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The Physiology of Insight :: Psychiatric Times

Psychiatric Times

Neurologic Explanations

All parts of the brain are concerned with simple behavior. Only the prefrontal lobes in the foremost section have been liberated from having to do with sensation and movement. They have the luxury of overseeing our most sophisticated functions-and this is all they do. When they are working correctly, they set us apart from less evolved forms of life by providing us with the substrate for mind as well as brain. They are responsible, in large part, for self-consciousness, self-control, curiosity, empathy, complex attention and motivation.

Medical journals of the 1800s documented examples of frontal lobe damage (the notorious Phineas Gage was diagnosed after a tamping iron exploded through the left lobe of his brain, leaving a permanent hole in the skull). But modern frontal lobe research began in 1949, when British neurologists S.S. Ackerly and Arthur Benton met a 20-year-old man-JP-they examined and discussed in a series of classic papers spanning the next two decades. His erratic behavior provoked confusion and frustration for everyone in his world, except himself.

JP distinguished himself early on. In grade school, he used to borrow a classmate's glove, defecate into it, then return it. He exposed himself to other children and lacked any sense of sportsmanship. With adults he displayed what the authors called "Chesterfieldian manners," but with peers, JP bullied remorselessly, stole and lied. He blamed his problems on the malevolence of others, yet appeared strangely satisfied with his life circumstances.

The two doctors were intrigued by the qualities JP was missing. They noted his absence of anxiety ("one of man's most important weapons in dealing with the frustrations that beset him in his upward ascent"); his incapacity for insight; his inability to modify behavior with punishment ("an unawareness of his total life situation involving todays and tomorrows"); his lack of concern for others.

Ackerly and Benton were also behavioral neurologists, interested in the connections between brain anatomy and complex behavior, connections that may not be apparent to other medical or psychological specialists. As part of their research, they returned to early hospital records to study JP's neurologic beginnings, long before social or psychological influences could have had effects.

JP was the product of a prolonged and difficult labor. After an accident at age 4, he suffered a seizure on the left side of his body. Sixteen years later, after repeated unsuccessful psychiatric hospitalizations, a pneu-moencephalogram was performed. Doctors injected air into the aqueducts of the brain in order to visualize tissue defects (a procedure now mercifully obsolete), and discovered that most of his left frontal lobe had been destroyed. Exploratory surgery found that the right lobe was missing altogether-probably a prenatal condition.

JP did not seem an obvious victim of brain damage. He had an average IQ. His academic performance was satisfactory. His memory was intact. His electroencephalogram was normal. Yet, in spite of his intelligence, he was unable to apply the lessons and mistakes of the past toward prevention in the future.

Ackerly and Benton followed him for three decades. His simple life strategies never changed. In a follow-up paper, written when JP was 50, the neurologists described their patient as "the same uncomplicated, straightforward, outrageously boastful little boy" they had first met at age 20. They diagnosed his amalgam of absences-the unpresent anxiety, insight, remorse, concern-as "a primary social defect." They concluded that their frontal lobe-less man was "a very simplified human organism with only rudimentary mechanisms for social adjustment...limited and lacking in the kind of potential needed for growth and self-realization." In language unusual for scientists, and sounding rather sad, they wrote, "JP has been a stranger in this world without knowing it."

Strangers in the World

The stranger suffered from a neurological condition whose symptoms were not seizures or paralysis, but social weakness. Bruce Price, M.D., a behavioral neurologist at Harvard Medical School and chief of neurology at McLean Hospital in Massachusetts, said patients like this are missing "the physiology of insight."

In a 1990 paper published by the international journal Brain, Price and his colleagues in Boston described several patients whose perinatal injuries had left them with prefrontal damage. They were given a series of classic psychological tests designed to assess levels of moral development and reasoning. Early bilateral damage to the brain's prefrontal lobes, the authors concluded, leaves some children without obvious neurologic disease and without physical or mental defects. Instead, they are left with a unique and resistant disability: an inaptitude for moral development.

The damage is permanent and without compensation. These patients, often misdiagnosed and difficult to identify, don't suffer simply from bad genes or bad family; they are missing the physical material-cell to cell and synapse to synapse-responsible for the insight, foresight, judgment, empathy and abstraction ability necessary to become moral beings.

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