Anxiety disorders in children and adolescents in the first six months after traumatic brain injury

The study's objective was to assess the nature, rate, predictive factors, and neuroimaging correlates of novel (new-onset) definite anxiety disorders and novel definite/subclinical anxiety disorders (in a broader group of children with at least subclinical anxiety disorders) after traumatic brain injury (TBI). Children with TBI from consecutive admissions to five trauma centers were enrolled and studied with psychiatric interviews soon after injury (baseline) and again 6 months post-injury. Novel definite anxiety disorder and novel definite/subclinical anxiety disorders were heterogeneous and occurred in 8.5% (N=12) and 17% (N=24) of participants, respectively, in the first 6 months after injury. Novel definite anxiety disorder was significantly associated with younger age at injury and tended to be associated with novel depressive disorder, as well as lesions of the superior frontal gyrus. Novel definite/subclinical anxiety disorder was significantly associated with concurrent psychiatric problems of personality change due to TBI and novel definite/subclinical depressive disorder, as well as with lesions of the superior frontal gyrus and a trend-association with frontal lobe white-matter lesions. These findings suggest that anxiety after childhood TBI may be part of a broader problem of affective dysregulation related to damaged dorsal frontal lobe and frontal white-matter systems, with younger children being at greatest risk for developing novel anxiety disorder after TBI.     

Frontal lobe lesions,diffuse damage,and neuropsychological functioning in traumatic brain-injured patients

Abstract

This study quantified lesion volume in relation to damage location and executive functioning in traumatic brain-injured (TBI) patients. Magnetic resonance (MR) scans of 68 TBI patients were analyzed by taking volumetric measures of lesion sites. Patients were grouped according the presence/absence of frontal lobe lesions. Measures of frontal lesion volume were studied as predictors for outcome on designated tests of executive functioning (Halstead Category Test and Wisconsin Card Sorting Test). Results showed no significant differences in level of deficit between groups. In addition, no significant differences were found between groups on other tests of neuropsychological functioning (Trail Making Test, Parts A and B, and Wechsler Adult Intelligence Scale-Revised). These results suggest that tests that are traditionally used to detect “frontal lobe” damage may not be adequate for distinguishing specific frontal lobe dysfunction, and do not add anything unique about frontal lobe integrity and neuropsychological functioning in TBI patients.     

Clinical correlates of aggressive behavior after traumatic brain injury

The authors assessed aggressive behavior in 89 patients with traumatic brain injury (TBI) and 26 patients with multiple trauma but without TBI using a quantitative scale (the Overt Aggression Scale) and examined its clinical correlates. Aggressive behavior was found in 33.7% of TBI patients and 11.5% of patients without TBI during the first 6 months after injury. Aggressive behavior was significantly associated with the presence of major depression, frontal lobe lesions, poor premorbid social functioning, and a history of alcohol and substance abuse. Interventions aimed at treatment of depression and substance abuse and enhancing social support may help reduce the severity of this disruptive behavior.     

Clinical rating of cortical atrophy and cognitive correlates following traumatic brain injury

We report on the utility of using a rapid, easy-to-use, visually based semi-quantitative neuroimaging atrophy rating scale in individuals with traumatic brain injury (TBI) and normal control subjects. Magnetic resonance (MR) scans were rated using a standardized semi-quantitative MR rating method. A four-point scale was used to rate each scan for atrophy in frontal, temporal, and parietal areas. Seventy-five TBI subjects (50 males, 25 females) and 75 age- and gender-matched control subjects were compared for atrophy ratings. Clinical atrophy ratings were also compared to a quantitative measure of atrophy, the ventricle-to-brain ratio, and with the TBI subjects' scores on standard neuropsychological tests. TBI patients had significantly higher clinical atrophy ratings in frontal and temporal lobe areas compared to controls. The clinical atrophy ratings significantly correlated with the ventricle-to-brain ratio, a quantitative measure of atrophy in the same TBI subjects. Higher clinical ratings of frontal and temporal atrophy correlated with deficits in memory and executive function. These findings indicate that clinical ratings of trauma-induced atrophy can be reliably performed and are associated with neuropsychological outcome and quantitative measures of cerebral atrophy.     

Pathological laughing and crying in multiple sclerosis: a preliminary report suggesting a role for the prefrontal cortex.

As part of a wide ranging study investigating the prevalence, demographic and disease related characteristics of pathological laughing and crying (PLC) in multiple sclerosis (MS), a putative role for the prefrontal cortex was also explored. Eleven multiple sclerosis (MS) patients with carefully defined PLC were compared to a control group of 13 MS patients without PLC on various cognitive indices known to be sensitive to frontal lobe dysfunction. Although the two groups did not differ with respect to age, sex, physical disability, disease course, duration of MS, years of education, premorbid IQ, and depression, the PLC group performed more poorly on the Stroop test and a measure of verbal fluency. They also showed a trend to make more total errors on the Wisconsin Card Sort Test. The relevance of these findings to the pathogenesis of PLC is discussed, in particular whether the syndrome is, in part, mediated by dysfunction of the prefrontal cortex.     

Longitudinal changes in cortical thickness in children after traumatic brain injury and their relation to behavioral regulation and emotional control

The purpose of this study was to assess patterns of cortical development over time in children who had sustained traumatic brain injury (TBI) as compared to children with orthopedic injury (OI), and to examine how these patterns related to emotional control and behavioral dysregulation, two common post-TBI symptoms. Cortical thickness was measured at approximately 3 and 18 months post-injury in 20 children aged 8.2-17.5 years who had sustained moderate-to-severe closed head injury and 21 children aged 7.4-16.7 years who had sustained OI. At approximately 3 months post-injury, the TBI group evidenced decreased cortical thickness bilaterally in aspects of the superior frontal, dorsolateral frontal, orbital frontal, and anterior cingulate regions compared to the control cohort, areas of anticipated vulnerability to TBI-induced change. At 18 months post-injury, some of the regions previously evident at 3 months post-injury remained significantly decreased in the TBI group, including bilateral frontal, fusiform, and lingual regions. Additional regions of significant cortical thinning emerged at this time interval (bilateral frontal regions and fusiform gyrus and left parietal regions). However, differences in other regions appeared attenuated (no longer areas of significant cortical thinning) by 18 months post-injury including large bilateral regions of the medial aspects of the frontal lobes and anterior cingulate. Cortical thinning within the OI group was evident over time in dorsolateral frontal and temporal regions bilaterally and aspects of the left medial frontal and precuneus, and right inferior parietal regions. Longitudinal analyses within the TBI group revealed decreases in cortical thickness over time in numerous aspects throughout the right and left cortical surface, but with notable "sparing" of the right and left frontal and temporal poles, the medial aspects of both the frontal lobes, the left fusiform gyrus, and the cingulate bilaterally. An analysis of longitudinal changes in cortical thickness over time (18 months-3 months) in the TBI versus OI group demonstrated regions of relative cortical thinning in the TBI group in bilateral superior parietal and right paracentral regions, but relative cortical thickness increases in aspects of the medial orbital frontal lobes and bilateral cingulate and in the right lateral orbital frontal lobe. Finally, findings from analyses correlating the longitudinal cortical thickness changes in TBI with symptom report on the Emotional Control subscale of the Behavior Rating Inventory of Executive Function (BRIEF) demonstrated a region of significant correlation in the right medial frontal and right anterior cingulate gyrus. A region of significant correlation between the longitudinal cortical thickness changes in the TBI group and symptom report on the Behavioral Regulation Index was also seen in the medial aspect of the left frontal lobe. Longitudinal analyses of cortical thickness highlight an important deviation from the expected pattern of developmental change in children and adolescents with TBI, particularly in the medial frontal lobes, where typical patterns of thinning fail to occur over time. Regions which fail to undergo expected cortical thinning in the medial aspects of the frontal lobes correlate with difficulties in emotional control and behavioral regulation, common problems for youth with TBI. Examination of post-TBI brain development in children may be critical to identification of children that may be at risk for persistent problems with executive functioning deficits and the development of interventions to address these issues.     

Tyrosine hydroxylase, but not dopamine beta-hydroxylase, is increased in rat frontal cortex after traumatic brain injury

Chronic frontal lobe functional deficits after traumatic brain injury (TBI) may be associated with altered catecholamine systems in the frontal cortex. To test this, tyrosine hydroxylase (TH) and dopamine beta-hydroxylase (DBH) levels were examined by immunohistochemistry and Western blot at 1, 7, 14, and 28 days after TBI or sham surgery. No alterations in DBH levels were observed by Western blot at any time point examined, but there was a significant increase in TH expression 28 days after TBI (optical density 334 +/- 68% or 3.3-fold, ipsilateral and 218 +/- 39% or 2.2-fold, contralateral) relative to the sham controls. The increase in TH may reflect a compensatory response of dopaminergic neurons to upregulate their synthesizing capacity and increase the efficiency of dopamine neurotransmission chronically after TBI.     

Neurophysiologic and neuroradiologic features of intractable epilepsy after traumatic brain injury in adults

BACKGROUND: There is controversy regarding the precise mechanism by which epilepsy results after traumatic brain injury (TBI). Previous reports have suggested that mesial temporal lobe epilepsy may result from TBI only in young children, while neocortical epilepsy arises from TBI in later life. These conclusions were based on surgical series and may be biased because of patient selection. OBJECTIVE: To determine the frequency of mesial temporal lobe as opposed to neocortical epilepsy in patients with intractable epilepsy resulting from TBI after the age of 10 years. PATIENTS AND METHODS: We identified 23 patients with intractable epilepsy who had TBI after the age of 10 years, preceding the onset of epilepsy. Patients were studied by simultaneous videotape and scalp electroencephalographic recording of typical seizures; magnetic resonance imaging; neuropsychologic studies; and, when appropriate, intracarotid amobarbital testing. Two patients underwent anterior temporal lobectomies. RESULTS: Of the 23 patients, 8 (35%) had mesial temporal lobe epilepsy, based on the finding of hippocampal sclerosis on a magnetic resonance imaging scan, consistent interictal and ictal electroencephalographic recordings, evidence of temporal lobe dysfunction on neuropsychologic testing, and characteristic seizure semiology. Two of these patients underwent anterior temporal lobectomies with clinical benefit, and hippocampal sclerosis was confirmed pathologically. In 2 cases, patients were not treated surgically because of bilateral temporal lobe dysfunction noted on intracarotid amobarbital testing. Eleven patients had neocortical epilepsy; 1 had primary generalized epilepsy; and, in 3, the site of seizure onset was not localized. CONCLUSIONS: Mesial temporal lobe epilepsy can result from TBI in adolescents and adults as well as in children, and can often be bilateral and associated with multifocal injury. This information may be useful in developing prophylactic therapy for posttraumatic epilepsy.     

Memory Dysfunctions after Mild and Moderate Traumatic Brain Injury : Comparison between Patients with and without Frontal Lobe Injury

Objective

The purpose of this study was to assess memory dysfunction in patients with mild and moderate traumatic brain injury (TBI) with and without frontal lobe injury (FLI).

Methods

The subjects were 110 TBI patients, who had recovered from the acute clinical phase, and comprised 20 (18.2%) mild TBI (MTBI) patients with FLI, 16 (14.5%) MTBI patients without FLI, 51 (46.4%) moderate TBI (MOTBI) patients with FLI and 23 (20.9%) MTBI patients without FLI. All patients were administrated the Korean version of the Memory Assessment Scale (K-MAS).

Results

Almost all the Summary Scale scores on the K-MAS failed to show any differences between TBI patients with and without FLI, but differences did emerge by types at severities. TBI patients with FLI showed higher Global Memory ability than TBI patients without FLI if their TBI was only mild, but when their TBI was more severe, this finding was reversed, and TBI patients with FLI showed lower Verbal and Global Memory abilities than TBI patients without FLI.

Conclusion

Different kinds of assessment tools are needed for the measurement of memory abilities in TBI patients with FLI, and that the selection of the appropriate tool depends on the severity of the TBI.     

Psychosocial outcome of TBI in children with unilateral frontal lesions.

To evaluate effects of unilateral frontal lesions on psychosocial and global outcome of traumatic brain injury (TBI) in children, Study 1 compared matched groups of 22 school aged children who had sustained TBI either with or without unilateral frontal lesions. Study 2 evaluated effects of unilateral extrafrontal lesions in 18 TBI patients as compared with 18 nonlesional TBI patients. Communication, Daily Living, and Socialization domains and the Maladaptive Behavior Scale of the Vineland Adaptive Behavior Scales (VABS) were used to assess psychosocial outcome, and the Glasgow Outcome Scale (GOS) measured global outcome. All patients underwent magnetic resonance imaging at least 3 months post injury. Children with frontal lesions had worse scores on the Daily Living and Socialization domains and a higher frequency of maladaptive behavior than those without frontal lesions, but there was no difference in cognitive function. Disability was twice as common in the frontal lesion group relative to children without frontal lesions. Volume of frontal lesion was related to the Socialization domain. Side of lesion had no effect, nor did presence of an extrafrontal lesion (Study 2). Unilateral frontal lesions adversely affect late psychosocial outcome of TBI in children.     

Mirror asymmetry of Category and Letter fluency in traumatic brain injury and Alzheimer's patients

In this study we contrasted the Category fluency and Letter fluency performance of 198 normal subjects, 57 Alzheimer’s patients and 57 patients affected by traumatic brain injury (TBI). The aim was to check whether, besides the prevalence of Category fluency deficit often reported among Alzheimer’s patients, the TBI group presented the opposite dissociation. According to some recent claims, in fact, the deficit of TBI would be equally severe for both fluency types. The inquiry followed different approaches for data analysis, including the evaluation of a unique index (Fluency Type Index or FTI), independent of the overall fluency and aimed at expressing at individual subject level the relationship between Category and Letter fluency. The results confirmed that Alzheimer’s patients are more defective on Category than Letter fluency, and also clearly indicated that an opposite pattern applies to TBI patients. TBI seems to cause a relatively more severe impairment of Letter than Category fluency, probably due to its impact on the frontal lobe structures. We discuss whether, on the basis of the statistical distribution of our data, it is worth considering as homogeneous populations broadly defined groups as Alzheimer’s or TBI patients.     

轻中型颅脑损伤后认知功能障碍的DTI研究

目的应用弥散张量成像(diffusion tensor imaging,DTI)技术探讨轻中型颅脑损伤病人不同部位脑白质微结构改变与其认知功能障碍的相关性。方法分析127例轻中型颅脑损伤病人的临床资料,伤后10 d采用蒙特利尔认知评估量表(Mo CA)评定有无认知功能障碍,并常规行头颅MRI检查,采集DTI数据,测量两侧额叶、颞叶内侧、顶叶,胼胝体膝部和压部,中脑部位的感兴趣区各向异性分数(FA值)、表观弥散系数(ADC值),并与Mo CA评估结果进行相关性分析。结果以Mo CA量表为标准评定,无认知功能障碍41例(32.28%,无认知障碍组),存在认知功能障碍86例(67.72%,认知障碍组),主要表现为视空间与执行功能、注意力和计算力、语言、抽象能力、延迟记忆的障碍。与无认知障碍的病人相比,认知障碍的病人两侧额叶、颞叶内侧、胼胝体膝部FA值降低,ADC值增加,差异具有统计学意义(P0.01)。结论轻中型颅脑损伤病人早期存在显著认知功能障碍,以视空间与执行功能、注意力和计算力、语言、抽象能力、延迟记忆障碍为主。颅脑损伤后早期认知功能障碍与病人额叶、颞叶、胼胝体白质受损密切相关。     

Patients with epilepsy and psychogenic non-epileptic seizures: an inpatient video-EEG monitoring study

Seizure and EEG characteristics of patients with epilepsy and concomitant psychogenic non-epileptic seizures (PNES) were compared to age and sex matched controls with epilepsy alone in a retrospective case control study. 39 patients with clearly documented epileptic and non-epileptic events were compared to 78 age and sex matched controls, sequentially admitted for video-EEG monitoring with documentation of epilepsy alone. Frontal seizures were higher in prevalence in patients with PNES who had concomitant epilepsy (P<0.001), while temporal seizures were higher in prevalence in patients with epilepsy alone (P<0.04). On regression analysis, the odds of having a frontal seizure was found to be significantly lower in the epilepsy alone group compared to the epilepsy+PNES group (odds ratio 0.13, 95% CI, 0.033-0.51). This significant association between frontal lobe epilepsy and PNES may be related to misattribution of frontal seizures for PNES events, or may reflect frontal lobe cortical dysfunction in this subgroup.     

Predictors of personality change due to traumatic brain injury in children and adolescents six to twenty-four months after injury

Phenomenology and predictive factors of personality change due to traumatic brain injury (TBI) 6 to 24 months after injury was investigated in children, ages 5 to 14 years, enrolled from consecutive admissions and followed prospectively for 2 years. Injury and preinjury psychosocial variables were assessed. Personality change occurred in 13% of participants between 6 and 12 months after injury and 12% in the second year after injury. Severity of injury consistently predicted personality change, and preinjury adaptive function predicted personality change only in the second year postinjury. Lesions of the superior frontal gyrus were associated with personality change between 6 and 12 months following injury, after controlling for severity of injury and the presence of other brain lesions. Only lesions in the frontal lobe white matter were significantly related to personality change in the second year after injury. After childhood TBI, neural correlates of personality change evolve between 6 and 12 months and 12 to 24 months after injury. The data implicate the dorsal prefrontal cortex and frontal lobe white matter in the emergence of personality change involving the effortful or conscious regulation of affective states.     

Traumatic brain injury and the frontal lobes: What can we gain with diffusion tensor imaging?

Traumatic brain injury (TBI) is a leading cause of death in the young population and long-term disability in relation to pervasive cognitive-behavioural disturbances that follow frontal lobe damage. To date, emphasis has been placed primarily on the clinical correlates of frontal cortex damage, whilst identification of the contribution of subjacent white matter lesion is less clear. Our poor understanding of white matter pathology in TBI is primarily due to the low sensitivity of conventional neuroimaging to identify pathological changes in less severe traumatic injury and the lack of methods to localise white matter pathology onto individual frontal lobe connections. In this paper we focus on the potential contribution of diffusion tensor imaging (DTI) to TBI. Our review of the current literature supports the conclusion that DTI is particularly sensitive to changes in the microstructure of frontal white matter, thus providing a valuable biomarker of the severity of traumatic injury and prognostic indicator of recovery of function. Furthermore we propose an atlas approach to TBI to map white matter lesions onto individual tracts. In the cases presented here we showed a direct correspondence between the clinical manifestations of the patients and the damage to specific white matter tracts. We are confident that in the near future the application of DTI to TBI will improve our understanding of the complex and heterogeneous clinical symptomatology which follows a TBI, especially mild and moderate head injury, which still represents 70-80% of all clinical population.     

Ventral frontal cortex functions and quantified MRI in traumatic brain injury

Ventral frontal cortex is commonly involved in traumatic brain injury (TBI). The smell identification test (SIT), object alternation (OA), and the Iowa gambling task (IGT) are associated with this brain region in experimental and neuropsychological research. We examined the relationship of performance on these tests to residual structural brain integrity quantified from MRI in 58 TBI patients, including 18 patients with focal cortical contusions and 40 patients with diffuse injury only. Image analysis yielded regional volumetric measures of gray matter, white matter and cerebrospinal fluid. Multivariate analyses identified distributed patterns of regional volume loss associated with test performance across all three behavioral measures. The tasks were sensitive to effects of TBI. In multivariate analyses, performance in all three tasks was related to gray matter loss including ventral frontal cortex, but the SIT was most sensitive to ventral frontal cortex damage, even in patients without focal lesions. The SIT was further related to temporal lobe and posterior cingulate/retrosplenial volumes. OA and the IGT were associated with superior medial frontal volumes. Complex tasks, such as OA and the IGT, do not consistently localize to a single cortical region. The SIT is associated with the integrity of ventral frontal regions, but it is also affected by distributed damage, although the contribution of undetected olfactory tract or bulb damage could not be ruled out. This study illustrates the scope and limitations of functional localization in human ventral frontal cortex.     

fNIRS-based investigation of the Stroop task after TBI

To evaluate neural changes during a Stroop task among individuals with TBI using functional near-infrared spectroscopy (fNIRS). Thirteen healthy controls and 14 patients with moderate to severe TBI were included in this study. Oxygenated hemoglobin (HbO) was recorded every tenth of a second using a 52-channel fNIRS unit. Data were acquired using a block design during a Stroop task (i.e., Condition A = Dot Color Naming, Condition B = Incongruent Condition). Visual stimuli were presented on a computer monitor. Behaviorally, response accuracy was similar between groups for condition A, but the TBI group made more errors than the control group during condition B. During condition A, the patient group demonstrated significant increases in HbO within bilateral frontal regions compared to controls (p?<?0.01). When examining the Stroop interference effect (B-A), controls showed increased HbO in bilateral frontal lobes and left inferior parietal region suggesting increased neural response to increased cognitive demand, whereas no differences were detected among the TBI group (p?<?0.05). No between group differences in latency of HbO response was observed during either condition. While the TBI group performed as accurately as controls on the simpler dot color naming condition of the Stroop task, neural activity was greater within the frontal lobes during this relatively simple task among the TBI group suggesting neural inefficiency. Furthermore, the spatial distribution of neural activity related to the interference effect was not different among patients, suggesting the neural demand for the simpler task was comparable to that of the more cognitive demanding task among the TBI sample. The results suggest that fNIRS can identify frontal lobe inefficiency in TBI commonly observed with fMRI.     

The effect of moderate to severe traumatic brain injury (TBI) on different aspects of memory: a selective review

Deficient learning and memory are frequently reported as a consequence of traumatic brain injury (TBI). Because of the diffuse nature of the injury, patients with TBI are not the ideal group for studying brain-behavior relations. Nevertheless, characterization of the memory breakdown following TBI could contribute to the assessment and rehabilitation of this patient population. It is well documented that memory is not a unitary system. Accordingly, in this article I review studies that have investigated the long-term effect of moderate to severe TBI on different memory aspects, including explicit and implicit tests of memory. This review demonstrates that TBI affects a large range of memory aspects. One of the conclusions is that the memory impairment observed in TBI patients could be viewed, at least to some degree, as a consequence of a more general cognitive deficit. Thus, unlike patients suffering from global amnesia, memory in patients with TBI is not selectively impaired. Nevertheless, it is possible to detect a subgroup of patients that do meet the criteria of amnesia. However, the most common vulnerable memory processes following TBI very much resemble the memory deficits reported in patients following frontal lobe damage, e.g., difficulties in applying active or effortful strategy in the learning or retrieval process. The suggested similarity between patients with TBI and those suffering from frontal lobe injury should be viewed cautiously; considering the nature of TBI, patients suffering from such injuries are not a homogeneous group. In view of this limitation, the future challenge in this field will be to identify subgroups of patients, either a priori according to a range of factors such as severity of injury, or a posteriori based on their specific memory deficit characteristics. Such a research approach has the potential of explaining much of the variability in findings reported in the literature on the effect of TBI on memory.     

Problem–solving ability in chronic schizophrenia

Abstract. We tested the hypothesis that patients with schizophrenia are more prone to impairment in planning and problem–solving as compared with normal controls and patients with traumatic brain injury (TBI) by administering the Tower of Hanoi (TOH) task. A total of one hundred and fifty–three participants (51 in each group) were recruited. The performance of the patient groups was markedly worse than normal controls in terms of profile score, number of rule–breaking behaviour, and mean execution time. Two–way 3 (group) x 6 (complexity) ANOVAs indicated that significant main effects of group and complexity were observed in the number of moves, planning time to initiate the first move and subsequent execution time. The general performance of TOH in the schizophrenia group was very similar to that of the TBI group. Subsequent comparison of sub–groups of frontal and posterior lobe damage indicated the pattern of performance in schizophrenia patients lie between them. Taken together, these findings suggest that neither focal frontal nor temporal lobe damage is a sufficient explanation for the problem–solving deficits in patients with schizophrenia.     

Genital automatisms in complex partial seizures

OBJECTIVE: To determine which brain region is responsible for the generation of sexual automatisms. METHODS: Ninety consecutive patients with medically refractory focal epilepsy (74 with temporal lobe and 16 with frontal lobe epilepsy) referred to an epilepsy monitoring unit were studied. The occurrence of the following sexual automatisms was assessed during prolonged video-EEG monitoring: 1) repeatedly grabbing or fondling the genitals and 2) pelvic or truncal thrusting or similar movements. RESULTS: Five patients repeatedly fondled or grabbed their genitals during or immediately after some of their seizures. All five had temporal lobe epilepsy, as evidenced from prolonged video-EEG monitoring, high-resolution MRI, and good to excellent outcome after epilepsy surgery. Sexual automatisms did not occur with frontal lobe epilepsy. CONCLUSION: Sexual automatisms cannot be related exclusively to frontal lobe seizures. As previously proposed, apparently sexual hypermotoric pelvic or truncal movements are common in frontal lobe seizures, but this study suggests that discrete genital automatisms, like fondling and grabbing the genitals, are more common in seizures evolving from the temporal lobe.