Epileptic homocide: a case report

Epilepsy, violence, and crime. A historical analysis

In the 19th and early 20th century, epilepsy was one of the most investigated disorders in forensic psychiatry and psychology. The possible subsidiary symptoms of epilepsy (such as temporal confusion, alterations of consciousness, or increased aggression) played pivotal roles in early forensic and criminal psychological theories that aimed to underscore the problematic medical, social and legal status of epileptic criminals. These criminals were considered extremely violent and capable of committing sudden, brutal acts. Although the theory of "epileptic criminality" was refuted due to 20th-century developments in medicine, forensic psychiatry, and criminal psychology, some suppositions related to the concept of epileptic personality have lingered. This paper explores the lasting influence of the theory of epileptic personality by examining the evolution of the theories of epileptic criminality both in the international and the Hungarian context. Specifically, it calls attention to the twentieth-century revival of the theory of epileptic personality in the works of Leopold Szondi, István Benedek and Norman Geschwind. The paper shows that the issue of epileptic personality still lingers in neuropsychology. In doing so, biological reductionist trends in medical-psychological thinking are traced, and attention is drawn to questions that arise due to changing cultural and medical representations.

Epilepsy and homicide

PURPOSE

We report the rare case of a patient with intractable epilepsy and escalating aggression, resulting in murder, who had complete resolution of her seizures and explosive behavior following a right temporal lobectomy.

PATIENTS AND METHODS

We searched the available literature from 1880 to 2013 for cases of epilepsy being used as a court defense for murder and collected information regarding the final sentencing outcomes. We selected 15 papers with a total of 50 homicides.

RESULTS

We describe the case of a 47-year-old woman with drug-resistant right temporal epilepsy who developed increasing emotional lability, outbursts of anger and escalating violent behavior culminating in a violent murder. The patient was imprisoned while awaiting trial. In the interim, she underwent a successful temporal lobectomy with full resolution of seizures, interictal rage and aggressive behaviors. After the surgery, her charges were downgraded and she was transferred to a psychiatric facility.

CONCLUSION

The aggressive behavior associated with epilepsy has been described in the literature for over a century. A link between epilepsy and aggression has been disproportionally emphasized. These patients share some common characteristics: they are usually young men with a long history of epilepsy and lower than average intelligence. The violent act is postictal, sudden-onset, more likely to occur after a cluster of seizures and is usually related with alcohol abuse.

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.

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.

Hughlings Jackson's Dr Z: the paradigm of temporal lobe epilepsy revealed

On 10 January 1894, a distinguished physician died in London of an overdose of chloral hydrate. The event was of vital interest to Hughlings Jackson who attended the post-mortem examination with a bevy of witnesses. He begged his colleague Walter Colman "to search the taste region of Ferrier on each half of the brain very carefully." They were rewarded by finding " a very small focus of softening in that region (in the uncinate gyrus) of the left half of the brain." Jackson had thus discovered the most discrete and circumscribed lesion of the temporal lobe yet described to assoicate with the most detailed and elegant self report of psychomotor epilepsy yet published. For the physician, whom Jackson and Colman called "Dr Z" in their report in Brain(2) had been Jackson's patient since 1877 and his own account of his epileptic experience had occupied six pages of Jackson's 1888 article "On a particular variety of epilepsy...."(7) Jackson had himself witnessed several of Dr Z's attacks. The case enabled Jackson to argue that the complex symptomatology of the seizure was due to "reflex" effects of epileptic discharges in that area of brain. It is the paradigm of temporal lobe epilepsy.

A case of insane automatism?

Epileptic automatism is now believed to be a rare disorder, and only a very small number of cases have been described (Knox, 1968; Gunn and Fenton, 1971; and Gunn, 1978) in which aggressive behaviour has occurred during automatism. There are important legal issues involved if a serious crime is committed and insane automatism is given as the defence.