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tivity is motivated by the drive for sexual satisfaction and procurement of food; in humans, it may be a matter of curiosity According to Panksepp and others, these activities are governed by expectancy circuits, involving nuclear groups in mesolimbic and mesocortical dopaminergic circuits connected with the diencephalon and mesencephalon via the medial forebrain bundles; lesions that interrupt these connections are said to abolish the expectancy reactions Positron emission tomography (PET) studies correlate functional dif culty in the initiation of movements with impaired activation of the anterior cingulum, putamen, prefrontal cortex, and supplementary motor area (Playford Aggressive behavior A et al) Placidity We would repeat that in our experience, a quantitative reduction in all activity is the most frequent of all psychobehavioral alterations in patients with cerebral disease, particularly in those with involvement of the anterior parts of the frontal lobes There are fewer thoughts, fewer words uttered, and fewer movements per unit of time That this is not a purely motor phenomenon is disclosed in conversation with the patient, who seems to perceive and think more slowly, to make fewer associations with a given idea, to initiate speech less frequently, and to exhibit less inquisitiveness and interest This reduction in psychomotor activity is recognized as a personality change by the Placidity family Release of oral behavior Depending on how this state is viewed, it may be interHypersexual behavior B preted as a heightened threshold to stimulation, inattentiveness Figure 25-3 A Localization of lesions that, in humans, can lead to aggressive or inability to maintain an attentive attitude, impaired thinking, behavior and placidity B Localization of lesions that, in humans, can lead to apathy, or lack of impulse (abulia) In a sense, all are correct, placidity, release of oral behavior, and hypersexuality (Reproduced with perfor each represents a different aspect of the reduced mental acmission from Poeck, 1969) tivity Clinicoanatomic correlates are inexact, but bilateral lesions deep in the septal region (basal frontal, as sometimes occur with bleeding from an anterior communicating aneurysm) have rein the majority of cases Falconer and Serafetinides have desulted in the most striking lack of impulse, spontaneity, and coscribed patients with rage reactions in whom there was a hamarnation (Fig 25-3) An impairment of learning and memory functoma or sclerotic focus in this region However, the precise anattions may be added Typically the patient is fully conscious, is wide omy has not been demarcated awake, and looks around ie, is visually attentive Upon recovery, memory is retained for all that happened In this respect abulia Aggressive Behavior in Acute Toxic-Metabolic Encephalopdiffers from stupor and hypersomnolence athies Here the patient is not in a clear-headed state and rage or Patients who exhibit abulia are dif cult to test because they aggression is superimposed on an encephalopathy of toxic or metarespond slowly or not at all to every type of test Yet on rare ocbolic origin The most dramatic examples in our experience have casions, when intensely stimulated, they may speak and act norbeen associated with hypoglycemic reactions When the patient is mally It is as though some energizing mechanism (possibly strialeft alone, the aggressive behavior is undirected and disorganized, tocortical), different from the reticular activating system of the but anyone in the immediate neighborhood may be struck by ailupper brainstem, were impaired ing limbs In medical writings, this type of activity is described as Quite apart from this abulic syndrome, which has already been bizarre behavior but is rarely characterized further Such patients discussed in relation to coma and to extensive lesions of the frontal are clearly out of contact Their attention cannot be gained for a lobes (Chaps 17 and 22), there are lesser degrees of it, in which a moment, and attempts at physical restraint provoke an even more lively, sometimes volatile person has been rendered placid (hypobviolent reaction ulic) by a disease of the nervous system This corresponds to lesser A similar state may occur with phencyclidine and cocaine indegrees of frontal lobe damage than that described above with septoxication and at times with other hallucinogens, always with agtal lesions; most often the damage is bilateral but sometimes on itation and usually hallucinosis Outbursts of rage and violence the left only, as discussed in Chap 22 Diseases as diverse as hywith alcohol intoxication are somewhat different in nature: some drocephalus, glioma, strokes, trauma, and encephalitis may be instances represent a rare paradoxical or idiosyncratic reaction to causative Formerly, the most consistent changes of this type were alcohol ( pathologic intoxication, see page 1006); in other cases, observed following bilateral prefrontal leukotomy Barris and alcohol appears to disinhibit an underlying sociopathic behavior Schuman and many others have documented states of extreme plapattern cidity with lesions of the anterior cingulate gyri Unlike the case in depression, the mood is neutral; the patient is apathetic rather Placidity and Apathy than depressed The alteration in emotional behavior described above differs The animal organism normally indulges in and displays highly enfrom that observed in the Kluver-Bucy syndrome, which results ergized, exploratory activity of its environment Some of this ac-.

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from total bilateral temporal lobectomy in adult rhesus monkeys (see also page 397) While these animals were rather placid and lacked the ability to recognize objects visually (they could not distinguish edible from inedible objects), they had a striking tendency to examine everything orally, were unusually alert and responsive to visual stimuli (they touched or mouthed every object within their visual elds), became hypersexual, and increased their food intake This constellation of behavioral changes has been sought in human beings for example, after removal of the temporal lobes but the complete syndrome has been described only infrequently (Marlowe et al; Terzian and Dalle) Pillieri and Poeck have collected cases that have come closest to reproducing the syndrome (Fig 25-3) Unfortunately, many human examples have occurred in conjunction with diffuse diseases (Alzheimer and Pick cerebral atrophies, meningoencephalitis due to toxoplasmosis, herpes simplex, or AIDS) and hence are of less use for anatomic analysis With bitemporal surgical ablations, placidity and enhanced oral behavior were the most frequent consequences; altered sexual behavior and visual agnosia were less frequent In all patients who showed placidity and an amnesic state, the hippocampi and medial parts of the temporal lobe had been destroyed, but not the amygdaloid nuclei Perhaps the most consistent type of reduced emotionality in humans, albeit one that is restricted in scope, is that associated with acute lesions (usually infarcts or hemorrhages) in the right or nondominant parietal lobe Not only is the patient indifferent to the paralysis but, as Bear points out, he is unconcerned about his other diseases as well as personal and family problems, is less able to interpret the emotional facial expressions of others, and is inattentive in general Dimond and coworkers interpret this to mean that the right hemisphere is more involved in affective-emotional experience than the left, which is committed to language Observations derived from the study of split-brain patients and from selective anesthetization of the cerebral hemispheres by intracarotid injection of amobarbital (Wada test) lend some support to this probably oversimpli ed view Rarely, lesions of the left (dominant) hemisphere appear to induce the opposite effect a frenzied excitement lasting for days or weeks The full range of placidity reactions in neurology has not been catalogued Unfortunately, neurologists and psychiatrists have tended to neglect this aspect of behavior.

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