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Postictal Violence and Epilepsy

Received April 8, 1997; revised July 8, 1997; accepted July 21, 1997. From the Department of Neurology and Psychiatry & Biobehavioral Sciences, University of California at Los Angeles; and the Neurobehavior Unit, West Los Angeles Veterans Affairs (VA) Medical Center. Address reprint requests to Dr. Mendez, Neurobehavior Unit (691/116AF), West Los Angeles VA Medical Center, 11301 Wilshire Blvd., Los Angeles, CA 90073. E-mail: mmendez{at}UCLA.edu

Key Words: Violence • Epilepsy • Seizures

The belief that epilepsy is linked with violence has existed since ancient times. This belief peaked in the 19th century when the criminologist Cesare Lombroso promoted the association of epilepsy with aggressive, sociopathic tendencies.¹ Modern studies reject the notion that most persons with epilepsy are prone to violence; however, epidemiological studies reveal a greater occurrence of violence among those with seizures as compared with those without seizures.^2–4 Most of this violence occurs during seizure-free periods and results from associated factors such as poor impulse control, cognitive impairments, or psychopathology.⁵

Although uncommon, violent acts may also result directly from seizures.^6,7 Aggressive behaviors can occur as seizure prodrome, as ictal behaviors, as violent automatisms, or as part of the postictal confusional period. These violent acts are usually not well organized or specifically directed. Epileptic patients rarely have purposeful, organized violence as a direct manifestation of seizures or ictal discharges.^7,8 I report the case of a rare patient with directed aggression as a postictal phenomenon and review the literature on epilepsy and violence.

Case Report

A 37-year-old, left-handed man with epilepsy presented with aggressive episodes. His seizures began at age five after sustaining a head injury from a fall. The seizures consisted of an olfactory aura followed by "spacing out" or alteration of consciousness for about 1 minute. These partial complex seizures (PCSs) occurred several times per day whenever his anticonvulsant therapy was suboptimal. In addition, the patient had occasional secondary generalized tonic/clonic seizures, with urinary incontinence and tongue-biting.

During the postictal period, as he began to recover consciousness, the patient experienced an overwhelming sense of threat or of having been harmed. These feelings became focused on any individual who was in his immediate environment. That person was believed to have beaten or otherwise hurt him and was going to harm him further. The patient felt compelled to attack these individuals, often inflicting significant physical injury on them. Although his postictal confusion would clear in about 1 hour, his sense of being harmed or threatened slowly diminished over about 24 hours after a seizure. After the resolution of these feelings, he felt great remorse over the harm that he had done. Nevertheless, on several occasions, he was charged with aggravated assault.

In addition to his seizure disorder, the patient had a history of depression and was diagnosed with bipolar affective disorder. On examination, the patient had a depressed affect but was oriented, alert, and conversant. He had normal verbal fluency, auditory comprehension, repetition, naming, and reading. His delayed verbal and visual recognition scores were within normal limits, and he had normal calculations, abstractions, praxis, and gnosis testing. The general physical examination was unremarkable, and the neurological examination showed normal cranial nerves, coordination, motor, reflex, and sensory examinations. Magnetic resonance imaging and single photon emission computed tomography brain scans were normal, but sleep-deprived electroencephalograms (EEGs) revealed temporal-lobe epileptiform activity (spike waves and sharp waves) predominantly in the left-anterior temporal region.

The patient's aggressive postictal episodes abated with control of his PCSs. Carbamazepine was added to his original regimen of valproate and sertraline, and he remained under good seizure control.

Discussion

The persistent view that violent acts may be seizures is reflected in the epilepsy defense in criminal trials and in popular fiction such as The Terminal Man.^7,9 It is true that, compared with the general population, violent behavior occurs more often among epileptic patients, and epilepsy occurs more often among prisoners and delinquents.^3,4,10 Most aggression in epilepsy, however, is interictal rather than seizure-related and correlates with male gender, psychopathology, low intelligence or cognitive deficits, brain defects or prior head trauma, abnormal neurological studies, medication side effects, and possibly with the experience of child abuse.^4,5,11,12

This report describes a patient with aggressive acts as a direct consequence of seizures. Aggressive or violent behavior can occur from epileptic discharges or their postictal changes.^6,7 Postictal violence is most commonly resistive behavior during the postictal delirium due to attempts at restraint.^7,8 In their confusion, epileptic patients can misinterpret attempts by onlookers to protect them.¹³ Other postictal violent acts are due to postictal psychosis or to continued confusional ambulation, as in poriomania and somnambulism.¹⁴ In contrast, the patient I have described had a paranoid interpretation that outlasted both the ictus and the postictal confusion.Unlike violence associated with a dissociative disorder, he remembered his violent behavior and actually reported it. His behavior was consistent with electrical discharges in temporal limbic structures, resulting in a heightened sense of threat. This experience is also consistent with ictal depression and other psychic auras that can outlast the inducing ictus by hours or days.¹⁵

Can violence itself be a seizure? Following the infamous Torsney case, in which a New York City policeman who had never had seizures successfully claimed the epilepsy defense, criteria for ictal violence have been proposed that include a careful video-EEG assessment.³ Since then, there has been little evidence that ictal violence is directed or well organized into a series of coordinated steps. Nevertheless, simple violent automatisms, such as spitting or flailing the arms, can occur at the onset of PCSs, and secondary violent automatisms can occur as reactions to fear, hallucinations, or other disagreeable ictal experiences (Table 1).^2,16 In addition, some propose that brief, violent outbursts can be subtle seizure equivalents from epileptiform temporal-limbic discharges.^2,17 Prisoners, delinquent adolescents, and violent patients often have paroxysmal seizure-like symptoms and nonspecific EEG changes.^4,10,18 Most studies, however, fail to show overt seizures among most of these patients or differences in seizure variables between epileptic patients with and without violence.^4,5,18

View this table: [in this window] [in a new window]

Table 1

Similar to our patient, aggression and violence may be associated with left temporal-lobe seizure foci. On a hostility inventory, epileptic patients with left-temporal foci were more suspicious and had more hostile feelings than did other patients or control subjects.¹⁹ Among maximum-security mental patients, focal EEG and computed tomography abnormalities occurred in the left-temporal lobe in 20%–40% of the most violent patients.¹⁸ Moreover, some epileptic patients have amelioration of aggression with resection of the left-anterior temporal lobe.²⁰

There are various potential mechanisms for violence among epileptic patients. This report describes a previously unrecognized mechanism: a persistent perception of threat precipitated by left-temporal limbic discharges and lasting beyond the periictal period. Clinicians need to be aware of the different relationships between epilepsy and violence, particularly in deciding on alternative management with anticonvulsant medications, psychoactive drugs, or, in some cases, surgery.

REFERENCES

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3. Mungus D: An empirical analysis of specific syndromes of violent behavior. J Nerv Ment Dis 1983; 171;243–271
4. Lewis DO, Pincus JH, Shanok SS, et al: Psychomotor epilepsy and violence in a group of incarcerated adolescent boys. Am J Psychiatry 1982; 139:882–887[Abstract/Free Full Text]
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15. Devinsky O, Bear DM: Varieties of depression in epilepsy. Neuropsychiatry Neuropsychol Beh Neurol 1991; 4:49–61
16. Fornazzari L, Farcnik K, Smith I, et al: Violent visual hallucinations and aggression in frontal lobe dysfunction: clinical manifestations of deep orbitofrontal foci. J Neuropsychiatry Clin Neurosci 1992; 4:42–44[Abstract/Free Full Text]
17. Lion JR: The intermittent explosive disorder. Psychiatric Annals 1992; 22:64–66
18. Wong MT, Lumsden J, Fenton GW, et al: Electroencephalography, computed tomography and violence ratings of male patients in a maximum-security mental hospital. Acta Psychiatr Scand 1994; 90:97–101[Medline]
19. Devinsky O, Ronsaville D, Cox C, et al: Interictal aggression in epilepsy: the Buss-Durkee Hostility Inventory. Epilepsia 1994; 35:585–590[Medline]
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