A case highlighting the association of epilepsy with psychopathology is reported. The patient suffered a rare and extreme behavioral disturbance, characterized by persistent disruptive behavior and intermittent bizarre and violent outbursts. These outbursts often appeared purposeful, but some of them were later diagnosed as ictal manifestations of temporal lobe epilepsy. Temporal lobectomy resulted in remission both of the epilepsy and of the more persistent behavioral disturbance. Ictal behavioral change was masked by interictal behavioral disturbance, leading to delayed diagnosis and prolonged psychosocial dysfunction. It is important to record the paroxysmal abnormal behavior with simultaneous electroencephalographic recording if there is a suspicion of organic disease. Physical and psychosocial factors in the relationship between epilepsy and extreme psychiatric disturbance are considered. This case demonstrates how successful epilepsy treatment may produce amelioration of associated psychiatric disturbance. J. Am. Acad. Child Adolesc. Psychiatry, 1998, 37(10):1085–1090.