- Email: [email protected]
Aggression and Violence in Patients with Epilepsy
364 seizures (without a readily demonstrable EEG correlate) or a combination of epileptic and nonepileptic seizures is very difficult to rule out given her history of paroxysmal and epileptiform EEG abnormalities and hippocampal atrophy on MRI.
REFERENCE 1.
Herzog AG. Late-onset congenital adrenal hyperplasia: presentation as nonepileptic seizures. Epilepsy Behav 2000;1:191–3.
Letters to the Editor
Andrew G. Herzog, M.D., M.Sc. 1 Harvard Neuroendocrine Unit Beth Israel Deaconess Medical Center 330 Brookline Avenue Boston, Massachusetts 02215 doi:10.1006/ebeh.2000.0111
1 To whom correspondence should be addressed. E-mail: [email protected].
Aggression and Violence in Patients with Epilepsy To the Editor: Marsh and Krauss (1) provide an intelligent and thorough review of the literature on violence, epilepsy, and related areas, together with helpful case illustrations. They conclude that true ictal violence exists but is extremely rare, postictal violence is more common but usually undirected, and that most aggressive behavior in people with epilepsy occurs interictally. Within a broader survey of violent behavior, my co-editors and I reached similar conclusions (2). Interictal violence has complex origins, but limbic and other brain injury and socioeconomic and psychological factors all take part. The brain injury, not the seizure discharge, plays the chief biological role, as nicely outlined in the superb accompanying editorial by Brower and Price (3). These findings highlight a larger contradiction in epilepsy advocacy, which must continue to tear down barriers when inappropriate, but must also support special awareness and protections when needed (4). As part of the continued struggle against stigma, we must emphasize that people with epilepsy are not, as a whole, more aggressive than the general population. On the other hand, we cannot abandon those people with epilepsy who live with substantial cognitive or psychological burdens, including emotional lability and other factors that may predispose to inappropriate aggression. Our increasing array of anticonvulsants, many with their own positive mental effects, offer hope for improving seizure control while minimizing side effects and even helping cognitive/affective problems. As we better understand relevant limbic, cortical, and brain stem structures involved in various aggressive behaviors, other therapies may emerge. However, the greatest help comes from simCopyright © 2000 by Academic Press All rights of reproduction in any form reserved.
ply recognizing the cognitive and emotional burdens of our patients and being willing to treat them with existing therapies, including changes in anticonvulsants and addition of serotonergic or other behaviormodifying therapy when needed. A related area still awaits adequate research: the person with epilepsy as a survivor of violence. Domestic violence and child abuse may result in brain injury, causing or aggravating a seizure disorder. Additionally, many people with epilepsy carry special physical, psychological, or economic vulnerabilities. The extent to which persons with seizures may be overrepresented among survivors of violence cries out for adequate study (5). So far, this silent population within a silent population remains unheard. Abuse survivors also have a high incidence of pseudoseizures and other somatic and pseudosomatic conditions (6), requiring correct diagnosis and a more thoughtful approach to coordinated neurologic, medical– gynecologic, and psychotherapeutic care.
REFERENCES 1. 2.
3. 4.
5.
Marsh L, Krauss GL. Aggression and violence in patients with epilepsy. Epilepsy Behav 2000;1:160 – 8. Grisolı´a JS. Temporal lobe mechanisms and violence. In: Grisolı´a JS, Sanmartı´n J, Lujan JL, Grisolı´a S, editors. Violence: from biology to society. Amsterdam: Elsevier, 1997: 43–52. Brower MC, Price BH. Epilepsy and violence: When is the brain to blame? Epilepsy Behav 2000;1. Grisolı´a JS, Lobatz M. Medico-legal neurology: special topics. In: Lutsep H, editor. Neurology: an on-line textbook. www. emedicine.com (in press). Rosenberg HJ, Rosenberg SD, Williamson PD. A comparative study of trauma and post traumatic stress disorder prevalence in epilepsy patients and psychogenic nonepileptic seizure patients. Epilepsia 2000;41:447–52.
365
Reply 6.
Reilly J, Baker GA, Rhodes J, Salmon P. The association of sexual and physical abuse with somatization characteristics of patients presenting with irritable bowel syndrome and nonepileptic attack disorder. Psychol Med 1999;29:399 – 406.
James Santiago Grisolı´a, M.D.
Centro Reina Sofı´a para el Estudio de la Violencia (Queen Sofı´a Center for the Study of Violence) doi:10.1006/ebeh.2000.0102
1
Professional Advisory Board Epilepsy Foundation of America
1 To whom correspondence should be addressed at 4033 Third Avenue, Suite 410, San Diego, CA 92103.
Reply To the Editor: We thank Dr. Grisolia for his favorable opinion of “Aggression and Violence in Patients with Epilepsy” (1). We agree with his comments regarding the need to combat the stigma associated with epilepsy and recognize that some patients with epilepsy have vulnerabilities that render them susceptible to aggressive behaviors. Fortunately, aggression or violence in patients with epilepsy is relatively uncommon and we hope that our review will be helpful to patients in that regard. We also agree with Dr. Grisolia that the presence of additional psychiatric illness or cognitive vulnerabilities can aggravate the various burdens already associated with living with epilepsy. Unfortunately, the stigma associated with psychiatric illnesses and erroneous thinking by patients and practitioners about the practice of psychiatric care can also be significant deterrents to the adequate treatment of psychiatric conditions or behaviors that coexist with epilepsy. Dr. Grisolia also suggests that domestic violence may be an underrecognized cause of posttraumatic epilepsy, in addition to its role in psychogenic nonepileptic seizures and other medical and psychiatric conditions. We have not seen evidence of domestic violence and child abuse as a specific cause of seizures among the adults with epilepsy in our universitybased practices, though that does not preclude the possibility. We note that some studies have shown a higher frequency of sexual and physical abuse in patients with conversion disorders presenting as epilepsy relative to patients with known complex partial seizures (2). However, other studies note that psychological trauma, in general (and not just domestic violence or sexual abuse), is associated with conversion phenomena (3) as well as intractable seizures (4). Accordingly, psychiatric phenomena in epilepsy patients should be evaluated without adherence to restricted
notions about the role of abuse. A comprehensive approach to psychiatric care involves appreciation of the complex interactions between brain pathology, life events, cognitive and temperamental attributes, and individual goal-driven behaviors. Each of these different “perspectives” influences the phenomenology, diagnosis, etiology, and treatment of the psychiatric condition and provides a framework for the management of patients with epilepsy (5).
REFERENCES 1. 2.
3.
4.
5.
Marsh L, Krauss GL. Aggression and violence in patients with epilepsy. Epilepsy Behav 2000;1:160 – 8. Alper K, Devinsky O, Perrine K, Vazquez B, Luciano D. Nonepileptic seizures and childhood sexual and physical abuse. Neurology 1993;43:1950 –3. Arnold LM, Privitera MD. Psychopathology and trauma in epileptic and psychogenic seizure patients. Psychosomatics 1996;37:438 – 43. Rosenberg HJ, Rosenberg SD, Williamson PD, Wolford II GL. A comparative study of trauma and posttraumatic stress disorder prevalence in epilepsy patients and psychogenic nonepileptic seizure patients. Epilepsia 2000;41:447–52. Schwartz JM, Marsh L. The psychiatric perspectives of epilepsy. Psychosomatics 2000;41:31– 8.
Laura Marsh, M.D. 1 Department of Psychiatry Gregory L. Krauss, M.D. Department of Neurology John Hopkins Hospital 600 North Wolfe Street Baltimore, Maryland 21287 doi:10.1006/ebeh.2000.0118 1
To whom correspondence should be addressed.
Copyright © 2000 by Academic Press All rights of reproduction in any form reserved.
REFERENCE 1.
Herzog AG. Late-onset congenital adrenal hyperplasia: presentation as nonepileptic seizures. Epilepsy Behav 2000;1:191–3.
Letters to the Editor
Andrew G. Herzog, M.D., M.Sc. 1 Harvard Neuroendocrine Unit Beth Israel Deaconess Medical Center 330 Brookline Avenue Boston, Massachusetts 02215 doi:10.1006/ebeh.2000.0111
1 To whom correspondence should be addressed. E-mail: [email protected].
Aggression and Violence in Patients with Epilepsy To the Editor: Marsh and Krauss (1) provide an intelligent and thorough review of the literature on violence, epilepsy, and related areas, together with helpful case illustrations. They conclude that true ictal violence exists but is extremely rare, postictal violence is more common but usually undirected, and that most aggressive behavior in people with epilepsy occurs interictally. Within a broader survey of violent behavior, my co-editors and I reached similar conclusions (2). Interictal violence has complex origins, but limbic and other brain injury and socioeconomic and psychological factors all take part. The brain injury, not the seizure discharge, plays the chief biological role, as nicely outlined in the superb accompanying editorial by Brower and Price (3). These findings highlight a larger contradiction in epilepsy advocacy, which must continue to tear down barriers when inappropriate, but must also support special awareness and protections when needed (4). As part of the continued struggle against stigma, we must emphasize that people with epilepsy are not, as a whole, more aggressive than the general population. On the other hand, we cannot abandon those people with epilepsy who live with substantial cognitive or psychological burdens, including emotional lability and other factors that may predispose to inappropriate aggression. Our increasing array of anticonvulsants, many with their own positive mental effects, offer hope for improving seizure control while minimizing side effects and even helping cognitive/affective problems. As we better understand relevant limbic, cortical, and brain stem structures involved in various aggressive behaviors, other therapies may emerge. However, the greatest help comes from simCopyright © 2000 by Academic Press All rights of reproduction in any form reserved.
ply recognizing the cognitive and emotional burdens of our patients and being willing to treat them with existing therapies, including changes in anticonvulsants and addition of serotonergic or other behaviormodifying therapy when needed. A related area still awaits adequate research: the person with epilepsy as a survivor of violence. Domestic violence and child abuse may result in brain injury, causing or aggravating a seizure disorder. Additionally, many people with epilepsy carry special physical, psychological, or economic vulnerabilities. The extent to which persons with seizures may be overrepresented among survivors of violence cries out for adequate study (5). So far, this silent population within a silent population remains unheard. Abuse survivors also have a high incidence of pseudoseizures and other somatic and pseudosomatic conditions (6), requiring correct diagnosis and a more thoughtful approach to coordinated neurologic, medical– gynecologic, and psychotherapeutic care.
REFERENCES 1. 2.
3. 4.
5.
Marsh L, Krauss GL. Aggression and violence in patients with epilepsy. Epilepsy Behav 2000;1:160 – 8. Grisolı´a JS. Temporal lobe mechanisms and violence. In: Grisolı´a JS, Sanmartı´n J, Lujan JL, Grisolı´a S, editors. Violence: from biology to society. Amsterdam: Elsevier, 1997: 43–52. Brower MC, Price BH. Epilepsy and violence: When is the brain to blame? Epilepsy Behav 2000;1. Grisolı´a JS, Lobatz M. Medico-legal neurology: special topics. In: Lutsep H, editor. Neurology: an on-line textbook. www. emedicine.com (in press). Rosenberg HJ, Rosenberg SD, Williamson PD. A comparative study of trauma and post traumatic stress disorder prevalence in epilepsy patients and psychogenic nonepileptic seizure patients. Epilepsia 2000;41:447–52.
365
Reply 6.
Reilly J, Baker GA, Rhodes J, Salmon P. The association of sexual and physical abuse with somatization characteristics of patients presenting with irritable bowel syndrome and nonepileptic attack disorder. Psychol Med 1999;29:399 – 406.
James Santiago Grisolı´a, M.D.
Centro Reina Sofı´a para el Estudio de la Violencia (Queen Sofı´a Center for the Study of Violence) doi:10.1006/ebeh.2000.0102
1
Professional Advisory Board Epilepsy Foundation of America
1 To whom correspondence should be addressed at 4033 Third Avenue, Suite 410, San Diego, CA 92103.
Reply To the Editor: We thank Dr. Grisolia for his favorable opinion of “Aggression and Violence in Patients with Epilepsy” (1). We agree with his comments regarding the need to combat the stigma associated with epilepsy and recognize that some patients with epilepsy have vulnerabilities that render them susceptible to aggressive behaviors. Fortunately, aggression or violence in patients with epilepsy is relatively uncommon and we hope that our review will be helpful to patients in that regard. We also agree with Dr. Grisolia that the presence of additional psychiatric illness or cognitive vulnerabilities can aggravate the various burdens already associated with living with epilepsy. Unfortunately, the stigma associated with psychiatric illnesses and erroneous thinking by patients and practitioners about the practice of psychiatric care can also be significant deterrents to the adequate treatment of psychiatric conditions or behaviors that coexist with epilepsy. Dr. Grisolia also suggests that domestic violence may be an underrecognized cause of posttraumatic epilepsy, in addition to its role in psychogenic nonepileptic seizures and other medical and psychiatric conditions. We have not seen evidence of domestic violence and child abuse as a specific cause of seizures among the adults with epilepsy in our universitybased practices, though that does not preclude the possibility. We note that some studies have shown a higher frequency of sexual and physical abuse in patients with conversion disorders presenting as epilepsy relative to patients with known complex partial seizures (2). However, other studies note that psychological trauma, in general (and not just domestic violence or sexual abuse), is associated with conversion phenomena (3) as well as intractable seizures (4). Accordingly, psychiatric phenomena in epilepsy patients should be evaluated without adherence to restricted
notions about the role of abuse. A comprehensive approach to psychiatric care involves appreciation of the complex interactions between brain pathology, life events, cognitive and temperamental attributes, and individual goal-driven behaviors. Each of these different “perspectives” influences the phenomenology, diagnosis, etiology, and treatment of the psychiatric condition and provides a framework for the management of patients with epilepsy (5).
REFERENCES 1. 2.
3.
4.
5.
Marsh L, Krauss GL. Aggression and violence in patients with epilepsy. Epilepsy Behav 2000;1:160 – 8. Alper K, Devinsky O, Perrine K, Vazquez B, Luciano D. Nonepileptic seizures and childhood sexual and physical abuse. Neurology 1993;43:1950 –3. Arnold LM, Privitera MD. Psychopathology and trauma in epileptic and psychogenic seizure patients. Psychosomatics 1996;37:438 – 43. Rosenberg HJ, Rosenberg SD, Williamson PD, Wolford II GL. A comparative study of trauma and posttraumatic stress disorder prevalence in epilepsy patients and psychogenic nonepileptic seizure patients. Epilepsia 2000;41:447–52. Schwartz JM, Marsh L. The psychiatric perspectives of epilepsy. Psychosomatics 2000;41:31– 8.
Laura Marsh, M.D. 1 Department of Psychiatry Gregory L. Krauss, M.D. Department of Neurology John Hopkins Hospital 600 North Wolfe Street Baltimore, Maryland 21287 doi:10.1006/ebeh.2000.0118 1
To whom correspondence should be addressed.
Copyright © 2000 by Academic Press All rights of reproduction in any form reserved.