The belief that epilepsy is linked with violent behavior acquired a highly stigmatizing value in the late 19th century on the basis of degenerative theory. This widespread medical view lost general acceptance among experts in the 1990s after several large-scale studies showed that aggressive phenomena can arise during epileptic seizures, but are extremely rare. The concept of postictal psychosis (PIP) shed a new light on this old dispute. With this concept, the significance of the chronological relationship between seizures and violent behaviors in patients with epilepsy is newly stressed, which made a simple "yes" or "no" answer to the question implausible. In this review, we discuss violent behaviors at five chronological points relative to seizures and demonstrate representative cases. As shown in our previous study, well-directed violent attacks occurred during 22.8% of the PIP episodes, 4.8% of the IIP episodes, and 0.7% of the postictal confusions. Compared with the other two situations, proneness to violence stood out in the PIP episodes. Suicidal attempts showed a similar trend. Purposeful, organized violence as a direct manifestation of seizures or ictal automatism is highly exceptional. Violent acts could occur in postictal confusion as an expression of unconscious, vigorous resistance against efforts of surrounding people to prevent the affected individual from roaming or fumbling about. In contrast, some PIP episodes can be highly alarming, especially if a violent act has been previously committed in preceding episodes. Violent acts by patients with epilepsy should be treated differently according to the various pathophysiological backgrounds from which the violence arises.
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