Postictal Aggression Research Articles

Criminal liability and epilepsy: a case report of a postictal attempted homicide from Tunisia.

Patients with epilepsy who have been charged with a serious offense may be referred by the courts for forensic psychiatric examination. A detailed psychiatric and neurological examination is often necessary to assist the courts in making the right decision, as exemplified in the current case presentation. The forensic case of a 30-year-old Tunisian male with temporal epilepsy who exhibited an inadequate response to the treatment is presented here. The patient attempted to kill his neighbor after a cluster of seizures, showing apparent postictal aggression. An antiepileptic treatment was introduced a few days after the person's detention and was followed by forensic psychiatric examination, but the latter was not done until three months afterwards. On forensic examination, the patient's thought processes were clear with no evidence of a thought disorder or psychosis. Both medical and psychiatric opinions stated that the attempted homicide was due to a postictal psychosis. The patient was transferred to a psychiatric facility for further management and was found not guilty by reason of insanity. This case illustrates the difficulties that experts may encounter in establishing criminal liability after aggressive behavior associated with epilepsy. It highlights shortcomings in Tunisian law (and promptness of forensic psychiatric examination) that should be addressed to ensure fairness of the legal process.

Seizure-related injury and postictal aggression in refractory epilepsy patients

ObjectiveIn the general population, injury related to seizures often involves falls, head trauma, soft tissue injuries, burns and fractures. Additionally, postictal deleterious behavior changes can by experienced by patients. We seek to identify the risk for seizure-related injury (SRI) and postictal aggression (PIA) in patients with refractory epilepsy. MethodsSelf-reported SRI and PIA were gathered through a seizure questionnaire as part of the epilepsy center’s seizure safety protocol. Retrospective review of questionnaire, clinical course, and demographic data was completed. Statistical analysis of variables of interest was done using nonparametric methods. Results126 patient questionnaires were completed over a one-year duration. Most patients reported seizure related injury (56.3 %) and postictal aggression (52.4 %). Increased disease duration was associated with seizure related injury and its severity (Kwallis p = 0.025), with number of antiepileptic drugs (AEDs) as significant factors (p = 0.012). Postictal aggression was also associated with a longer duration of epilepsy (Ranksum p = 0.037, t-test p = 0.04) and higher seizure frequency (p = 0.017). Patients who reported seizure related injury and postictal aggression were on more AEDs (p = 0.0003, p = 0.01, respectively), with first-generation AEDs being most contributory. ConclusionThe majority of patients with seizures report seizure-related injuries and postictal aggression. Duration and AED regimen are significant risk factors and screening practices can potentially guide safety measures and recommendations.

Complex partial seizure with postictal aggression as a presentation of atypical eclampsia: a case report

Background: Complex partial seizure with sudden onset in near term pregnancy can be challenging to the attending clinician and it is essential to proceed with a presumptive diagnosis of eclampsia, especially in resource poor settings. Unlike generalized tonic clonic seizures, which are more common in eclampsia, complex partial seizures may not jeopardize the fetus with the same severity. However the associated postictal aggression manifested in self-inflicted trauma poses an imminent risk onto the fetus.
 Case presentation: A nineteen year old gravida two para one living zero woman presented with seizure at thirty six weeks and three days of gestation in a district hospital. The blood pressure recordings during her entire pregnancy were normal and proteinuria was not present. Her previous pregnancy had a similar course, with self-inflicted trauma to her abdomen in a postictal state and resulted in loss of fetus. She did not have any seizures in between then and the current admission. While being managed in the labor ward, the family physicians witnessed complex partial seizure with postictal aggression. The delivery was expedited with caesarean section and she had no further seizure activity.
 Conclusion: Complex partial seizures with postictal aggression in pregnancy are rare but can be an atypical presentation of eclampsia and poses a diagnostic dilemma to the clinician.

Successful Management of Difficult-to-Treat Aggression With Low-Dose Propranolol in a Patient With Intellectual Disability

To the Editor: People with intellectual disability often exhibit various behavioral problems, which are referred to as “challenging behaviors.” Aggression is among the commonest of these, affecting about 7% of this population.1 The management of aggression in these patients involves both behavior therapy2 and medications.3 Various medications, such as lithium, anticonvulsants, and antipsychotics, have been used, but their evidence base is limited3–5 and recent research suggests that antipsychotics, in particular, should not be routinely used.6 Propranolol is a centrally acting β-adrenergic antagonist used in a variety of medical conditions. It has also been used to manage aggression in various neuropsychiatric conditions, including organic brain syndromes,7,8 schizophrenia,9 dementia,10 and intellectual disability.11,12 Doses used in these studies have been as high as 520 mg/d,13 but some authors have reported benefits at much lower doses.10,14 The following is the case of a young man with intellectual disability, epilepsy, and severe aggression who responded remarkably to low-dose propranolol. Case report. Mr A, a 20-year-old man diagnosed as having moderate intellectual disability and generalized epilepsy, presented to our clinic with severe aggression, both verbal and physical, occurring with little or no provocation over the past 3 years. These episodes would last up to several hours and often led to food refusal. Before this, he could attend to his personal needs, helped his mother in household tasks, and could communicate in short sentences despite an articulation defect. However, after the onset of his aggression, it was difficult to engage him in any activities, including basic self-care. There was no evidence of a mood disorder or psychosis or of seizures either preceding or following the episodes of aggression. He was seizure-free for the past 4 years on carbamazepine 1,000 mg/d and diazepam 10 mg/d, and he had never exhibited postictal aggression in the past. He had already received trials of olanzapine (up to 15 mg/d for 6 weeks) and chlorpromazine (up to 400 mg/d for 3 months) without significant improvement and was currently on olanzapine 10 mg/d and chlorpromazine 300 mg/d in addition to his medications for epilepsy. As his mother reported features of autonomic arousal—such as increased perspiration, motor agitation, and rapid breathing—during each episode, he was given a trial of propranolol, starting at 20 mg/d and increased by 20 mg every week. At 40 mg/d, there was a significant reduction in his aggression, and his food intake was better. On further increasing the dose to 60 mg/d, his mother reported that he was essentially “normal,” with no significant episodes of aggression. Over the next year, olanzapine and chlorpromazine were tapered and stopped, and he remained stable. He has been well on carbamazepine 1,000 mg/d, propranolol 60 mg/d, and diazepam 10 mg/d for the past 3 months with no recurrence of either seizures or aggression, and it is now possible to engage him in household tasks and speech therapy. The management of aggression in the intellectually disabled is a clinical challenge. The best evidence suggests that antipsychotics are of limited use, and the evidence for other medications is even more limited. Behavioral management is valuable, but may not be feasible in a very violent or uncooperative patient, and pharmacotherapy may be required initially in such cases. Propranolol is effective in reducing aggression in a variety of neurologic and psychiatric conditions. Its exact mechanism of action is unknown, but may involve central β-adrenergic blockade,15 peripheral effects on the sympathetic nervous system,11,16 or serotonergic blockade.17 It may be effective not only in aggression, but also in the self-injurious behavior commonly seen in the intellectually disabled.18 Recent evidence suggests that it may improve some aspects of learning in patients with autism.19 Given these properties, and the uncertainties surrounding other treatment options, low-dose propranolol may be a valuable treatment option in the management of aggression in intellectually disabled adults, even if they do not respond to other drugs.

Improving safety outcomes in the epilepsy monitoring unit

Long term video electroencephalography (EEG) in epilepsy monitoring units (EMU) is used to diagnose and treat patients with epilepsy. Injury occurs in the EMU, including reports of death. No standardized patient safety protocols exist. Our objective is to determine the frequency and contributing factors to injury in the EMU.We reviewed medical records and video EEG of patients with epilepsy admitted to our EMU from December 1, 2008 to June 1, 2009. Data was collected on seizure type, onset, length, and frequency. Seizure related falls, injury, and adverse events were recorded. Data regarding the physical environment and treatment during seizures were analyzed too.20 patients with 170 seizures were collected. Of the 170 total seizures captured, only 1 injury (0.6%) and 6 falls occurred (3.5%). 5 of the 6 falls were related to patients being ambulatory. No seizures resulted in prolonged stay. Of the 170 seizures captured, other adverse events included 1 status epilepticus (0.6%), 2 postictal aggression (1.2%), 4 objects in mouth (2.4%), 14 ambulatory at seizure onset (8.2%) and 5 postictal ambulation from bed (2.9%). Staff responded to 69 out of 170 seizures (40.6%). Of the 101 seizures without staff response, 57 seizures were electrographic without seizure detection software or push button activation.Falls and adverse events that can lead to injury occur in the EMU, yet the degree of actual injury is minimal. To improve safety outcomes, standardized protocols with appropriate outlined nursing care and procedures for continuous monitoring of patients by staff need to be employed.

Subacute postictal aggression in patients with epilepsy

Three men with epilepsy (age range, 38–62) who exhibited brief episodes of violent behavior during the postictal period are described. Disease duration ranged from 27 to 44 years. Patients had both complex partial seizures and secondarily generalized tonic–clonic seizures, which were refractory to antiepileptic drugs. Postictal aggression occurred shortly after a seizure and lasted 5–30 minutes. The patients displayed physically and verbally aggressive behavior toward others, but regained consciousness promptly and showed regret afterward. Interictal EEGs revealed temporal spikes, SPECT showed hypoperfusion in the temporal and frontal areas in two patients, and neuropsychological examination revealed poor frontal lobe function in two patients. Characteristics of our cases are consistent with subacute postictal aggression (SPA) reported previously. Epilepsy of prolonged duration and brain dysfunction involving a broad area including the temporal and frontal lobes may be associated with the occurrence of subacute postictal aggression.

Seizure behaviour in a patient with post-traumatic stress disorder following rape. Notes on the aetiology of ‘pseudoseizures’

A patient is described who began to have paroxysmal convulsive behaviour, followed by a post-ictal aggression, which was initially diagnosed and treated as epilepsy. The behaviour began after the patient was raped. She had many of the symptoms of post-traumatic stress disorder. It is suggested that the paroxysmal behaviour was an ‘acting out’ of intrusive and vivid memories of the rape, so called ‘flashback’. Because the rape had occurred comparatively recently and the events that occurred during the rape were known, it was easy, in this particular patient, to understand the relationship between the previous trauma and the paroxysmal behaviour. The case throws some light on the relationship between similar paroxysmal behaviour in the victims of child sexual abuse and the trauma they had suffered and explains why they behave in the way that they do.

Psychomotor epilepsy and aggressive behavior.

The literature states that patients with psychomotor epilepsy are prone to aggressive acting-out behavior. Of 150 epileptic patients whose seizures were photographed, 42 had ictal psychomotor automatisms and 15 had postictal psychomotor attacks. There was no instance of ictal or postictal aggression in this study. When there was danger of aggressive behavior, it could promptly be averted by abandoning restraint efforts. To define the characteristics of the aggression prone individual, 700 charts were reviewed; 34 patients were found who had committed aggressive acts. The profile of the aggression-prone individual which emerged was that of a young man of lower-than-average intelligence with a history of behavioral difficulties dating back to school age and who did not have strong religious ties. Presence or absence of psychomotor epilepsy was not a relevant variable.