to the editor
TRANSCRIPT
132 Letters to the Editor
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REPLY
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To the Editor:
Dr. Montouris raises a number of excellent pointsregarding nonepileptic seizures in response to my ed-itorial (1). As reflected in the second edition of Non-Epileptic Seizures (2), the spectrum of diagnostic possi-bilities for nonepileptic seizures is really quite broad.Dr. Mountouris’ comments draw on her extensiveclinical experience in Memphis, Tennessee, where Ibelieve there exist a disproportionate number of pa-tients with nonepileptic seizures who have somato-form disorders. I fully agree that they constitute asignificant subgroup of all patients with psychogenicnonepileptic seizures, but other centers have encoun-tered proportionally greater numbers of patients withconversion disorders, dissociative disorders, or anxi-ety disorders. Therefore, we must choose terms thatare all-inclusive rather than specific to the particularpatient mix of one region or another.
Dr. Montouris makes very pertinent points regard-ing the value of video-EEG, the economic impact ofthis disorder, and the ethical issues surrounding pro-vocative testing. The comment I made in my editorialabout “throwing down the gauntlet” and evaluatingthe utility of provocative testing belies a significantissue and serious problem in diagnosis. Obviously,
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such a study runs the potential risk of creating psy-chological trauma, but so does an inaccurate diagno-sis. I would argue that the benefits of such researchmay outweigh the risks and that we will only know byactually performing the study in a carefully monitoredfashion.
REFERENCES
1. Gates JR. Nonepileptic seizures: time for progress. EpilepsyBehav 2000;1:2–6.
2. Gates JR, Rowan AJ, editors. Non-epileptic seizures. 2nd ed.Boston: Butterworth–Heinemann, 2000.
John Gates, M.D.1
Minnesota Epilepsy Group, P.A.310 Smith Avenue NorthSuite 310St. Paul, Minnesota 55102
1 To whom correspondence should be addressed. Fax: (651) 220-248. E-mail: [email protected].
doi:10.1006/ebeh.2000.0054
Temporal Lobectomy and Dreams: An Insight into theMechanism of Inhibition?
To the Editor:Dreams are implicated in cognitive, emotional, andmnemonic processes, but their role remains controver-sial. Evidence from brain-damaged patients and PETstudies in normal individuals accumulates, but thefunctional neuroanatomy of dreams is poorly under-stood. Right cerebral hemisphere specialization foremotional and visuospatial processing suggests a crit-ical role in the generation of dreams (1), althoughdreaming occurs in patients with only an isolated lefthemisphere (2). Further, in normals, areas in bothhemispheres are metabolically activated during REMsleep (3, 4). We report the dream of a patient 1 monthafter her right temporal lobectomy and its possibleimplications regarding cortical mechanisms of dream-ing.
This 29-year-old right-handed woman was well un-til age 15, when she began having partial seizures
characterized by laughter and smiling with a mirthfulfeeling lasting approximately 90 seconds. These epi-sodes became more frequent over time, with occa-sional impaired consciousness and oral and hand au-tomatisms. At age 17, CT scan and angiography re-vealed a right internal carotid artery aneurysm. At age18, she underwent embolization, but the aneurysmcontinued to compress the right mesial temporal lobe.Her seizures were refractory to medication, and at age22 she underwent resection of the aneurysm and asmall portion of the anteromesial temporal lobe with-out complications. She was seizure-free for severalmonths on carbamazepine, but then had simple partialseizures (;14 times per year), complex partial seizures(;10 per year), and generalized tonic clonic seizures(;4 per year). Partial seizures were refractory to morethan four antiepileptic drugs. CT scan showed MCAclip and tissue loss within the right temporal tip andcalcification in the sylvian fissure.