Violence and epilepsy

A 16-year-old right-handed male with a 1-year history of aggressive behavior associated with coprolalia was seen for a second opinion regarding possible seizures. He was diagnosed with complex-partial seizures starting at age 6. During his seizure he would appear to be pointing at people with his hands. This was followed by flailing movements of the arms for brief periods of time followed by post-event fatigue and amnesia. He was suspected to have focal seizures, though a behavioral disorder was also considered. Carbamazepine was begun, which led to complete resolution of the episodes. He remained in control of the attacks and medication was withdrawn at age 9. He was well until 14 years of age when he began having brief episodes of uttering profanities while he would point at people. Seizures were considered, though he was tried on lamotrigine without success. Video-EEG monitoring was performed at age 15 (Fig. 28.1). During the monitoring session, multiple episodes were captured, though none were associated with any EEG changes. He was felt to manifest motor tics with coprolalia and was diagnosed with Tourette's syndrome. Clonidine was ineffective. A brain MRI was normal, as was a complete neurological examination. He had an episode at school in which he cursed and made threatening gestures to his teacher. She described his movements as though he was holding a gun. He was suspended from school and brought by his parents for a second opinion. A diagnostic study was performed.