CHAPTER 14 - IMAGES OF VIOLENCE
» Violence and Aggressive Behavior Abstracts

SPECT can be helpful in understanding causes and treating aggressive behavior. I have found a consistent triad of SPECT findings common in children, teenagers and adults who exhibit aggressive behavior. These findings include:

• abnormalities (either increased or decreased activity) in the left temporal lobe, often the seat of aggressive thoughts
  
  
• increased activity in the anterior cingulate gyrus, which often causes problems with repetitive thoughts and shifting attention (a person may get stuck on the aggressive thoughts that are present) and
  
  
• decreased activity in the prefrontal cortex, leading to poor internal supervision.

When these three findings are present it is often helpful to intervene with anticonvulsant medication to stabilize temporal lobe abnormalities and decrease violent thoughts, a serotonergic agent to help decrease anterior cingulate activity and improve cognitive flexibility, and sometimes a psychostimulant to activate prefrontal cortex activity and enhance impulse control.

underside surface view
arachnoid cyst occupying the space of the left temporal lobe in a violent 9 year old boy

John

John, a right-handed 79-year-old contractor, had a longstanding history of alcohol abuse and violent behavior. He had frequently physically abused his wife over 40 years of marriage and had been abusive to the children when they were living at home. Almost all of the abuse occurred when he was intoxicated. At age 79, John underwent open-heart surgery. After the surgery he had a psychotic episode, lasting 10 days. His doctor ordered a SPECT study as part of his evaluation. The study showed marked decreased activity in the left outside frontal-temporal region, a finding most likely due to a past head injury. When the doctor asked John if he had ever had any significant head injuries, John told him about a time when he was 20-years-old. While driving an old milk truck, that was missing it's side rear mirror, he put his head out of the window to look behind him. His head struck a pole, knocking him unconscious for several hours. After the head injury he had more problems with his temper and memory. There was a family history of alcohol abuse in 4 of his 5 brothers. None of his brothers had problems with aggressive behavior.

left lateral surface view
note marked area of decreased activity in the left frontal and temporal region

Given the location of the brain abnormalities (left frontal-temporal dysfunction) he was more likely to exhibit violent behavior. The alcohol abuse, which did not elicit violent behavior in his brothers, did in him. Knowing this information earlier might well have been useful in obtaining help for his problems.

Bradley

Bradley was diagnosed with attention deficit/hyperactivity disorder (ADHD) and left temporal lobe dysfunction (diagnosed by EEG) at the age of 14. Before then (from grades 1-8) he had been expelled from 11 schools for fighting, frequently cut school and had already started drinking alcohol and using marijuana. He had a positive response to Ritalin. He improved three grade levels of reading within the next year, attended school regularly and had no aggressive outbursts. However, Bradley had a negative emotional response to taking medication. Two years after starting his medication he decided to stop it on his own without telling anyone. His anger escalated. One night his uncle came to his home and asked Bradley to help him "rob some bitches." Bradley went with his uncle who forced a woman into her car, made her go to her ATM and withdraw money. The uncle and Bradley then raped the woman twice. He was apprehended two weeks later and charged with kidnapping, robbery and raped.

As the psychiatric forensic consultant I ordered a series of brain SPECT studies: the rest study showed mild decreased activity in the left prefrontal cortex and the left temporal lobe. While performing a concentration task there was marked suppression of the prefrontal cortex, a finding commonly found in attention deficit hyperactivity disorder and both temporal lobes. A third scan was done 1 hour after taking 15 mg. of methylphenidate. This scan showed marked activation in the prefrontal cortex and both temporal lobes, although there was still some mild deactivation in the left temporal lobe. After understanding the history and reviewing the scan data it was apparent that Bradley already had a vulnerable brain that was consistent with long term behavioral and academic difficulties. His substance use may have further suppressed an already underactive prefrontal cortex and temporal lobe diminishing executive abilities and unleashing aggressive tendencies. It is possible that with an explanation of the underlying metabolic problems and brief psychotherapy on the emotional issues surrounding the need to take medication this serious problem might have been averted.

underside surface view, concentration study, no medication
marked decreased prefrontal and temporal lobe activity

Rusty

Twenty-eight-year-old Rusty had a severe methamphetamine problem. He was unable to keep steady work, he was involved in a physically abusive relationship with his girlfriend (arrested four times for assault and battery), he was mean to his parents even though they tried to help him. He failed five drug treatment programs. Since Rusty's mom scheduled his SPECT study he was unaware of it until the morning of the scan. He showed up loaded with a gram of methamphetamine from the night before. Rusty told me about his drug abuse. I decided to scan Rusty that morning with the effects of the methamphetamine still in his system and then a week later off all drugs. When Rusty was under the influence of high dose methamphetamine his brain looked suppressed in activity. A week later, however, off all drugs, he had a terribly hot or overactive left temporal lobe, probably causing his problems with violent behavior. Rusty was likely self-medicating an underlying temporal lobe problem with high dose methamphetamine. Given this finding, I put Rusty on Tegretol (an anti-seizure medication which stabilizes activity in the temporal lobes). Within 2 weeks Rusty felt better than he had in years. He was calmer, his temper was under control and for the first time in his life he was able to remain gainfully employed. An additional benefit of the scan was that I showed Rusty the serious damage he was doing to his brain by abusing the methamphetamines. Even though the drugs helped his temporal lobe problem, they were clearly toxic to his brain.

active side view on high dose methamphetamine		active side view off methamphetamine
underside active view notice hot area deep left temporal lobe		top-down surface view notice multiple holes across cortex

Jose

Jose, a 16-year-old gang member, was arrested after he and another gang member beat another teenager nearly to death. They were charged with attempted murder. Their gang claimed the color red. One evening, when they were in an intoxicated state (from both alcohol and heavy marijuana usage), they approached a boy who was wearing a red sweater walking his dog across the street. They asked him, "What colors do you bang?" (asking him about his gang affiliation). When the boy said he did not know what they were talking about Jose replied, "Wrong answer," and the two gang boys started to physically attack the boy, hitting and kicking him repeatedly until he was unconscious. The public defender ordered neuropsychological testing on Jose which found frontal lobe dysfunction and evidence of ADHD, depression and learning disabilities. The psychologist suggested a resting and concentration SPECT series for independent verification. The SPECT series was significantly abnormal. Both studies showed marked increased activity in the cingulate gyrus, consistent with problems shifting attention. At rest, his SPECT also showed mildly suppressed prefrontal cortex activity. While doing a concentration task there was also marked suppression of the prefrontal cortex and both temporal lobes, consistent with ADHD, learning disabilities and aggressive tendencies.

left side active view marked increased cingulate
at rest mild decreased pfc activity		during concentration marked decreased pfc and temporal lobe activity

Paul

Paul, a 28 year old gardener, came to my clinic for work-related problems. He had increasingly intense feelings of rage toward his boss. Paul said that his boss was prejudiced against him because he was Hispanic. He frequently thought about killing his boss. He reported that only the thought of his wife and small daughter prevented him from doing physical harm to his boss. He needed to maintain his job in order to support his family. Paul could not get the anger toward his boss out of his head. He reported that since childhood he had many explosive outbursts. He saw himself as someday being on the top of a tower shooting down at people. His anger was diffuse. He described himself as having an extremely short fuse, especially while driving. At the age of 7 he ran full speed into a metal basketball pole and was unconscious for several minutes. Paul had no evidence of a psychotic disorder or a significant depression, although he did complain of short periods of confusion, fear for no reason and episodes of deja vu. His EEG was within normal limits. A brain SPECT study was obtained in order to further evaluate any underlying brain abnormalities that might have been contributing to his difficulties.

Paul's brain SPECT study was significantly abnormal. It revealed normal activity in the prefrontal cortex at rest that worsened when he tried to concentrate (problems with impulsivity). There was also moderate marked increased uptake in the deep aspects of the left temporal lobe (short fuse) and his cingulate gyrus (stuck on thoughts). Because of the clinical picture and information from the brain SPECT study Paul was placed on the anticonvulsant Tegretol at therapeutic levels, along with Prozac several weeks later. After six weeks, he reported that he noted a sense of increased inner control and inner peace. His periods of confusion, deja vu and fearfulness diminished. His anger outbursts decreased and he was able to go to work at a new job.

underside active view		left side active view
note marked increased activity in the left temporal lobe and cingulate (arrows)

Steven

Steven, a 39-year-old radio station engineer, was admitted to the hospital for suicidal thoughts. He was recently separated from his wife of eight years. During their relationship there had been mutual physical spousal abuse for which he had spent some time in jail. Steven also complained of having a very "short fuse." He found himself frequently yelling at other drivers on the road and was easily upset at work. On admission he was tearful, had problems sleeping and poor concentration. He was depressed and experienced suicidal thoughts. He reported short periods of confusion, periods of feeling intense rage with little provocation, and episodic periods where he would see shadows out of the corners of his eyes. His EEG was within normal limits.

Steven's brain SPECT study revealed marked increased uptake in the deeper aspects of the left temporal lobe and marked increased activity in the cingulate gyrus.

underside active view		left side active view
note marked increased activity in the left temporal lobe and cingulate (arrows)

With the clinical picture and information from the brain SPECT it was decided to start Steven on an anticonvulsant in addition to an antidepressant. He was placed on Tegretol at therapeutic levels along with Prozac. Even though he continued to feel sad about the break up of his marriage, he felt calmer, in better self-control and his suicidal thoughts abated. He did report that he wished he had known about the dysfunction in his temporal lobe years earlier. He felt it might have changed the outcome of his marriage.

Jody

In December 1996 Jody Gordon walked into the McDonald's in Vallejo, California where he had been fired from his job the year before. He carried two guns and a knife. Three teenage girls, employees of McDonald's, were sitting at a table having a snack after a meeting they had been called into work for. Jody asked the manager for his job back. When the manager refused Jody walked over to the girls and started shooting. He killed one of the girls and wounded the other two.

As part of his defense I was asked to perform a brain SPECT study to evaluate his brain function. He had one of the most severe decreases in prefrontal cortex function I had ever seen. I then had him come back for a second scan and gave him 20 milligrams of Adderall to see if I could enhance the severe prefrontal hypoperfusion. To my amazement, the Adderall significantly enhanced the activity in his brain, especially in his prefrontal cortex. I wondered if he would have committed this terrible crime if he had more access to the part of his brain involved in decision making.

underside surface view, NO MEDS very poor pfc activity

underside surface view, with Adderall improved pfc, especially on left side

top down surface view
marked damage to the left hemisphere

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