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, ADD 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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