Hypergraphia for Poetry in an Epileptic Patient

SIR: Some epileptic patients write profusely about their thoughts and feelings.^1,2 This hypergraphia may occur as part of the Geschwind syndrome, a controversial personality disorder characterized by circumstantiality, viscosity or “stickiness” in social interactions, an intense preoccupation with moral or philosophical issues, and irritability or ease to anger.^1,2 This report describes a unique patient who developed an irrepressible urge to write in rhyme concomitant with the onset of a seizure disorder.

Case Report

A 58-year-old right-handed man complained of being driven to write poetry. For 5 years, he experienced words as “continuously rhyming in his head” and felt the need to write them down and show his writings to others. He did not talk in rhyme, write excessively in nonrhyme, or read poetry. The patient had not had a preoccupation with poetry until age 53 when he had the subacute onset of behavioral changes with irritability and anger.

Coincident with his behavioral changes, he began having partial complex seizures with at least two secondarily generalized tonic-clonic episodes. His seizures manifested as a sensation “rising” in his stomach followed by a brief alteration of consciousness. Seizure control with phenytoin and gabapentin ameliorated his irritability and anger but did not diminish his constant need to write in rhyme. A prior evaluation attributed his new-onset seizures to small cerebrovascular events from hypertension and the antiphospholipid syndrome.

The patient underwent a repeat evaluation. On examination, he was circumstantial and somewhat viscous. He repeatedly emphasized the significance of his symptom of poetry writing, and continually responded in written poetry. Language, mental status, and neurological examinations were otherwise normal except for a slightly broad-based and unsteady gait. He had right temporal spikes on electroencephalograms and small strokes in the right thalamus and the right cerebellum on neuroimaging.

Discussion

This patient has right hemisphere epilepsy and hypergraphia limited to rhyme. It is unlikely that the location of his small thalamic and cerebellar strokes would, in and of themselves, result in his hypergraphia. It is also unlikely that ongoing ictal or subictal activity is the source of his behavior since it persisted despite good seizure control. Alternatively, his hypergraphia may correspond to persistent interictal hypometabolism or local hypofunction in the right hemisphere.

Although investigators have suggested that interictal hypergraphia is associated with epileptic foci in the right hemisphere,^1,2 both language and rhythm are particularly associated with the contralateral left hemisphere. Recent functional MRI evidence, for example, indicates that rhyme judgment tasks are accomplished by the left hemisphere.^3,4 The main brain regions activated in these studies are the left inferior frontal cortex, the left inferior posterior temporal or fusiform gyrus, and adjacent areas.^3,4

It is possible that hypofunction in the right hemisphere can lead to disinhibition in the left hemisphere, with release of writing and rhyming abilities. For example, right temporal lesions can cause auditory agnosia with enhancement of rhythm appreciation.⁵ These conclusions are tentative; investigators need to further study the interesting phenomenon of hypergraphia among patients with epilepsy.