CHAPTER 9 - IMAGES OF THE RING OF FIRE
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One of the new patterns we feel we have discovered is one we affectionately term the ring
of fire. It consists of marked hyperactivity throughout the cortex, often in a ring like
pattern. It shows the hyperfrontality pattern (increased cingulate activity with increased
left and right lateral prefrontal cortex activity) frequently seen in obsessive compulsive
spectrum disorders and hyperactivity in the left and right lateral parietal and temporal
lobe regions. We have seen this pattern most frequently in children and teenagers. It
reminds us of the patchy increased uptake seen commonly in Bipolar Disorder. We wonder if
it represents a functional brain pattern for children and teens who are vulnerable to
Bipolar Disorder. The children and teenagers are not what most clinicians would consider
in a manic state and their symptoms may or may not cycle. In a group of 70 patients with
this pattern the most common symptoms were moodiness, problems shifting attention,
oppositional behavior, irritability, temper problems, hypersensitivity to noise and/or
touch, inattention, distractibility and impulse control problems. This pattern seems to be
made worse by psychostimulants and serotonergic agents and better by anticonvulsants, such
as Depakote or Neurontin and the new antipsychotics, such as Risperdal or Zyprexa.
Notice the marked hyperactivity throughout the cerebral cortex in a "ring-like"
pattern. Also note that the surface views look normal. This scan series is of a 14 year
old boy who had serious problems with oppositional and aggressive behavior. His moods were
erratic and he had longstanding behavioral problems despite being a very good student.
There was a family history of alcohol abuse and depression. He had a very positive
response to Risperdal which had a calming effect on the cerebral hyperactivity.
This next case series is of a 12 year old girl who was referred to the clinic for
aggressive outbursts, moodiness and chronic irritability. Her pattern was similar to the
one shown above and she had a similarly positive response to Risperdal.
Tanya, a 17 year old female, was brought for evaluation because of severe temper problems,
conduct problems (runaway and school truancy), a 5 year history of alcohol abuse that had
escalated in the prior 2 years and depression with suicidal ideation. Her parents felt her
behavior was "willful" and she could change if she wanted to change. Initially
they were opposed to psychiatric treatment, but reluctantly came after she had a suicide
attempt. Her scan revealed marked hyperactivity throughout the cortex in a "ring of
fire" pattern, along with marked increased left basal ganglia activity. She had a
nice response to Neurontin and Prozac obtaining more level moods, less temper outbursts
and more cooperative behavior.
The Ring of Fire and Alcohol Induced Violence
20-year-old single male, who often became violent when he drank alcohol, even though he
reported that alcohol made him feel better. From the age of 18 to 20 he was arrested 10
times for violent, aggressive behavior, all while he was intoxicated. The arrests were
mostly for drunk and disorderly in public, one was for assault his girlfriend, and the
last one, which precipitated the study, was for armed robbery.
On the night of the last crime this man started drinking about 10:00 PM. He drank 750
milliliters of peach schnapps within a half-hour followed by 40 ounces of malt liquor beer
the next half-hour. He then "drag raced" a friend on the street and became
involved in a motor vehicle accident. He fled the scene on foot. A short while later he
called a taxicab. He had the cab driver drive him and a friend around for about 20
minutes. At exactly 12:10 AM he pointed a loaded gun at the cab driver's head and
demanded all his money. He got $25 and ran away on foot. The next morning, after sobering
up, he turned himself into the police.
At the request of his defense attorney SPECT imaging was performed. Since he seemed to
only be aggressive when he drank alcohol he was imaged with and without alcohol. The first
SPECT study was performed "drug and alcohol" free. The second study was
performed after he consumed 750 milliliters of peach schnapps, followed by 40 ounces of
malt liquor beer (the alcohol was the same brand he drank on the night of the crime
consumed in the same time frame).
The "non-alcohol" study revealed marked overactivity in the cingulate gyrus,
right and left frontal lobes, right and left parietal lobes and the right temporal lobe -
the "ring of fire." As noted, these findings are often associated with anxiety,
cyclic mood tendencies and irritability.
For the alcohol study, his blood alcohol level was 0.2g/dl(%). This study showed an
overall dampening effect on the hyperactive areas of the brain (frontal, parietal and
right temporal lobe), with only the cingulate gyrus showing excessive activity (although
significantly less activity than on the non-alcohol study). In addition, the right and
left prefrontal cortex was now significantly underactive, as were the left and right
temporal lobes.
Given the marked hyperactivity in his brain in a drug and alcohol free state, along with
his report that he felt more relaxed when he drank, it is not unreasonable to assume he
may have been using alcohol as a way to settle down his brain and feel more comfortable
(self-medication). Unfortunately, by self-medicating, he was inducing a
"violent" pattern in his brain. Increased cingulate activity, abnormal left
temporal lobe activity and decreased prefrontal cortex activity is the triad of symptoms
that have been found in violent patients. He drank himself into a violent state as a way
to medicate underlying abnormalities in his brain.
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No Alcohol
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Alcohol Intoxicated State
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