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Acute Fear, Anxiety, Elation, and Euphoria
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The phenomenon of acute fear and anxiety occurring as a prelude to or part of a seizure is familiar to every physician Williams s study, already mentioned, is of particular interest; from a series of about 2000 epileptics, he was able to cull 100 patients in whom an emotional experience was part of the seizure Of the latter, 61 experienced feelings of fear and anxiety and 21 experienced depression Daly has made similar observations These clinical data call to mind the effects that had been noted by Pen eld and Jasper when they stimulated the upper, anterior, and inferior parts of the temporal lobe and cingulate gyrus during surgical procedures; frequently the patient described feelings of strangeness, uneasiness, and fear In most instances, consciousness was variably impaired at the same time, and some patients had hallucinatory experiences as well In these cortical stimulations, neuronal circuits subserving fear are coextensive with those of anger; both are thought to lie in the medial part of the temporal lobe and amygdala, as discussed earlier Both in animals and in humans, electrical stimulation in this region
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The normal pattern of sexual behavior in both males and females may be altered by cerebral disease quite apart from impairment due to obvious physical disability or to diseases that destroy or isolate the segmental re ex mechanisms (see Chap 26) Hypersexuality in men or women is a rare but well-documented complication of neurologic disease It has long been believed that lesions of the orbital frontal lobes may remove moralethical restraints and lead to indiscriminate sexual behavior, and that superior frontal lesions may be associated with a general loss of initiative that reduces all impulsivity, including sexual In rare cases, extreme hypersexuality marks the onset of encephalitis or develops gradually with tumors of the temporal region Possibly the limbic parts of the brain are disinhibited, the ones from which MacLean and Ploog could evoke penile erection and orgasm by electrical stimulation (medial dorsal thalamus, medial forebrain bundle, and septal preoptic region) In humans, Heath has observed that stimulation of the ventroseptal area (through depth electrodes)
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can arouse each emotion, but the circuitry subserving fear appears to be located lateral to that of anger and rage Destruction of the central part of the amygdaloid nuclear complex abolishes fear reactions These nuclei are connected to the lateral hypothalamus and midbrain tegmentum, regions from which Monroe and Heath as well as Nashold and associates have been able to evoke feelings of fear and anxiety by electrical stimulation Depression is less frequent as an ictal emotion, although it occurs often enough as an interictal phenomenon (Benson et al) Of interest is the observation that lesions of the dominant hemisphere are more likely than nondominant ones to be attended by an immediate pervasive depression of mood, disproportionate to the degree of severity of physical disability (Robinson et al) We are inclined to the view that the onset of depression after a stroke is a reaction to disability, ie, a reactive depression, akin to that which follows myocardial infarction (Chap 57) Odd mixtures of depression and anxiety are often associated with temporal lobe tumors and less often with tumors of the hypothalamus and third ventricle (see review by Alpers), and they sometimes occur at the onset of a degenerative disease, such as multiple system atrophy Elation and euphoria are less well documented as limbic phenomena, nor has this elevation in mood in some patients with multiple sclerosis ever been adequately explained Feelings of pleasure and satisfaction as well as stirring sensations are unusual but well-described emotional experiences in patients with temporal lobe seizures, and this type of affective response, like that of fear, has been elicited by stimulating several different parts of the temporal lobe (Pen eld and Jasper) In states of hypomania and mania, every experience may be colored by feelings of delight and pleasure and a sense of power, and the patient may remember these experiences after he has recovered
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tensive encephalopathy, amyotrophic lateral sclerosis, and multiple sclerosis, as already indicated; but in a number of less common processes, such as progressive supranuclear palsy and Wilson disease, it may be quite a prominent feature Abrupt onset, of course, points to vascular disease Placidity and Apathy These may be the earliest and most important signs of cerebral disease Clinically, placidity and apathy must be distinguished from the akinesia or bradykinesia of Parkinson disease and the reduced mental activity of depressive illness Here, Alzheimer disease, normal-pressure hydrocephalus, and frontal corpus callosum tumors are the most common pathologic states underlying apathy and placidity, but these disturbances may complicate a variety of other frontal and temporal lesions, such as those occurring with demyelinative disease or as an aftermath of ruptured anterior communicating aneurysm Outbursts of Rage and Violence Most often such an outburst is but another episode in a lifelong sequence of sociopathic behaviors (see Chap 56) More signi cance attaches to its abrupt appearance as a sudden departure from an individual s normal personality If an outburst of rage accompanies a seizure, the rage should be viewed as the consequence of the disruptive effect of seizure activity on temporal lobe function; however, as indicated earlier, an outburst of uncontrolled rage and violence is only rarely a manifestation of psychomotor epilepsy Lesser degrees of poorly directed combative behavior, as part of ictal or postictal automatism, are more common Rarely, rage and aggressivity are expressive of an acute neurologic disease that involves the mediotemporal and orbitofrontal regions, such as a glioma We have several times observed such states in the course of a dementing disease and in a stable individual as a transient expression of an obscure encephalopathy Rage reactions with continuous violent activity must be distinguished from mania, in which there is ight of ideation to the point of incoherence, euphoric or irritable mood, and incessant psychomotor activity; from organic drivenness, in which continuous motor activity, accompanied by no clear ideation occurs, usually in a child, as an aftermath of encephalitis; and from extreme instances of akathisia, where incessant restless movements and pacing may occur in conjunction with extrapyramidal symptoms Extreme Fright and Agitation Here the central problem must be clari ed by determining whether the patient is delirious (clouding of consciousness, psychomotor overactivity, and hallucinations), deluded (schizophrenia), manic (overactive, ight of ideas), or experiencing an isolated panic attack (palpitation, trembling, feeling of suffocation, etc) Rarely does panic prove to be an expression of temporal lobe epilepsy In an adult without a characterologic trait of anxiety, an acute panic attack may signify the onset of a depressive illness or schizophrenia Bizarre Ideation Developing over Weeks or Months While these symptoms are usually due to a psychosis (schizophrenia or manic-depressive disease), one should consider a tumor or other lesion of the temporal lobe, particularly when accompanied by psychomotor seizures, aphasic symptoms, rotatory vertigo (rare), and quadrantic visual eld defects Such states have also been described in hypothalamic disease, suggested by somnolence, diabetes insipidus, visual eld defects, and hydrocephalus (see Chap 27)
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