Also of interest are the effects of slow-growing tumors of the temporal lobe. Malamud described outbursts of rage in association with temporal lobe gliomas. Other of his patients harboring such tumors had no rage reactions but exhibited a clinical picture superficially resembling schizophrenia. It is noteworthy that 8 of the 9 patients with temporal lobe glioma described by Malamud also had seizures. The anteromedial part of the left temporal lobe has been the site of the tumor in the majority of cases. Falconer and Serafetinides have described patients with rage reactions in whom there was a hamartoma or sclerotic focus in this region.
A special form of violent outburst can occur during REM sleep. REM sleep behavior disorder, which may be associated with certain degenerative brain diseases, is detailed in Chap. 18, on Sleep.
Here the patient is not in a clear-headed state and rage or aggression is superimposed on an encephalopathy of toxic or metabolic origin. The most dramatic examples in our experience have been during hypoglycemic reactions. When the patient is left alone, the aggressive behavior is undirected and disorganized, but anyone in the immediate neighborhood may be struck by the agitated individual. Attempts at physical restraint provoke an even more violent reaction.
A similar state may occur with phencyclidine and cocaine intoxication, and with other hallucinogens, accompanied by agitation and, usually, by hallucinosis. Perhaps the most berserk episodes we have encountered have been after ingestion of large amounts of designed street drugs such as the hallucinogen dragonfly and with cannabis derivatives such as K4 (Spice). These furious behaviors may last for hours or days and are resistant to large doses of haloperidol and benzodiazepines. We have found α2-agonists such as dexmedetomidine to be effective. Outbursts of rage and violence with alcohol intoxication are somewhat different in nature: some instances represent a rare paradoxical or idiosyncratic reaction to alcohol (see Chap. 42); more typically alcohol appears to disinhibit an underlying sociopathic behavior pattern.
Animals normally indulge in and display highly energized, exploratory activity of their environment. Some of this activity is motivated by the drive for sexual satisfaction and procurement of food; in humans, it may be a matter of curiosity. These activities are governed by “expectancy circuits,” involving nuclear groups in mesolimbic and mesocortical dopaminergic circuits connected with the diencephalon and mesencephalon via the medial forebrain bundles; lesions that interrupt these connections are said to abolish the expectancy reactions. Positron emission tomography (PET) studies correlate functional difficulty in the initiation of movements with impaired activation of the anterior cingulum, putamen, prefrontal cortex, and supplementary motor area (Playford et al).
A quantitative reduction in all activity is probably the most frequent of all psychobehavioral alterations in patients with cerebral disease, particularly in those with involvement of the anterior parts of the frontal lobes. There are fewer thoughts, fewer words uttered, and fewer movements per unit of time. That this is not a purely motor phenomenon is disclosed in conversation with the patient, who seems to perceive and think more slowly, to make fewer associations with a given idea, to initiate speech less frequently, and to exhibit less inquisitiveness and interest. This reduction in psychomotor activity is recognized as a striking personality change by the family.
Depending on how this state is viewed, it may be interpreted as a heightened threshold to stimulation, inattentiveness or inability to maintain an attentive attitude, impaired thinking, apathy, or lack of impulse (abulia). In a sense, all are correct, for each represents a different aspect of the reduced mental activity. Impairment of learning and memory functions may be added. Typically, the patient is attentive, wide awake, and looks around. If recovery occurs, memory is retained for all that happened. In this respect, abulia differs from stupor and hypersomnolence.