mise à jour du
5 février 2004
J of Psyhosomatic Research
Yawning and epilepsy
L Goldie, J Green
Department of clinical neurophysiology University London
The Maudsley hospital, Denemark Hill London


Yawning and seizures
This communication reports observations made during an investigation into the emotional aspects of epilepsy indicating an association between yawning and anxiety and between yawning and spike and wave attacks in cases of petit mal epilepsy.
An association between petit mal attacks and yawning has not previously been reported in the litterature, but an association between yawning and other types of epilepsy has been recorded, notably by Gowers, Wilson, Symonds and Penfield. A physiological study and review of the literature of yawning was done by Barbizet and by Lasciewicz in the normal and in association with certain tumours. Yawning was also observed in the case of an anencephalic monster by Gamper. The psychological significance of yawning has received little attention and the biological significance of yawning is shortly discussed by Darwin in his Expression of the Emotions in Man and Animals. Apart from these references there are many unpublished clinical and common observations on the association of yawning with various states but few of them have been formally investigated.
In this study observations have been made on three patients during interviews totalling 97,5 hr whilst recording the electroencephalogram (EEG), respiratory changes, psychogalvanic reflex (PGR) and pulse changes, these being recorded on magnetic tape and EEG paper simultaneously and correlated. The interview room and recording rooms were placed adjacently and separated by a one-way screen, the furniture being arranged so that the patient was under continuous observation from the recording room. All sounds were relayed from the interview room to a loudspeaker in the recording room, besides being recorded on magnetic tape and paper.
The significance of yawning was apparent towards the end of a series of experiments and it become necessary in the assessment to total yawns and sighs together as noted on the record and also those estimated to be yawns by the waveform on the respiratory trace: this excluded any bias towards associating yawns with attacks because clinical details during attacks were more accurately noted than inter-attack periods.
The present report describes observations on three young girls suffering from epilepsy, being classical petit mal with 3 per sec spike and wave episodes on the electroencephalogram.
G. W. Aet 14, started attacks at 7 years. Her seizures were unresponsive to all forms of medication and occurred at the approximate frequency of 1 in 15 min, but they could drop to 2 per day. On physical examination nothing abnormal was detected in the central nervous system. She was a girl of passive personality and of average intelligence.
M. R. Aet 13, started her attacks at 8 years. Her attacks were refractory to drugs and occurred at the approximate frequency of up to 25 per day. She had a suspected lesion on the right side but this was not confirmed by spinal air-encephalogram, although the resting routine EEG showed an asymmetrical waveform. She was a cooperative and vivacious girl but liable to be overactive and provocative; she was of average intelligence.
C P. Aet 12, started her attacks at 10 years. Her seizures were refractory to drugs and had a very variable frequency of from none to 70 per day. On physical examination nothing abnormal was detected in her central nervous system apart from a slight asymmetry of her skull on the X-ray. She was a reserved, anxious, worrying girl liable to emotional outbursts at home; her intelligence was above average.
RESULTS It was originally noted that yawning or sighing in one case (G. W.) occurred during electrical spike and wave attacks on the EEG, and also that they often started with or were preceded in the previous 20 sec by yawning or sighing thus showing a significant relationship between yawns and sighs and spike and wave attacks. It was also observed that when the interviewer (L. G.) left the room, the patients often yawned as he left, as he got up to leave, or just after he left the room: it was shown that in 3 cases there was a highly significant association between yawns or sighs and exits. In order to test the relationship of yawns or sighs to these situations the experimental period was divided up into periods of silence (lapses in conversation of over 20 sec), conversation, spike and wave attacks and also a resting period when the patient was alone in the room. For present purposes the times were all added together to give the totals as shown.
On the null hypothesis that no relationships exist, it was assumed that two equal periods of time in specified situations were likely to contain equal numbers of yawns or sighs. The observed against the expected incidence of yawns or sighs was tested. Tests of significance were done comparing the observed proportions with an expected one of 0-5 using the arc sin transformation, described by Davies.
A comparison was made between yawns or sighs associated with attacks (i.e. those occurring during spike and wave attacks and also coincident with the 20 sec preceding the onset of spike and wave), and the rest of the time recorded. It was found that in one case (G. W.). 80 yawns or sighs were associated attacks and occurred in 2h 59 min (attack time): during the rest of the time of recording. 37 h 7 min, 271 yawns or sighs were recorded. The null hypothesis was that yawns or sighs would occur equally frequently in equal periods of time in "attack states" or "non-attack states". In this case the ratio of yawns or sighs in the two states was 80-20 and the null hypothesis was discarded at a very high level of significance (P < 0-001). Bearing in mind that the figure for yawns or sighs occurring during conversation is all inflated one due to the possible miscalculation resulting from artefact when the patient was talking, it is safe to say that yawns or sighs occur most frequently here in association with the attack state. Another and more accurate comparison between yawning or sighing occurring in association with attacks (80 yawns or sighs in 2 hr 59 min) and those occurring during silences and resting periods (31 yawns or sighs in 7 h 6 mn) also showed that yawns or sighs were associated with attacks at a high level of significance (P < 0-001).
Of the yawns or sighs associated with attacks (G. W). 27 occurred during spike and wave attacks and 53 were coincident with the onset or the 20 sec preceding the onset of spike and wave. The null hypothesis was again applied to these two situations and showed that there was a sigifflicant relationship (P < 0-01) that the yawns or sighs appear to occur rather more frequently associated with the period preceding and coincident with the onset of attacks than during attacks.
A comparison was made between periods when the patient was alone in the room and when the interviewer (O) was in the room but no conversation occurring. The total time of resting alonc (G. W.) was 4 h 2 min, during which 21 yawns or sighs occurred: the total time of silence, O being present, was 3 h 16 min, during which 10 yawns or sighs occurred. The same hypothesis was applied and showed that the difference was insignificant. Since the periods of recording of the patient alone usually occurred at the beginning of sessions, this test also showed that there was no difference between the beginning of recording in this respect as opposed to the rest of the time of silence. This suggests that the patient is not more likely to yawn or sigh during silences because of fatigue or boredom than because of sleepiness at the commencement of a session.
A comparison was made between resting time when the patient was alone, and the interview time including silences when O was in the room. In one case (M. R.), yawns or sighs occurring in resting periods (O absent) (5 yawns or sighs in 3 h) compared with gross interview time (O present) (78 yawns or sighs in 25 h 19 min) showed that more yawns or sighs occurred when 0 was present than when he was absent and on the null hypothesis as above, at a very high level of significance (P < 0-001).
There was a highly significant association between yawns or sighs and O leaving the room as shown in one case (G. W.), where 28 yawns or sighs occurred in association with 37 exits by O. If an average period of 20 sec is allowed for O to exit, yawns or sighs during recording time may be compared with those at exit of O, and on the null hypothesis as tested above, the results in all three cases are very highly significant (P < 0.001) (G. W. where 28 yawns or sighs occurred during 12 min 20 sec exit time, compared with 271 yawns or sighs in 37 h 7 min rest of recording time; C. P. where 12 yawns or sighs occurred during 9 min 20 sec exit time, compared with 23 yawns or sighs in 23 h 3 min rest of recording; and M. R. where 13 yawns or sighs occurred in 12 min exit time, compared with 83 yawns or sighs in 28 hr19 min rest of recording).
Yawns or sighs occurring in the 20 sec following a spike and wave attack were rare. It should be noted that the interviewer, during these experiments, never yawned.Only highly significant or relevant comparisons as tested on the null hypothesis that two situations do not differ, are shown.
DISCUSSION Yawning is a complex physiological phenomenon according to Laskiewicz divisible into slow, short yawning with widely opened glottis, and prolonged yawning in which the vocal chords are contracted and the glottis is tightened. The reflex has from antiquity been known to be influenced by psychical states and there are many observations on the association of paroxysmal yawning with certain pathological conditions. Yawning is therefore a phenomenon which par excellence gives all indication of the influence of certain psychical states on centres in the nervous system subserving the yawning reflex.
It seemed worthwhile to report the observations on the association of yawning with certain alterations in state as there are so few references in the literature to objective studies of yawning as an accompaniment of psychical changes.
The yawning reflex is present from birth and has been observed in an anencephalic infant by Gamper. Laskiewicz in reporting two cases of cerebellar abscesses of otitic origin with repeated and protracted yawning and one with an acute supperative inflammation of the middle car and "repeated and protracted yawning", reviews some of the published instances of its association with certain disease processes. Amongst these he mentions inflammatory processes and neoplasms in the posterior cranial fossa, especially cerebellar abscesses and abscesses of the internal auditory meatus; though inflammatory processes of the basal ganglia in the mesencephalon are said to be, unlike the cerebellum, rarely associated with yawning. Along with other authors, notably Barbizet, he notes the occurrence of yawning as a prelude to epileptic attacks. Gowers mentions yawning as a prodrome to epilepsy and describes it in association with narcolepsy and vagal attacks; Wilson, Symonds and Penfield also describe instances of yawning as a prodrome to epileptic attacks. Philip Bard (personal communication) has noted that in chronic animal preparations after ablation of the cortex and certain other higher centres, yawning can still take place. D. A. K, Black (personal communication) noted protracted deep yawning during the experimental production of uraemic states by exsanguination in dogs, and a frequent association between paroxysmal yawning and uraemia and internal haemorrhage in humans. Other states are less clearly delineated, and include nausea, hunger, thirst and oxygen as found in unaired rooms and at high altitudes.
The reflex is subject to psychical influences and is generally taken to be an expression of weariness, exhaustion, anxiety or boredom, though one would not have expected opposite conditions such as boredom and anxiety to have the same effect. As an expression of emotional states, little has been written on it. It has been noted in children (Platt, personal communication) that during psychotherapy when they have been told something they do not want to hear, they may yawn repeatedly: they may also do so when feeling extremely persecuted during or after temper tantrums.
Darwin briefly refers to yawning In his classic volume on Expressiotion of the Emotions in Man and Animals and mentions yawning in connection with weeping, since tears are frequently secreted. With fear he observed that there is a strong tendency to yawn. An interesting observation was on the expressive value of yawning in baboons who show their passion and threaten their opportents by opening their mouths widely as in the act of yawning, this action frequently leading to a real yawn. Some species of
Macacus and Cercopithecus behave in a like manner and the hypothesis was advanced that the act served the purpose of showing an enemy a formidable set of teeth. Lasciewjcz notes that yawning in humans can be produced by the imagination of, as well as the sight of a yawner, and also by long and anxious waiting. Yawning is notoriously infectious, probably more so than other mimical automatisms elicited by suggestion, such as laughing and weeping. These latter probably produce their effect by eliciting analogous psychic states. It may be conjectured that the highly infectious nature of yawinng is not due simply to suggestjon or mimicry but may be a more complex phenomenon due to the effect of the yawn, which rnay be seen as an expression of boredom or ennui.
In this communication an association between yawning, and, on the one hand a psychological situation. and on the other the onset of spike and wave attacks has been observed. It may be concluded that yawning is a low level reflex which can be evoked
both by the presence of pathological lesions in the central nervous system and by toxic states and is also well know to occur incertain psychological states. This study does not include observations on the biochemical alterations that probably result from psychical change and themseves predispose to yawning, but one can speculate upon the biological significance of this universal reflex. Man in common with the rest of the mammalian species is possessed of a set of drives or needs which are partly innate and ofphysiological origin, and partly acquired as a result of early experience. His survival and health depends upon the gratification of these needs which include such basic factors as oxygen, water, food, sleep, excretion and warmth; on the otherhand thereis a need for affection. esteem, mastery and a sense of belonging. Non-gratification of such needs either of physiological origin or acquired origin arouses anxiety and it is in these conditions that yawning may occur. Thus for example yawning is seen in oxygen deficiency, either from environmental conditions (e.g. high altitude) or from pathological conditions (e.i. uraemia. cardiac failure) and is seen under conditions of thirst, hunger and sleep deprivation: it has however in humans a notoriotisly infectious quality. In these terms the occurrence of yawning in psychological states may superficially have the same meaning, that is a state of deprivation. A psychological change can be reflected in yawning, which in certain instances can be directly related to petit mal attacks. The significance of this for the precipitation of epilepsy is worthy of consideration
(1) In 3 epileptic patients, continuous recording of the E.E.G. and respiration and sound together with observation of the patients over long periods bas been carried out.
(2) The periods of observation have been divided into periods of inactivity and periods during interviews.
(3) The occasions of yawns or sighs, and spike and wave episodes in the EFG have been correlated uith the psychological status of the patients.
(4) A significant relationship bas been found between yawning or sighing and the onset of spike and wave attacks on the one hand and between these and psychological stimulation on the other.
(5) Yawns and sighs occurred significantly more frequently during periods of stimulation than during periods of silence and inactivity.
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