Violence. The neurologic contribution: an overview.

The role of cultural forces in either promoting or discouraging interpersonal violence is so obvious that it has been allowed to obscure the part played by biologic disorders in determining responses to endogenous and environmental challenges. Neuroscientists and clinicians have demonstrated, however, that aggression has a neuroanatomic and chemical basis, that developmental and acquired brain disorders contribute to recurrent interpersonal violence, that both biologic and sociologic factors are involved, and that to ignore either is to invite error.

Violence: a product of biosocial interactions.

All behavior is seen to be a result of interactions between the brain on the one hand and environmental challenges and endogenous drives on the other. Intergenerational transfer theory fails to explain cases of habitual aggression that have no identifiable social origin, and there is compelling evidence for the existence of brain-environmental interaction. The key roles that may be played by age, gender, neurological factors, and biological defects in aggressive and antisocial behavior are reviewed.

Historical perspective on neurobehavior.

The current penetration of psychology, psychiatry, and sociology by neurobiologists is traced from its slow inception in the nineteenth century to the exponential explosion of information in recent decades, which has shown that behavior is a biosocial phenomenon, resulting from interactions between the brain and the environment. Therefore, to exclude either from the equation is to invite error.

The episodic dyscontrol syndrome and aggression.

This article concerns the syndrome of episodic dyscontrol, not psychopathic behavior. It is discussed as a symptom of many disorders, both psychologic and physical; organic causes and correlates, pathophysiology, and pharmacologic treatment are given.

Neurological findings in adult minimal brain dysfunction and the dyscontrol syndrome.

This paper reports the neurological findings in 286 patients with a history of recurrent attacks of uncontrollable rage occurring with little or no provocation and dating from early childhood or from a physical brain insult at a later date. Objective evidence of developmental or acquired brain defects was found in 94 per cent. The most common abnormality was minimal brain dysfunction, which was present in 41 per cent. The diagnosis was not made on behavioral symptoms alone; there had to be positive neurological and/or laboratory evidence (electroencephalogram, computerized axial tomography scan, x-rays, psychological tests). The most common symptom apart form episodic dyscontrol was complex partial seizures which had occurred at some time in the life of 30 per cent of the patients. In many the seizures had not been recognized as epileptic because of their subtle form and rare occurrence. Convulsions and dramatic attacks with unconsciousness were rare. One third of the patients presented a variety of psychiatric disorders persisting for days, weeks, or months in addition to episodic rage. Another type of periodicity was exhibited by women whose episodes occurred solely or mainly in the premenstrual week. Detection of both adult minimal brain dysfunction and complex partial seizures requires detailed and well informed interrogation because many of the symptoms are far from obvious and are unlikely to be uncovered by a superficial medical history or neurological examination.

Prevention of recurrent stroke.

Victims of atherothrombotic infarction of the brain, the most common variety of stroke, frequently have recurrent strokes. Risk factors believed to accelerate such events include hypertension, diabetes mellitus, hyperlipidemia, atherosclerotic disease (of heart, aortocervical and intracranial vessels), erythrocythemia, stress, tobacco smoking, hyperuricemia, and perhaps obesity. Most prior studies indicate average anticipated 5 year mortality of 35 to 65 percent and stroke recurrence rate of 20 to 40 percent. A consistent effort to control risk factors in 88 survivors of a first cerebral infarction yielded 17 percent mortality and 16 percent stroke recurrence rates during the 5 years following first stroke. This sustained and systematic approach to risk factor management seemed beneficial to these stroke victims.

Maternal deaths associated with postpartum vulvar edema.

Reported are three maternal deaths in four patients who presented with a similar syndrome following a normal antepartum course and normal labor and delivery managed by regional or local anesthesia and midline or proctoepisiotomy. Beginning about the second postpartum day, the patients developed unilateral perineal edema and induration which progressed to generalized vulvar, vaginal, perineal, and gluteal edema and induration. These patients developed marked leukocytosis, fever, and ultimately vascular collapse; three of them died. The one patient who survived had a similar course except for vascular collapse. Unilateral vulvar induration and edema associated with fever and marked leukocytosis are ominous signs. Aggressive treatment should include the use of multiple antibiotic, crystaloid, colloid, and steroid drugs and appropriate monitoring. By this report we hope to bring attention to this rare but lethal syndrome.

Preventing stroke after TIA.

Previous reports suggest the probability of stroke after TIA as 20 percent in the first year and 45 percent within five years. Forty-five TIA victims were treated in a stroke prevention program for an average of five years. Efforts were made to correct or control all risk factors. Eight of the 45 experienced further TIA'S, Three had subsequent strokes and two had myocardial infarctions. Two deaths were reported. This stroke prevention program offers an improved prognosis for victims of TIA.

Conjunctival microangiopathy. An early sign of degenerative vascular disease?

Biomicroscopic examination of the bulbar conjunctival vessels regularly discloses degenerative microangiopathy in patients with overt arteriosclerotic cerebral vascular disease. Examination of a group of normotensive nondiabetic adults aged 21 to 39 years disclosed similar but less severe changes in 56 per cent of the men and 26 per cent of the women. The incidence was higher (88 per cent of the men and 45 per cent of the women) in those with a strong family history of early death from arteriosclerotic disease. There was no consistent correlation between the severity of the microangiopathy and the values for hematocrit, cholesterol, triglycerides or blood pressure. Conjunctival microangiopathy, like atherosclerosis of larger vessels, starts in the second and third decades and advances with age. We suggest that microangiopathic changes in the conjunctival vessels may provide the first readily detectable evidence of degenerative vascular disease.

Propranolol for the control of belligerent behavior following acute brain damage.

The belligerence of 7 patients who had suffered an acute brain insult was effectively controlled by propranolol in doses of 60 to 320 mg per day. Of the 7 patients, 3 were treated in the acute stage after a stroke, a severe closed head injury, and a gunshot wound of the brain, respectively. A chronic postconcussion syndrome associated with chronic irritability was present in 2, and 2 were not chronically irritable but suffered from intermittent attacks of explosive rage in response to minor irritations. In all instances the belligerent behavior was controlled without inducing general sedation.