Hypergraphia

American neurologists Stephen Waxman and Norman Geschwind were the first to describe hypergraphia, in the 1970s. The patients they observed displayed highly compulsive detailed writing, sometimes with literary creativity. The patients kept diaries, which some used to meticulously document minute details of their everyday activities, write poetry, or create lists. Case 1 of their study wrote lists of her relatives, her likes and dislikes, and the furniture in her apartment. Beside lists, the patient wrote poetry, often with a moral or philosophical undertone. She described an incident in which she wrote the lyrics of a song she learned when she was 17 several hundred times and another incident in which she felt the urge to write a word over and over again. Another patient wrote aphorisms and certain sentences in repetition.[2]

A patient from a separate study experienced continuous "rhyming in his head" for five years after a seizure and said that he "felt the need to write them down."[3] The patient did not talk in rhyme, nor did he read poetry. Language capacity and mental status were normal for this patient, except for recorded right-temporal spikes on electroencephalograms. This patient had right-hemisphere epilepsy. Functional MRI scans of other studies suggest that rhyming behavior is produced in the left hemisphere, but Mendez proposed that hyperactive electrical activity of the right hemisphere may induce a release of writing and rhyming abilities in the left hemisphere.[3]

Macro and micrographic writing by the same epileptic patient

In addition to writing in different forms (poetry, books, repetition of one word), hypergraphia patients differ in the complexity of their writings. While some writers (e.g. Alice Flaherty and Dyane Harwood) use their hypergraphia to help them write extensive papers and books, most patients do not write things of substance. Flaherty defines hypergraphia, as a result of temporal lobe epilepsy, as a condition that "increase[s] idea generation, sometimes at the expense of quality."[4] Patients hospitalized with temporal lobe epilepsy and other disorders causing hypergraphia have written memos and lists (like their favorite songs) and recorded their dreams in extreme length and detail.[4]

There are many accounts of patients writing in nonsensical patterns including writing in a center-seeking spiral starting around the edges of a piece of paper.[5] In one case study, a patient even wrote backward, so that the writing could only be interpreted with the aid of a mirror.[2] Sometimes the writing can consist of scribbles and frantic, random thoughts that are quickly jotted down on paper very frequently. Grammar can be present, but the meaning of these thoughts is generally hard to grasp and the sentences are loose.[5] In some cases, patients write extremely detailed accounts of events that are occurring or descriptions of where they are.[5]

In some cases, hypergraphia can manifest with compulsive drawing.[6] Drawings by patients with hypergraphia exhibit repetition and a high level of detail, sometimes mixing both compulsive writing and drawing together.[7]

Image of the temporal lobe

Hypergraphia is a symptom of temporal lobe epilepsy, a condition of reoccurring seizures caused by excessive neuronal activity, but it is not a common symptom among patients. Less than 10 percent of patients with temporal lobe epilepsy exhibit characteristics of hypergraphia. Temporal lobe epilepsy patients may exhibit irritability, discomfort, or an increasing feeling of dread if their writing activity is disrupted.[10] To elicit such responses when interrupting their writing suggests that hypergraphia is a compulsive condition, resulting in an obsessive motivation to write.[8] A temporal lobe epilepsy may influence frontotemporal connections in such a way that the drive to write is increased in the frontal lobe, beginning with the prefrontal and premotor cortex planning out what to write, and then leading to the motor cortex (located next to the central fissure) executing the physical movement of writing.[8]

Most temporal lobe epilepsy patients who suffer from hypergraphia can write words, but not all may have the capacity to write complete sentences that have meaning.[5]

Certain drugs have been known to induce hypergraphia including donepezil. In one case study, a patient taking donepezil reported an elevation in mood and energy levels which led to hypergraphia and other excessive forms of speech (such as singing).[11] Six other cases of patients taking donepezil and experiencing mania have been previously reported. These patients also had cases of dementia, cognitive impairment from a cerebral aneurysm, bipolar I disorder, and/or depression. Researchers are unsure why donepezil can induce mania and hypergraphia. It could potentially result from an increase in acetylcholine levels, which would have an effect on the other neurotransmitters in the brain.[11]

Another potential cause of hypergraphia is one of the body's neurotransmitters, dopamine (DA). Dopamine has been known to decrease latent inhibition, which causes a decrease in the ability to habituate to different stimuli. Low latent inhibition leads to an excessive level of stimulation and could contribute to the onset of hypergraphia and general creativity. This research implies that there is a direct correlation between the levels of DA between neuronal synapses and the level of creativity exhibited by the patient. DA agonists increase the levels of DA between synapses which results in higher levels of creativity, and the opposite is true for DA antagonists.[4]