Pathologic degrees of motor or mental restlessness and hyperactivity, seen characteristically in delirium tremens, represent the opposite extreme from abulia. Akathisia refers to constant restless movements and inability to sit still; in some patients, this is a consequence of the prolonged use of phenothiazines, butyrophenones, newer antipsychosis drugs, and l-dopa, but it is also seen in a major feature of agitated depressions. Hyperactivity-inattention disorders describe yet another form of excessive motor activity that usually accompanies an attention deficit syndrome of children, mostly boys (attention-deficit hyperactivity disorder [ADHD]). In the manic form of bipolar disease (and to a lesser extent in hypomania), continuous activity and insomnia are added to the flight of ideas and the euphoric (although somewhat irritable) mood. Following certain cerebral diseases, notably some forms of encephalitis and during recovery from traumatic lesions of the frontal lobes, the patient may remain in a state of constant uncontrollable and sometimes destructive activity. Kahn referred to this state as “organic drivenness.”
Disorders of Social Behavior
Behavioral disturbances are common manifestations of all delirious–confusional states, particularly those of toxic–metabolic origin, but also those caused by more obvious structural disease of the brain. The patient may be completely indifferent to all persons around him, or the opposite, when any approach may excite anger and aggressive action. Family members may be treated with disrespect, regarded with suspicion, or falsely accused of harming the patient, stealing his possessions, or trying to poison him. The embarrassment consequent to urinating in public or soiling the bed may be absent and, particularly in men, there may be lewd behavior toward the opposite sex. In its most extreme form, usually seen in the later stages of dementing diseases, irascible behavior degenerates to kicking, screaming, biting, spitting, and an aversion to being touched, making it entirely impossible to approach the patient. These aspects of disordered mental function are the most alarming to the family and are difficult to manage in the hospital. Previously upstanding, socially appropriate, and abstemious persons may lose all regard for their actions and become profligate, gamblers, or alcoholics. In cases of damage to the frontal lobes, even beyond a neglect for social conventions, there can be an indifference to others and to the consequences of the patient’s actions on other members of society.
In contrast, docility and amiable social behavior characterize certain conditions such as Down and Williams syndromes, and social indifference and a lack of ability to interpret the emotional state of others are major features of autism (see “Delirium” later on).
Loss of Insight
The state of being aware of the nature and degree of one’s deficits and their consequences becomes manifestly impaired or abolished in relation to many cerebral diseases, not just those of the frontal lobes. It is common in all but the mildest confusional states. This is reflected by the observation that patients with confusional or dementing states rarely seek advice or help for their illnesses; instead, the family usually brings the patient to the physician or some behavioral anomaly causes police or social services to refer the patients to medical care. And, after the diagnosis has been made, the loss of insight may be reflected in a lack of compliance with planned therapy. It is apparent that diseases that produce abnormalities of insight also reduce the patient’s capacity to make accurate introspections concerning his psychic function.
Lack of insight is a far more complex phenomenon than the operational definition given above suggests. In particular, there are many restricted forms of unawareness of gross neurologic deficits. These are the agnosias, discussed in Chap. 21.