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Section 8
The Neurology of Explosive Rage:
The Dyscontrol Syndrome
By Frank A. Elliott, M.D.

Question 8 | Test | Table of Contents


Explosive rage triggered by seemingly minimal provocation and accompanied by physical or verbal aggression occurs in two groups of conditions: functional psychoses and personality disorders on the one hand, and neurological and metabolic diseases on the other. The term “dyscontrol syndrome” is sometimes used for symptoms arising from poor impulse control, whether the cause is organic or functional. It is an important cause of wife and child battery, senseless assaults, motiveless homicides, self-injury, dangerously aggressive driving, domestic infidelity, divorce, and (in children) educational and social difficulties. Even if the violence is only verbal, it can destroy domestic relationships and wreck careers. All these disasters, including homicide, are represented in the cases of organic dyscontrol listed in this report.

Prevalence
The prevalence of explosive rage, whether psychogenic or organic in origin, is much underestimated. In the first place, it is often regarded as a quirk of personality rather than a matter for medical concern, especially in strata of society in which violence is so common that it excites little comment. Secondly, few patients are willing to admit to an uncontrollable temper, whether from a sense of shame, fear of commitment, or fear of legal sanctions, and the family often helps in the cover-up. Consequently the true state of affairs does not emerge unless the physician asks the right questions: “Do you have difficulty in controlling your temper? Have you been charged with traffic violations or dangerous driving? Are you especially sensitive to alcohol?” It is also necessary to inquire, but at later interview, about the more delicate question of inability to control sexual impulses, which is present in a few cases.

A third cause of under-reporting is that, despite the extensive literature on violent behavior, little of this information has found its way into medical teaching; we are not taught what to look for, and therefore fail to realize the significance of what we see. Moreover, as several authors have pointed out, we tend to shun violent patients because they can be troublesome. Symptomatic of this attitude is the frequent use of euphemisms in the literature. Patients are described as “irritable” or “hyperresponsive”, or “explosive personalities.”

The Anatomy of Explosive Rage
Experimental and clinical evidence links explosive rage to disorders involving the phylogenetically ancient limbic system, which includes the amygdala and hippocampus of the temporal lobe, the hypothalamus, the fornix, the cingulate gyri and cingulate bundle, the septum pellucidum, and the septal area (see illustration).

The first hint of this relationship was given by Boerhaave who noted that in rabies, which involves the brainstem and hippocampus, the patient may gnash his teeth and snarl like a dog, and in 1892 Gowers spoke of them as “exhausted by attacks of fury.” In the same year Goltz reported that in dogs the removal of a large portion of the forebrain gave rise to savage behavior in response to minor provocation. Since then it has been shown that electrical stimulation of the amygdala can produce either rage or tameness, depending upon the precise placement of the electrodes, and that in man and animals explosive rage can be abolished by bilateral amygdalotomy. In the cat, damage to the ventromedial nucleus of the hypothalamus produces—after a delay of many weeks—a permanently savage animal; paradoxically, electrical stimulation of the same nucleus can elicit aggressive behavior. In man, tumors of the third ventricle and other midline structures can give rise to either rage or profound apathy, and pathological aggression can be abolished by bilateral postero-medial hypothalamotomy. Tumors of the corpus callosum which spread to involve the overlying cingulate gyri usually cause apathy, but explosive rage can occur if the septal area is involved. Bilateral cingulotomy can control aggressive behavior. Repeated attacks of rage were the outstanding feature of a case of a cyst of the septum pellucidum described by Leslie.

These few examples, drawn from an extensive literature, indicate that the limbic system contains within itself mechanisms for the production and control of angry aggression. This does not mean that the system is an autonomous “centre” for aggressive behavior, or that all forms of aggressive behavior are due to disorders of the limbic system. In mature individuals anger is subject to a measure of cortical control and some patients who are given to explosive rage can learn to contain it. On the other hand, in man at any rate, cold, calculating, predatory aggression, carried out for profit, is properly viewed as originating in the neocortex.
- Battered Women. Roy, Maria. Van Nostrand Reinhold Company: New York. 1997.

Personal Reflection Exercise #2
The preceding section was about the neurology of explosive rage. Write three case study examples regarding how you might use the content of this section in your practice.

QUESTION 8
Experimental and clinical evidence links explosive rage to disorders involving which system of the brain? To select and enter your answer go to Test.

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