Epilepsy and violence: historical misconceptions, scientific evidence, and legal realities.

BACKGROUND: Epilepsy has historically been mischaracterized as a disorder associated with aggression and criminal behavior. Misconceptions dating back to the 19th century, particularly those propagated by Cesare Lombroso, have contributed to persistent stigma and misinformed legal interpretations.

METHODS: This narrative review examines the historical, clinical, neuroscientific, and legal literature on the purported link between epilepsy and violent behavior. Key seizure phases-ictal, postictal, and interictal-are analyzed alongside recent findings from psychiatric comorbidity studies and forensic neurology.

RESULTS: There is no consistent evidence that epilepsy per se leads to violent or criminal acts. Aggressive behavior in people with epilepsy (PWE) is rare and typically arises from confusional states during the postictal phase or from psychiatric comorbidities. Modern classification schemes and video-EEG telemetry have clarified the behavioral distinctions across seizure phases. Legal defenses based on mental insanity often fail to accurately reflect the neurobiological underpinnings of seizure-related behaviors.

CONCLUSIONS: Violence in epilepsy must be understood as a context-dependent and biologically nuanced phenomenon. Relying on outdated legal constructs, such as blanket insanity defenses, perpetuates stigma and undermines clinical reality. Integration of neuroscientific evidence and seizure-phase classification improves forensic clarity and supports more equitable judicial outcomes for PWE.