Ictal reciprocal cravings modulated by medication: a case report and discussion. ( 'Sex? or Chocolate?')
Case: A 43yr old right handed woman with focal seizure disorder related to traumatic right temporal lobe injury, noted an extraordinary variation in her seizure manifestation with change in medication. Her usual seizure incorporated an experiential component of orgasm with craving for coitus. This was present off medication, and also whilst medicated with carbamazepine. However once changed to levetiracetam, the craving for coitus was replaced by a craving for chocolate, with the same temporal progression in relation to her seizure. Once carbamazepine was reinstated, craving for chocolate reverted to craving for coitus. Investigations were concordant for right temporal focus for seizure.
Discussion: Primal drives are well represented amongst seizure phenomenae. Folk wisdom suggests that if access to physical or emotional intimacy is restricted and access to chocolate provided, that chocolate is often preferentially sought to compensate for intimacy deprivation. However until now there has been no direct evidence of functional or anatomic co-localisation of the substrates responsible, and the ‘chocolate’ centre of the brain has remained shrouded in mystery. Anatomic localisation of brain function frequently dominates in the clinical manifestation of seizure, and experiential phenomenae, particularly those related to pleasure sensations, are thought to arise more frequently from the right temporal region. Variation in antiepileptic medication often results in change in seizure phenomenology, and different antiepileptic agents are known to have variable effects on the neurotransmitter-mediated reward systems.
Conclusion: To our knowledge, this is the first evidence of co-localisation of ictal orgasmic sensation and desire for sexual satiation, with desire for chocolate, within the functional ictal zone. Potential mechanisms for change in seizure evolution evoked by varying effects of medication, include change in seizure propagation, and/or change in specific representation vulnerability. The reciprocal relation raises interesting questions regarding ‘decision’ mechanisms for pathways of seizure propagation.