably the clinical pattern varies with the precise locality of the lesion and the direction and extent of spread of the electrical discharge Because of their focal origin and complex symptomatology, all these types of seizures are best subsumed under the heading of complex partial seizures This term is preferable to temporal lobe seizures, since typical complex partial seizures sometimes arise from a focus in the medial-orbital part of the frontal lobe Also, seizures originating in the parietal or occipital lobes may be manifested as complex partial seizures because of seizure spread into the temporal lobes Often the brief ictal aura is not re ected in cortical epileptic activity and therefore may be missed by routine surface EEG recordings Complex partial seizures are not peculiar to any period of life, but they do show an increased incidence in adolescence and the adult years In the series of Ounsted and coworkers, about onethird of such cases could be traced to the occurrence of severe febrile convulsions in early life (see further on) As a corollary, about 5 percent of all their patients with febrile seizures continued to have seizures during adolescence and adult life; in the latter group there were many in whom the seizures were of the temporal lobe type Also, in Falconer s series in which a temporal lobectomy was performed for intractable epilepsy, there were many patients who had previously had this complicated type of febrile seizure Neonatal convulsions, head trauma, and various other nonprogressive perinatal neurologic disorders are antecedents that place a child at risk of developing complex partial seizures (Rocca et al) Twothirds of patients with complex partial seizures also have generalized tonic-clonic seizures or have had them at some earlier time, and it has been theorized that the generalized seizures may have.

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An example of the look and feel of the Stacked Columns option is shown in the following illustration You can see that this would also be a very direct chart to offer for analysis