The sign of the cross as a learned ictal automatism?

Described here is a case of a patient who made the sign of the cross during right mesial temporal seizures, documented by intracranial depth electrode and simultaneous scalp video-EEG. The patient was ultimately found to have predominantly left temporal lobe epilepsy, and she was rendered seizure free for many years following a left anterior temporal lobe resection. Most interestingly, however, was a suggestion that in her case, making the sign of the cross may have represented a learned ictal behavioral phenomenon: the patient had been forced, over a period of many years, to make this gesture as an atonement in the postictal period. The movement ultimately came to be performed unconsciously, during the ictus, associated with a lateralized seizure discharge in the right temporal lobe. In contrast to seizure-induced experiential phenomena and typical motor automatisms, where the behavioral manifestations have no recognized association with learning, we wondered whether the pathophysiological mechanisms of chronic focal epilepsy had subserved in this case a psychological learning process, whereby right temporal seizures were ultimately able to recruit and activate an adjacent neural memory circuit.