Differential Diagnosis

• Single most likely diagnosis
  • Epilepsy (specifically, a focal seizure with impaired awareness): The episode of altered behavior, uncharacteristic violence, and lack of recollection are consistent with a seizure. The feeling of intense pleasure beforehand could be an aura, and the abnormal movements of the right hand suggest a focal onset.
• Other Likely diagnoses
  • Psychogenic non-epileptic seizure (PNES): The episode of altered behavior and lack of recollection could be consistent with PNES, especially if there are underlying psychological issues. However, the presence of an aura and focal abnormal movements make epilepsy more likely.
  • Frontal lobe seizure: Similar to epilepsy, but with a specific focus on the frontal lobe, which could explain the violent behavior.
  • Dissociative disorder: The episode of altered behavior and lack of recollection could be consistent with a dissociative disorder, but the presence of an aura and focal abnormal movements make this less likely.
• Do Not Miss diagnoses
  • Encephalitis or meningitis: Infections of the brain or meninges can cause altered behavior, seizures, and focal neurological signs. Although unlikely, these conditions are medical emergencies that require prompt diagnosis and treatment.
  • Space-occupying lesion (e.g., tumor, abscess): A lesion in the brain could cause focal seizures, altered behavior, and other neurological symptoms. Although rare, this diagnosis is critical to rule out due to its potential for serious consequences.
  • Vasculitis or autoimmune encephalitis: These conditions can cause a range of neurological symptoms, including seizures, altered behavior, and focal signs. Although unlikely, they are important to consider due to their potential for serious consequences.
• Rare diagnoses
  • Hypothalamic hamartoma: A rare benign tumor that can cause gelastic seizures (seizures characterized by laughter or a feeling of pleasure).
  • Kluver-Bucy syndrome: A rare condition characterized by altered behavior, hypersexuality, and other symptoms, often caused by a lesion in the temporal lobe.
  • Autoimmune epilepsy: A rare condition in which the immune system attacks the brain, causing seizures and other neurological symptoms.