Ego and Central Nervous System Function—a Frame of Reference

EGO AND CENTRAL NERVOUS SYSTEM FUNCTIONA FRAME OF REFERENCE RALPH W. WADESON, JR., M.D.* I. Introduction The opportunity to observe, interview, and evaluate many patients with temporal lobe or psychomotor epilepsy was provided during psychiatric consultations on the Neurosurgical Unit ofthe National Institute ofNeurological Diseases and Blindness. In addition to the over-all emotional and characterological problems suffered by these patients, there was abundant material relating to the phenomena ofthe seizure itself. From the first evidence ofthe aura to the last manifestation ofthe ictus, there seemed to be a fractionation ofego function. The presence of a disease focus producing abnormal electrical activity in the temporal lobe ofthe brain often sets in motion a sequence ofevents portraying a panoramic view ofcentral nervous system function. As this phenomenon unfolds during the "march" of the epileptic discharge, the sequence may include symbolic thinking, hallucinations, illusions; disturbances ofvision, audition, taste, and olfaction; autonomic visceralphenomena ; somatic sensory and motor phenomena; performance ofcomplex behavior ; and disturbances ofspeech and memory. It was the great variety of these manifestations that led to this effort to formulate a frame ofreference that would encompass physical, emotional, and intellectual aspects ofbrain function. The first to formulate such a systematic approach to central nervous system function was HughlingsJackson, who stated [i]: "The whole central nervous system, the organ ofthe mind included—the mind, ofcourse, * Psychiatric Consultant to the Neurosurgical Service, National InstituteofNeurological Diseases and Blindness, National Institutes of Health, Bethesda, Address: Maryland. 2829 Connecticut Avenue , N.W., Washington, D.C. 20008. The author is indebted to Dr. Maitland Baldwin for many meaningful questions and suggestions about this paper during its preparation. 52O Ralph W. Wadeson,Jr. · Ego and Central Nervous System Function Perspectives in Biology and Medicine · Summer 1963 not included—is a sensorimotor mechanism ofthree levels, the distinction I make is not ofkind but merely ofdegree—it is that the praefrontal lobe is only greatly more complex, etc., than the 'motor region.' " Jackson said further [2]: "There is from lowest to highest centres: (1) increasing complexity (differentiation), representation of a greater number of different movements; (2) increasing definiteness (specialization), representation ofmovements for more particular duties; (3) increasing integration, representation ofmovements ofwider ranges ofthe body in each part of the centres; (4) the higher the centres the more inter-connections oftheir units (cooperation)." AU ofthe above factors seem evident in the frame ofreference presented here and, in addition, there are two more which seem to be worth mentioning . (1) The higher the level offunction, the less distinction there is between sensory andeffector function. (2) The higher thelevel ofsensory experience , the more possible ways the effector mechanisms can express or modify it. However, the major emphasis here is upon formulating a frame of reference for extending the levels concept to include "the mind" [1], i.e., psychological phenomena. In doing so, these are related to some aspects of Ego psychology; because the Ego as it is conceptualized by Novey [3] and others is a multifunctioning system, parts of which are affected by other of its parts. And the function of the Ego according to Freud [4] is to mediate between man's inner drives and external reality and to permit delayed response to reality. This enables the individual to make the best possible adjustment to any given stimulus by means oftotal central nervous system function. II. Clinical Examples of Temporal Lobe Seizure Phenomena The following cases were chosen because they contained rather elaborate and detailed descriptions ofcentral nervous system phenomena resulting from temporal lobe seizure activity. The events are annotated, so they can be traced on the frame ofreference which is presented subsequently. Patient A was a twenty-seven-year-old right-handed male who at the age ofeight suffered from a severe attack ofscarlet fever complicated by pertussis. At that time he had two severe convulsions and his father stated that it was feared he might die. He made a good recovery, however, and had an uneventful history until age fourteen, at which time he became aware ofoccasional peculiar sensations arising in his epigastrium (S-2) and 521 moving up into his throat (S-2) followed by awareness of tachycardia (S-2, E-2) and sweating (S-2, E-2). He...