Rage reactions of the intensity described above may be encountered in the following medical settings: (1) rarely as part of a temporal lobe seizure; (2) as an episodic reaction without recognizable seizures or other neurologic abnormality, as in certain sociopaths; (3) in the course of a recognizable acute neurologic disease; and (4) with the clouding of consciousness that accompanies a metabolic or toxic encephalopathy; (5) as a reaction to designed psychogenic drugs (dragonfly, K4, and others).
Rage in Temporal Lobe Seizures (See Also “Focal Seizures” in Chap. 15)
According to Gastaut and colleagues, a directed attack of uncontrollable rage may occur either as part of a seizure or as an interictal phenomenon. Some patients describe a gradual heightening of excitability for 2 to 3 days, either before or after a seizure, before bursting into a rage. While such attacks have been observed, they are rare. Geschwind emphasized that a profound deepening of all of the patient’s emotional experiences is a frequent occurrence in temporal lobe epilepsy. A lesser degree of aggressive behavior as part of a temporal lobe seizure is not uncommon; it is usually part of the ictal or postictal behavioral automatism and tends to be brief in duration and poorly directed. Usually, the lesion is in the temporal lobe of the dominant hemisphere.
In some instances of this type, the patient has a life-long history of being hot-headed, intolerant of frustration, and impulsive, exhibiting behavior that would be classified as sociopathic (Chap. 47). There are others, however, who, at certain periods of life, usually adolescence or early adulthood, begin to have episodes of wild, aggressive behavior. Alcohol or some other drug may trigger episodes. One suspects epilepsy, but there is no history of a recognizable seizure or interruption of consciousness, typical of focal temporal lobe epilepsy. We have been consulted from time to time on patients who report a proclivity to anger, cursing, and momentary unreasonableness in behavior that is acquired in adulthood. Each of these patients described a first-order relative with the same traits. Most such individuals are remorseful afterward and otherwise function at a high cognitive level. In a very few such cases, in which aggression has resulted in serious injury to others (or homicide), depth electrodes placed in the amygdaloid nuclear complex have recorded what could be construed as seizure discharges. Attacks of excitement and various autonomic accompaniments have been aroused by stimulation of the same region, and the abnormal behavior has in some instances been relieved by ablation of the abnormally discharging structures. Mark and Ervin have documented a number of examples of this “dyscontrol syndrome,” but we are doubtful that they are truly epileptic.
Violent Behavior in Acute or Chronic Neurologic Disease One encounters patients in whom intense excitement, rage, and aggressiveness begin abruptly in association with an acute neurologic disease or in a phase of partial recovery. In most cases, the medial and anterior temporal lobes have been damaged. Serious head injury with protracted coma may be followed by personality changes consisting of aggressive outbursts, suspiciousness, poor judgment, indifference to the feelings of family, and variable degrees of cognitive impairment. Hemorrhagic leukoencephalitis, lobar hemorrhage, infarction, traumatic contusion, and herpes simplex encephalitis affecting the medial and orbital portions of the frontal lobes and anterior portions of the temporal lobes may have the same effect (Fig. 24-3). Fisher noted the occurrence of intense rage reactions as an aftermath of a dominant temporal lobe lesion that had caused a Wernicke type of aphasia. Cases of this type have also been reported with ruptured aneurysm of the circle of Willis and extension of a pituitary adenoma; references to these reports can be found in the articles of Poeck (1969) and of Pillieri.