Seizures

1
Seizures
2

• The EEG is most useful in diagnosing and
  categorizing seizures. During a seizure (ictus),
  paroxysmal EEG activity may arise from either
  normal or abnormal background activity.
  Paroxysms, a sudden intensification of symptoms,
  usually consist of bursts of spikes, slow waves,
  or complexes of both.

3

• An EEG should ideally be recorded during the
  ictus, but seizures rarely occur during routine
  recordings. When they do, EEGs may be obscured
  by muscle movement artifacts. The EEGs obtained
  immediately after the seizure, in the postictal
  period, generally show only slow, low voltage
  activity, called postictal depression.

4

• Fortunately, EEGs obtained between seizures, in
  the interictal period, contain specific
  abnormalities that suffice for definitive
  diagnosis in up to 80 percent of cases. On the
  other hand, since about 20 percent of epilepsy
  patients have essentially normal routine EEGs,
  normal interictal EEGs do not exclude a diagnosis
  of seizures.

5

• Several maneuvers are used to evoke diagnostic
  EEG abnormalities in suspected cases. Patients
  are usually asked to hyperventilate for about 3
  minutes or to look directly into a stroboscopic
  light during the EEG. If these maneuvers do not
  yield diagnostic information and if a strong
  suspicion of seizures persists, an EEG is
  performed after sleep deprivation. In about one
  third of epileptic patients, this EEG reveals
  abnormalities not apparent from routine studies.

6

• The EEG is also useful in diagnosing the
  locked-in syndrome, in which people who have
  sustained pontine or medullary infarctions are
  alert but cannot speak or move their trunk or
  limbs. Since the cerebrum and upper brainstem
  are normal, these otherwise devastated people
  have normal cerebral activity, including
  cognitive function, and therefore a normal EEG.

7

• Patients with the locked-in syndrome must be
  differentiated from ones in a persistent
  vegetative state, a condition that typically
  follows cerebral anoxia from cardiac arrest, drug
  overdose, or carbon monoxide poisoning. These
  patients have marked cerebral cortex injury and
  thus profound dementia accompanied by an
  inability to speak or move. As would be expected
  from their extensive cerebral damage and mental
  as well as physical incapacity, they have a
  markedly abnormal EEG.

8

• Most seizures and varieties of epilepsy are
  classified either as partial, with either
  elementary (simple) or complex symptoms, or as
  generalized, usually absences or tonic-clonic.
  Partial seizures originate from paroxysmal
  electrical discharges in a focus, a discrete
  region of the cerebral cortex usually injured by
  a structural lesion.

9
Seizure Disorders

• Important distinguishing points between types of
  seizures Partial, having a defined focus in the
  brain to which the seizure is limited Vs.
  Generalized, widespread, most of the brain
  becomes involved in the seizure
• Simple, producing an alteration in consciousness
  Vs. Complex, producing a loss of consciousness
• Not all seizures produce a convulsion a
  convulsion involving the skeletal muscles will
  only occur if motor areas of the brain are
  involved in the seizure.

10

• In general, partial seizures with motor symptoms
  have their focus in the contralateral frontal
  lobe those with sensory symptoms, in the
  parietal lobe those with visual symptoms, in the
  occipital or temporal lobe and those with
  auditory symptoms, in the temporal lobe.

11

• During and between partial seizures, the EEG
  typically shows abnormalities in channels
  overlying the particular focus. Since neither
  the entire cortex nor deep structures are
  involved when seizures begin, or often throughout
  their entire course, consciousness is preserved.

12
A grand mal (big, bad) seizure is a complex,
generalized seizure, with convulsions. The
seizure is often preceded by subjective symptoms
of an aura. The aura symptoms result from
initial activity at a focal site. These symptoms
can be sensory, as in a foul smell or taste,
seeing flashes of light, etc., emotional as in
reports of feelings of euphoria or panic. The
symptoms of the aura reflect the focal point in
the brain in sensory cortex, limbic system, etc.
13
The actual onset of the grand mal is the tonic
phase in which the persons skeletal muscles
forcefully contract and the person typically
makes a vocal outburst as air is forced from the
lungs. The tonic phase can last 15 seconds (or
more) and then is replaced with the clonic phase
in which the muscle groups contract jerkily,
relax and contract again in a convulsion. The
tonic phase involves the motor cortex firing
continuously. The tonic phase involves
subcortical structures inhibiting the former
activity.
14

• Although partial seizures usually last between
  several seconds and several minutes, occasionally
  they continue for hours or days while the
  discharge remains confined to its original focus.
  In such cases, called epilepsy partialis
  continua or focal status epilepticus, symptoms
  persist and interfere with normal activity, but
  routine activity can also continue despite the
  seizure.

15

• More often, discharges become more extensive and,
  enlarging in a slow, brushfire-like manner,
  involve adjacent areas of the cortex and create
  additional symptoms. Discharges can also spread
  over the entire cortex or travel through the
  corpus callosum to the other cerebral hemisphere.
  If the entire cerebral cortex is engulfed,
  secondary generalization, patients lose
  consciousness, develop bilateral motor activity,
  and have generalized EEG abnormalities.

16
Other Seizures...
Other less dramatic seizures may involve a
convulsion which spreads from muscle group to
muscle group as the seizure spreads along the
precentral gyrus, producing a Jacksonian march
after a famous neurologist. Complex movements
can occur involuntarily in other seizures in
which a person may walk away in an unresponsive
state or engage in habitual behaviors termed
automatisms.
17
Other Seizures...
A petit mal seizure will likely just produce an
alteration in consciousness or an absence spell
in a child who appears to stare blankly, spacing
out and being unresponsive for a few
seconds. Other such simple partial seizures can
produce alterations in the behaviors composing a
personality, possibly producing self-reports of
having very different memories, emotions,
etc. Seizure activity results from uninhibited
excitatory brain activity the excessive
glutamate released in seizures and be toxic to
neurons. Brain damage can be likely in the
hippocampus from this excitotoxicity.
18

• In contrast to partial seizures, discharges in
  generalized seizures arise from the thalamus or
  other subcortical structures and immediately
  spread upward to the entire cerebral cortex.
  Also, generalized seizures are usually caused by
  a genetic disorder or metabolic aberration. Most
  important, they are characterized by
  unconsciousness and generalized EEG
  abnormalities, although not necessarily by gross
  motor activity. Like partial seizures,
  generalized seizures can persist, in which cases
  they are a life-threatening condition called
  generalized status epilepticus.

19
Partial Seizures
20

• Partial seizures are said to have elementary
  symptoms when their clinical manifestation is
  only a particular movement, a single sensation,
  or a simple phenomenon. However, an impaired
  consciousness, with or without psychological
  abnormalities or coordinated motor activity,
  denotes complex symptoms.

21

• Seizures with elementary motor symptoms, formerly
  called focal motor seizures, usually consist of
  rhythmic jerking (clonic movement) of a body part
  that may be as limited as one finger or as
  extensive as an entire side. These seizures can
  develop into focal status epilepticus or undergo
  secondary generalization. Sometimes, in a
  jacksonian march, a seizure discharge spreads
  along the motor cortex, and movements that began
  in a finger extend to the entire arm and, then,
  to the face.

22

• After any partial motor seizure, affected muscles
  may be weakened. A post-itcal monoparesis or
  (Todds) hemiparesis may remain for up to 24
  hours. Thus, the differential diagnosis of
  transient hemiparesis includes transient ischemic
  attacks (TIAs), hemiplegic migraines,
  psychologialc aberrations, and Todds hemiparesis.

23

• Seizures with elementary sensory symptoms usually
  consist of tingling or burning paresthesias in
  regions of the body that have extensive cortical
  representation, such as the face. Sometimes a
  sensory loss, a negative symptom, might be the
  seizures only manifestation.

24
Partial elementary seizures with special
sensory symptoms, consisting of specific but
simple auditory, visual, or olfactory sensations,
can also occur. Most important, sensory seizures
can create vivid and realistic sensations best
described as hallucinations however, they are
almost always recognized by patients as being the
result of cerebral dysfunction, rather than real
events.
25

• Auditory symptoms are usually repetitive noises,
  musical notes, or single words that have no
  meaning. Visual symptoms usually are seen as
  bright lines, spots, or splotches of color that
  move slowly across the visual field or, like a
  view through a kaleidoscope, as stars rotating
  around the center of vision.

26

• Elaborate visual phenomena alone or combined with
  auditory or emotional symptoms, in contrast, are
  complex symptoms that must be differentiated
  from these and other visual hallucinations.
  Olfactory symptoms usually consist of vaguely
  recognizable smells, such as the most frequent
  one, burning rubber. Since olfactory
  hallucinations usually result from discharges in
  the anterior inferior tip of the temporal lobe,
  the uncus, partial seizures with olfactory
  symptoms are often called uncinate seizures or
  fits. Typically, as discharges spread from the
  incus to involve larger areas of the temporal
  lobe, partial complex seizures ensue.

27
Partial Complex Seizures
28

• Partial complex seizures begin between late
  childhood and the early thirties and are the
  single most frequent seizure variety, affecting
  about 65 percent of epilepsy patients. Many old
  studies of psychiatric disorders are misleading
  because they did not acknowledge the
  preponderance of patients who had partial complex
  seizures, and they also relied upon patients
  descriptions of nonspecific sensations and
  without EEG correlation.

29

• Current studies, which use telemetry, have
  defined ictal and postictal seizure
  manifestations and separated them from nonseizure
  disturbances. Nevertheless, several issues about
  partial complex seizures remain unsettled. A
  major one is the genuineness of the broad range
  of purported ictal symptoms, including violence.
  Another is the relationship between partial
  complex epilepsy and interictal mental
  abnormalities, such as personality disorders,
  psychosis, and cognitive impairment.

30

• In the past, less cumbersome but less accurate
  titles, psychomotor seizures and temporal lobe
  seizures or epilepsy (TLE), have been used. The
  term psychomotor seizures is properly applied
  only to the rare variety of partial complex
  seizures with exclusively behavioral
  abnormalities. Likewise, TLE is inappropriate
  because the seizures originate in the frontal and
  other lobes rather than in the temporal lobe in
  about 10 percent of cases, leaving this term at
  risk of contradicting the location of the focus
  of the seizures. TLE is also inconsistent with
  the current classification of seizures based on
  symptoms, rather than anatomic origin.

31

• As for symptoms of partial complex seizures,
  about 10 percent of patients have a premonitory
  sensation, an aura, which is not only a warning
  it is actually the first part of the seizure.
  During most of the seizure, patients usually have
  only a blank stare and are inattentive and
  uncommunicative. They always (by definition)
  have impaired consciousness.

32

• In most cases, they have memory impairment or
  total loss, amnesia, presumably because the
  limbic system in the temporal lobe is beset with
  seizure discharges. Since the amnesia is so
  striking, it may appear to be a patients only
  symptom. (Therefore, partial complex seizures
  must be strongly considered among the neurologic
  causes of the acute amnestic syndrome).

33

• Usually the only physical sign of partial complex
  seizures is automatisms, which are simple,
  repetitive, and purposeless face or hand
  movements, such as swallowing, kissing, and lip
  smacking, or fumbling, scratching, and rubbing
  the abdomen. Automatisms are present in more
  than 80 percent of complex seizures and occur
  more frequently than psychological aberrations.

34

• Patients may sometimes assume postures of perform
  simple activities, such as standing, walking,
  pacing, or even driving. It is often unclear,
  however, whether these usually rote activities
  are manifestations of a seizure or are naturally
  occurring actions that have persisted despite the
  seizure.

35

• Likewise, in about 25 percent of cases, patients
  utter brief phrases or mutter unintelligibly.
  Many time the actions and words are cued by the
  environment. For example, a child with a partial
  complex seizure may clutch and continually stroke
  a nearby stuffed animal while repeating some
  endearing word. What would distinguish this
  activity from normal would be the childs
  impaired consciousness, apparent self-absorption,
  and subsequent failure to recall the event.

36

• Symptoms might occasionally be complex visual or
  auditory hallucinations accompanied by an
  appropriate emotion. Special sensory phenomena
  that are more elaborate than in partial
  elementary seizures, however, are notorious but
  rarely occurring.

37

• Although a wide variety of symptoms could be
  considered manifestations of seizures, certain
  ones cannot be accepted in isolation. In
  particular, the various experimental phenomena,
  such as déjà vu, jamais vu, dream-like states,
  mind-body dissociations, and floating feelings,
  are rarely associated with clinical or EEG
  evidence of seizures. These experimental
  phenomena are too nonspecific and have been so
  romanticized that they have virtually no
  diagnostic value when described by a well-read or
  flighty patient.

38

• Another frequent disturbance that has a dubious
  association with partial complex seizures is the
  rising epigastric sensation. This is a
  perception of a swelling in the abdomen that, as
  if progressing upward within the body, turns into
  tightness in the throat and then a feeling of
  suffocation. Although this symptom could be an
  aura, it has a striking similarity to a common
  psychogenic disturbance, globus hystericus, in
  which people also feel tightening of the throat
  and inability to breathe.

39

• Following a partial complex seizure, which
  usually has a duration of 2 to 3 minutes,
  patients typically have confusion, clouding of
  their sensorium, and a tendency to sleep. If the
  seizure involved the brains language centers,
  patients may have postictal aphasia. Also, for
  15 to 30 minutes after the seizure, at least 40
  percent of patients have a markedly elevated
  serum prolactin concentration.

40

• Another important but a decidedly uncommon
  complication of partial complex seizures is
  partial complex status epilepticus. Despite its
  prevalence in popular literature, only about two
  dozen cases have been described in neurologic
  journals, and many were not documented with
  telemetry. When this condition does occur,
  patients have 1 ½ to 24 hours of confusion that
  is sometimes accompanied by aphasia, automatisms,
  and other purposeless motor activity. Confusion
  is so pronounced that patients are incapable of
  clear thought or complicated activity, much less
  the homicidal rampages portrayed in novels.
  However, the attack may be disruptive enough to
  merit its description, ictal psychosis.

41

• Ictal Sex and Violence. In many people,
  seizure-symptoms that occur during sexual
  activity are simply the result of anxiety or
  hyperventilation. Also, although epileptic
  patients commonly fumble with buttons or tug at
  their clothing, and thus may seem to partially
  undress, true exhibitionism is extraordinarily
  rare.

42

• Nevertheless, rudimentary sexual activities, such
  as masturbation, scratching of the pubic area,
  thighs, and pelvic thrusting, do occur. For
  example, in one study, 4 of 61 patients with
  refractory partial complex seizures had such
  activity, but it was not accompanied by more
  complex sexual behavior. Only several times has
  sexual intercourse or orgasm as a seizure symptom
  been reported in the neurologic literature.

43

• The extent of ictal violence, violence as a
  manifestation of seizures, has been a major
  controversy. However, by excluding experimental
  phenomena as being equivalent to a partial
  complex seizure and relying on telemetry, several
  reliable observations have been made. Ictal
  violence occurs in less than 0.1 percent of
  seizures.

44

• In most cases of apparent violence, patients are
  only combating restraints that are placed during
  or after the seizure, i.e., resistive violence.
  When overt violence occurs, it is not
  accompanied by a major affective state, such as
  rage, and it is fragmented, unsustained, and
  neither directed nor destructive, i.e., ictal
  violence is not aggressive. It usually
  consists only of random shoving, pushing, or
  kicking, or of verbal abuse, such as screaming.

45

• It does not consist of sequences of actions with
  people or mechanical devices, such as cars or
  guns it shows no signs of premeditation. Like
  other seizures, those with violent manifestations
  are accompanied by impaired consciousness and
  usually automatisms, and they are not provoked by
  social factors, such as threats.

46

• Although almost all neurologists do not accept
  episodic violence as the sole manifestation of
  partial complex seizures, a minority have
  attributed aggressive violence to seizures.
  Likewise, possibly under medical or social
  pressures, the legal system has occasionally
  accepted such an explanation. For example, in 15
  cases described between 1889 and 1981, seizures
  have been used in appeal as a defense for murder,
  homicide, manslaughter, or disorderly conduct.

47
Interictal Mental Abnormalities
48

• Personality Changes. Some studies have found
  that patients with so-called temporal lobe
  epilepsy had distinctive personality trait
  abnormalities. They described patients as being
  hypo-sexual, humorless, circumstantial, and
  overly concerned with general philosophic
  questions, such as the order of the universe. In
  addition, those patients characteristically had
  hypergraphia, a tendency to write excessively and
  compulsively.

49

• Related older studies also suggested that
  different emotional abnormalities depended upon
  whether the seizure focus was in the right or
  left temporal lobe. Right-sided foci supposedly
  predisposed a patient to anger, sadness, and
  elation, and left-sided ones to ruminative and
  intellectual tendencies.

50

• Recent studies, often based on telemetry and
  strict methodology, have refuted many of these
  contentions. They find no distinctive
  personality traits in patients with partial
  complex epilepsy. Epileptic patients were found
  to have the same incidence of behavioral problems
  as patients with other neurologic disorders, and
  with few exceptions, patients with partial
  complex seizures were not beset with more
  behavioral problems than patients with other
  varieties of seizures.

51

• Likewise, recent evidence indicates there is no
  difference in personality traits when foci are in
  different temporal lobes, or even other brain
  areas, and there is no difference in personality
  traits among patients with different varieties of
  epilepsy. As a general rule, mental disturbances
  are associated with a history of onset of
  seizures in childhood, episodes of status
  epilepticus, and multiple seizure types use of
  two or more anticonvulsants in treatment and
  signs of brain damage on neurologic examination
  or CT or MRI scan.

52

• Crime. Another established interictal trait of
  epilepsy patients is a high incidence of crime.
  For example, among incarcerated men, the
  incidence of epilepsy is at least four times as
  great as in the general population. However,
  taking the association of crime and epilepsy at
  face value is liable to be misleading. Crimes of
  adult epileptic prisoners are no more violent
  than those of nonepileptic ones.

53

• Also, violence is no more prevalent among
  patients with partial complex seizures than among
  those with other seizures. The consensus is that
  crime does not originate in epilepsy, but that
  seizures, head trauma, and other brain injuries
  lead to conditions, such as poor impulse control
  and lower socioeconomic status, that predispose
  persons to crime.

54
Generalized Seizures
55

• Generalized seizures are characterized by an
  immediate loss of consciousness accompanied by
  symmetric, synchronous, paroxysmal EEG
  discharges. These seizures are usually the
  result of either an autosomal dominant genetic
  disorder, a physiologic disturbance, or a
  metabolic aberration, including drug and alcohol
  withdrawal. Unlike partial seizures, generalized
  seizures lack an aura, lateralized motor or
  sensory disturbances, and focal EEG
  abnormalities. Also, they practically never
  result from brain tumors, cerebral infarctions,
  or other cerebral cortex injuries. Most
  generalized seizures are of either the absence
  (petit mal) or tonic-clonic (grand mal) variety.

56
Absences

• Absence seizures usually begin between ages 4 and
  10 years and, unlike other major seizure
  varieties, usually disappear in early adulthood.
  However, in about 40 percent of patients,
  tonic-clonic seizures replace the absences.

57

• Absences, which can occur many times daily, are
  1-second to 10-second lapses in attention
  accompanied in almost all cases by automatisms,
  subtle clonic limb movements, and blinking.
  Notably, the blinking occurs rhythmically at
  3-Hz, which is the frequency of the associated
  EEG abnormality. Although children do not have
  retrograde amnesia and they maintain muscle tone
  and bladder control, their mental and physical
  activity is interrupted. After the ictus, as
  though it had never occurred, there is no
  confusion, agitation, or sleepiness.

58

• Children with unrecognized absences may be
  misdiagnosed as being inattentive or mentally
  retarded. More important, they may be
  misdiagnosed as having partial complex seizures,
  even though the two conditions can be
  differentiated. The distinction is especially
  important when, on rare occasions, absence status
  epilepticus or nonconvulsive generalized status
  epilepticus leads to a several-hour episode of
  apathy, psychomotor retardation, and confusion.
  The attack can be diagnosed only with an EEG, and
  it can usually be terminated by intravenous
  administration of diazepam (Valium). This
  condition usually develops only in children and
  young adults with a history of absences or other
  seizures who have suddenly stopped taking their
  anticonvulsants. As discussed previously, it is
  a cause of acute confusion in an epileptic
  patient.

59
Tonic-Clonic Seizures

• Tonic-clonic seizures, unlike absences, begin at
  any age after infancy, persist into adult life,
  and cause massive motor activity and profound
  postictal residual symptoms. Although patients
  may have a prodromal phase of malaise or mood
  change, tonic-clonic seizures are usually
  unheralded, explosive events. In the initial
  tonic phase, patients lose consciousness, roll
  their eyes upward, and extend their neck, trunk,
  and limbs as if to form an arch. Subsequently,
  they undergo a dramatic clonic phase in which
  their limbs, neck, and trunk are wracked by
  violent jerks.

60

• In the postictal period, which has great
  diagnostic importance, patients are usually
  confused, disoriented, and amnesic, both for the
  ictus and, in a retrograde pattern, the events
  preceding it. They may be irrational, agitated,
  and combative. Postictal behavioral
  disturbances, which can last for several hours,
  can be so striking as to be misdiagnosed as a
  functional postictal psychosis.

61

• During the tonic phase, if the superimposed
  muscle artifact can be eliminated by
  administering muscle relaxants, the EEG shows
  repetitive, increasingly greater spikes occurring
  at about 10-Hz in all channels. In the clonic
  phase, the spikes, which become less frequent but
  greater in amplitude, are interrupted by slow
  waves.

62

• Afterward, the EEG shows postictal depression.
  The postictal EEG is often the only one
  available, but it can confirm the diagnosis.
  Similarly, the EEG is also slow after ECT.
  Following either a tonic-clonic seizure or
  ECT-induced seizure, the serum prolactin level
  rises for 15 to 30 minutes in more than 80
  percent of cases. Following a pseudoseizure, in
  contrast, the EEG is relatively normal, and the
  prolactin level remains at baseline.

63

• Interictally, 20 to 30 percent of patients with
  tonic-clonic seizures have asymptomatic, brief
  bursts of spikes, polyspikes, or slow waves.
  Seizures and accompanying EEG abnormalities may
  be precipitated by photic stimulation or
  hyperventilation.

64
Disorders That Mimic Seizures
65
Pseudoseizures

• Psychogenic episodes mimicking seizures,
  pseudoseizures, are more prevalent in women,
  children, and adolescents. Like other
  psychogenic deficits, pseudoseizures are
  associated with character disorders, affective
  illness, and other major psychopathology. In
  some epileptic patients, pseudoseizures occur
  together with seizures and can be responsible for
  apparently intractable epilepsy. Therefore,
  although patients may appear to have only
  pseudoseizures, they should undergo an
  investigation for seizures, as well as a
  psychiatric evaluation.

66

• Unlike tonic-clonic seizures, pseudoseizures
  begin slowly with gradual developing flailing,
  struggling, alternating limb movements
  (out-of-phase clonic movements), and similar
  side-to-side head movements that are often
  accompanied by sexually suggestive pelvic
  thrusting. As fatigue ensues, the movements
  decline in intensity and regularity, but their
  duration is often greater than 2 minutes, which
  is much longer than a tonic-clonic seizure.
  Also, the movements usually have no tonic phase,
  and there is usually no tongue-biting, other
  bodily injury, or incontinence. Despite the
  apparent generalized nature of the pseudoseizure,
  consciousness is preserved, and subsequent
  confusion and retrograde amnesia are absent.

67

• If an EEG were obtained during a pseudoseizure
  and muscle artifact were eliminated, it would be
  normal. One performed afterward, which is more
  feasible, would not show postictal depression.
  In addition, the serum prolactin concentration,
  which is usually elevated after a generalized or
  partial complex seizure, would not rise.

68

• Pseudoseizures with a tonic-clonic appearance are
  usually a crude caricature, but ones mimicking
  partial seizures are often subtle. Patients who
  mimic partial elementary seizures usually have
  apparent memory lapses, episodes of inattention,
  visual aberrations, other subjective phenomena,
  or nonspecific sensations, such as dizziness or
  epigastric sensations.

69

• Although these symptoms could be manifestations
  of seizures, when they result from pseudoseizures
  rarely appear to include automatisms or undergo
  progression to a generalized seizure.
  Nevertheless, since partial complex seizures may
  induce bizarre thought and behavior, the clinical
  distinction in most studies is no more reliable
  than 85 to 90 percent. In difficult cases,
  long-term (several day) continuous EEG cassette
  recording, video-monitoring, or other telemetry
  is usually required to make a reliable diagnosis.

70
Episodic Dyscontrol Syndrome
71

• The episodic dyscontrol syndrome, which is
  roughly equivalent to recurrent rage attacks,
  consists almost exclusively of violent outbursts,
  for which the patient typically later claims
  total amnesia, and dysphoria. In contrast to
  violent partial complex seizures, episodic
  dyscontrol outbursts are at least momentarily
  purposeful, aggressive, and accompanied by a
  highly charged affect.

72

• The violence, which may be preceded by dysphoria,
  is senseless destructive and consists of
  screaming, punching, wrestling, and throwing
  glasses or bottles. Also unlike seizures, these
  attacks can be provoked by threats, various other
  external circumstances, and especially by alcohol
  consumption. When triggered by alcohol, they can
  be called pathologic or alcohol idiosyncratic
  intoxication.

73

• Episodic dyscontrol attacks are commonplace is
  young men with diffuse but subtle cerebral
  damage, especially as a result of either
  congenital cerebral injury or head trauma. Thus,
  these attacks are apt to occur among teen boys
  and young men with minor neurologic impediments
  and borderline intelligence, who may also have
  seizures. The coexistence of episodic dyscontrol
  syndrome and seizures is undoubtedly responsible
  for some reports of aggression in epileptic
  patients. Suggested medical treatments for
  episodic dyscontrol syndrome, in addition to
  prohibiting alcoholic beverages, have included
  stimulants, beta blockers, and anticonvulsants,
  most recently carbamazepine. However, no
  particular treatment has been proved effective.