seizures

Psychological Reports, 1990, 6 7 , 935-945.

O Psychological Reports 1990

INFANTICIDE IN LIMBIC (?) PSYCHOTIC TRIGGER REACTION IN A MAN WITH JACKSONIAN AND PETIT MAL (?) SEIZURES: "KINDLING" BY TRAUMATIC EXPERIENCES ' ANNELIESE A. PONTIUS Haward Medical School Summary.-A tenth case (a subtype of complex partial seizures) is proposed as a Limbic (?) Psychotic Trigger Reaction. Upon crying, an infant girl was hit fatally by her devoted father while he was off anticonvulsants prescribed for Jacksonian and petit ma1 (?) seizures with "porencephalic cyst involving motor cortex and limbic system." Crying revived traumatic memories of frequently repeated ("kindling") experiences of his mother crying when hit by his father, in turn sometimes hit by patient while helping the mother. Hitting also had been helpful (cogrutlve rmsmatch between helpful and harmful hitting) during the victim's accidental choking 11 days earlier. This had occurred on the same day his distant mother died. Two days later he attempted suicide with anticonvulsants. Symptoms of the weU remembered, unmotivated infanticide included flat affect, olfactory and command hallucinations, and delusions of grandeur (his mother leaving him millions and power).

The puzzling relationship between ideas and human action remains still unsolved (Newell, 1981). The goal of the present case study is to alert the clinician and theoretician to frequently neglected aspects of human acts by glancing through a bizarrely distorted magnifying glass, as it were, at an infanticide which was not drive-motivated but memory-triggered. This is the tenth case discussed in relation to a newly proposed subtype of complex partial seizures with a psychotic episode and virtually full recall of homicidal action, called Limbic (?) Psychotic Trigger Reaction (Pontius, 1981, 1984, 1987, 1988, 1989). I hypothesized on the basis of the symptomatology that the limbic system was temporarily dysfunctional, reciprocally (Nauta, 1971) involving the frontal lobe system (Pontius & Ruttiger, 1976; Pontius & Yudowitz, 1980). In the context of a specific external trigger stimulus (of various modalities) which revives frequent traumatic experiences, a limbic "kindlingH-like mechanism (Adamec, 1987; Adamec & Stark-Adamec, 1986) is implicated, triggering a limbic seizure-like episode: such loner-type male patients had ruminated and had been exposed to frequently repeated, although typically only moderately traumatic experiences, which they had kept to themselves (Pontius, 1981, 1984, 1987, 1988, 1989). The present case is of particular interest in that the neurological con'Address requests for reprints to Anneliese A. Pontius, M. D., Associate Clinical Professor of Psychiatry, Harvard Medcal School, Department of Psychiatry, Massachusetts General Hospital, Department of Psychiatry, Fruit Street, Boston, MA 02114.

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sultant, blind to the hypothesis of limbic system involvement, formed the impression of: "porencephalic cyst, involving motor cortex and limbic system." (In previous cases, the limbic system was shown to be abnormal on objective tests for Case 5 (Pontius, 1984, pp. 307-310), and general EEG studies had at some time been found to be abnormal for Cases 3 and 7 (Pontius, 1984, pp. 301-305, 311-314). The present patient had an history of several head injuries, including an injury only a month prior to the infanticide. Cases 3, 4, 5 , and 6 also had known histories of brain traumata (Pontius, 1984, p. 320). As to the methodology, the following presentation is based on a detailed, mostly clinical case study, which is still the main road to the study of certain complex human behaviors (Geschwind, 1984). The emphasis here is on neuropsychological and ne~roph~siological implications. One purpose of the present study is the subtyping of psychoses within limbic dysfunctioning. Legal aspects dealing with the much coarser 19th century concept of "insanity" (psychosis) are not addressed here (see previous discussions, Pontius, 1981, 1984, 1987, 1989). History Based on clinical interviews with the patient and his wife, an history was compiled for Mr. Q who was charged with infanticide of his few months old daughter. He had been her devoted main caretaker because her mother showed "incompetence." The mother was his present third wife after previously having been widowed and divorced. He was a small, right-handed, white man in his late twenties, of low middle socioeconomic status. H e had completed a trade school education. He suffered from a congenital spastic paresis of his left arm which was atrophic. During his preadolescence, Mr. Q had a car accident, after which he incurred Jacksonian seizures. He was placed on Dilantin and phenobarbital, but to the present time he still suffered four seizures a year on the average. Reportedly, he never drank any alcohol or used "street drugs," because his medication did not agree with them. During preadolescence and adolescence, his mother kept him mostly indoors and had placed him in an "epilepsy colony" for several years. O n this, his sister commented to Mr. Q: "just grow up and be independent." Contributing to this placement in the "epilepsy colony" had been an incident, in which Mr. Q had again witnessed his frequently drunken father "bashing" Mr. Q's crying mother in the face. Typically such an experience was followed by the arrival of the police cars accompanied by the sound of their sirens. In defense of his crying mother, Mr. Q had struck out, breaking his father's back. Mr. Q spontaneously commented, that ever since he "can not stand women or babies crying or the sound of sirens." One month prior to the infanticide, Mr. Q suffered another head injury, after which he

KINDLING IN LIMBIC (?) PSYCHOTIC TRIGGER REACTION

93 7

h t his father on the head with a hammer for having made Mr. Q's mother cry again. Previously, Mr. Q also had several psychiatric hospitalizations, mostly with the diagnosis of "schizophrenia, schizo-affective type." H e had sporadic d y suffered from auditory hallucinations and from delusions, mostly of grandeur, and was described as alternately withdrawn and excitable. H e had escaped on several occasions either after fights or once after having had sexual intercourse with a woman patient. His diagnosis on his last discharge had been "organic brain syndrome with psychosis." His latest psychiatric hospitalization followed his spontaneously confessed motiveless infanticide (for which he felt fully responsible). The neurological consultant's impression added to the diagnosis of organic brain syndrome with psychosis, that Mr. Q suffered from a "porencephalic cyst, involving motor cortex and limbic system." Skull x-ray and routine encephalogram were within normal limits, which does not rule out any seizures. I n addition to a sister, Mr. Q had two brothers but for over a decade has had no contact with either one of them or with his mother. When a teenager, after an argument with his mother, he had made her promise never to write to him, a promise she kept until her death.

Life Events Leading to a Specgic Trigger Experience (Based on Clinical Interviews) Mr. Q, a loner who had never verbalized his feelings, had frequently experienced repeated parental, familial, and especially maternal deprivation on various levels. H e had experienced general lifelong feelings of deprivation his first wife died of cancer, associated with his physical handicaps.~~urther, and his second marriage to a "promiscuous" wife ended in divorce. Both marriages had produced a boy and a girl each and he was never reported to have mistreated any of his children, for whom he often provided care. His present third wife, the mother of a single girl (the present victim), was described by Mr. Q as "incompetent, a spend thrift, unable to care for the child," which had become Mr. Q's task. (It is of note that these deprivations appear to be compensated by Mr. Q's delusions of receiving great bounty from his mother.)

Events Preceding the Infanticide (Based on Clinical Interviews and Police Records) Within the context of such repeated negative "maternal" experiences, one notes that 11 days prior to the infanticide, he learned his mother had suddenly died of a heart attack. Two days later, Mr. Q seriously attempted suicide by overdosing with his anticonvulsant medications. H e commented that, although he had had no contact with his mother for over a decade, he had felt very close to her, believing they had the same character.

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Furthermore, his suicidal attempt also appeared to be precipitated by the infant-victim's cholung accident unfortunately on the day Mr. Q's mother died. Mr. Q , who was the infant's devoted caretaker, had tried in vain to dislodge an obstruction by hitting (sic!) the infant on the back, but she had to be hospitalized and had to receive an intraveneous blood drip. Mr. Q was convinced that this blood, which he "smelled," could transfer cancer (of which his first wife had died) and that his child would die, as his mother had just died. In general, the infanticide occurred within the described context of Mr. Q's mental constellation of death and suicide [see an analogous example in Case 9 (Pontius, 1987)], in which homicide and suicide were interlinked, probably within the context of loss of boundaries. In the present case, boundaries were blurred between his mother, the victim, and the patient, who had also functioned as the infant's caring "mother" In particular, the following sequence of events led to the infanticide: by "hiding" his actual srate of mind, Mr. Q had obtained a premature discharge from the hospital after his serious suicidal attempt. As is frequently observed in severely head-injured persons (see Elsass & Kinsella, 1987, p. 77), he wanted to be alone and stayed indoors for 11 days, hardly sleeping the night before the homicide, working on the budget to undo his wife's spendthrift behavior. At the doctor's instruction, to prevent further suicidal attempts, his wife had locked up his anticonvulsant medications, so he had had none on that fateful day. As usual, Mr. Q was taking care of his infant daughter after her recovery from her choking accident. At the time of the infant's fatal crying, Mr. Q still believed that she would die. This belief was activated by the infant's continual crying, which in turn revived the memories of his hurt mother's crying, who had now just died. Thus, an association had apparently been formed in Mr. Q's mind among crying, being hurt, and dying. Upon the infant's crying, Mr. Q hit her repeatedly (about eight times), a repetition which implicates transcient frontal lobe dysfunctioning whereby a plan of action, once started, cannot be readily reprogrammed by new external percepts (such as, a child's increasingly weakened crying.) At first, Mr. Q believed he was hitting the bed. Only when the victim stopped crying did he realize that he had struck the baby and saw that she was black and blue. At first, he "could not move for a few minutes." Then he had "run out into the street, around and around a block for 5 rnin.," looking for his wife. He leaned against a wall, as he began "shaking in a Jacksonian seizure." He told his wife: "I think I lulled the child." Within minutes the police arrested Mr. Q and observed him having a "Jacksonian seizure" at that time. For a while Mr. Q was unable to walk and could hear the police officers tallung but could not talk himself. When he regained his ability to speak, he lamented the loss of his child. (He had not been observed to have f d e n to the


939

ground, to have foamed at the mouth, or to have lost bladder or bowel control.)

Mental Status (Based on Several Psychiatric Interviews) This small, frail-appearing, right-handed, white married man in his late 20s was charged with infanticide of his few months old daughter. H e appeared to be of average native intelligence, had completed a trade school education and worked sporadically, last as a switchboard operator. At the time of the examination, his thought processes were mostly relevant and coherent with some overconcreteness, particularly indicated by his poor abstraction of the meaning of proverbs. His motor behavior was unremarkable except for a congenital spastic paresis of the left arm, which was atrophic. His speech showed a mild trace of dysarthria. H e was cooperative in a passive way and gave the impression of superficial friendliness. His affect was moderately blunted. H e reported having felt "depressed" ever since his mother died suddenly, when he had seriously attempted suicide (see above), and shortly after his admission to the hospital. H e refused to take his anticonvulsant medication as well as food, still wanting to die, because he had "nothing to look forward to." H e lamented: "nobody wants to feed (sic!) me; nobody visits me." As a loner, he had had no contact with his family for over a decade and commented that h e preferred reading to socializing. Auditory hallucinations around the time of the infanticide had commanded: "go ahead, hit her, hit her!" Further, he had suffered olfactory hallucinations (smelling the blood in the infant's i.v drip), delusions of persecution (that the blood transfusion would give cancer to the infant). Presently he had ideas of reference and auditory hallucinations in the form of television announcements, which were associated with delusions of grandeur about inheriting many millions of dollars from his mother which would bring h m great power. H e believed that he inherited property located along a major highway and concluded: "I could stop people from travehng the highway, it is my right of way." Further, indicating the ambivalent side to maternal bounty and power, he insisted: "Mary was not the mother of Jesus, but God (father) was Jesus' mother" (reminiscent of Mr. Q having functioned as the "mother" to the victim). H e still experienced flashbacks "seeing my wife (his present third wife) with the dead child," "hearing women and babies crying." H e added, "when I was hurt, my mother and I cried, and when I could not cry, I screamed." I n view of a differential diagnosis (see below) to temporal lobe epilepsy, there had been no changes in his heterosexual orientation, though he had undergone a religious conversion within a major denomination. H e was oriented as to time, place, and person. His memory functions for immediate, recent, and remote r e c d were within normal limits at the

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time of the present examination. There had been some possible temporary mildly altered state of consciousness around the time of the infanticide, although he was able to recall the main details of this act. His general information was limited, as was his ability to perform simple calculations, e.g., he overestimated the population of his city nearly 100-fold, and he believed there were 26 nickles to one dollar. His insight and judgement were limited as well. During the psychiatric examinations h e recalled several recent dreams, which mostly centered on his victim and/or his losses. "The day before my mother died, I dreamt of sending her a card but had no address. I cried. I n another dream I was out on an open field eating an apple, talking with people." Also, "I dreamt how she (the infant) came into the world, and how I took care of her. My wife was sick and was not home often." Again, "I dreamt I was killing my daughter through two seizures." ( O n one occasion he believed that his killing of his child during seizures might have actually happened). H e elaborated that at the time of his arrest "I was so hurt, losing my child, I told the DA anything to stay in a shell." H e added that he had not told the District Attorney that he had had a Jacksonian or petit mal seizure while changing his daughter's diapers: "I killed her by falling, holding her by her throat, and I choked her." Asked whether he actually remembered this, he rationalized "That's the only way it could have happened, I remember me falling with her." H e elaborated, "I had (at first) a petit mal. I tripped and my head was moving to the side, my eyes were blinking, and I had my child in my hands and went into a Jacksonian convulsion. I did not tell to protect other epileptics in the 'epilepsy colony' from discrimination against them."

Congruity Between Mental Status and Symptoms of "LimbicH(?)Psychotic Trigger Reaction A specific, individualized external trigger stimulus (crying) evoked (not "provoked") homicide, which was not drive-motivated, was committed under flat affect, and later was well recalled. Crying had revived frequently repeated past experiences ("kindling" effect?) of his crying mother who had been hit by his father, whom the patient now hit in order to help his mother. There were blurred boundaries among crying, a distant mother who had died 11 days prior to the infanticide, and the crying victim with whom the patient had vicariously identified as her devoted caretaker. The same day, experiencing a "cognitive mismatch" between helpful and harmful hitting, Mr. Q had helpfully hit the infant during her choking accident, believing she would die soon-as had his mother-and experiencing olfactory hallucinations of "smelling" that her blood drip was filled with lethal "cancer cells." Two days after this accident and his mother's death, he seriously attempted


94 1

suicide by overdosing with his anticonvulsants, so he had not been taking these medications at the time of the infanticide. In addition to the specific clinical symptom pattern, implicating limbic system dysfunctioning (with secondary frontal lobe system involvement), the neurological consultant's clinical impression was "porencephalic cyst involving motor cortex and limbic system."

Specific Neurophysiological and Neuropsychiatric Aspects of the Limbic (?) Psychotic Trigger Reaction-Related Infanticide Command hallucinations.-The present case can clarify certain aspects of command hallucinations, which were commented upon by Mukherjee (1987, p. 135) in connection with Case 6, a teenager who had had childhood psychiatric hospitalizations and experienced command hallucinations (to kill and to rape a 70-yr.-old woman, a stranger) (Pontius, 1984, pp. 310-311). Mukherjee wondered why such patients ignore such command hallucinations but then "unpredictablyM act on them. Mukherjee observed that the postulation of a specific context-dependent trigger stimulus "may open a new avenue of inquity into this area" of command hallucinations. H e added, however, that not necessarily homicide, but a wide spectrum of behaviors can follow command hallucinations. I n response to this latter aspect, attention is here drawn to the specific context surrounding the trigger stimulus in Limbic (?) Psychotic Trigger Reaction, which appears to be a distinctive factor "evokingn obedience to such a command hallucination in such cases. Kindling and related mechanisms.-Within such a specific constellation of factors, the likely effect of long-standing "kindLng" (repeatedly hearing Mr. Q's hurt mother cry) also plays a role. In "kindling" even a mild but frequently repeated electrical, chemical, or experiential stimulus can trigger a limbic seizure, apparently also in humans as has been experimentally effected with mammals (Adamec, 1987; Adamec & Adamec-Stark, 1986). In turn, it is reasonable to assume that such limbic hyperactivation is associated with at least relative, temporary underfunctioning of the frontal lobe system in that both systems are in a reciprocal relationship (Nauta, 1971). Such a frontolimbic imbalance (Pontius, 1984, 1987, 1988, 1989) can then facilitate acting upon otherwise out-of-character hallucinatory commands, such as killing. In turn, "kindling" is congruent with "failed habituation to earlier traumatic experience," considered by Mukherjee (1987, p. 135) "to deserve consideration" with regard to psychotic trigger reaction. To this aspect he elaborates on the interrelation between "frontal cortex" and the "role of noradrenergic projections from the pontine locus coeruleus to the limbic system (amygdala, hippocampus, septa1 area)." The physiological concept of "state dependence" (anonymous referee)

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could offer an alternative explanation in those cases for whom there is an history of known head injury and of previous aggressive acts. Thus, Mr. Q's potential concussion associated with grieving ("ACTH facilitation"), further exacerbated by lack of anticonvulsant medication, may have stimulated arousal of aggression. Even if such "state dependencym contributed to the present infanticide, this would, however, not necessarily rule out but rather be congruent with a reactivation of limbic-dominated mechanisms, by analogy known to ethologists (such as "kindling"). A possible "defense attack" aspect of Limbic (?) Psychotic Trigger Reaction was discussed by Adamec (1987, pp. 130-134) who generously recommended specific neurophysiological tests. The forensic setting of such patients within maximum security facilities, however, is not conducive to these and other "objective tests" (Pontius, 1987, p. 121; 1989, p. 671). In addition, there are persisting fundamental problems with the interpretation and differentiation of brain-imaging techniques. DilCJerential diagnoses and "controls".-"Controls" for these cases can consist of all other homicidal cases constituting three main categories, all ruled out by the list of 13 specific symptoms summarized above (Pontius, 1984, pp. 327-330): (1) various nonpsychotic homicidal acts, (2) homicide linked to functional psychoses (e.g., schizophrenia), (3) homicide linked to organic states with significant memory impairment, and/or absence of a detectable external memory-evoked triggering event. Details of differential diagnoses to Limbic (?) Psychotic Trigger Reaction have previously been discussed (Pontius, 1981, 1984, p. 300; 1987, 1989) and are here only summarized: (1) impulsive acting out, (2) episodic behavior disorder, (3) schizophrenia, paranoid type, (4) monomania, (5) Gdles de la Tourette disease, (6) temporal lobe epilepsy, (7) "reflex epilepsy," (8) anxiety and panic disorders. Further, the differential diagnostic aspects associated with various other lunds of seizures have been reviewed by Bacon and Benedek (1982, p. 206). Their list of psychoses associated with epilepsy is congruent with Limbic (?) Psychotic Trigger Reaction, particularly as to the following symptoms. These authors mention that epilepsy can occur with any type of psychosis, and there may be both disturbances of mood and of affect, especially depression. Further, they conclude: "most typically there is a clear or normal level of consciousness . . . clear memory of some or even of all the events, . . . goal-directed activity and normal cognitive functions." Bacon and Benedek (1982, p. 207) also noted that the EEG pattern may quickly improve after a seizure and show what Landolt (1958) called "forced normalization of the

EEG." As an example, Bacon and Benedek (1982, pp. 203-205) presented a case of psychosis associated with an epileptic disorder. Their patient had had


943

a grand mal convulsion three days prior to his felonious assault and criminal sexual conduct following his polite request to walk an older woman's dog was rejected. No details about this are reported, although the symptoms may show a certain overlap with certain cases of Limbic Psychotic Trigger Reaction (especially Case 6, Pontius, 1984, pp. 310-311; Pontius, 1988, Adamec, 1987, p. 131). Limbic involvement was present in two similar cases, associated with another subtype of partial complex limbic seizure, that of temporal lobe epilepsy. For a discussion see Pontius (1989, p. 663, Table 1): (a) Gloor (1987) reported a patient suffering from temporal lobe epilepsy and petit mal epilepsy, who during his aura experienced a revival of the trauma of having been held under water. Electrical stimulation of his right amygdala and surrounding hippocampal areas elicited a revival of the traumatic experience together with nausea and anxiety. (b) Even more pertinent to the present case, in Mark and Ervin's (1970) patient Jennie, homicidal action (of which she was aware) was evoked by the sound of a child crying. When this stimulus was replicated in the laboratory with implanted depth electrode recording, there was medial temporal lobe seizure activity. In short, the 10 reported cases of Limbic (?) Psychotic Trigger Reaction, although distinct, present a partial overlap with other related types of limbic seizures. The proposed new entity of Limbic (?) Psychotic Trigger Reaction suggests a specific diagnostic refinement in subclassification. -

-

Possible Interrelation Between Limbic (?) Psychotic Trigger Reaction and Jacksonian Seizures In light of certain neurophysiological findings (Goddard, 1986), Mr. Q's preexisting Jacksonian seizures and the events surrounding the infanticide support an interpretation of hls Limbic (?) Psychotic Trigger Reaction in the context of his transcient inability to walk and to talk shortly after the infanticide, while his language comprehension remained intact. Further, it is of note that the police reported that Mr. Q had a "Jacksonian seizure" at the time of his arrest within mlnuten after the infanticide. Goddard's (1986) experimental findings about the effect of "kindlingn in animals support the hypothesis that Mr. Q's probable paralysis of his speech and leg muscles occurred immediately following a seizure other than his usual Jacksonian seizures, namely, a Limbic (?) Psychotic Trigger Reaction. This limbic kind of seizure probably aborted his apparently oncoming Jacksonian seizure temporarily, which was then observed by the arresting police officers shortly after Mr. Q's infanticidal act. This specific sequence of probable events is supported by Goddard's findings (1986, p. 104), which in turn concur with observations by Efron (1961), whom Goddard cites. Both researchers found in animal experiments that "an aborted focal seizure (such as an aborted Jacksonian seizure) may be

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followed by a more striking Todd's paralysis (such as inability to walk and to talk) than one that is allowed to progress and to involve other areas" (parentheses added). Such reference to experimental findings makes sense in light of the fact that Mr. Q had suffered no prior "inability to speak" or any other kind of paralysis around the times of h s previous Jacksonian seizures, which apparently had been dowed to progress in their usual course. Neglected Factors in Normal Action Behavior As to normal action behavior, the presently observed pathological distortions emphasize the potentially lethal role of even moderately traumatic, but frequently repeated past traumatic experiences, constituting a lundling-like lowering of the seizure threshold of certain limbic structures, especially of the amygdala and hippocampus. Then, when memories have not been sufficiently externalized (as in loners' lack of verbalization), a specific seemingly innocuous external stimulus-only globally similar to the past traumata-can constitute a trigger for a limbic seizure-like episode of Limbic (?) Psychotic Trigger Reaction (Pontius, 1984, 1987, 1989). An episode of reciprocal underfunctioning of the frontal lobe system can then be expected, impairing planning, flexible reprogramming of action, and the consideration of its consequences (Pontius, 1981, 1984, 1987, 1989). REFERENCES

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ELSASS,L., & K ~ S E L L G. A , Social interaction following severe closed head injury. Psychological Medicine, 1987, 17, 67-78. GESCHWIND. N . Clinician-scientist. Science. 1984., 224.. 243. GLOOR, P Inputs and outputs to the amy6dala: whar t+ amyjdala trying to tell the rest of the brain. In K. E. Livingston & Hornyhew~cz(E s.), Lzmbic mechanisms, the continuing evolution of the limbic system concept. New York: Plenum, 1987. Pp. 189-209. GODDARD, G. V. Kindling and the forces that oppose it. In B. K. Doane & K. E . Livingston (Eds.), The limbic system: functional organization and clinical disorders. New York: Raven,

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LANDOLT, H . Serial EEG investigation during psychotic episodes in epileptic patients and during schizophrenic attacks. In L. de Haas (Ed.), Lectures on epilepsy. Amsterdam: Elsevier, 1958. Pp. 91-133. lvhuc, V. H., & ERVIN,F. R. Violence and the brain. New York: Harper & Row, 1970. MUKHERJEE, S. Commentary to A. A. Pontius' "Psychotic Trigger Reaction": neuro-psychiatric and neuro-biological (limbic?) aspects of homicide, reflecting on normal action. Integrative Psychiatry, 1987, 5, 134-135.

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NAUTA,W. J. H . The problem of the frontal lobes, a reinterpretation. Journal of Psychiatric Research, 1971, 8, 167-187. NEWELL,A. A basis for action. Behavioral and Brain Sciences, 1981, 4 , 633-634. PONTIUS,A. A. Stimuli triggering violence in psychoses. Journal of Forensic Sciences, 1981, 26, 123-128. PONTIUS,A. A. Specific stimulus-evoked violent action in "Psychotic Tr~ggerReaction": a seizure-like imbalance between frontal lobe and limbic systems' Perceptual and Motor Skills, 1984, 59, 299-333. (Monograph Suppl. I-V59) PONTIUS,A. A. "Psychotic Trigger Reaction": new-psychiatr~cand new-biological (limbic?) aspects of homicide, reflecting on normal action. Integmt~ve Psychiatry, 1987, 5 , 116-139. PONTIUS,A. A. Limbic system-frontal lobes' role in subtypes of -'atypical rape." Psychological Reports, 1988, 63, 879-888. PONTIUS, A . A. Subtypes of limbic system dysfunction evoking homicide in Limbic (?) Psychotic Trigger Reaction and in temporal lobe epilepsy-evolutionary constraints. Psychological Reports, 1989, 65, 659-671. PONTIUS,A. A,, & R ~ G E RK., F, Frontal lobe system, maturational lag in juvenile delinquents shown in Narratives Test. Adolescence, 1976, 11, 509-518. PONTWS,A. A,, & Y u ~ o w r r z ,B. S. Frontal lobe system dysfunction in some cr~minalactions as shown in Narratives Test. Journal of Nervous and Mental Disease, 1980, 168, 111-117. WIESER,H. G., & MELES,H . l? Limbic seizures: intracortical EEG activ~tyand clinical signs. In M. Girgis 6 L. G. Kiloh (Eds.), Limbic epilepsy and the dysconfrol syndrome. Amsterdam: Elsevier/North Holland Biomedical Press, 1980. Pp. 195-206.

Accepted October 26, 1990.