Managing Aggression in Epilepsy ARTICLE Hesham Y

BJPsych Advances (2017), vol. 23, 253–264 doi: 10.1192/apt.bp.115.015255 Managing aggression in epilepsy ARTICLE Hesham Y. Elnazer & Niruj Agrawal An earlier review (Treiman 1986) suggested a Hesham Y. Elnazer is a consultant Behavioural changes associated with epilepsy can two to four times greater prevalence of epilepsy in neuropsychiatrist based at the be challenging for patients and clinicians. Evidence National Centre for Brain Injury prisoners than in controls, although it maintained suggests an association between aggression and Rehabilitation, St Andrew’s Hospital, epilepsy that involves various neurophysiological that the prevalence was similar to that in the Northampton. He provides a tertiary and neurochemical disturbances. Anti-epileptics socioeconomic populations from which the care national neuropsychiatry prisoners came. The review refutes the belief that service. Niruj Agrawal is a have variable effects on behaviour and cognition consultant neuropsychiatrist based that need consideration. Early detection and violence is more common in epilepsy, finding no at St George’s Hospital, London, careful consideration of history, symptomatology greater prevalence in people with epilepsy than in and an honorary senior lecturer and possible common comorbid psychiatric those without or in patients with temporal lobe with St George’s, University of London. He provides a tertiary care disorders is essential. Appropriate investigations epilepsy compared with other types of epilepsy. should be considered to aid diagnosis, including neuropsychiatry service for South A retrospective study at a residential epilepsy West London and parts of Surrey electroencephalogram (EEG), video EEG telemetry centre found the prevalence of aggression to be and Sussex. and brain imaging. Optimising treatment of 27.2% over 1 year, compared with age and gender Correspondence Dr Hesham epilepsy, treatment of psychiatric comorbidities Y. Elnazer, St Andrews Hospital matched controls. The overall frequency was and behavioural management can have a major – Kemsley, Cliftonville road, positive effect on patients’ recovery and well- estimated at between 121 and 207 incidents per Northampton, NN1 5DG, UK. Email: being. 100 persons per year. Aggressive residents were [email protected]. younger than nonaggressive residents. Gender, Copyright and usage LEARNING OBJECTIVES age at onset of epilepsy, history of psychosis, degree © The Royal College of Psychiatrists • Understand the epidemiology of aggression in of mobility, abnormality on magnetic resonance 2017. epilepsy imaging (MRI) scan, intellectual disability and • Comprehend the link between anti-epileptics seizure frequency were not related to aggressive and aggression, including the important role of conduct. For a very small number of aggressive pharmacodynamics incidents (0.7%), acute psychosis was noted as the • Be aware of the pharmacological treatments causal factor, and these were more likely to result available for managing aggressive behaviour in in significant injury (Bogdanovic 2000). Although epilepsy this study gives evidence of a higher incidence of DECLARATION OF INTEREST aggression in people with epilepsy, it also gives None evidence of poor association between epilepsy and persondirected/instrumental aggression or possible consequences of damage. Aggressive behaviour is associated with epilepsy,a a. See Box 1 for definitions of some but there is evidence that its prevalence is no Temporality and causality of the epilepsy-related terms used in higher than in the general population (van Elst this article. 2000). Organic brain disease, low socioeco The chronological relationship between seizures nomic status and poor upbringing have all and violent behaviours is significant. Violence been identified as risk factors for aggression in early in a seizure is very rare and never supported epilepsy (Hermann 1984). Surgery for intractable by consecutive series of purposeful movements epilepsy, such as hippocampectomy or temporal (Treiman 1986). A study of violence and ictal lobectomy, also confers a higher vulnerability to psychotic episodes (Kanemoto 2010) showed that aggression (Engel 1993). directed (targeted) violent attacks were most A multicentre study in three regions of Italy common during postictal psychotic episodes concluded that aggressive behaviours in people (roughly 23%). They were much rarer during inter with epilepsy were different from those in the ictal psychotic episodes (about 5%) and postictal normal population, a feature that we return to periods of confusion (fewer than 1%). Individuals later in this article. The presence of compromised were more prone to both violence and suicide intellectual functioning, psychiatric disturbances attempts during postictal psychotic episodes. and disability, as well as the number of medica Purposeful, organised violence as a direct tions taken, age, illness duration, education and manifestation of seizures or ictal automatism was regional distribution all significantly affected highly unusual. It should be noted that this study, aggressiveness (Piazzini 2012). to which we will return later, did not take into 253 Downloaded from https://www.cambridge.org/core. 26 Sep 2021 at 00:54:16, subject to the Cambridge Core terms of use. Elnazer & Agrawal inappropriate conduct and aggressive outbursts. BOX 1 Some definitions Normal levels of serotonin, dopamine, adrenaline, Epilepsy: A tendency to unprovoked and Complex partial seizures: Epileptic acetylcholine and gammaaminobutyric acid recurrent seizures. seizures that include small areas in the (GABA) in the frontal lobes are believed to be Seizure/ictus: An abnormal paroxysmal temporal/frontal lobe; they often include essential for behavioural control. Animal studies electrical discharge of cerebral neurons. automatism (e.g. lip-smacking, picking indicate that raised dopamine and noradrenaline at clothes, word repeating) and loss of activity can significantly increase the likelihood Aura: Simple partial seizures, which may awareness of surroundings. They usually that the animal will respond to the environment in or may not progress into another seizure last for 1–2 minutes. an impulsively violent manner (Moyer 1968). type. Post-ictal phase: A transient period of Fit: The physical manifestation of a seizure. central nervous system abnormality, which Neurophysiological disturbances becomes apparent after the ictal phase. Generalised seizures: Epileptic seizures Repeated focal or generalised ictal and inter that manifest immediately and spread Kindling: The tendency of some regions ictal epileptiform activity results in an abnormal bilaterally through the cerebral cortex. of the brain to react to repeated low-level recurrent synaptic bombardment of distant bioelectrical stimulation by progressively They may present with or without tonic– projection areas. This may induce neuroplastic clonic convulsions and aura in secondary boosting synaptic discharges, thereby changes and sensory–limbic hyperconnection, generalised seizures, or without aura in lowering seizure thresholds. impairing the naturally occurring homoeostasis primary generalised seizures. Sensory–limbic hyperconnection: A that maintains the interictal state and thus neural process in which incoming stimuli Partial or focal seizures: Epileptic seizures disturbing normal neuronal and psychological that start in a specific area of the brain and are accorded undue emotional significance, functions (Engel 1991, 2002; Hamed 2007). then spread. A partial seizure may become resulting in characteristic changes of secondarily generalised if it spreads to both emotions and behaviour. The role of the amygdala and associated limbic hemispheres. (After Agrawal & Govender, 2011) structures The most important brain structures implicated in the mediation of aggressive behaviour are the account factors such as the effect of antiepileptic amygdala and associated limbic structures, the medication on behaviour. frontal lobes, periaqueductal grey and hypo Confusion during and after fits is the usual thalamus. The amygdala is involved in normal cause of aggression, as the patient unconsciously and abnormal emotional behaviours and serves resists restraint (Treiman 1986; Kanemoto 2010). an important role in anxiety, emotional memory Postictal psychotic episodes can pose a high risk and impulse control (Keele 2005). It is thought to of injury, especially if violence has been reported play a crucial role in the mediation of fearinduced in previous episodes. aggression (Eron 1977). The hippocampus and surrounding limbic system have also been impli Aetiology and pathogenesis cated in seizureinduced behavioural and cognitive Aggression can be fearinduced, territorial or a disorders and aggression (Engel 1993, 2002; learned behaviour reinforced by experience. Its Drevets 1998; Steriade 2000). Other brain areas purpose can be to achieve gain (instrumental) or involved in generating epileptic discharges and prevent loss (fearinduced). Aggressive behaviour behavioural symptoms include the temporal lobes, can also result from increasing anger in response orbitofrontal regions, anterior insula, anterior to a perceived threat or frustration. It can be driven cingulate gyrus and basal ganglia (Helmstaedter by a disrupted perception of the environment 2001; van Elst 2009; Broicher 2010). or an internal sense of threat. Cortical neural disturbances can affect perceptual judgement, Neuronal hyperexcitability and complex partial seizures causing subsequent

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