Seizure 42 (2016) 44–48Contents lists available at ScienceDirect
Seizure
journal homepage: www.else vie r .com/ locat e/y seiz
Ictal kissing: Electroclinical features of an unusual ictal phenomenon$
Çig
dem Özkaraa,*, Emine Taşkıranb, I_   rem Yıldırım c Çarpraz , Erhan c Bilir ,
Aylin Bican Demird, I_  brahim Borad, I_brahim Aydog
due, Şakir Delila, Francine Chassouxf
aDepartment of Neurology, Cerrahpaşa Medical Faculty, Istanbul University, Istanbul, Turkey
bDepartment of Neurosurgery, Cerrahpaşa Medical Faculty, Istanbul University, Istanbul, Turkey
cDepartment of Neurology, Medical Faculty, Gazi University, Ankara, Turkey
dDepartment of Neurology, Medical 
 Faculty, Uludag University, Bursa, Turkey
eDepartment of Neurology, Medical Faculty, Ege University, Izmir, Turkey
f Centre Hospitalier Sainte Anne, Paris, France
A R T I C L E I N F O A B S T R A C T
Article history: Purpose: The study aimed to describe the electroclinical features of ictal kissing, an unusual behavior that
Received 6 June 2016 may occur during focal seizures.
Received in revised form 10 September 2016 Method: Twenty-five patients collected from four epilepsy centers and previously published reports were
Accepted 23 September 2016 reviewed for their demographic, clinical, and electrophysiological features.
Results: Sixteen of 25 patients were female. The mean age was 32.9 years (9.9–51 years) and the average
Keywords: age at seizure onset was 14.5 years. All seizures were localized to the temporal lobe (TL) and lateralized to
Ictal kissing right side in 17 patients, left side in 2 patients, and unclear in 6 patients. A total of 55 ictal video
Temporal lobe
Limbic sytem electroencephalograms (EEGs) were analyzed. There were other symptoms such as speaking, spitting, 
Epilepsy hugging, and oral and upper-extremity automatisms along with different types of ictal kissing behavior
Emotion during the seizures. The median duration of all seizures was 106.7 
 73.73 s. Kissing occurred at a median
Automatism time of 71 s (1–95 s) after the onset of seizure, and ictal epileptiform discharges usually involved TL
during kissing episode.
Conclusion: Ictal kissing is mainly associated with right TL and female gender, although association with
left TL may also occurs, possibly related to the circuits involving temporo-insular structures.
ã 2016 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.1. Introduction
Automatisms are more or less coordinated, repetitive, motor
activities that occur when cognition is usually impaired. They often
resemble a voluntary movement and may consist of an inappro-
priate continuation of ongoing preictal motor activity. The patient
usually becomes amnesic for these events [1]. Automatisms are
categorized as oroalimentary, mimetic, manual or pedal, gestural,
hyperkinetic, hypokinetic, dysphasic, dyspraxic, gelastic, dacrystic,
vocal, verbal, spontaneous and interactive in the International
League Against Epilepsy (ILAE) report of seizure semiology [1].
Some automatisms have lateralizing and localizing value [2] but$ This research did not receive any specific grant from funding agencies in the
public, commercial, or not-for-profit sectors.
* Corresponding author at: Istanbul University, Cerrahpasa Faculty of Medicine,
Department of Neurology, Fatih, Istanbul, Turkey. Fax: +90 212 633 01 76.
E-mail addresses: cigdem.ozkara@gmail.com, cigdemoz@istanbul.edu.tr
(Ç. Özkara).
http://dx.doi.org/10.1016/j.seizure.2016.09.013
1059-1311/ã 2016 British Epilepsy Association. Published by Elsevier Ltd. All rights restheir mechanisms and related inner driving sources are still need
to be investigated.
Ictal kissing is a rare automatism observed during focal
seizures. Only nine patients have been reported previously in
the literature. The seizures were localized mainly to TL in all and
lateralized to right hemisphere in eight of them [2–7]. Although
the clinical significance remains unclear, the occurrence of ictal
kissing was found to be associated with common psychological
features [7]. We report 16 additional cases from different centers
with ictal kissing and reviewed the previously reported nine
(4 from our center) cases. In 15 of them, we were able to analyze
the semiologic and electroencephalographic features associated
with ictal kissing automatism.
2. Methods
Medical records of 20 patients with documented ictal kissing
were provided from four epilepsy centers. Demographic, clinical,
video EEG, and imaging data, if available, were analyzed anderved.
C. Özkara et al. / Seizure 42 (2016) 44–48 45reviewed, including the previously reported 9 patients in the
literature [2–7].
All patients were resistant to antiepileptic drug medication and
subjected to pre-surgical evaluation, including inter-ictal and ictal
video EEG, magnetic resonance (MR) imaging, and FDG-PET in 15 of
them. Ictal video EEG recordings, which were available from
15 patients, were analyzed considering detailed semiologic and
electroencephalographic characteristics such as total seizure
duration, timing of kissing automatism, and other features of
the seizures.
3. Results
The demographic and clinical data of 25 patients are presented in
Table 1. Sixty-four percent of the patients were female. The mean age
was 32.9 years (9.9–51 years). The average age at seizure onset was
14.5 years (5–23 years). All patients had focal seizures, with or
without secondary generalization. Twenty-two patients were on at
least one antiepileptic drug; three patients did not take any drug
because they were seizure free. Past history was remarkable with
febrile seizures in 7, viral meningitis in 1, neonatal asphyxia in 2,
unremarkable or unknown in 16 patients. Neuropsychological
evaluation which was available in 13 patients revealed material
specific memory deficits in 8 (P1, 2, 4, 10, 11, 12, 13, 19, 20), attention
deficits in 4 (P3,11,12,13) and visuospatial deficits in 2 patients (P14,
16) and normal IQ in all. Psychiatric interview disclosed traumatic
childhood and unfulfilled affective needs with major depression in
4 patients who were published separately (P1, 2, 3, 4) [7]. Depression
was also diagnosed in 1 more patient (P19). However further
information related to their psychosocial status cannot be obtained
in other patients as they were recruited from different centers.
Nine patients out of 25 underwent surgery, all but one after
non-invasive investigations (P1,10,12,14,15,17, 21, 24 and 25). One
of these surgical patients, who was from Paris, underwent
stereoelectroencephalography (SEEG) prior to surgery. Eight
patients were seizure free since then. Three patients refused
surgery and five were on the waiting list.
Fifty-five ictal video EEGs obtained from 15 patients were
analyzed. Ictal kissing was observed in 28 events (50.9%) where TL
was involved at the time of kissing in all of them. The seizure onset
was located in the TL in 13 patients (10 on the right side, 3 on the
left) and was not determined in two patients because of movement
artifacts and hypermotor behavior.
Although the majority of the patients had right temporal
epileptiform discharges on inter-ictal EEG, they were bilateral in
four with a prominence of left TL in two patients (P5, 7). Both inter-
ictal and ictal EEG demonstrated left-sided abnormality in two
patients (P4, 15). SEEG investigation was recorded in only one
patient (P10), who revealed the involvement of temporal pole and
lateral temporal neocortex with propagation to the frontal lobe.
Unfortunately, kissing automatism was not observed during this
intracranial recording. Subdural recording was performed in P25,
who was one of the previously reported cases. It demonstrated
epileptiform discharges on the right frontal lobe during kissing.
The hand dominance was right in 16 right temporal lobe epilepsy
(TLE) patients, left in 2 right TLE (P2, 10), left hemispheric
dominance in one (P10) of those was demonstrated by the Wada
test, and left in only one left TLE patient (P4). The hand dominance
was not determined in one patient.
3.1. Semiologic features of seizures
The median duration of all seizures was 76.5 s (5–283 s). Kissing
occurred after a median time of 71 s (1–195 s) of seizure onset and
was usually preceded by other behaviors such as ictal speech and
oral and upper-extremity automatisms. Four patients presentedictal kissing within the first 35 s (5–33 s) after the onset while it
occurred after 35 s in the rest of the patients. Consciousness was
partially preserved in 16 seizures arising from right but not left TL.
Aura was described in 13 of 20 patients. Epigastric sensation
was the most frequent aura, followed by dreamy state, experiential
visual sensations, tinnitus, goose bumps, nausea, smelling
unpleasant odors, feelings of confusion, fear, strange sensation,
headache, staggers, and anxiety.
The kissing behavior differed from one patient to another. It was
not stereotypical even in the same patient. Six patients blew kisses
to the air during the seizure. Nearly half of the patients kissed the
hands or arm, one third of them kissed the cheek of the individuals
around, and one young woman engaged compulsively in lip kissing
(P4), which was accompanied by other behaviors such as water
drinking, speaking, and hand automatisms. This interesting patient
had left-sided hippocampal sclerosis (HS) on MRI with left-sided
ictal and inter-ictal epileptiform activity on EEG. Moreover patients
did not show any mirthful emotion but either sadness or neutral
during kissing behavior.
Seizures were always diurnal in all 20 patients except one (P8)
having seizures soon after she fell asleep, which were character-
ized by staring, lip smacking, and blowing kisses with incompre-
hensible speech. She had normal MRI and right-sided epileptiform
activity on EEG.
3.2. Imaging
MRI scan revealed lesions within the TL in 15 including mesial
temporal sclerosis (MTS) in 14 (11 right, 2 left, 1 bilateral), arterio-
venous malformation (AVM) in 1. Other observed lesions included
cortical dysplasia, posterior cerebral artery (PCA) infarct, AVM, and
frontal cortical and subcortical gliosis where it was normal in seven
(Table 1). MRI was normal, but histopathology was cortical
dysplasia type IIa in one (P21).
FDG-PET was available in 15 patients, which showed hypo-
metabolism at TL in 14 (left in 2, right in 12) and was normal in one
(Table 1).
In all patients with abnormal imaging, inter-ictal or ictal EEG
abnormalities correlated with the lesional areas.
4. Discussion
Careful analysis of ictal semiology is crucial for delineation of
epileptogenic zone. In this context, each ictal phenomenon reflects
the involvement of cortical regions by the epileptic discharge from
onset to propagation and is investigated in terms of lateralizing
and localizing importance. Several semiologic features are
described and listed by the ILAE terminology task force, such as
motor, nonmotor, and autonomic behaviors [1]. Automatisms are
classified as motor symptoms and defined as a more or less
coordinated, repetitive motor activity usually occurring when
cognition is impaired; the subject does not remember them
afterward. The automatisms often resemble a voluntary movement
and may consist of inappropriate continuation of ongoing preictal
motor activity in the same report [1]. There is a variety of
automatisms, such as oral, mimetic, manual, pedal, gesture, and
other presentations. Kissing was not mentioned in this report [1],
although it may partly fit oral automatisms when lip smacking, lip
pursing, chewing, licking, tooth grinding, and swallowing were
listed in this group. This may be due to its rare occurrence, as was
reflected by only nine patients reported in the literature, four of
which were those from 11 patients belonging to our center [2–7].
The mechanism of automatisms has three main speculative
explanations. They may emerge as a reaction to internal stimuli, as
an activation of a specific motor program with cortical stimulation,
or as the removal of inhibitor control as a release phenomenon [8].
46 C. Özkara et al. / Seizure 42 (2016) 44–48Table 1
Electroclinical and imaging features of patients with ictal kissing automatism.
Patients Gender/ Age at Handed MRI PET hypo- Inter-ictal EEG Ictal EEG Aura Associated ictal behaviors
age onset metabolism epileptiform
(yrs) (yrs) activity
P1,FS* F/28 16 R R MTS None R> LT R FT, spreading to bil FT Epigastric Religious speech, oral automatism, ictal water drinking, kissing
sensation technician’s hand, blowing kisses
P2,NM* F/35 17 L R MTS R T R T R> LT Feeling dreamlike Oroalimentary automatism, raising L hand, kissing cheek
and in another
place
P3,CG* M/26 16 R normal RT RT R> LT Tinnitus in the R Oroalimentary automatism, speech, blowing kisses, coughing
ear, goose bumps
P4,NI* F/29 5 L L MTS LT LT LT Smelling, bad Speech, L-hand automatism, water drinking, R-hand dystonia, kisses
odors from lip
P5,NG F/20 9 R Normal R T L >RT Nonlateralizing and None Hypermotor automatisms, L-hand dystonic posture, coughing, kisses
localizing ictal onset late from hand, religious speech, crying
built up at LT
P6,GO F/51 22 R R MTS R T R T R FT Palpitation, Oral automatism, bil upper-extremity automatism, kissing from cheek
paraphasia
P7,MR F/29 18 R Normal None Bil ant T None None Hand automatism, water drinking, hugging and kissing from cheek
P8,MS F/24 23 R Normal None R ant T None None Oroalimentary automatism, incomprehensible speech, blowing kisses
P9,BA1 M/46 12 R L T and O gliosis None L OT None Headache, grayout Hand automatism, blowing kisses
(PCA infarct)
P10,SF M/41 10 L R MTS R T- R T R TF Epigastric Oro-alimentary automatism,whistle, gargle, sucking, foreign-language
F_Insular sensation, nausea ictal speech, dance-like movements, pedaling, kissing from hand,
spitting
P11,FEO M/31 5 R Normal R T R T R T None Oroalimentary automatism, religious speech, utterance of noises,
kissing from hand
P12,GÖ F/32 12 R R MTS and O R T R T R T None Fondling on arm, kissing from cheek and arm
Ulegyria
P13,AD M/25 10 R R MTS R T R T R T Confusion feeling Right-hand and oral automatism, groaning, kissing from hand, hugging
P14,ZD F/23 17 R R MTS R T R T R T Strange sensation Staring, kissing from hand, R-hand automatism, L-arm dystonia,
religious speech
P15,KT M/20 9 R L MTS L T L T L T Epigastric Staring, kissing from hand, spitting, vomiting, incomprehensible
sensation speech
P16,FG F/22 9 R P neuronal R T R T R T, spreading to all R Anxiety Screaming, fear, hypermotor behavior, oral and R-hand automatism,
migration anomaly hemisphere kissing from cheek
P17,SSK F/41 9 R R MTS None R T R T None Staring, confusion, kissing from cheek, speech, R-hand automatism, L-
arm dystonia
P18,MG M/44 12 Unknown Normal Unavailable R > LT None None Aggression, hypermotor behaviors, blowing kisses, spitting
P19, BA2 F/32 5 R Bil MTS Normal L T L >RT Fear Oral and hand automatism, blowing kisses
P20, IK M/37 21 R L T AVM None None None Nausea, dry Speech, blowing kisses, bottom lip
mouth, taste
P21. Rashid F/39 33 R Normal R T R T R T Nausea Tingling arms and legs, oral automatism, blowing kisses, kissing from
et al. [5] hand
P22. F/46 26 R R MTS None SW, R T R T, spreading to the R > L F None Whimpering, oral automatism, fumbling with R hand, L-arm dystonic
Rashid posturing, hugging, kissing from cheek
et al. [5]
P23. F/48 18 R R MTS None SW, R > LT R FT, spreading to bil FT Warm, rising staring, repetitive leg movements, fumbling R hand, oral automatism,
Rashid sensation blowing kisses
et al. [5]
P24. Mikati M/24 10 R R MTS None Unknown R T, in some seizures evolving None Altered consciousness, spitting, repetitive hugging and affective
et al. [4] to bil FT kissing, head and eye deviation to the L
P25. F/29 19 R R F small cortical R T SW, R T R FT None R-hand automatism, L-arm dystonic posturing, lip smacking, hugging
Alsemari and subcortical and kissing her relative and/or attendant nurse with emotional
et al. [6] lesions gestures
Abbreviations: M—male; F—female; yrs—years; R—right; L—left; MTS—mesiotemporal sclerosis; T—temporal; OT—occipitotemporal; TF—temporofrontal; FT—frontotemporal; AVM—arteriovenous malformation; bil—bilateral.
C. Özkara et al. / Seizure 42 (2016) 44–48 47Swallowing due to excessive salivation may be an example for the
first hypothesis. The second mechanism refers to cortical activa-
tion of functionally localized behavior such as simple motor
movements usually when the patient is awake. This mechanism
may partly explain the emergence of automatisms, although some
case reports describe electrical cortical stimulation of insular
operculum, hippocampus, amygdala, and mesial frontal lobe–
induced oral automatisms [8,9] and stimulation of hypothalamic
hamartomas-induced laughing and crying [10]. By definition, more
complex, semi-purposeful automatic movements are seen when
the cognition is impaired, and such ictal events including kissing
automatism has never been reported to be induced by cortical
stimulation. The third mechanism proposing the temporary loss of
neocortical control leading to release phenomena may be
supported by the presence of similar stereotypic behavior in other
neurological disorders such as autism, dementia, and schizophre-
nia [11,12]. Moreover a dysmnesic phenomena, such as a
recurrence of a scene from the past with a strong emotional
connotation may also be suggested as a fourth mechanism (P10).
Epileptic seizures may cause not only excitation but also
inhibition of ongoing neuronal activity, leading to behavioral
dysfunction or disinhibition. Central pattern generators (CPGs)
located in the brain stem and spinal cord are essential for survival,
such as feeding-, locomotion-, and/or reproduction-inducing
behavior or emotions, along with innate motor patterns [13].
Kissing behavior may emerge after loss of inhibition on CPGs as an
innate behavior pattern during an ictal event; originate from daily
life activities; be inducement of an emotional connection,
including demonstration of love for a special person; or be a sign
of deferential behavior. Thus, the patients may share similar
complex emotional backgrounds. From this perspective, ictal
kissing may also be the result of reaction to an internal stimulus
occurring as a specific pattern of behavior in relation to loss of
conscious control or cortical inhibition.
From a psychological perspective, ictal kissing behavior may be
the expression of many kinds of feelings, such as love, respect, and
kindness. Except for some African tribes who consider kissing a
disgusting gesture, kissing in almost all cultures is a common social
interaction starting in early childhood [14]. It may be the reflection
of love and sexual desires with emotional bond or of the respect for
the person whose hand is kissed. Kissing stimulates the secretion
of endorphins during breast feeding when an innate infant
behavior resembling kissing induces oxytocin, a facilitator to pair
bonding and parental care [15]. Erotic kissing may originate from
behaviors related to feeding offspring or in birds feeding their
partners before mating. This behavior also includes feelings of
safety and trust, which are important features of the pair bond
between mother and child [14]. Our psychoanalytic investigation
of a small group of patients with ictal kissing revealed traumatic
childhood histories and intense unfulfilled affective needs with
major depression in all. In that report we proposed that the past
negative experiences and need for love may manifest itself through
the content of seizures as a desire to kiss or to be kissed [7].
Kissing is an emotional behavior. The limbic system which is
composed of the amygdala, hippocampus, parts of the thalamus,
and other structures (mammillary body, cingulate gyrus, fornix)
has a mojor role in producing emotion. It is a kind of “primitive
core” of the brain strongly associated with emotion. In lower
animals, the limbic system helps organize basic survival responses,
such a feeding, fighting, or reproduction where an obvious link to
emotion remains in humans [16].
Emotional behaviors may change according to the gender,
which is attributed to anatomo-functional differences in the mesial
temporal region [17]. Expression patterns of some behaviors in
male or female could be related to the their various unresolved
stages of a love relationship and cultural differences [18]. Althoughfemales consisted of the majority of the patients, there was no
association between type of kissing pattern and gender in this
study. Overall, we observed kissing from the hand or arm (40%),
from the cheek (30%), and from the lips and blowing kisses (30%)
without a specific gender predilection. Interestingly, the kissing
behaviors were not stereotypical even in the same patient, which
may be due to distraction by the environment. Therefore, an
association between gender and variable kissing patterns in terms
of anatomo-functional link remains speculative.
Kissing automatism is known to be rare but it is not possible to
estimate the real incidence in this group of patients as all of them
were from a selected population of surgical candidates which is the
major weakness of this study. Moreover, the wide difference at the
time of occurrence of kissing after a seizure onset, duration of
seizures, variety of phenomenology even in a single patient,
various underlying etiology, epileptogenic zone extending beyond
TL even extra temporal localization implies that the kissing
phenomenon is something reflecting a wide network activation by
seizure discharge propagation and thus TL involvement rather than
the being origin of it. Moreover, “tuning” of the emotional system
pre-ictally can be different from one moment to another which is
modulated by the limbic system and its connections, the pivotal
epileptogenic zone responsible for emotion related ictal signs as
mentioned above. This may explain the variability of the
occurrence within the seizures and among the patients as well.
The epileptogenic zone was demonstrated to be related to right/
language nondominant TL inprevious reports [3–6] except one [7]. In
this series of 25 patients (including the previously reported
5 patients) it was related to the right side in 16, left side in 4, and
unclear in 5 patients due to normal or bilateral MRI and EEG findings.
Rashid et al. implied that the importance of the preservation of
responsiveness and ictal speech were necessary for ictal kissing to
interact sufficiently with the environment [5]; however, the
epileptogenic zone in two of our patients was on the dominant TL
without speech and responsiveness during the seizure.
Lateralization of brain functions was defined for language-
related areas and for different functions, including emotion
processing. The right hemisphere was postulated to be responsible
for emotional processing [19], whereas valence theory proposes
that lateralization depends on the type of emotion; in this view,
happiness and affiliated emotions would be processed predomi-
nantly by the left hemisphere, and sadness by the right hemisphere
[20]. A majority of patients with ictal kissing have shown right-
hemisphere involvement without showing and happiness, which
may accord with both hypothesis. Not handedness but the type of
brain structures [21] was shown to be responsible in emotional
processing, which may explain the occurrence of ictal kissing in
patients with left-handed or left-hemispheric involvement.
All available video EEG recordings with kissing revealed ictal
discharges related to TL even in the patient with parietal cortical
malformation who had discharges propagating to right TL at early
phase. Three previously presented patients were also reported to
have right-TL involvement [5], whereas one with a right–frontal lobe
lesionwho was explored with subdural electrodes demonstrated the
spread to frontal from right mesial temporal who underwent
resection of both frontal lesion and and temporal lobectomy with
amigdalohippocampectomy [6]. One case with ictal kissing and
spitting precipitated by specific patterns was reported to have right
mesial temporal lesion and low-grade astrocytoma and remained
seizure free after surgery [4]. Temporal lobes were bilaterally
involved in three patients (P2, 3,19). There may be some relation to
Klüver–Bucy syndrome, which is presented by hyperorality and
inappropriate sexual behaviors like the previously reported patient
with ictal kissing [5] and ictal hyperorality [22]. The fact that the
majority of cases showed one-sided involvement depending on this
rare syndrome will not be valid for all patients.
48 C. Özkara et al. / Seizure 42 (2016) 44–48Thus, whether unilateral or bilateral, the majority of patients
presenting with ictal kissing in this study correlated with mainly
TL involvement according to the scalp EEG, which fails to show the
involvement of deep structures such as insula, although SEEG
investigation in one patient revealed insula to be included in the
epileptogenic area. However, involvement of the insular cortex in
almost all subgroups of TL epilepsies which was demonstrated in
PET studies [23] is well-known fact, which contributes the
mechanistic explanation of kissing automatism.
Several studies demonstrated the prominent role of right anterior
insula, a phylogeneticallyarchaic allocortical structure, inprocessing
emotion regardless of handedness and its significance as the
principal structure of the cranial nerve system responsible for
sentience and self-consciousness [24–26], right hemispheric activa-
tion dominanceduringsadness,andcontralateraldominancerelated
to happiness. It is not easy to consider kissing as a negative emotion;
however, ictal discharges may have both inhibitory and excitatory
effects. However, none of the patients were joyful but either sad or
neutral. Therefore, kissing may well be the resultof activation of right
hemisphere with negative emotions.
Responsiveness may be preserved in patients when the
nondominant hemisphere is involved during the seizure. However,
they continue to have different types of automatisms, and they can
respond to the examiner without being able to recall the event at all.
One can argue whether the consciousness is impaired during these
seizures. Our understanding and assessment of ictal consciousness,
focusing on both subjective and behavioral aspects of seizures, need
to be considered here. There have been suggestions that both the
internal and external milieu-the former related to the phenomenal
qualiaof experience, the latterrelatedtobehavior-mustbetaken into
account for a better understanding of altered states of consciousness
in epilepsy. A bidimensional model, in which any manifestation of
conscious experience can be plotted according to the level and
contents of consciousness, was proposed when the level axis
measures the degree of alertness/arousal, whereas the contents axis
measures the vividness of specific experiential phenomena reported
by the patient. In a recent paper it was argued that certain seizure
types might require more rigorous conceptual models for their
characterization, a three-dimensional model that includes a further
dimension related to the self, in addition to those of level and
contents [27]. A complex behavior such as kissing occurring while
the awareness and partial content is preserved during a seizure can
also beexplainedby the impactofa self-componentofconsciousness
according to the new proposal. And while the anterior-dorsal insula
wasregardedasthefinal stageofahierarchical processing,startingin
the posterior insula with pure sensory information, then integrating
emotional and cognitive valuation, ending in the anterior-dorsal
insular region with a full representation of a “sentient self,” the sine
qua non of self- awareness [28], invasion of insula with seizure
discharge may well responsible of disruption of self component of
consciousness as proposed.
5. Conclusion
Kissing automatism is a complex and rare ictal phenomenon,
associated with TLE but in itself reflecting the activation and/or
inhibition of networks involved with rather basic innate behavioral
patterns more than strict TLE pathology. It is correlated mainly
with right-TLE with a predilection in females. However, involve-
ment of dominant TL and male gender is rare but also possible.
Although the precise mechanism remains obscure, it may occur as
a release or dysmnestic phenomenon rather than a cortical
stimulation, possibly due to firing of extensive circuits centered at
the insular and TL or as the result of internal stimulation that
facilitates CPG with loss of conscious control.Conflict of interest statement
None of the authors has any conflict of interest to disclose.
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