Ecstatic seizures

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Ecstatic seizures
Other namesEcstatic epileptic seizures; Ecstatic convulsions; Ecstatic epilepsy; Ecstatic auras; Epilepsy with ecstatic seizures; Dostoevsky epilepsy; Dostoevsky's epilepsy
Symptoms Auras with intense positive affect, physical well-being, heightened awareness, feelings of certainty, time dilation, seizures, others [1]
DurationA few seconds to 2–3 minutes [2] [3]
Causes Epilepsy [2] [4] [1]
FrequencyRare [2] [1]

Ecstatic seizures, also known as ecstatic epilepsy or as Dostoevsky's epilepsy, are a rare type of epilepsy that involve seizures with an intensely blissful, euphoric, or ecstatic aura. [2] [4] They are a form of focal epilepsy. [2] [1] [4] [3] Symptoms include intense positive affect, physical well-being, and heightened awareness, as well as time dilation and other symptoms. [2] [1] They are often described as mystical, spiritual, and/or religious, and have sometimes been said to be "life-changing". [2] [1] [4] [5]

Contents

Ecstatic seizures are thought to be caused by epileptic activation of an area of the brain known as the dorsal anterior insula. [4] [2] Electrical stimulation of this part of the brain can induce ecstatic seizures. [1] [4] [2] [6] It has been theorized that ecstatic seizures caused by activation of the insula may be due to a temporary block of prediction errors associated with uncertainty and negative affect. [1] [7] [2] [8] Conceptual and neurological parallels have been drawn between ecstatic seizures and other intensely positive or mystical experiences, for instance with drugs like MDMA ("ecstasy") and psychedelics, as well as with moving musical enjoyment and deep states of meditation. [1] [9] [10] [3]

The Russian novelist Fyodor Dostoevsky, who himself had epilepsy and ecstatic seizures, first described these seizures in his writings in the mid-to-late 1800s. [1] [4] [5] [11] [12] The first cases of ecstatic seizures reported in the medical literature were published in the late 1800s and early 1900s. [13] [14] [1] As of 2023, around 50 cases of ecstatic seizures have been reported. [2] [1] The involvement of the anterior insula in ecstatic seizures was first elucidated in 2009, and ecstatic experiences were first artificially induced by stimulation of this brain area in 2013. [2] [1] [4] [5] [6] Some leading historical religious figures, such as Saint Paul the Apostle and Joan of Arc, have been suspected as having ecstatic seizures. [2]

Symptoms

The symptoms variably include feelings of increased self-awareness, mental clarity, certainty, feelings of "unity with everything that exists" (including the external environment), intense positive affect, a sense of intense serenity or bliss, mystical, spiritual, or religious experiences, physical well-being, a sense of "hyper-reality", and time dilation, among others. [2] [1] [4] [5] [15] [16] The term "oceanic" has also been invoked in describing the experiences. [14] The physical well-being includes a feeling of warmth ascending from the feet to the head or a feeling of the body being covered in velvet. [2]

The key and essential definitional criteria of ecstatic seizures include: [1]

  1. "Intense positive emotion (bliss)"
  2. "Enhanced physical well-being"
  3. "Heightened self-awareness or heightened perception of the external world (clarity)"

The state seems to primarily involve an absence of doubts or uncertainty rather than a primary intense positive emotion. [2] Ecstatic seizures have been compared to the bliss of enjoying music or orgasm and have been described as much better than sex. [1] [5] They have also been described as life-changing, for instance resulting in people no longer fearing death or converting from atheism to religion. [2] [1] Alternating ecstatic and unpleasant emotions, such as anxiety, have also been reported however. [1] [5]

A description of Russian novelist Fyodor Dostoevsky's ecstatic auras by his close friend Nikolay Strakhov was published as follows: [17] [18]

For several brief moments, I feel a contentedness which is unthinkable under normal conditions and unimaginable for those who have not experienced it. At such times, I am in perfect harmony with myself and with the entire universe. Perception is so clear and so agreeable that one would give 10 years of his life, and perhaps all of it, for a few seconds of such bliss.

Epileptic auras, generally speaking, last from a few seconds up to usually 20 to 30 seconds but to a maximum of about 2 to 3 minutes. [2] Thereafter, the seizure may or may not evolve into loss of consciousness and a generalized tonic–clonic seizure. [2] [1] In contrast to the auras in ecstatic seizures, most auras of seizures generally are unpleasant, including feelings of anxiety and fear (60%) as well as depression, while positive feelings are only rarely reported. [1]

There are some similarities and overlap of ecstatic epilepsy with Geschwind syndrome (occurs in about 7% of cases of temporal lobe epilepsy), orgasmic epilepsy, and certain other forms of epilepsy. [1] [19] [20] [17]

People with ecstatic or pleasant seizures often have a strong wish to prevent the auras from ending and have been known to try to prolong them. [20] In one case, a patient initially refused surgical resection of a brain tumor causing the seizures. [20] Noncompliance with anticonvulsant medication is common. [14] Others have admitted to lowering their medication doses in an attempt to achieve a level that could allow for ecstatic auras without seizures. [20] This is a difficult balance to strike however and has often not been successful. [20] There have been cases of epileptic individuals willingly self-inducing ecstatic or pleasurable seizures via exposure to known provoking epileptogenic stimuli, like flickering or flashing television screens. [1] [14] [21] [22] Positive emotions have been reported to be a trigger of ecstatic seizures in some. [3]

Causes

The primary brain area thought to be involved in the generation of ecstatic seizures is the dorsal anterior insula. [2] [4] [1] It is thought that the ecstatic feelings result from ictal hyperactivation of the anterior insular cortex. [5] The epilepsy is often caused by epileptogenic brain tumors. [3]

Brain imaging studies support activation of the anterior insula in ecstatic seizures. [4] [2] Additionally, several instances of reproducible ecstatic-like seizures have been induced during presurgical evaluation with electrical brain stimulation to the dorsal anterior insula. [1] [4] [2] [6] [15] [16] Intense time dilation has also been produced by stimulation of the right mid-dorsal insular region. [2] Stimulation of a variety of other brain areas, including the inferior temporal gyrus, temporal pole, left amygdala, inferior frontal gyrus, anterior cingulate cortex, and supplementary motor area, have also been reported to produce euphoric or pleasant feelings. [1] [2] However, ecstasy-like experiences have not been specifically described with these other areas. [1] [2] Stimulation of the right amygdala and the hippocampus have been associated with very unpleasant emotions. [1] It is thought that vast activation of the anterior insula is needed for generation of ecstatic seizures, which may underlie the few cases that have been observed with electrical brain stimulation. [1]

The theory of predictive coding posits that the brain is a prediction machine, is constantly modeling its environment and updating this model, and tries to minimize prediction errors (the mismatch between the predictions/model and the actual environment) and uncertainty to avoid surprise and to minimize energy expenditure. [4] [2] [15] Prediction errors are often experienced as aversive and threatening and can produce feelings of uncertainty and discomfort. [8] It has been theorized that ecstatic seizures, including feelings of certainty, clarity, trust, well-being, serenity, and inner peace, may be due to a temporary blockade of interoceptive prediction error generation and associated negative emotions. [1] [4] [2] [9] [7] This in turn results in an acute "ultimate stable state", with no ambiguity or "perfect prediction of the world", and associated positive feelings. [1] [7] [2] [8] A natural or physiological (but much less intense) analogue could be considered "aha!" or "eureka!" moments—that is, sudden understanding of a previously incomprehensible problem and associated joy, elation, and satisfaction—for instance discovering the cause of a difficult software bug in computer code. [15] The heightened awareness and time dilation in ecstatic seizures have been hypothesized to be related to the strongly salient nature of the experiences. [1]

There is an especially high density of nicotinic acetylcholine receptors in the dorsal anterior insula. [1] [23] This has raised questions about the role of acetylcholine in predictive and emotional processing and in the experience of ecstatic seizures. [1] [23]

Ecstatic seizures have been related to the subjective experiences of drugs of misuse, such as psychostimulant euphoriants and entactogens, like amphetamines, cocaine, and methylenedioxymethamphetamine (MDMA; "ecstasy"), as well as psychedelic hallucinogens, like ayahuasca (dimethyltryptamine), psilocybe mushrooms (psilocybin), and peyote (mescaline). [1] [10] [2] [3] The states produced by these drugs can show similarities to the blissful experiences of ecstatic seizures. [1] [10] [2] [3] [5] As an example, Alexander Shulgin, who discovered the subjective effects of MDMA, described his first experience with the drug as follows: "I feel absolutely clean inside, and there is nothing but pure euphoria. I have never felt so great or believed this to be possible. I am overcome by the profundity of the experience." [24] [25] Activation of the anterior insula may be involved in the positive feelings evoked by the previously mentioned drugs of misuse, similarly to ecstatic seizures. [10] [2] [3] [5] However, the experience of ecstatic seizures has been anecdotally described by some as beyond that which could be achieved with any drug. [1]

The causes of ecstatic seizures may also overlap with other non-epileptic and non-pharmacological ecstatic or mystical experiences. [2] The insula has been found to be activated by maternal and romantic love, as well as by pleasant and mesmerizing musical moments and deeper states of meditation. [1] [9] Besides the insula, the dopamine reward system of the ventral tegmental area and striatum or nucleus accumbens have also been found to be activated by musical moments. [1] There are many parallels between ecstatic auras and deeper states of meditation. [1] [10] [3] Greater activation of the dorsal anterior insula has been found in advanced meditators (>10,000 hours of practice) and with greater self-reported intensity of meditation. [1] [10] [3] More gray matter, a thicker cortex, and greater gyrification of the anterior insula have been found in meditators compared to non-mediators. [1] [10] In addition, more years of meditation is positively correlated with gyrification of the anterior insula. [1] [10] [3] Some people have also been known to have spontaneous and naturally occurring ecstatic and/or mystical experiences similar to those of ecstatic auras, often as single episodes in their lives, that are of non-epileptogenic origin and are outside of a meditative or religious context. [2] These have been referred to as "awakening experiences". [2]

The state in ecstatic seizures is in notable contrast to various neuropsychiatric disorders, like anxiety disorders, depression, and obsessive–compulsive disorder (OCD), in which there is intolerance of uncertainty and ambiguous situations, abnormally increased anticipation of aversive stimuli, subjective feelings of doubt (as opposed to certainty), and/or accompanying avoidance behavior. [1] [4] [9] [8] [2] Some of these conditions have been associated with increased activity of the dorsal anterior insula. [2] Ecstatic seizures may provide insight into the understanding and treatment of neuropsychiatric disorders. [4] [2] The dorsal anterior insula has been proposed as a potential novel therapeutic target for treatment of neuropsychiatric disorders like severe depression, for instance through non-invasive intermittent brain stimulation techniques. [16] This could be an alternative to the novel field of psychedelics for these conditions, under the assumption that transient mystical experiences could result in long-lasting therapeutic psychological benefits. [16]

History

Fyodor Dostoevsky (1821-1881; photo in 1879). Dostoevsky.jpg
Fyodor Dostoevsky (1821–1881; photo in 1879).

The first description of ecstatic seizures in the literature was by the 19th-century Russian novelist Fyodor Dostoevsky. [1] [4] [5] [11] [12] He had epilepsy and described his own ecstatic seizures in his writings, such as The Idiot (1869) and The Demons (1872). [1] [5] [11] [12] The first cases of ecstatic seizures in the medical literature were briefly described by William P. Spratling and others in the late 1800s and early 1900s. [13] [14] [26] [27] [28] Subsequently, a series of additional case reports were published in the 1950s and thereafter. [1] [29] [30] [31] [32] [33] [34] [35] The term "ecstatic seizures" was coined by psychologist James H. Leuba. [14] Greater awareness of ecstatic epilepsy began with a paper discussing Dostoevsky's epilepsy by French neurologist Henri Gastaut in 1978. [19] [18] [36]

The existence of ecstatic seizures, including those of Dostoevsky, was initially denied by some well-known epileptologists, such as Gastaut and others. [1] [5] [37] [38] [39] [18] This has been attributed to limited documentation of the seizures, which is in turn related to the fact that people with the auras are often reluctant to talk about the experiences and refrain from communicating them. [5] [2] [4] [1] This is due to the ineffability of the experiences or inability to convey them in words, their extremely abnormal nature (termed "hallucination of emotion"), and fears of being seen as being mentally deranged or as having psychiatric disorders. [5] [2] [4] [1] The ability to communicate the subjective experience of ecstatic auras is also highly dependent on a person's intelligence, power of introspection, and vocabulary. [1] [5] [6] [34]

By 2016, 52 cases of ecstatic epilepsy had been reported in the medical literature. [2] [1] [4] They have usually been reported as single cases. [2] [4] [5] In-depth characterizations of the experiences of such patients have been published. [5] [9] [14] [3] [1] It is thought that the incidence of ecstatic seizures is greatly underestimated, in part due to the reluctance of people to talk about them. [1] [4] [5] It is known that approximately 1% of people with temporal lobe epilepsy report religious or spiritual experiences associated with their epilepsy, though these are distinct from ecstatic seizures. [20]

Ecstatic seizures have been especially studied, reviewed, and brought greater attention to by Swiss neuroscientist Fabienne Picard and her colleagues beginning in 2009 and continuing to the present. [5] [10] [1] [4] [2] [9] [40] [15] [16] The involvement of the dorsal anterior insula in ecstatic seizures was elucidated by her team in 2009 and thereafter. [5] [10] [1] [4] [2] [9] [40] [15] [16] Cases of electrical brain stimulation inducing the experiences were published in 2013, 2019, and 2022. [6] [15] [16] There have also been unpublished cases, for a total of six or seven cases (both with and without ecstatic epilepsy) as of 2023. [2]

Society and culture

Notable individuals

The 19th-century Russian novelist Fyodor Dostoevsky had epilepsy and experienced ecstatic seizures. [1] [4] [5] [19] [41] Ecstatic seizures have often been referred to as "Dostoevsky's epilepsy" as he was the first and among the most notable documented cases of the condition. [13] [41] [42] [43] Dostoevsky had an average of about one seizure a month from age 20 or 25 years until his death at 59 years of age, which would be a total of around 400 to 500 seizures in his lifetime. [36] [18] [44]

Some historical leading religious figures have been suspected and theorized to have possibly had ecstatic epilepsy. [2] These include Saint Teresa of Ávila, [45] Saint Paul the Apostle, [46] [47] Joan of Arc, [40] [48] [49] [50] and Ramana Maharshi. [2] [19]

A character in the James Cameron film Avatar 2 (2022), named Kiri, experiences an epileptic seizure that results in "religious ecstasy". [2]

Related Research Articles

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Epilepsy is a group of non-communicable neurological disorders characterized by recurrent epileptic seizures. An epileptic seizure is the clinical manifestation of an abnormal, excessive, and synchronized electrical discharge in the neurons. The occurrence of two or more unprovoked seizures defines epilepsy. The occurrence of just one seizure may warrant the definition in a more clinical usage where recurrence may be able to be prejudged. Epileptic seizures can vary from brief and nearly undetectable periods to long periods of vigorous shaking due to abnormal electrical activity in the brain. These episodes can result in physical injuries, either directly, such as broken bones, or through causing accidents. In epilepsy, seizures tend to recur and may have no detectable underlying cause. Isolated seizures that are provoked by a specific cause such as poisoning are not deemed to represent epilepsy. People with epilepsy may be treated differently in various areas of the world and experience varying degrees of social stigma due to the alarming nature of their symptoms.

<span class="mw-page-title-main">Hypergraphia</span> Psychological condition wherein a person is compelled to write or draw

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<span class="mw-page-title-main">Temporal lobe epilepsy</span> Chronic focal seizure disorder

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<span class="mw-page-title-main">Epilepsy in children</span>

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<span class="mw-page-title-main">Fabrice Bartolomei</span> French neurophysiologist

Fabrice Bartolomei is a French neurophysiologist, and University Professor at Aix-Marseille University (AMU), leading the Service de Neurophysiologie Clinique of the Timone Hospital at the Assistance Publique - Hôpitaux de Marseille, and he is the medical director of the ‘Centre Saint-Paul - Hopital Henri Gastaut’. He is the coordinator of the clinical network CINAPSE that is dedicated to the management of adult and pediatric cases of severe epilepsy and leader of the Federation Hospitalo-Universitaire Epinext. He is also member of the research unit Institut de Neurosciences des Systèmes.

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  23. 1 2 Picard F, Sadaghiani S, Leroy C, Courvoisier DS, Maroy R, Bottlaender M (October 2013). "High density of nicotinic receptors in the cingulo-insular network". NeuroImage. 79: 42–51. doi:10.1016/j.neuroimage.2013.04.074. PMID   23631995.
  24. ↑ Weber, Bruce (7 June 2014). "Alexander Shulgin, Psychedelia Researcher, Dies at 88". The New York Times. Retrieved 26 August 2024.
  25. ↑ Shulgin, A.T.; Shulgin, A. (1991). Pihkal: A Chemical Love Story. Biography/science. Transform Press. ISBN   978-0-9630096-0-9 . Retrieved 26 August 2024.
  26. ↑ Leuba JH (1921). "Religious and Other Ecstasies". The Journal of Religion. 1 (4). University of Chicago Press: 391–403. doi:10.1086/480221. ISSN   0022-4189. JSTOR   1195158 . Retrieved 27 August 2024. In some instances, the "aura," as these premonitory symptoms are called, is in the nature of an ecstasy. In Modern Medicine Dr. Spratling reports the case of a priest under his care whose epileptic attacks were preceded by a rapturous moment. Walking, for instance, along the streets he would suddenly feel, as it were, "transported to heaven." This state of marvelous enjoyment would soon pass, and a little later on he would find himself seated on the curb of the sidewalk aware that he had suffered an epileptic attack.' The same author mentions elsewhere two other epileptic patients, "teachers of noted ability," who speak of their aura as "the most overwhelming ecstatic state it is possible for the human to conceive of."2
  27. ↑ Spratling WP (1904). Epilepsy and Its Treatment. W. B. Saunders. p. 466. Retrieved 27 August 2024. The confessions of Dostoieffsky and Flaubert are similar to feelings described to me by epileptics of superior intellectual endowment. Two in particular detailed the sensations of intellectual aura they experienced, which would readily pass for these confessions. They had such aura rarely, and declared it to be "the most overwhelming ecstatic state it is possible for the human mind to conceive of." Both were teachers of noted ability and both developed epilepsy through excessive alcoholic indulgence—not drinking enough at one time to produce drunkenness, but drinking systematically for years to fortify a nervous system exhausted through overwork.
  28. ↑ Spratling WP (1910). "Epilepsy". In Osler W (ed.). Osler's Modern Medicine: Its Theory and Practice. Vol. 7 (Diseases of the Nervous System). Philadelphia/New York: Lea Brothers. pp. 671–672. Psychic aura appear as sudden abnormal mental states which leave a definite impression of some extraordinary intellectual sensation. Dastoieffsky—the Russian novelist—declared he experienced a state of great ecstasy, of supreme joy, just before his attacks occurred, his postconvulsive state being one of the most painful mental depression. A well-educated priest, who was under the writer's care for some years, regularly experienced a similar state of well-being before and a marked melancholy extending over several days after his rather infrequent grand mal attacks, which invariably followed dietetic indiscretions committed late at night. In walking along the street he would suddenly feel "transported" to a state of marvellous joy, to find himself a little later seated on the curb of the sidewalk or in the middle of the street.
  29. ↑ Alajouanine T (1951). "Sur un équivalent épileptique: l'absence à début psycho-affectif" [An epileptic equivalent: absence with psychoaffective onset]. Bull Acad Natl Med (in French). 135 (23–24): 389–391. PMID   14869870.
  30. ↑ Penfield W, Kristiansen K (1951). Epileptic Seizure Patterns: A Study of the Localizing Value of Initial Phenomena in Focal Cortical Seizures. Springfield: Thomas. p. 55. Retrieved 27 August 2024.
  31. ↑ Mulder DW, Daly D (September 1952). "Psychiatric symptoms associated with lesions of temporal lobe". J Am Med Assoc. 150 (3): 173–176. doi:10.1001/jama.1952.03680030005003. PMID   14955412.
  32. ↑ Subirana A, Oller-Daurella L (1953). "Sur un phénomène à prédominance unilatérale précédant parfois les trains de pointeondé; discussion de sa possible genèse temporale" [Phenomenon of unilateral predominance preceding the chain of wave-spikes; discussion on possible temporal formation]. Rev Neurol (Paris) (in French). 88 (5): 363–364. PMID   13121707.
  33. ↑ Feindel W, Penfield W (November 1954). "Localization of discharge in temporal lobe automatism". AMA Arch Neurol Psychiatry. 72 (5): 603–630. doi:10.1001/archneurpsyc.1954.02330050075012. PMID   13206482.
  34. 1 2 Williams D (March 1956). "The structure of emotions reflected in epileptic experiences". Brain. 79 (1): 29–67. doi:10.1093/brain/79.1.29. PMID   13342275.
  35. ↑ Mullan S, Penfield W (March 1959). "Illusions of comparative interpretation and emotion; production by epileptic discharge and by electrical stimulation in the temporal cortex". AMA Arch Neurol Psychiatry. 81 (3): 269–284. doi:10.1001/archneurpsyc.1959.02340150001001. PMID   13626278.
  36. 1 2 Gastaut H (August 1984). "New comments on the epilepsy of Fyodor Dostoevsky". Epilepsia. 25 (4): 408–411. doi:10.1111/j.1528-1157.1984.tb03435.x. PMID   6378613.
  37. ↑ Baumann CR, Novikov VP, Regard M, Siegel AM (July 2005). "Did Fyodor Mikhailovich Dostoevsky suffer from mesial temporal lobe epilepsy?". Seizure. 14 (5): 324–30. doi:10.1016/j.seizure.2005.04.004. PMID   15878292.
  38. ↑ Rossetti AO (March 2006). "Dostoevsky's epilepsy: Generalized or focal?". Epilepsy Behav. 8 (2): 446–447, author reply 448. doi:10.1016/j.yebeh.2005.11.009. PMID   16406845.
  39. ↑ Hughes JR (November 2005). "The idiosyncratic aspects of the epilepsy of Fyodor Dostoevsky". Epilepsy Behav. 7 (3): 531–538. doi:10.1016/j.yebeh.2005.07.021. PMID   16194626.
  40. 1 2 3 Nicastro N, Picard F (April 2016). "Joan of Arc: Sanctity, witchcraft or epilepsy?". Epilepsy Behav. 57 (Pt B): 247–250. doi:10.1016/j.yebeh.2015.12.043. PMID   26852074.
  41. 1 2 Rayport SM, Rayport M, Schell CA (November 2011). "Dostoevsky's epilepsy: a new approach to retrospective diagnosis". Epilepsy Behav. 22 (3): 557–570. doi:10.1016/j.yebeh.2011.07.027. PMID   21982255.
  42. ↑ Cirignotta F, Todesco CV, Lugaresi E (December 1980). "Temporal lobe epilepsy with ecstatic seizures (so-called Dostoevsky epilepsy)". Epilepsia. 21 (6): 705–710. doi:10.1111/j.1528-1157.1980.tb04324.x. PMID   7439135.
  43. ↑ Morgan H (June 1990). "Dostoevsky's epilepsy: a case report and comparison". Surg Neurol. 33 (6): 413–416. doi:10.1016/0090-3019(90)90155-i. PMID   2161565.
  44. ↑ Voskuil PH (December 1983). "The epilepsy of Fyodor Mikhailovitch Dostoevsky (1821-1881)". Epilepsia. 24 (6): 658–667. doi:10.1111/j.1528-1157.1983.tb04628.x. PMID   6416820.
  45. ↑ Garcia Albea E (2003). "La epilepsia extática de Teresa de Jesús" [The ecstatic epilepsy of Teresa of Jesus]. Rev Neurol (in Spanish; Castilian). 37 (9): 879–887. PMID   14606057.{{cite journal}}: CS1 maint: unrecognized language (link)
  46. ↑ Landsborough D (June 1987). "St Paul and temporal lobe epilepsy". J Neurol Neurosurg Psychiatry. 50 (6): 659–664. doi:10.1136/jnnp.50.6.659. PMC   1032067 . PMID   3302109.
  47. ↑ Vercelletto P (December 1994). "La maladie de Saint Paul. Extase et crises extatiques" [Saint Paul disease. Ectasia and exstatic seizures]. Rev Neurol (Paris) (in French). 150 (12): 835–9. PMID   7676119.
  48. ↑ d'Orsi G, Tinuper P (August 2006). ""I heard voices...": from semiology, a historical review, and a new hypothesis on the presumed epilepsy of Joan of Arc". Epilepsy Behav. 9 (1): 152–157. doi:10.1016/j.yebeh.2006.04.020. PMID   16750938.
  49. ↑ Foote-Smith E, Bayne L (1991). "Joan of Arc". Epilepsia. 32 (6): 810–815. doi:10.1111/j.1528-1157.1991.tb05537.x. PMID   1743152.
  50. ↑ Schildkrout B (2023). "What caused Joan of Arc's neuropsychiatric symptoms? Medical hypotheses from 1882 to 2016". J Hist Neurosci. 32 (3): 332–356. doi:10.1080/0964704X.2023.2171799. PMID   36857627.
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