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Aggressiveness, Anger, Rage, and Violence
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Aggressiveness is an integral part of social behavior The emergence of this trait early in life enables the individual to secure a position in the family and later in an ever-widening social circle Individual differences, probably inherited, are noteworthy Timidity, for example, is a persistent trait, recognized in infancy (Kagan) Males tend to be more aggressive than females The degree to which excessively aggressive behavior is tolerated varies in different cultures In most civilized societies, tantrums, rage reactions, and outbursts of violence and destructiveness are not condoned, and one of the principal objectives of training and education is the suppression and sublimation of such behavior The rate at which this developmental process proceeds varies from one individual to another In some, especially males and the mentally backward, it is not complete until 25 to 30 years of age; until that time, the deviant behavior is called sociopathy (see Chap 28) Undoubtedly, from our own casual and others more systematic observations, this is in part an inherited tendency That seemingly groundless outbreaks of unbridled but disorganized rage may rarely represent the initial or main manifestation of disease is not fully appreciated A patient with these symptoms may, with little provocation, change from a reasonable state to one of the wildest rage, with a blindly furious impulse to violence and destruction In such states the patient appears out of contact with reality and is impervious to all argument or pleading As far as one can tell, this pattern of behavior is associated with a feeling of anger What is so obviously abnormal is the provocation of the attack by some tri ing event and a degree of violence that is out of all proportion to the stimulus There are examples also of a dissociation of affect and behavior in which the patient may spit, cry out, attack, or bite without seeming to be angry This is especially true of the mentally retarded
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Although the functional anatomy of these states of anger, rage, and aggressiveness has not been fully established, all the human and animal data point to an origin in the temporal lobes and particularly in the amygdala In humans, stimulation of the medial amygdaloid nuclei, through depth electrodes, evokes a display of anger, whereas stimulation of the lateral nuclei does not; destruction of the amygdaloid complex bilaterally reportedly reduces aggressiveness (Kiloh; Narabayashi et al) (Lesions in the mediodorsal thalamic nuclei, which receive projections from the amygdaloid nuclei, render humans more placid and docile) In an unintended experiment in a patient with Parkinson disease, Bejjani and colleagues found that aggressive behavior could be induced by stimulation of the posteromedial hypothalamus As with the comparable elicitation of depression from an aberrant electrode in the substantia nigra that was reported by the same group, it is not clear whether the effect was due to changes in adjacent neuronal pathways or whether the physiologic response was excitatory or the result of inhibition of neuronal activity Sex hormones in uence the activity of these temporal lobe circuits; testosterone promotes aggressiveness and estradiol suppresses it, suggesting an explanation for sex differences in the disposition to anger Surprisingly, propranolol and lithium have bene ted such patients more than haloperidol, the phenothiazine drugs, or sedatives Observations in experimental animals have corroborated the observations in humans As mentioned earlier, bilateral removal of the amygdaloid nuclei in the macaque greatly reduces the reactions of fear and anger Electrical stimulation in or near the amygdala of the unanesthetized cat yields a variety of motor and vegetative responses One of these has been referred to as the fear or ight response, in which the animal appears frightened and runs away and hides; another is the anger or defense reaction, characterized by growling, hissing, and piloerection However, structures other than the amygdaloid nuclei are also involved in these reactions Lesions in the ventromedial nuclei of the hypothalamus (which receive an abundant projection of bers from the amygdaloid nuclei via the stria medullaris and possibly the ventral amygdala fugal pathway) have been shown to cause aggressive behavior, and bilateral ablation of Brodmann area 24 (rostral cingulate gyrus) has produced the opposite state tameness and reduced aggressiveness, at least in some species 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; or (4) with the clouding of consciousness that accompanies a metabolic or toxic encephalopathy Each of these circumstances is considered below Rage in Temporal Lobe Seizures (See also page 277) 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 Certainly such attacks have been observed, but they are very rare However, 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 Similarly, a feeling of rage or severe anger occurs but is relatively infrequent
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as an ictal emotion much less common than feelings of fear, sadness, or pleasure (Williams reported only 17 cases of anger among 165 patients with ictal emotion) Geschwind has emphasized the frequency of a profound deepening of all of the patient s emotional experiences in temporal lobe epilepsy Rage Attacks without Apparent Seizure Activity In some instances of this type, the patient had from early life been hot-headed, intolerant of frustration, and impulsive, exhibiting behavior that would be classed as sociopathic (Chap 56) 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 set them off One suspects epilepsy, but there is no history of a recognizable seizure and no interruption of consciousness, which is so typical of complex partial epilepsy We have been consulted from time to time by patients (men and suprisingly, also women) who report a proclivity to anger, cursing, and momentary unreasonableness in behavior that is acquired in adulthood; the question was of seizures as the cause Usually such individuals are remorseful afterwards and otherwise function at a high cognitive level, but others have been sociopaths The electroencephalogram (EEG) is either normal or nonspeci cally abnormal This seems to be an inherited trait 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 From time to time 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 are implicated Cranial trauma is the most frequent cause of what has been called organic personality disorder of the explosive type 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, and herpes simplex encephalitis affecting the medio-orbital portions of the frontal lobes and anterior portions of the temporal lobes may have the same effect (Fig 25-3) Fisher has 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 Also of interest in this connection are the effects of slowgrowing tumors of the temporal lobe Malamud described outbursts of rage in association with temporal lobe gliomas Other patients harboring such tumors had no rage reactions but exhibited a clinical picture super cially resembling schizophrenia It is noteworthy that 8 of the 9 patients with temporal lobe glioma described by Malamud also had seizures Several similar examples have been reported (see Poeck for references) The anteromedial part of the left temporal lobe has been the site of the tumor
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