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many unpublished clinical and common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
SUMMARY
(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.
Specchio
N, Carotenuto A et al. Ictal yawning in a
patient with drug-resistant focal epilepsy:
Video/EEG documentation and review of literature
reports.Epilepsy Behav
2011
