L'Épilepsie comme "crise" de la conscience: Perspectives narratives, philosophiques, et neuroscientifiques

Abstract

“Each seizure is like a sort of hemorrhage of innervation. The center of image formation in my brain suffers a seminal leak, a hundred thousand images erupt at once, in visual fireworks. There is an atrocious clenching of body and soul (several times I have been sure I had died). But what constitutes personality, rational being, always held fast; otherwise, suffering would have been nullified, because I would have been purely passive, whereas I always retained consciousness, even when I could no longer speak.” Flaubert, Gustave, 1821-1880. Correspondance, 1853 (Paris, L. Conard) 270-271

The most intimate correspondence of Gustave Flaubert reveals that the renowned French author, prized for his mastery of free indirect discourse and other “realist” effects in works such as Madame Bovary and L’Éducation Sentimentale, suffered from epilepsy. Careful examination of his correspondence reveals that these works are imbued with references to his seizures, presented in highly metaphorical, imaginative and literary language not typically associated with epilepsy. In his description of the experience of having a seizure, Flaubert notes that “I always retained consciousness” despite a “rational ebbing”; he was mentally present during his seizures, although not in control of the contents or modalities of his consciousness. This assertation is distinctly different from popular understandings of epileptic seizures, which often assume that someone having a seizure is completely unaware of their surroundings, or unconscious, as their body is racked by convulsions. Flaubert’s description demonstrates that not only was he present, he also suffered an interruption, a dismantling, of his normal conscious state: “a hundred thousand images erupt at once” and there is a “terrible clenching of body and soul”. This raises the question, do seizures somehow unleash the floodgates of sensorial memory (images, sounds, tastes), even as the body loses control? It is evident that Flaubert was not fully conscious during his seizures, as we would describe that characterizes our everyday experience of consciousness, yet it is also evident that he was not fully unconscious. The medical field has long recognized this characteristic of seizures, that the state of consciousness during a seizure is not exactly the same as the conscious state of an individual not having a seizure. To distinguish between the two, the term ictal state refers to the period during which an individual is having a seizure and may demonstrate abnormal mental states, while the interictal state refers to any time that the individual with epilepsy is not having a seizure. Yet these distinctions fail to signal that the qualia of consciousness may be different between these two states, and different for different individuals. In the French literary sphere, a number of individuals with epilepsy have written on the subjective experience of having a seizure, delving into the most minute details of the conscious state during a seizure. These narratives, ranging from patient memoirs to graphic novels, demonstrate that each individual with epilepsy experiences a seizure differently, and different types of seizures can differentially affect the conscious state. For example, for those with focal seizures with preserved awareness (seizures that involve abnormal electrical activity in only one part of the brain) authors note a loss of sensation of the body, but not of the mind: “There was a tearing of my soul from my body,” attested Flaubert. Alternatively, for those with generalized tonic-clonic seizures (seizures that involve abnormal electrical activity throughout the entire brain), there is often a complete loss of perception of the body and within the mind: “For each seizure, time stops, like a little death” (Durand, Une Cicatrice dans la tête). If the subjective experience of having a seizure differs from one individual to another, is it also true that epilepsy can differentially affect human consciousness? Or is it more appropriate to say that the ictal consciousness is not bound by the same rules that we have assigned to the interictal consciousness of the individual with epilepsy? On a more fundamental level, what does human consciousness consist of? What is the connection between the physical human brain and the intangible mind? Science, unfortunately, has yet to answer these questions, despite the many advancements of neuroscience in recent decades. Philosophy, on the other hand, has put forth many theories of the relationship between the physical body (and brain) and the intangible mind, including those of René Descartes, Immanuel Kant, Sigmund Freud, Henri Bergson, and Maurice Merleau-Ponty. In recent years, philosophy has become increasingly integrated with neuroscience, as seen in the works of Stanislas Dehaene, Catherine Malabou, Antonio Damasio, and Andrea Cavanna. Still, very little consideration has been given to epilepsy’s effects on the conscious state and what these effects reveal about human consciousness itself. This is where literature must intervene. The works of individuals with epilepsy, such as Flaubert, Valérie Pineau-Valencienne, and Élodie Durand, give us a glimpse into an ictal consciousness that is at the same time neurological, ontological, cultural, and subjective in its nature. Literature holds a key to understanding how epilepsy influences the conscious mind, through individuals’ representations of the conventions, patterns, and characteristic features of ictal and interictal consciousness. Joint consideration of neuroscience and literature is thus necessary for a fuller understanding of the relationship between epilepsy and consciousness. The present thesis aims to explore these very questions and considerations. This thesis takes an interdisciplinary approach to examining epilepsy from the perspectives of literature and neuroscience, framed by philosophical theory, to explore what the modifications of human consciousness during a seizure—a “crisis” of consciousness—can reveal about consciousness itself. French literature was selected as the core of this thesis due to the breadth of literary works that discuss epilepsy, philosophical works that present theories of human consciousness, and the organic inspiration provided by Flaubert’s correspondence. The dialogue between these fields offers great possibilities for progress in our understanding of interictal consciousness, ictal consciousness, and more generally, human consciousness itself. The thesis first addresses neuroscience’s understanding of epilepsy, the underlying biology of epilepsy, and how consciousness is defined and conceptualized within the clinical context. Then, it presents a formal literary analysis of a variety of literary texts by authors depicting epilepsy, be it their own epilepsy, that of a relative, or of a fictional character. Although a seizure is a unique event for each individual, common representational patterns exist among narrative accounts of the experience of having a seizure. These include i) a loss of the corporeal self, with preservation of the conscious self, ii) a loss of the conscious self, with a plunge into the unconscious, iii) hallucinations and their frequent confusion with reality, iv) modifications, most frequently uncontrollable outpourings, of memory, and 5) violent and hallucinogenic transitions between the ictal and interictal states. The above-mentioned literary texts of individuals with epilepsy inspired the second component of this thesis: an analysis of the spoken narratives of patients with epilepsy at Duke University Hospital. In this research study, which required Duke Health Internal Review Board approval, patients with epilepsy in the Epilepsy Monitoring Unit were interviewed about their subjective experience of having a seizure. Patients were presented with a series of questions about this experience and the specific wording they used to describe seizures was documented. Conversational analyses were used to identify the presence of specific narrative expressions, figures of speech, and representational patterns that patients used to describe epilepsy. These representations are then aligned with various philosophers’ theories of consciousness to consider the intertwinement of literature, neuroscience, and philosophy, with the intention of unifying these domains. A new concept to describe human consciousness is presented; namely, consciousness in equilibrium. This term refers to the notion that consciousness may take on varying states which possess differing qualia, but that internal forces continually work to guide it back to a baseline state. In the same sense that many biological processes are regulated by homeostasis, consciousness, too, is regulated by homeostatic functions. This equilibrium lies along a spectrum, ranging from fully conscious states to fully unconscious states, such that the states of consciousness may at times blend together rather than take on discrete qualia. Significant perturbations away from equilibrium, provoke what many call an abnormal state of consciousness in the individual. This may be likened to how chemical imbalances in the body perturb it away from its resting state, homeostasis, and may provoke physical illness. Epilepsy, then, perturbs this equilibrium, taking the individual to a state of consciousness outside of homeostatic limits, but still within the capabilities of the human mind. An individual may feel divorced from the perception of the body, as Flaubert described during his focal seizures with preserved awareness: “there is an atrocious clenching of body and soul”. Alternatively, an individual may deviate so far from equilibrium that consciousness itself no longer seems to exist, as in the case of Durand, who suffered from generalized tonic-clonic seizures: “Here where I am, I no longer am” (Durand, 2010). Overall, this thesis, a product of interdisciplinary inquiry, presents a novel exploration of human consciousness considered from the perspective of epilepsy. It puts French literature, neuroscience, and philosophy in dialogue with one another to advance towards a new conception of ictal and interictal consciousness. A double critique is presented: a humanistic critique of neuroscience and a neuroscientific critique of works in the humanities. This bidimensional model considers subjective and objective perspectives, permitting enriched study of the different types of epilepsy and its effects on consciousness. These considerations are not only of intellectual interest, it also presents important humanistic and clinical benefits. Patients with epilepsy often report feeling deprived of autonomy and powerless with respect to their seizures. Improving dialogue will empower individuals to make use of narrative tools to explore the psychological tension caused by epilepsy. Epilepsy here is no longer merely a neurological condition; it is also the key to a pressing question shared by all: what do I know about my own consciousness? Epilepsy here is no longer merely a neurological condition; it is a phenomenological and philosophical prompt to explore the ictal crises of consciousness that highlight, by contrast, the limitations of normative consciousness of consciousness.