Ictal aggression is very rare.^36,66 Delgardo-Escueta et al. found an incidence of about 1 in 1,000 seizures with ictal aggression in a large survey of several thousand seizures documented by video-telemetry.¹⁸ However, it can be argued that as such, looking for ictal aggression in the context of the tightly controlled arena of an electroencephalogram (EEG) suite is not going to provide a true view on the frequency of the problem. This is because patients with aggressive episodes are less likely to be accepted for evaluation, and such episodes of aggressive release are more likely to occur in a community rather than a laboratory setting. In ictal aggression, hostile and verbal or physical aggressive behavior is often directed toward nearby objects or persons and may or may not be provoked.²⁷ The patients are generally amnesic for these aggressive episodes and often express remorse or feelings of shame for their behavior after the event.^19,28

Postictal aggression is more common than ictal aggression and, although it is still believed to be rare, it may be under-recognized and unreported.⁷⁷ Postictal aggressive behavior usually follows a cluster of complex partial seizures or secondary generalized seizures in patients in whom such episodes are not the usually expression of their epilepsy. Some evidence points to ictal pain or dysphoria as predisposing factors for the later development of postictal aggressive behaviour.³² If the episode occurs in the context of a postictal confusional state, poorly structured aggressive behavior is not that rare. This aggression is poorly directed, and the patient, rather than someone who is attacked, is most likely to come to harm. If postictal aggression is part of a postictal confusional state, the disruptive behavior immediately follows the seizure without a lucid interval intervening between the ictus and the outbreak of the disruptive behavior. In this state, patients are often resistive, but within their confusion can be very aroused, angry, and fearful.^41,46

Postictal psychosis typically follows a cluster of complex partial or secondary generalized seizures in patients with longstanding chronic and often therapy-refractory epilepsy. Generally these states follow a lucid interval—the calm before
the storm—which might last anywhere between hours and days up to 1 week. Observers may notice an insidious onset of affective symptoms with arousal, restlessness, agitation, and often anxiety, fear, and anger, although the behavioral state can erupt quite suddenly. Subsequently, overt psychotic symptoms with delusions and hallucinations might follow. The latter might be accompanied by aggressive behavior that sometimes is very dramatic and dangerous.^29,40,49,78 Although aggressive behavior in the context of a delusional state is often rather disorganized if there is some clouding of consciousness, this is not necessarily the case. Over 50% of patients with postictal psychotic states have minimal or no such associated confusion, and aggressive behavior can be well-structured and goal-directed. Patients often feel angry and aroused, although they may appear calm and concentrated to the observer.^41,72

Kanemoto et al. make the important observation that well-directed and self-destructive behavior might even be a hallmark of postictal psychosis.⁴¹ The psychosis may be missed, either because it is not probed for, or because the behavior is such that it is not possible to obtain a good mental state evaluation. The latter is the more problematic in those with learning disabilities. The aggressive behavior might then be structured and goal-directed, but without any obvious sign of delusions or hallucinations.^41,46,72 The awareness of the problem of postictal psychoses and associated aggressive behavior is of particular importance for epilepsy-monitoring centers because, in this context, many patients with chronic therapy-refractory epilepsy are seen and diagnosed following an acute reduction of their medication for diagnostic purposes. If a history of previous postictal events exists, doctors should be aware of the risk of postictal psychosis and aggression, and should closely monitor the behavior of these patients. Outbursts of aggression, especially with psychotic intensity, are dangerous not only for the patients but also the nurses and attending physicians themselves.

Interictal aggressions are the most common, but generally less dramatic forms of aggressive behaviors in patients with epilepsy. These can be seen in the context of an antisocial personality disorder which, in turn, might be the consequence of the sometimes difficult psychosocial background and upbringing of patients with epilepsy, Or it might be part of a prolonged psychotic episode, an interictal affective disorder, or a psychosis of a paranoid- or schizophrenia-like type.^49,41

In patients with epilepsy and mental handicap, interictal aggression is a common management problem. In these patients, the aggressive behavior is often the result of poor social and communication competence in expressing personal needs and rarely results in severe violence.³⁷

An interictal syndrome of episodic affective aggression, independent of observable ictal activity, major psychiatric disorder, or antisocial personality disorder, is well described and has been referred to as episodic dyscontrol or IED.^{4,23,47,52,64,71} Episodic dyscontrol is characterized by several discrete epi- sodes of extreme arousal and rage that are out of proportion to any precipitating psychosocial stressor, but that result in severe aggressive and violent behavior. As mentioned earlier, this form of possible epilepsy-related aggression has been described and discussed in Chapter 283.