Patient drawing

Phillipa's copy of complex figure

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 interested in the prefrontal lobes because 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.

I’ll never forget the very first patient I came across who suffered from a severe frontal-lobe syndrome. Phillipa, an attractive 35-year-old woman, 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 her 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.

To her family and friends, Phillipa had turned into a different person, a person that they didn’t understand, couldn’t share memories with, no longer acted like their mother, their wife, their lover, their best friend, and who, at times, seemed too strange even to love. Just two months previously, this intelligent woman with a university degree in English literature worked as a primary school teacher, and shared a busy life with her husband and their two children, just eight and 10 years old. Then one Saturday afternoon 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. She’d 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. Physically, she 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. According to her husband, before her brain damage she’d been 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,” he told me. “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.”

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 is Phillipa’s attempt (lower drawing) 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’s husband struggled to look after her at home until one day his children ran away, terrified by their mother’s unpredictable violent outbursts. The children were found that evening, cold and frightened, and Phillipa was placed in a psychiatric nursing home where she has remained ever since. She still seems to enjoy visits from her family, but if they stay too long she begins yelling and swearing, and within minutes of them leaving has forgotten they were ever there. In these tragic cases, family members probably suffer more than the patient, who is spared by a lack of insight. Perhaps this is the mind’s way of coping: severely disabled people who retain their insight may exist in a private hell, and require years of medication and therapy to help them cope with depression. Therapy and rehabilitation are of no use to Phillipa, but for her family therapy helped them move on, finally able to free themselves of undeserved guilt.

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