Special report. The nature of aggression during epileptic seizures

Aggression and psychiatric comorbidity in children with hypothalamic hamartomas and their unaffected siblings

OBJECTIVE

To assess aggression and psychiatric comorbidity in a sample of children with hypothalamic hamartomas and gelastic seizures and to assess psychiatric diagnoses in siblings of study subjects.

METHOD

Children with a clinical history of gelastic seizures and hypothalamic hamartomas (n = 12; age range 3-14 years) had diagnoses confirmed by video-EEG and head magnetic resonance imaging. Structured interviews were administered, including the Diagnostic Interview for Children and Adolescents-Revised Parent Form (DICA-R-P), the Test of Broad Cognitive Abilities, and the Vitiello Aggression Scale. Parents were interviewed with the DICA-R-P about each subject and a sibling closest in age without seizures and hypothalamic hamartomas. Patients were seen from 1998 to 2000.

RESULTS

Children with gelastic seizures and hypothalamic hamartomas displayed a statistically significant increase in comorbid psychiatric conditions, including oppositional defiant disorder (83.3%) and attention-deficit/hyperactivity disorder (75%). They also exhibited high rates of conduct disorder (33.3%), speech retardation/learning impairment (33.3%), and anxiety and mood disorders (16.7%). Significant rates of aggression were noted, with 58% of the seizure patients meeting criteria for the affective subtype of aggression and 30.5% having the predatory aggression subtype. Affective aggression was significantly more common (p < .05). Unaffected siblings demonstrated low rates of psychiatric pathology on semistructured parental interview and no aggression as measured by the Vitiello Aggression Scale.

CONCLUSIONS

Children with hypothalamic hamartomas and gelastic seizures had high rates of psychiatric comorbidity and aggression. Parents reported that healthy siblings had very low rates of psychiatric pathology and aggression.

Neuropsychological effects of epilepsy and antiepileptic drugs

Epilepsy and its treatment can have deleterious cognitive and behavioural consequences. Affected individuals have a higher prevalence of neuropsychological dysfunction than the general population because of complex interactions among several multifaceted and overlapping influences--for example, underlying neuropathologies, ictal and interictal neuronal discharges, a plethora of antiepileptic drugs, and numerous psychosocial issues. Research into the clinical relevance of these factors has been dogged by a range of methodological pitfalls including lack of standardisation of neuropsychological tests, small numbers and multiple testing, and statistical failure to appreciate differential effects of interactive elements in individual patients. Although antiepileptic drugs can impair neuropsychological functioning, their positive effect on seizure control might improve cognition and behaviour. Each person should be assessed individually with respect to factors unique to his or her seizure disorder and its treatment.

Aggression and violence in patients with epilepsy

Violence has been associated with epilepsy. However, the links between violent behaviors and epilepsy involve multiple factors. These range from behaviors associated with underlying brain dysfunction to postictal delirious and psychotic states and rare cases of ictal aggression. This review describes the differential diagnosis of violent acts in epilepsy and the features that can be used to evaluate these behaviors.

Epilepsy and behavior: a brief history

Behavioral changes-both real and imagined-have formed a halo around epilepsy since antiquity. The myth of epilepsy as a curse has been largely vanquished in modern cultures, but the disorder remains a social stigma for many patients. In ancient Rome people with epilepsy were avoided for fear of contagion, in the Middle Ages they were hunted as witches, and in the first half of our century they were labeled deviants and their marriage and reproduction were restricted by eugenistic medical doctors. Religious conversion experiences can occur in temporal relationship to changes in seizure frequency. Many religious leaders may have had epilepsy. However, changes in religious sentiment are not characteristic of epilepsy patients. Recognized since the late 19th century, postictal psychosis has stimulated theories regarding the mechanism of mania and psychosis. Understanding the pathophysiology of behavioral changes in epilepsy may offer insight into the psychopathology of other diseases.

The postictal state: a neglected entity in the management of epilepsy

Some of the disability deriving from epilepsy derives from the postictal state (PS). The PS may be complicated by impaired cognition, headache, injuries, or secondary medical conditions. Postictal depression is common, postictal psychosis relatively rare, but both add to the morbidity of seizures. The mechanisms of the PS are poorly understood. Alteration of cerebral blood flow both results from and contributes to the PS. Many neurotransmitters or neuromodulators are involved in the physiology of the PS. Response to glutamate may partially desensitize after a seizure. Endogenous opiates and adenosine serve as natural antiepileptic medications in some circumstances. Nitric oxide has numerous effects on brain excitability, and may be particularly important in regulating postictal cerebral blood flow. Just as the pathophysiology of seizures is complicated, so is that of the PS multifactorial. As a practical issue, it would be very useful to have medications that reduce the morbidity of the PS.

Aggressive behaviour at a residential epilepsy centre

There is an extensive literature on epilepsy and violence, but no study has addressed aggression (i.e. apparently intentional violence) in a residential-care population. We performed a retrospective study at the Chalfont Centre for Epilepsy (a residential-care facility in rural Buckinghamshire) in order to determine the frequency and character of episodes of aggression. This allowed us to identify a group of aggressive subjects who were compared with age- and sex-matched control subjects drawn from the remaining residents. We found the prevalence of aggression to be 27.2% in 1 year amongst long-term residents. The overall frequency was estimated at between 121 and 207 incidents per 100 persons per year. A few incidents (0.7%) were related to an acute psychosis but they were more likely to result in significant injury. Offenders were younger than non-aggressive residents. Gender, age of onset of epilepsy, history of psychosis, mobility, abnormality on MRI scan, learning disability and seizure frequency were not associated with aggressive conduct.

On some clinical implications of the ventral striatum and the extended amygdala. Investigations of aggression

In this paper, we have first reviewed the animal studies which suggest an association between the amygdala and aggressive behavior. This is followed by a review of the literature of aggression in epilepsy, emphasizing the less controversial peri-ictal aggressions, with the more controversial assertion that temporal lobe epilepsy in particular is associated with an increase in interictal aggression. We then go on to describe the results of some investigations using the MRI to examine amygdala pathology in a group of patients presenting with affective aggression in comparison with a control group. The main findings are that the patients with aggression tend to have lower IQs and more psychopathology than the control group. There is no difference in amygdala T2 and volumetric assessments between the groups, but a subgroup of patients are defined with aggression, left-sided amygdala atrophy, and a history of encephalitis.

Motiveless firesetting: implicating partial limbic seizure kindling by revived memories of fires in "Limbic Psychotic Trigger Reaction"

23 unselected juvenile firesetters (M age 12.0 yr.) consisted of seven with schizophrenia, three with organic mental disorder, six with posttraumatic stress disorder, two with severe mental retardation, and two with conduct disorders. Three previously nondestructive boys (M age 11.0 yr.), all of them loners, did not fit such traditional diagnoses. Their fleeting (c. 20 min.) symptoms included flat affect, autonomic arousal, and delusions or hallucinations. It appeared that their motiveless, unplanned acts were each preceded by a chance encounter with an individualized stimulus which revived the three boys' repeatedly ruminated memories of intermittently experienced merely moderate stresses associated with fire, smoke, or matches. Such a sequence of events is characteristic of seizure kindling. One boy's abnormal EEG was congruent with seizures in the temporal lobe area, which includes the amygdala, i.e., that part of the limbic system particularly susceptible to seizure kindling. The three boys' consistent symptomatology was very similar to that reported for 17 men with bizarre homicidal acts implicating a kindled partial seizure called "Limbic Psychotic Trigger Reaction." In primates, too, similar partial nonconvulsive "behavioral seizures" with psychosis-like symptoms can be elicited through experiential kindling.

Violence and the epilepsy defense

The essence of the epilepsy defense is the argument that a crime was committed as a result of the perpetrator having epilepsy, and thus that he or she should not be held responsible for a violent crime. Neurologists are frequently asked to pass judgment regarding whether an alleged act may have been the result of an epileptic condition; therefore, neurologists should be informed as to what criteria should be used to decide if a given act was, or could have been, the result of an epileptic seizure. This article discusses three cases where epilepsy is used as the defense argument. In addition, this article reviews types of epileptic seizures, syncopal events, and pseudoseizures.

Case study: neurological brain waves causing serious behavioral brainstorms

A case highlighting the association of epilepsy with psychopathology is reported. The patient suffered a rare and extreme behavioral disturbance, characterized by persistent disruptive behavior and intermittent bizarre and violent outbursts. These outbursts often appeared purposeful, but some of them were later diagnosed as ictal manifestations of temporal lobe epilepsy. Temporal lobectomy resulted in remission both of the epilepsy and of the more persistent behavioral disturbance. lctal behavioral change was masked by interictal behavioral disturbance, leading to delayed diagnosis and prolonged psychosocial dysfunction. It is important to record the paroxysmal abnormal behavior with simultaneous electroencephalographic recording if there is a suspicion of organic disease. Physical and psychosocial factors in the relationship between epilepsy and extreme psychiatric disturbance are considered. This case demonstrates how successful epilepsy treatment may produce amelioration of associated psychiatric disturbance.

On Morel's 'épilepsie larvée: the first Danish epileptologist Frederik Hallager's opposition in 1884 against Morel's psychical epileptic equivalents

In 1860 B. A. Morel published some cases of masked epilepsy, i.e., paroxysmal behaviour disturbances or "epileptic equivalents". The majority behaved criminally. Hughlings Jackson opposed and Hallager showed that all the cases related later as épilepsie larvée could be explained as postepileptic attacks, general paralysis, paradoxical normalization, schizophrenia, mania and otherwise. True criminal behaviour was exceptional. The present author agreed. There is no need for épilepsie larvée. It is discussed whether Blumer's recent "Paroxystic neurobehaviour disorder" will revive "Morel's disorder".

Images of epilepsy in literature

Literature primarily reflects and affirms existing attitudes and conceptions regarding the epilepsy population. In the fiction of many nations for many centuries, individuals with epilepsy have emerged as evil or saintly, as geniuses, or as objects of pity whose lives were not worth living. The character who had epilepsy was outside the realm of personal identification--too far beneath or too far above us. Nevertheless, there were exceptions. Literature, as well as film and television, especially in the last 2 decades, has shown both readers and audiences that there are human beings who have epilepsy (rather than who are epileptics). These human beings are simply part of the continuum of what we know as normal: no more and no less than merely human.

Intensive neurodiagnostic monitoring in psychiatry

A series of technological advances have made it possible to closely monitor electrophysiological and behavioural manifestations of episodic clinical events over prolonged periods of time, with the ability to review the records at leisure or to submit them to computer analysis. The more promising techniques are time-locked video/EEG monitoring, cable telemetry, radiotelemetry, ambulatory cassette recording, intensive plasma anti-epileptic drug monitoring and continuous neuropsychological monitoring. The greatest promise of these techniques is for the diagnosis, research and management of epilepsy. For psychiatry, they offer additional help in the differential diagnosis of non-epileptic events from epilepsy, the most important of which are psychogenic seizures and episodes of aggression. This paper discusses the potential role of these techniques in the assessment of non-epileptic events and transient cognitive impairment in clinical psychiatry.

A review of the pharmacotherapy of aggression in children and adolescents

Aggressive behavior in children and adolescents is a heterogeneous phenomenon occurring in a wide variety of illnesses. No single etiologic model seems adequate to explain this phenomenon. In many cases, pharmacotherapy may prove to be a useful adjunct to treatment. Potentially useful medications are described in reference to psychiatric diagnosis. Pharmacological treatment can be helpful in the management of the aggressive youth when judiciously applied in the context of a comprehensive treatment plan.

The dangerous agitated patient. What to do right now

Short-term management of the agitated patient involves the use of psychological, behavioral, diagnostic, and pharmacologic options. Knowledge of verbal interventions may help physicians prevent personal injury and destruction of property. Accurate diagnosis allows safe and effective pharmacologic intervention. Involuntary treatment in emergency situations is legal; however, clearly documenting all clinical events is essential.

Automatism, medicine and the law

The law on automatism is undergoing change. For some time there has been a conflict between the medical and the legal views. The medical profession believes that the present division between sane and insane automatism makes little medical sense. Insane automatism is due to an internal factor, that is, a disease of the brain, while sane automatism is due to an external factor, such as a blow on the head or an injection of a drug. This leads to the situation where, for example, the hypoglycaemia resulting from injected insulin would be sane automatism, while hypoglycaemia while results from an islet tumour would be insane automatism. This would not matter if the consequences were the same. However, sane automatism leads to an acquittal, whereas insane automatism leads to committal to a secure mental hospital. This article traces the development of the concept of automatism in the 1950s to the present time, and looks at the anomalies in the law as it now stands. It considers the medical conditions of, and the law relating to, epilepsy, alcohol and drug automatism, hypoglycaemic automatisms, transient global amnesia, and hysterical automatisms. Sleep automatisms, and offences committed during a somnambulistic automatism, are also discussed in detail. The article also examines the need of the Courts to be provided with expert evidence and the role that the qualified medical practitioner should take. It clarifies the various points which medical practitioners should consider when assessing whether a defence of automatism is justified on medical grounds, and in seeking to establish such a defence. The present law is unsatisfactory, as it does not allow any discretion in sentencing on the part of the judge once a verdict of not guilty by virtue of insane automatism has been passed. The judge must sentence the defendant to detention in a secure mental hospital. This would certainly be satisfactory where violent crimes have been committed. However, it is inappropriate in many cases where non-violent confusional crimes, such as petty larceny, have been committed. Suggestions are made for desirable changes in the law.

Subtypes of limbic system dysfunction evoking homicide in limbic (?) Psychotic trigger reaction and temporal lobe epilepsy--evolutionary constraints

Within an evolutionary context two subtypes of limbic system dysfunctioning are compared: (1) the previously proposed limbic psychotic trigger reaction, in which nondrive motivated homicide is triggered by a specific individualized external stimulus, which evokes a brief-lasting active reliving of past (moderately) stressful, frequently repeated ("kindled"?) situations. The brief-lasting out-of-character homicidal episode with flat affect is typically associated with first-time formed or unformed hallucinations of various modalities and with overactivation of the autonomic nervous system. There is no (noticeable) loss of consciousness, enabling the patient's full recall (at times with suicidal attempts) (Pontius, 1981, 1984, 1987). (2) A rare case of homicide during a fugue state with echopraxia in temporal lobe epilepsy is discussed.

Epilepsy and violence

Epileptic automatism and violence are seldom found among temporal lobe epileptics. The case of a 19-year-old girl who killed a 20-month-old child during an epileptic attack is described, and the literature and medico-legal issues are briefly reviewed.

Epilepsy and arson

A man temporarily developed an organic personality change, psychosis and epilepsy after a frontal lobe operation for a subarachnoid haemorrhage. While affected, he set fire to his house. The arson is thought to have been a direct result of a seizure. The case and its legal management are discussed.

Partial seizures in children: clinical features, medical treatment, and surgical considerations

Partial seizures are not uncommon in children. They are classified into two types: simple partial, without impairment of consciousness, and complex partial, with impaired consciousness. For both types, the hallmark is onset of the seizure from a portion of one cerebral hemisphere, as indicated by focal spikes or sharp waves on EEG. The symptoms of simple partial seizures may include focal motor or somatosensory phenomena, special sensory phenomena, autonomic symptoms, or psychic symptoms, and these symptoms may occur alone or they may progress into a complex partial seizure with alteration of consciousness. The complex partial phase may include simply an arrest of ongoing activity with altered awareness and a blank empty stare, or there may also be automatisms, including movements which are gestural, alimentary, mimicking, verbal, or ambulatory. Automatisms are predominantly seen in complex partial seizures arising from temporal areas, but they also may be seen in seizures with extratemporal onset. If the epileptic discharge spreads throughout both cerebral hemispheres, the child will have a secondarily generalized tonic-clonic convulsion. EEG should be performed in any child who is suspected of having partial seizures. If there are focal spikes or sharp waves, then there is strong supportive evidence for a diagnosis of partial seizures in the proper clinical setting. It should be remembered, however, that a normal routine EEG cannot be used to "rule out" a diagnosis of epilepsy in patients who have episodes that sound like simple or complex partial seizures. An underlying etiology may be found in a significant percentage of children with partial seizures. Most of these etiologies are static, and the seizures are the result of a previous cerebral insult, but some patients may have slow-growing gliomas or other mass lesions. MRI or CT is indicated in essentially any child with partial seizures. Medical treatment is based on the idea of using single drugs to maximally tolerated doses, if needed, before beginning with two-drug regimens. If the child continues to have seizures despite aggressive trials of medication, then it is important to consider epilepsy surgery, either temporal lobectomy or other cortical resection. When children are identified as candidates for epilepsy surgery, they should be referred to specialized centers for further testing.(ABSTRACT TRUNCATED AT 400 WORDS)

Psychosocial dimensions of epilepsy: a review of the literature

The literature on psychosocial dimensions of epilepsy has been reviewed utilizing the framework developed by Dodrill et al. (Epilepsia 1980; 21:123-35). Factors considered were family background, emotional adjustment, interpersonal adjustment, vocational adjustment, financial status, adjustment to seizures, and medicine and medical management. The published studies highlighted a number of issues and sometimes rendered varying and contradictory conclusions. In general, epilepsy fosters certain reactions in family members. If negative, these reactions may be detrimental to the person with epilepsy. The association between specific emotional adjustment factors and epilepsy is not conclusive. Studies have been published which support as well as refute this association. Studies indicate that persons with epilepsy experience lower rates of marriage and more sexual difficulties than do nonepileptic persons. Studies report greater unemployment and underemployment in epileptic persons than in the population at large. Studies suggest that some persons with epilepsy manifest an attitude of nonacceptance of self. Some are reluctant to disclose their disability to others. The studies also indicate the presence of a discriminatory attitude by some nonepileptic persons toward epileptic persons. Several factors are associated with successful medical management of epilepsy. The emphasis in research studies with regard to psychosocial aspects of epilepsy focuses predominantly on individual deficiencies rather than on strengths and abilities.

Legal implications of epilepsy

Physicians who care for patients with epilepsy may function as agents or targets of social control. As agents, they may assist in the identification and control of epileptic drivers, may provide information that enables fair and appropriate job placements for epileptic persons, and give testimony that helps the legal system resolve issues relating to the liability of epileptic persons for harm attributed to seizures or interictal behavioral disturbances. As targets, they may be charged with negligent failure to diagnose, treat, or inform about epilepsy or its associated problems, with failure to exercise due care in protecting persons harmed by their patients, or with failure to preserve confidentiality of medical information. Although legislation and judicial decisions have defined some of the physician's legal duties with reasonable clarity, areas of uncertainty remain, particularly regarding the issue of violating medical confidentiality for the benefit of persons other than the patient.

The aetiology of aggression in temporal-lobe epilepsy

A retrospective case-note survey was carried out on 31 subjects admitted with temporal-lobe epilepsy to the Maudsley hospital from 1974-1983 inclusive. Fourteen aggressive subjects were compared with the non-aggressive patients on 95 organic, developmental, and social variables. Aggressive behaviour was associated with male sex, early onset of seizures, and a history of long-standing behavioural problems. Aggressive subjects had lower mean IQ scores and poorer occupational records than controls. No relationship was found between aggression and the presence of specific EEG or CAT scan findings, or a history of psychosis. The results demonstrate the complex interplay between organic and socially mediated factors underlying aggressive behaviour in temporal-lobe epilepsy.

An approach to the neurology of aggression

Aggressive behavior is controlled at multiple anatomical levels within the human brain. To illustrate hierarchical neural controls over aggression, we compare and contrast the roles of the hypothalamus, amygdaloid complex, and orbital prefrontal cortex in terms of their distinctive sensory inputs, effector channels, and principles of integration as deduced from observations in animals and man. We illustrate characteristic syndromes of human aggression resulting from hypothalamic, temporolimbic, or frontal cortical lesions. The application of this perspective to research on criminal violence is discussed.

The Berserker/Blind Rage syndrome as a potentially new diagnostic category for the DSM-III

It is proposed that a new type of disorder be incorporated in the DSM-III under the category of Dissociative Disorders. The disorder, the Berkserker/Blind Rage Syndrome is characterized by (a) violent overreaction to physical, verbal, or visual insult, (b) amnesia during the actual period of violence, (c) abnormally great strength, (d) specifically target-oriented violence. Some case studies are presented for illustration and a parallel is made with the Viking Berserkers of the Middle Ages.

Epilepsy and violence: medical and legal issues

A possible relationship between epilepsy and violence has been debated for over a century. The debate has taken on new importance because of the increasing use of the "epilepsy defense" in criminal cases. In this review the following issues are addressed: (1) Is epilepsy more common among violent criminals and patients? (2) Is violence more common among epileptics? (3) Can directed violence or aggression occur as part of an epileptic seizure? (4) What medical and legal criteria should be used to determine whether a specific violent crime was the result of an epileptic seizure? Answers to these questions may be summarized as follows. (1) There is a two- to fourfold greater prevalence of epilepsy in prisoners than in control populations, but the prevalence is similar to the prevalence in other lower socioeconomic populations from which most prisoners come. There is no greater prevalence of epilepsy in persons convicted of violent crimes than in other prisoners matched as controls. (2) There is no evidence that violence is more common among epileptics than among non-epileptics, and no evidence that violence is more common in patients with temporal lobe epilepsy than in those with other types of epilepsy. (3) Ictal violence is rare, and when it does occur usually takes the form of "resistive violence" as the result of physical restraint at the end of a seizure, while the patient is still confused. Violence early in a seizure is extremely rare, stereotyped, and never supported by consecutive series of purposeful movements. (4) Five criteria should be used to determine if a specific violent act was the result of an epileptic seizure: a. the diagnosis of epilepsy should be established by a neurologist with special competence in epilepsy; b. the presence of epileptic automatisms should be documented by the case history and closed-circuit TV-EEG; c. aggression during epileptic automatisms should be documented on closed-circuit TV-EEG; d. the aggressive act should be characteristic of the patient's habitual seizures; and e. a clinical judgment should be made by the neurologist as to the possibility that the violent act was part of a seizure.

Effects of experimental temporal lobe seizures upon hypothalamically elicited aggressive behavior in the cat

An experiment was performed in order to determine the effects of temporal lobe seizures upon hypothalamically elicited aggressive behavior in the cat. Seizures were induced by electrical stimulation of the pyriform cortex or those subnuclei of the amygdala which had previously been shown to modulate aggressive responses at subseizure current levels. The results clearly indicate that a significant modification of affective defense thresholds following seizures was a direct function of the locus of stimulation. Specifically, seizures generated from the pyriform cortex and medial aspects of the amygdala (sites associated with prior facilitation of affective defense as determined by subseizure electrical stimulation) were followed by a reduction in threshold for this response. In contrast, an elevation in affective defense thresholds occurred when seizures were generated from the central or lateral nuclei of the amygdala (sites associated with prior suppression of affective defense as determined by subseizure electrical stimulation). The primary pathway utilized in the facilitation of affective defense appears to involve the stria terminalis, its bed nucleus, and the anterior medial hypothalamus. Preliminary data suggest that seizures generated from the pyriform cortex or amygdala can also modify quiet biting attack behavior, but in a manner opposite to that demonstrated for affective defense.

Biopsychosocial characteristics of children who later murder: a prospective study

The authors document the childhood neuropsychiatric and family characteristics of nine male subjects who were clinically evaluated as adolescents and were later arrested for murder. Those subjects are compared with 24 incarcerated delinquents who did not go on to commit violent offenses. The future murderers displayed a constellation of biopsychosocial characteristics that included psychotic symptoms, major neurological impairment, a psychotic first-degree relative, violent acts during childhood, and severe physical abuse. The authors relate this combination of factors to prediction of violence and discuss ethical issues that are involved in intervention to prevent violence.

The success of EEG in confirming epilepsy--revisited

This study was designed to re-examine the question of how sensitive the first EEG is in confirming a definite seizure disorder. Patients (358) with a diagnosis of "epilepsy" were randomly selected and their EEGs reviewed. An abnormal EEG was found in 84% (epileptiform paroxysms in 77-82%), while 16% had a normal tracing. However, after careful review with up to 7 years of follow-up, slightly more than 1/2 of those with a normal EEG did not actually have epilepsy, 1/4 did and in the remaining 1/4 insufficient information was available for a definite diagnosis. The incidence of normal records among patients with definite epilepsy then fell to 4.7%. With the evaluation of additional patients with "epilepsy" and a normal EEG (200), a similar distribution was found. The final diagnosis for the group without seizures was a behavioral-psychiatric condition in 1/4, syncope in 1/5 and pseudoseizure in 1/6.

Metabolic and behavioral consequences of lidocaine-kindled seizures

Daily administration of lidocaine results in progressive increases in frequency and duration of convulsions in response to a dose of drug which was previously subconvulsive--a pharmacological kindling phenomenon. The effects of such lidocaine-kindling on local cerebral glucose utilization were determined by the 2-[14C]deoxyglucose method. Lidocaine-treated animals, in the absence of convulsions, exhibited decreased glucose utilization in most brain structures compared to saline-treated animals and showed no increase in aggressive behavior. In animals displaying lidocaine-kindled convulsions there were marked increases in glucose utilization in either the hippocampus and amygdala or in perirhinal cortical areas during the seizure administration; these animals also displayed long-lasting increases in irritable behavior. Seizure duration was positively correlated with the rate of glucose utilization in the hippocampus, amygdala and septum, but inversely correlated in several non-limbic areas. These data suggest that lidocaine-kindled seizures are highly localized to limbic and perirhinal structures and are associated with important behavioral consequences.