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The Frontal-lobe syndrome

Embellishments on the copy (lower figure) of the top drawing indicate disinhibited behaviour.
I thought I’d write a “series” of blogs on the different neuropsychological disorders in “Trouble In Mind” including an extract from the relevant chapter. My “Psychology Today” blogs also comment on neuropsychological disorders, but usually the content is not as directly related to my book content, as it is not appropriate to post extracts from the book on that site. I’ll also focus on a different disorder on each site in any given month.

I decided to begin at the front of the brain, with the frontal lobes. These days, everyone seems to know about the frontal lobes; the parts of the brain that continue to develop through our teens and into our early twenties. To be more precise, the area that is commonly referred to as the frontal lobe, is the front of the frontal lobe; labelled the prefrontal lobe. Humans have the most highly developed prefrontal cortex of any animal, and it is probably this, more than anything else, that has catapulted humankind to the top of the evolutionary tree. Of course, others would say it is language, and more specifically the ability to speak, which has allowed us to take control of the world (and destroy it at a high level). And still others believe we owe our supremacy to our ability to walk upright and free our hands for tool making. All of these theories are probably correct, and indeed all of these evolutionary steps are interrelated.

As a clinical neuropsychologist, I am most interested in the prefrontal lobes as these areas of the brain are terrifyingly vulnerable to damage—damage from accident, such as traumatic head injury; from environmental influences such as alcohol; and from neurological disorders such as dementia. The prefrontal lobes are also richly connected to most other parts and systems in the brain, and thus when connections to and from the frontal lobes are damaged this can also result in frontal lobe symptoms. For example, people with Parkinson’s Disease can show some frontal lobe symptoms, including a difficulty switching mental set, because of a disruption of the dopamine pathway between the basal ganglia, deep inside the brain, and the frontal lobes.

The “frontal lobe syndrome” as it is commonly called, is a loose collection of symptoms frequently observed in patients who suffer prefrontal lobe dysfunction —that is, these brain areas no longer work or function as they should, either because of damage to the prefrontal lobes themselves, or because connections to and from them are damaged. These symptoms include impairments in the following cognitive abilities: organisation and making forward plans; foreseeing the consequences of one’s actions; emotional control, inhibiting inappropriate behaviours; insight into one’s behaviours; ability to learn from mistakes; thinking abstractly; working memory; remembering to remember (eg: what you were meant to buy from the shop); motivation; initiative; getting started on some new activity. People with very severe frontal lobe damage to both the left and right frontal lobes can show all these symptoms, but people with milder frontal lobe damage demonstrate just some of them, and in some cases even those symptoms may be subtle.

In the following opening paragraphs from Chapter 4 of “Trouble In Mind”, I meet Phillipa, and am drawn into the topsy-turvy world of the “frontal-lobe” patient. I called this chapter “The CEO has left the building: Control and the frontal lobes”. The frontal lobes are often called the “executive lobes” as they are truly the CEOs of our brain. Without them we can still read, write, talk, travel, play, and carry on with activities that are well learnt, but give us anything novel to do and we are stumped. The illustration here is also from Chapter 4: the lower drawing is Phillipa’s attempt to copy the figure above. Her embellishments on her copy—which she was quite aware of and found very amusing—are expressions of her impaired ability to behave appropriately. It is their inappropriate behaviours and their lack of insight into the severity of their problems that makes patients with a marked frontal-lobe syndrome almost impossible to rehabilitate, and distressingly difficult for families to cope with.

*****

Phillipa batted her eyes at the doctor who was standing with me at her bedside.

“You’re pretty cute. When I get out of this place—wherever I am—we could have a good time together.”

“So where do you think you are?” asked the recipient of her attentions. He, along with everyone else on the ward, was well accustomed to Phillipa’s inappropriate behaviors.

“It’s no bloody hotel, that’s for sure—too many bloody beds in the room. So you tell me, smarty-pants!”

“You’re in Auckland Hospital, in the neurosurgery ward. You came in nearly two months ago now; don’t you remember?” the doctor replied, grinning at her.

“Of course I remember. What do you think I am, a bloody idiot?” Phillipa looked annoyed for a moment but then chuckled. Her face was marked by deep scars, and her inch or so of brownish hair was not yet long enough to conceal the surgical scars on the left side of her scalp.

“No, we know you’re brighter than most of us in here.” The doctor nodded his head toward me. “This is Jenni Ogden; she’s a psychologist. Tell her what you used to do.”

Phillipa scowled at me. “Who are you? Another one of these school inspectors all over the place? You know what I am. I’m a teacher, and I don’t need you coming to check up on me.”

“Hullo, Phillipa,” I said. “I’m not an inspector. I’m just a student. I’m doing some research in psychology for my PhD and wanted to talk to you about possibly being involved in my study.”

“PhD, huh. That’s pretty bright. You and me could run rings around this bloke here. Fancies himself as a doctor. But he’s cute; gotta give him that.”

*****
I was in the early stages of my doctorate, and Phillipa was the first patient I assessed who displayed many of the bizarre behaviors that commonly follow severe damage to the frontal lobes. I had read her file, and in fact had already seen her in action when assessing other women in the same room. She would greet anyone who passed by her bed by calling out loudly: “Hullo, you there. Come over here and talk to me.” It did not seem to matter to Phillipa whom she greeted in this manner: another patient’s visitor, a doctor she did not know, or the woman who cleaned the floor. Most people looked embarrassed, replied with a brief “Hullo,” and moved rapidly away. Their exits would be punctuated by loud swearing from Phillipa or comments such as “You snaky bastard, run for your life!” On one occasion I had seen the nurse quickly pulling the curtain around her bed after Phillipa began to undress, gaily unconcerned about exposing her naked self to the other patients and their visitors.

But this was the first time I had met her formally, as I hoped she would now have recovered sufficiently from her dreadful head injuries and subsequent surgery—almost two months previously—to cope with my neuropsychological tests. She had been brutally beaten over the head with an iron bar when she surprised a burglar who had broken into the primary school where she taught. It was a Saturday afternoon and she had gone to the deserted school to catch up on some work preparation. By chance, the headmaster also decided to do some weekend work and, coming in shortly after the assault and finding clear signs of a break- in, discovered Phillipa lying in a pool of blood and deeply unconscious. Without doubt, she would have died if she had lain there much longer. The frontal bone of her skull had been shattered, and the underlying brain was badly damaged on the left. To save her life the neurosurgeon had to do what amounted to a partial left frontal lobectomy— cutting away the anterior part of her left frontal lobe, the prefrontal lobe. Fortunately, the more posterior cortex of the frontal lobe wasn’t damaged, preserving Phillipa’s ability to speak. She had sustained some moderately severe damage to the right prefrontal lobe as well, so it was not surprising that she was left with a severe “frontal lobe syndrome.”

Her assaulter was caught and jailed for many years, but Phillipa’s term was for life. She was only 35 when the assault happened, an intelligent woman with a university degree in English literature who worked as a primary school teacher in a small town north of Auckland. She and Larry, her husband, had led a busy life with their two children, just eight and 10 years old. Physically, Phillipa recovered very quickly from her head injury and neurosurgery. Within a month, although weak down her right side, she was able to sit up in bed or in a wheelchair. Her physical disability paled into insignificance compared with her cognitive and psychological problems. I met with Larry to find out about the Phillipa he had known before her brain damage.

“She was a practical, positive person who didn’t suffer fools gladly. She could do three things at once and hardly ever seemed to get tired or uptight, even when the kids were acting up and she had another two hours’ marking to do,” Larry told me, his eyes sad. “And although she had a great sense of fun, and the kids in her class loved her, she was really pretty conventional. I think that’s what is hardest about these changes in her personality. She’s so—well, immodest—now sometimes.” He blushed, and then stumbled on. “She would never have sworn in public like she does now, and before, she would never get undressed in front of people, not even in front of our own children. I know it’s just her brain damage talking, but if she continues like this I can’t see how we could cope with her at home.”

(Copyright: “Trouble In Mind: Stories from a neuropsychologist’s casebook” Oxford University Press, New York, 2012, pp.95-98).


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