Manic Depression Caused By Frontal Lobe Injuries

After an accident, a woman looks to find a cure for her manic depression.

By Bruce H. Dobkin|Monday, June 01, 1992
RELATED TAGS: MENTAL HEALTH
Gayle was hurled into the windshield when her husband’s car broadsided a pickup truck that had rolled through a stop sign. Her forehead splintered the glass. She regained consciousness in the emergency room but recalled almost nothing about her first day in the hospital. A scan of her brain revealed a few scattered bruises and mild swelling within the frontal lobes.

A week after the accident she returned home and celebrated her thirty-fifth birthday with her husband, Roger, and their two young children. When I examined her later that month, she could not recall the gift they had given her. With the help of an outpatient rehabilitation program, she worked to improve her attention span and overcome her lapses in remembering small daily events.

Within ten weeks of the accident, Gayle had grown distinctly apathetic. At first we suspected a mild withdrawal instigated by the frustration and embarrassment that comes from forgetting who had called on the phone or what she had read in the newspaper. But when she started taking long naps during the day and closing her eyes when her husband or therapists tried to engage her in conversation, we realized that she had developed a serious depression. A housekeeper had to take responsibility for the children. I considered a drug to lift her depression but decided to wait a few weeks before adding a chemical that might interfere with her still unfolding recovery.

On the next visit, as I stood to greet her and Roger, she burst into my examination room. It’s so good to see you, she bubbled. Then she grasped me in a hug and pressed herself into me. Roger put his hands on her shoulders, pulled her around, and said, Honey, you remember Dr. Dobkin, don’t you?

I retreated to my chair. How are things going?

Wonderful, she exclaimed. I use my diary to help me remember little things. I’m working again, back to sculpting in clay, but I’m ready for marble. I drive to the market and cleaners and help with the kids’ car pool. I want to get back to teaching this coming semester if it’s all right with everybody. I--

Roger interrupted her torrent of thoughts. Honey, slow down. He turned to me. She’s been a little hyper the past week or two.

Oh, I just need to catch up, she said. I noticed that her hand stroked his inner thigh. There’s just a lot going on. I mean, there’s the kids and the car pool and my work and, of course, she added as she squeezed his thigh, I take care of Roger.

I stopped her stream of words with some specific questions. I learned that Gayle no longer took naps. She busied herself all day and was up much of the night sculpting, but her newly found energy sounded endless and unnatural. I moved on and checked her ability to remember. She recalled two of the four items that I asked her to memorize for ten minutes, and she recounted the bold headline about a local tragedy in the morning paper. This was a great improvement. I gave her a standard test of one of the left frontal lobe’s language functions, asking her to name as many words as she could in a minute that began with the letter f, then a, then s. Her list began: There’s the f-word and, of course, you can do f-ing, and there’s fornicate and fornicating, and fire, finger, friend, friendly, fit, fried, filth, fellow, fiend, fix, filthy, fellatio, and with a laugh, she added phallus. She was having a good time. I said nothing. Her husband slumped deeper into his chair.

Hoping to avoid another embarrassing remark, I cut short my questions and moved on to the physical examination. She wore only one earring and her belt rode above her waist because she had not run it through the back loops of her slacks. Her hair, dress, and almost frenetic manner brought to mind a disheveled bag lady on the streets. As she sat on the exam table, I leaned in from her left side and looked into her eyes with an ophthalmoscope to check the optic nerves for a sign that might suggest more swelling of her brain. She brushed her cheek against my face and pertly asked, Will you listen to my heart? Two of the buttons of her blouse were already undone, and she unbuttoned two more to expose her breasts.

That’s not necessary, I said, but I’d like you to go with my secretary to schedule another brain scan. Just a routine follow-up. Roger, why don’t we go over some things while Gayle’s tied up? As she left, I turned to the husband.

It’s been incredible, he blurted out. This woman is not my introspective, modest wife. Something’s going on.

He described the dramatic sequence of changes since the head injury. For the first few weeks Gayle’s spirit seemed blunted and her attention span and memory for recent events were at their worst. Small demands made by her five-year-old irritated her. In their personal life, she seemed at first to tolerate his lovemaking and perhaps enjoy it, though not in the tender and spontaneous way she had over the 12 years of their marriage. When the depression hit, she rejected even her husband’s most minimal advances. He started to convince himself that he was at fault. He had encouraged her to get back to running the household and taking care of their children. Had he pushed her in a way that revealed her inadequacies and gave her the blues? His guilt weighed all the more heavily because, for months before the accident, Gayle had asked him to repair the passenger’s seat belt in his car. Had it functioned, she would not have struck her head.

Then, just over a week ago, her gloom had lifted. She came home from therapy one afternoon, Roger said, and cleaned out the supplies in the kitchen pantry and laundry room. She did the same thing the next day. Gayle just threw bottles and boxes away without rhyme or reason. And she started making asides, even at dinner in front of the kids, about feeling turned on.

At first, he was delighted that her zest for life and arousal for sex had recovered. But to his embarrassment, her remarks about what she wanted to do with him, including oral sex, grew increasingly explicit and public. Out of nowhere, she’ll tell me how hot she’s getting and then throw herself at me in a bad imitation of a porno flick, said her husband. He hesitated and rubbed his hands.

This isn’t going to be easy for either of us to discuss, I admitted, but I need to know all of it.

Reluctantly, he continued. Several times, he found Gayle masturbating on the family room couch while watching MTV. She would say hello and ask, Want to finish me off? The kids were playing in an adjacent room. When friends visited, her explicit language about sex persisted. That past Saturday evening, she had approached several of their friends, male and female; they had to wriggle free from her caresses.

Roger tried to fulfill her bursting passion every night in what had turned into a shallow sex marathon to the sound of her incessant squeals during foreplay and intercourse. When he rolled away from her, she went off to her workshop and sculpted bizarre male torsos with heavy genitals, instead of the faces that she had worked on since her art school days.

Gayle’s personality change presumably arose from her frontal lobe injuries. Spotty damage there could have altered the communication between nerve-cell networks that provide self-awareness and self-monitoring, as well as the capacity to foresee the consequences of actions and words. We had seen some of her poorly thought out responses to questions posed in our written neuropsychological tests soon after the trauma. She would jump impetuously to a wrong answer or use a strategy that lacked insight to solve a problem. As her apathy lifted, perhaps that same lack of impulse control loosened her regard for sexual restraint. It was also possible that her hypersexuality was caused by a specific injury within a pathway linking the reproductive drive with brain areas that control sexual responsiveness. Either way, we still could not judge whether the damage was permanent.

In addition, she had acquired what looked like a case of manic depression, a psychiatric disorder with a biochemical cause that leads to cycles of mood swings. For Gayle this included lack of interest in sex and loss of libido when depressed, then uncontrollable urges and racing thoughts when manic. Paranoia and dangerously explosive behavior sometimes accompany mania. Roger and I agreed that her unrepressed passion might lead to some sort of compromising situation. On the other hand, we had to keep in mind that she seemed to enjoy these highs, as do some manic patients who use their energy in creative ways before becoming overwhelmed by delusional thoughts and sleep deprivation. If her change of personality could be modified with a drug or behavioral therapy, would she see her misplaced lust as a problem? Or would she regard the treatment as an interference?

I called a colleague in psychiatry. He evaluated her that day and settled on a trial with lithium, a drug often used to prevent manic- depressive cycles and their associated psychotic features. Gayle agreed to try it. She had some notion, it seemed, that she was out of control.

Unfortunately, lithium did not do the trick. Despite adjustments in her medication, she went on to ride the waves of weeks of sexually obsessed highs, then a month of uninterested lows, with shorter bouts of behavior that seemed more normal. Roger and the children never knew what sort of wife and mother to expect at the breakfast table each morning.

Gayle called me during one of her highs. She cooed about how wonderful her doctors had been, yakked on for five minutes with all sorts of unconnected thoughts, then told me a very obscene joke. I cut her off and said that her psychiatrist was going to propose that she take a new medication and that I hoped she would use it. Based on a few reports of similar cycles in brain-injury cases, we then tried carbamazepine, a drug used primarily to treat epilepsy but also given to calm agitated behavior in some people after head trauma. In a week or two, her bewitchment ended and Gayle once more became the prudent lady everyone had known. Evidently the drug had altered the activity of nerve cells that help to modulate emotions and drives.

Gayle’s case adds to a bevy of clues hinting at where the sex drive is secluded in the brain. In experimental studies, electrical stimulation of certain deep midline clumps of neurons within the frontal lobes induces an animal to copulate, whereas destruction of these clusters leads to complete sexual abstinence. Similar stimulation of neighboring neurons in this region produces, in men, an erection and a pleasurable sensation akin to an impending orgasm. In addition, injuries to the temporal lobes, the banana-shaped tissues flanking the frontal lobes, can apparently cause a change in sexual tastes. From 5 to 35 percent of those arrested for exhibitionism have a detectable brain injury or degenerative disease within the frontal and temporal lobes. The chemical messengers that link the nerve pathways for sexual arousal probably include dopamine, the neurotransmitter that’s in short supply in people with Parkinson’s disease. When these people’s dopamine is replenished with medication, their libido often increases.

About a year after her accident, Gayle had recovered enough to teach an art history class at a community college. She had been off her medication for a month without a relapse when she handed me an announcement about an upcoming gallery show of her sculptures. None of them, she assured me, would depict male genitals; she could not relate to those cartoonish torsos that she had molded late at night during her manic binges. But just as I was feeling comfortable with her reined-in sexuality, she added, with a touch of longing, that she sometimes recalled the warm, orgasmic sensation that had blanketed her on those nights.
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