Page 497 - ILAE_Lectures_2015

During a complex partial seizure Sullivan attacked and seriously injured an elderly neighbour.
The seizure and the attack were witnessed, so there was no medical doubt that the assault took
place during an epileptic automatism, and this was accepted by both the prosecution and the
defence. Sullivan wished to establish the defence of sane automatism (automatism simpliciter),
and pleaded not guilty. The trial judge, His Honour Judge Lymbery, ruled that this plea was not
available to the defence and that if Mr Sullivan carried out the act during an epileptic seizure,
then he must plead not guilty with the defence of automatism due to disease of the mind.

The case went to Appeal in the House of Lords and was rejected. Commenting on the verdict
of the House of Lords, Mr Lionel Swift who presented the appeal said: ‘From the point of view
of the administration of the law and justice to epileptics and others, the reasoning of the House
of Lords is, with respect, impeccable ... It matters not whether the impairment (of mind) is
organic, as in epilepsy, or functional. It matters not whether the impairment is permanent or
transient, or capable of control by drugs. Provided that (impairment) is his condition at the
material times, he comes within the definition of being temporarily insane. At the time he
committed the act, Sullivan was completely unaware of what he was doing and, therefore, he
was insane at the time3.’

The present standing of the difference between sane and insane automatism is as follows:
Automatism simpliciter occurs when the mind is disordered by an external factor such as an
injection of insulin, a blow on the head, the injection of an anaesthetic or even a reflex action
resulting from a bee sting. An insane automatism occurs when the mind is disordered due to an
intrinsic factor which leads to a situation that is prone to recur and may result in violence. Thus
any organic condition of the brain or the body resulting in a disorder of the mind, even if
temporary, is an insane automatism. Automatic acts carried out during sleep, during dissociated
states, and during any psychiatric or medical condition causing a disruption of brain function
which is due to an internal condition is now insanity. This clearly leads to differences which
appear to be nonsensical, for a violent act committed while the mind is disordered due to an
excess of insulin is automatism simpliciter if the insulin is injected, while it is an insane
automatism if the insulin comes from an insulinoma of the pancreas.

Epilepsy and criminality

Not infrequently, psychiatrists and neurologists are called upon to decide whether or not a crime
has been committed during an epileptic seizure, and whether or not the defence of automatism
is one that can be substantiated by the medical facts of the case4. Usually the offence is fairly
trivial, for example, shoplifting during either a post-ictal confusional state or during the
automatism of a complex partial seizure. Occasionally, however, defendants may claim the
defence of epileptic automatism when there is little evidence to support this. The physician
should satisfy themselves on the following six points before going to court to substantiate the
diagnosis of epileptic automatism:

1. The patient should have a previous diagnosis of epilepsy. It is clearly unlikely that a
crime will be committed during a first seizure. Thus, unless there is overwhelming evidence,
the diagnosis of epilepsy should be rejected if the act is said to have occurred during a first
seizure. The case of epilepsy is strengthened if there is evidence that the patient is either subject
to ictal or post-ictal automatisms, and that the behaviour described during the crime is consistent
with behaviour that has been previously described during such an automatism.

2. The act should be out of character for the individual and inappropriate for the
circumstances. Clearly, if the defendant is habitually aggressive and commits a violent and
aggressive crime, it is much more difficult to substantiate the diagnosis of epileptic automatism
than if the act occurs in a patient who is mild mannered and tolerant. It is also important that
the act should be inappropriate in the circumstances in which it occurred. A violent act of