Developmental Consequences of Childhood Frontal Lobe Damage
Paul J. \s=b\
A
33-year-old
Eslinger, PhD; Lynn M. Grattan, PhD; Hanna Damasio, MD; Antonio
woman
underwent
neurologic
and
neu-
ropsychological studies 26 years after she sustained damage
to the frontal lobe. The findings ofthe neurologic examination
normal, and magnetic resonance imaging revealed a lesion in left prefrontal cortex and deep white matter. Cerebral blood flow studies showed an abnormal pattern in both left and right frontal regions. The patient exhibited striking neuropsychological defects in higher cognition, most notably in self-regulation of emotion and affect and in social behavior. Analysis of her behavioral development failed to yield a pattern of abrupt onset of defect immediately after the lesion occurred. On the contrary, there was a delayed onset of defects, followed by a period of seeming progression, and finally an arrest of development in adolescence. We suggest that this peculiar pattern is the natural consequence of the varied changes that occurred in brain development and social cognition during the patient's formative years. While certain long-term neuropsychological deficits in our case are similar to those following frontal damage in adults, the delayed onset and progression of deficits are different. (Arch Neurol. 1992;49:764-769) were
lobe le¬ in detailed case sions in adults have studies and group analyses.1"13 The spectrum cognitive and behavioral changes have been incorporated in several models that address not only location of lesion and disruption of intrinsic frontal lobe mechanisms, but also pathologic features within the multiple neural systems that interact with the frontal lobes.13"16 By comparison, few cases of focal, stable frontal lobe lesions sustained in childhood have received comparable attention. Those available allude to significant, long-term impairment in social behavior and emotional maturity.17"21 Study of such cases is relevant to diagnostic, management, and theoret¬ ical issues, many of which have been raised only through investigations with animal models or through develop¬ mental studies in normal children.22"31 Neuropsychological impairments associated with child¬ hood cerebral diseases have been noted to continue well be¬ yond the recovery of overt physical and neurologic symp¬ toms. Unlike the effects of adult brain injury, the neuropsychological consequences of early cerebral injury
consequences of frontal The neuropsychologicalbeen described of associated
for publication February 21, 1992. Department of Medicine, Division of Neurology, and the Department of Behavioral Science, Pennsylvania State University College of Medicine, The Milton S. Hershey Medical Center, Hershey, Pa (Dr Eslinger); the Department of Neurology, University of Maryland School of Medicine, Baltimore (Dr Grattan); and the Department of Neurology, Division of Behavioral Neurology and Cognitive Neuroscience, University of Iowa College of Medicine, Iowa City (Drs H.
Accepted From the
Damasio and A. R. Damasio). Reprint requests to Division of Neurology, The Milton S. Hershey Medical Center, 500 University Dr, Hershey, PA 17033 (Dr Eslinger).
R.
Damasio, MD, PhD
may not be immediately apparent or may vary throughout a comparative study 30 years ago of development.32"34 In with children and adults brain lesions, Teuber and Rudel35 differentiated three patterns of outcome after childhood le¬ sion: (1) fixed impairments with no recovery over time; (2) recovery over time by various compensatory processes; and (3) delayed onset of impairments throughout development. More recent neuropsychological studies indicate that there may be some anatomic basis for these outcome differences. That is, nonfrontal cerebral lesions in childhood have been associated with impairments that are frequently identifiable in the early stages and show various degrees of recovery, such as aphasia, amnesia, and visual disorders.36"39 However, frontal lobe damage in childhood poses special questions about the pattern of outcome that may arise from the fact that the frontal lobes undergo a longer, multistage maturation process extending well into adolescence.13-26"30-40"42 Hence, frontal lobe damage at varying ages prior to adulthood may lead to a different onset of impairments and pattern of recovery. In the following study, we examined the consequences of early frontal lobe damage on higher cognitive and psy¬ chological development in a 33-year-old woman who sus¬ tained her injury at 7 years of age. METHODS
Neuropsychological
Studies
The patient underwent comprehensive neuropsychological and neuroimaging studies 26 years after she sustained damage to the frontal lobe. Cognitive evaluation with the Benton Laboratory Com¬ prehensive Neuropsychological Examination assessed intellect, learning and memory, language, visual perception, constructional praxis, executive functions, and academic achievement.'''43"52 The patient's personality and social behavior were assessed Multiphasic through numerous clinical interviews, the Minnesota Personality Inventory, Hogan's Empathy Scale,53 and a Moral hidgment Interview.54 Collateral data were obtained through the pa¬ tient's daily diary, her parents' report, academic records, and notes from psychotherapy sessions spanning 7 years of young adulthood.
Neuroimaging Studies Neuroimaging studies included computed tomography, mag¬
netic resonance imaging (Ti- and T2-weighted images), and single photon emission computed tomography with xenon 144. These
images were analyzed by an investigator blinded to the patient's neurologic and neuropsychological data. A standard method of anatomical analysis was used to interpret all abnormal images.55 RESULTS
Premorbid History The patient was the older of two children born to the same pair of biological parents in a middle-class semirural community. Her birth was uncomplicated and followed a normal pregnancy. Developmental milestones (eg, speech, language, sitting up, and toilet training) were entirely nor-
Downloaded From: http://archneur.jamanetwork.com/ by a University of Manitoba User on 06/16/2015
mal. Social and emotional development were appropriate until the time of her brain injury at 7 years of age. Her first-grade teacher noted her to be always proper, immac¬ ulately dressed and groomed, and often the only child in the classroom to remember her umbrella on rainy days. Premorbidly, the patient's level of academic achievement was average. Her parents and sister are also of average educational and occupational achievement. There is no family history of mental illness, substance abuse, or social-emotional impairment.
Neurologic History At 7 years of age, the patient sustained a spontaneous intraparenchymal hemorrhage of unknown cause in the left frontal region. An emergency craniotomy was per¬ formed to evacuate the hemorrhage. The patient remained in coma for 5 days and was hospitalized for 1 month. Thereafter, with the exception of treatment for primary generalized tonic-clonic seizures, which have been well controlled, her physical recovery was complete and nor¬
mal. The parents were instructed to return the child to school and usual activities. Clinical neurologic examina¬ tion results have been normal.
Neuropsychological Examination The patient's clinical presentation varied with the con¬ text of evaluation. Within her familiar home environment, she was friendly, verbal, and well oriented. During exam¬ ination at the University of Iowa Hospitals and Clinics, Iowa City, she was hostile, with puerile affect and disinhibition. A consistent pattern during personality and cog¬ nitive assessment was her lack of attention to detail, her disorganized approach to problem solving, her difficulty in establishing a plan and in executing multiple steps to¬ ward a relatively remote goal, and cognitive rigidity. She demonstrated an impulsive response style and, unless en¬ couraged, failed to give in-depth thought to questions and tasks. Results of formal testing indicated an overall lowaverage range of intellect (Wechsler Adult Intelligence Scale-Revised intelligence quotient [IQ] scores: verbal IQ, 81, performance IQ, 84, and full scale IQ, 80). Considerable subtest variability occurred. The patient had particular difficulty with subtests requiring "freedom from distractibility" (ie, arithmetic, digit span, and digit symbol substi¬ tution), but was average in verbal and nonverbal reason¬ ing, comprehension, and perceptual ability. Despite her 12 years of formal education, her academic achievement lev¬ els were at the third-grade level or lower in spelling, arith¬ metic, and oral word reading. Her learning and memory were within the low-average range, and she did not appear amnesic in any way. Her conversational speech was spontaneous, fluent, and nonparaphasic, without evidence of word selection or prosodical disturbance. Dichotic listening revealed a mild left ear extinction, with normal results on screening audiometry. Her verbal associative fluency was defective, but her category (semantic) fluency was intact. Visual pattern discrimination, spatial judgment, and block constructions were within the average range. Copy of the Rey-Osterrieth complex figure was spatially disor¬ ganized, perseverative, and sloppy. Her construction im¬ proved significantly, however, when it followed a pro¬ grammed format that presented one element at a time.56 Measures of executive and self-regulatory processes in-
significant difficulties in organizing information, utilizing examiner feedback to modify her responses, and planning toward a remote goal. She exhibited significant cognitive rigidity in tasks requiring shifting of response set51 (ie, reactive flexibility) and divergent production49 (ie, spontaneous flexibility). Finally, on a modified cognitive estimation task,9 she had difficulty in making judgments about environmental events. For instance, she reported that 90% of the US population was male; proposed that one dicated
in 6 hours; and Angeles a 5 miles
could drive from New York to Los decided that race horses galloped at hour.
rate
of
per
Personality and Social Behavior The patient presented an austere but sloppy appearance. Her clothing consisted of a simple dress and sandals, with¬ out makeup. She specifically pointed out that her attire, hair¬ style, and omission of makeup were purposely selected to be compatible with the teachings of her religion. However, since our evaluation marked a special occasion, she decided to make an exception and wore a necklace. Assessment of the patient's personality and social and emotional development suggested that she had significant difficulties with managing and expressing strong emo¬ tions, establishing meaningful relationships, and integrat¬ ing multiple aspects of her social and emotional self into a stable and consistent presentation over time. Specifically, the Minnesota Personality Inventory profile was valid, but abnormal (Welsh code 46"98'71230-5: F'LK/). Women generating a similar pattern of responses have been described as excessively demanding and de¬ pendent, unable to profit from experience, and harboring considerable hostility, which they are unable to effectively or directly express. In addition, the patient's responses were similar to those of individuals who experience and demonstrate significant emotional shallowness toward others and have seriously disrupted interpersonal rela¬ tionships. She also generated a very low score on the stan¬ dardized measure of empathy (27:2 SD below the mean), which was confirmed by parental report on an equivalent form. The finding indicates that the patient has unusual difficulty in apprehending the viewpoints and situations of other people. Her analysis of moral dilemmas suggests that she views such complex situations in terms of concrete and Stereo¬ typie notions of "good" and "bad" behavior. In the forefront of her responses are fixed rules. For instance, she decided it would be wrong for a poor young man to steal an expensive drug from a greedy dispenser because, "It's against the law. It's against the Ten Commandments. That's against the Bible. That's against morals." When the genuine plight of the poor young man was pointed out to her, she quickly changed her approach to the problem. She indicated that when laws and rules do not permit a person to do what they want, then the person should change the rules, basing her response on motives of instrumental he¬ donism and interpersonal concordance. The discrepancy between her responses was never resolved. Her approach to these conflicting situations did not adhere to a set of consistent ethical principles or values, but was driven by a varying rationale that would serve to meet immediate needs or to indicate in an absolute inflexible way what was good and bad behavior. Her level of moral reasoning most closely resembled that of early adolescents, 10 to 13 years of age.54
Multiphasic
Downloaded From: http://archneur.jamanetwork.com/ by a University of Manitoba User on 06/16/2015
Fig 1.—Magnetic resonance imaging scan (T2-weighted images) showing deep left prefrontal lobe lesion.
Through retrospective analysis of family and academic records, as well as extensive interviews with the patient's parents, we attempted to gauge the impact of her early frontal lobe lesion on her daily living. During the 3 years immediately following her injury (7 to 10 years of age), she
became a slower learner and a lower achiever in school. In late childhood and early adolescence, significant difficul¬ ties became progressively evident in social and emotional domains. She eventually maintained only one friend, alienating herself from others through noncooperative in¬ teractions and frequent arguments. She became pregnant 1 year after high school graduation by the first man she dated, and was married. After 7 years of marital conflicts, her husband divorced her and gained custody of their child because of the patient's impulsive and immature be¬ unable to regulate her emotions and havior. She unable to learn from her experience as a wife, homemaker, and mother. For instance, while she was able to wipe a ta¬ ble, wash a dish, measure a quantity, and open a can, she could not plan or execute the steps necessary for meal preparation or even cleaning a room. Thereafter, her pro¬ miscuity increased. She proclaimed her love for numerous antisocial and unsavory characters, reporting up to seven boyfriends at a time. She eventually met a self-proclaimed preacher, and after a 2-month courtship decided to marry him because his religion accepted second marriages. This relationship, however, has been marked by conflicts and abnormal sexual activity for several years. She justifies her
appeared
difficult relationship as "obedience to her religion" and cites skewed and concrete biblical references to justify it. Meanwhile, her increasing church involvement appears to provide a structure for her identity and behavior, dictating her dress, interpersonal contacts, and daily activities. Her few friendships are initiated through the church, but are short-lived after repeated overstepping of interpersonal boundaries. She extends her visits beyond the time for which she is welcome and quickly depends on newfound friends to meet all of her emotional needs. The patient's vocational record has also been maladaptive. After high school graduation she attended beautician train¬ ing school for 1 year. However, she was dismissed from her first position because she persistently made hurtful state¬ ments, asked embarrassing questions, and gave impulsive responses. Since that time she has been unable to hold a job for more than a few weeks, although she has the intellectual capacity and physical ability to learn the basic tasks of a semiskilled occupation. Her work is characterized by poor interpersonal skills, by her inability to execute the required activities throughout the course of a day, and by her failure to learn from mistakes. Moreover, she responds to criticism by externalizing blame, becoming obstinate, and telling her employers how they should be managing their business. Despite a poor work record for 12 years, the patient remains naive, and unrealistic rigid in her job-hunting strategies, about her vocational abilities. Her approach is to read the newspaper and apply for positions that "look interesting,"
Downloaded From: http://archneur.jamanetwork.com/ by a University of Manitoba User on 06/16/2015
Fig 2.—Depiction of the lesion seen the left hemisphere.
in
Fig
1
on
the
best-fitting template system and the projection of the lesion onto a lateral and mesial image of
such as an airline stewardess and a store manager. Another aspiration is to open a religious book store in the West, be¬ cause a friend informed her there were none. When asked about these vocational goals, her responses are devoid of any financial or practical planning, as well as anticipation of the various steps leading to employment.
Neuroimaging Results Neuroanatomical interpretation of the magnetic reso¬ nance images revealed damage in the left prefrontal region, involving Brodmann's areas 9, 46, and 32. The le¬ sion extended deep into the white matter, reaching the most superior portion of the left frontal horn and damag¬ ing the white matter underlying Brodmann's areas 45 and 24. No structural abnormality could be detected in the right frontal lobe (Figs 1 and 2). Single photon emission computed tomography with xe¬ non 144 inhalation revealed abnormally low blood flow in
both left and right frontal cortices, suggesting bilateral ab¬ normal function (Fig 3). COMMENT The patient's frontal lobe lesion at 7 years of age occurred during an important phase of matura¬ tion. 13-2
Paul J. \s=b\
A
33-year-old
Eslinger, PhD; Lynn M. Grattan, PhD; Hanna Damasio, MD; Antonio
woman
underwent
neurologic
and
neu-
ropsychological studies 26 years after she sustained damage
to the frontal lobe. The findings ofthe neurologic examination
normal, and magnetic resonance imaging revealed a lesion in left prefrontal cortex and deep white matter. Cerebral blood flow studies showed an abnormal pattern in both left and right frontal regions. The patient exhibited striking neuropsychological defects in higher cognition, most notably in self-regulation of emotion and affect and in social behavior. Analysis of her behavioral development failed to yield a pattern of abrupt onset of defect immediately after the lesion occurred. On the contrary, there was a delayed onset of defects, followed by a period of seeming progression, and finally an arrest of development in adolescence. We suggest that this peculiar pattern is the natural consequence of the varied changes that occurred in brain development and social cognition during the patient's formative years. While certain long-term neuropsychological deficits in our case are similar to those following frontal damage in adults, the delayed onset and progression of deficits are different. (Arch Neurol. 1992;49:764-769) were
lobe le¬ in detailed case sions in adults have studies and group analyses.1"13 The spectrum cognitive and behavioral changes have been incorporated in several models that address not only location of lesion and disruption of intrinsic frontal lobe mechanisms, but also pathologic features within the multiple neural systems that interact with the frontal lobes.13"16 By comparison, few cases of focal, stable frontal lobe lesions sustained in childhood have received comparable attention. Those available allude to significant, long-term impairment in social behavior and emotional maturity.17"21 Study of such cases is relevant to diagnostic, management, and theoret¬ ical issues, many of which have been raised only through investigations with animal models or through develop¬ mental studies in normal children.22"31 Neuropsychological impairments associated with child¬ hood cerebral diseases have been noted to continue well be¬ yond the recovery of overt physical and neurologic symp¬ toms. Unlike the effects of adult brain injury, the neuropsychological consequences of early cerebral injury
consequences of frontal The neuropsychologicalbeen described of associated
for publication February 21, 1992. Department of Medicine, Division of Neurology, and the Department of Behavioral Science, Pennsylvania State University College of Medicine, The Milton S. Hershey Medical Center, Hershey, Pa (Dr Eslinger); the Department of Neurology, University of Maryland School of Medicine, Baltimore (Dr Grattan); and the Department of Neurology, Division of Behavioral Neurology and Cognitive Neuroscience, University of Iowa College of Medicine, Iowa City (Drs H.
Accepted From the
Damasio and A. R. Damasio). Reprint requests to Division of Neurology, The Milton S. Hershey Medical Center, 500 University Dr, Hershey, PA 17033 (Dr Eslinger).
R.
Damasio, MD, PhD
may not be immediately apparent or may vary throughout a comparative study 30 years ago of development.32"34 In with children and adults brain lesions, Teuber and Rudel35 differentiated three patterns of outcome after childhood le¬ sion: (1) fixed impairments with no recovery over time; (2) recovery over time by various compensatory processes; and (3) delayed onset of impairments throughout development. More recent neuropsychological studies indicate that there may be some anatomic basis for these outcome differences. That is, nonfrontal cerebral lesions in childhood have been associated with impairments that are frequently identifiable in the early stages and show various degrees of recovery, such as aphasia, amnesia, and visual disorders.36"39 However, frontal lobe damage in childhood poses special questions about the pattern of outcome that may arise from the fact that the frontal lobes undergo a longer, multistage maturation process extending well into adolescence.13-26"30-40"42 Hence, frontal lobe damage at varying ages prior to adulthood may lead to a different onset of impairments and pattern of recovery. In the following study, we examined the consequences of early frontal lobe damage on higher cognitive and psy¬ chological development in a 33-year-old woman who sus¬ tained her injury at 7 years of age. METHODS
Neuropsychological
Studies
The patient underwent comprehensive neuropsychological and neuroimaging studies 26 years after she sustained damage to the frontal lobe. Cognitive evaluation with the Benton Laboratory Com¬ prehensive Neuropsychological Examination assessed intellect, learning and memory, language, visual perception, constructional praxis, executive functions, and academic achievement.'''43"52 The patient's personality and social behavior were assessed Multiphasic through numerous clinical interviews, the Minnesota Personality Inventory, Hogan's Empathy Scale,53 and a Moral hidgment Interview.54 Collateral data were obtained through the pa¬ tient's daily diary, her parents' report, academic records, and notes from psychotherapy sessions spanning 7 years of young adulthood.
Neuroimaging Studies Neuroimaging studies included computed tomography, mag¬
netic resonance imaging (Ti- and T2-weighted images), and single photon emission computed tomography with xenon 144. These
images were analyzed by an investigator blinded to the patient's neurologic and neuropsychological data. A standard method of anatomical analysis was used to interpret all abnormal images.55 RESULTS
Premorbid History The patient was the older of two children born to the same pair of biological parents in a middle-class semirural community. Her birth was uncomplicated and followed a normal pregnancy. Developmental milestones (eg, speech, language, sitting up, and toilet training) were entirely nor-
Downloaded From: http://archneur.jamanetwork.com/ by a University of Manitoba User on 06/16/2015
mal. Social and emotional development were appropriate until the time of her brain injury at 7 years of age. Her first-grade teacher noted her to be always proper, immac¬ ulately dressed and groomed, and often the only child in the classroom to remember her umbrella on rainy days. Premorbidly, the patient's level of academic achievement was average. Her parents and sister are also of average educational and occupational achievement. There is no family history of mental illness, substance abuse, or social-emotional impairment.
Neurologic History At 7 years of age, the patient sustained a spontaneous intraparenchymal hemorrhage of unknown cause in the left frontal region. An emergency craniotomy was per¬ formed to evacuate the hemorrhage. The patient remained in coma for 5 days and was hospitalized for 1 month. Thereafter, with the exception of treatment for primary generalized tonic-clonic seizures, which have been well controlled, her physical recovery was complete and nor¬
mal. The parents were instructed to return the child to school and usual activities. Clinical neurologic examina¬ tion results have been normal.
Neuropsychological Examination The patient's clinical presentation varied with the con¬ text of evaluation. Within her familiar home environment, she was friendly, verbal, and well oriented. During exam¬ ination at the University of Iowa Hospitals and Clinics, Iowa City, she was hostile, with puerile affect and disinhibition. A consistent pattern during personality and cog¬ nitive assessment was her lack of attention to detail, her disorganized approach to problem solving, her difficulty in establishing a plan and in executing multiple steps to¬ ward a relatively remote goal, and cognitive rigidity. She demonstrated an impulsive response style and, unless en¬ couraged, failed to give in-depth thought to questions and tasks. Results of formal testing indicated an overall lowaverage range of intellect (Wechsler Adult Intelligence Scale-Revised intelligence quotient [IQ] scores: verbal IQ, 81, performance IQ, 84, and full scale IQ, 80). Considerable subtest variability occurred. The patient had particular difficulty with subtests requiring "freedom from distractibility" (ie, arithmetic, digit span, and digit symbol substi¬ tution), but was average in verbal and nonverbal reason¬ ing, comprehension, and perceptual ability. Despite her 12 years of formal education, her academic achievement lev¬ els were at the third-grade level or lower in spelling, arith¬ metic, and oral word reading. Her learning and memory were within the low-average range, and she did not appear amnesic in any way. Her conversational speech was spontaneous, fluent, and nonparaphasic, without evidence of word selection or prosodical disturbance. Dichotic listening revealed a mild left ear extinction, with normal results on screening audiometry. Her verbal associative fluency was defective, but her category (semantic) fluency was intact. Visual pattern discrimination, spatial judgment, and block constructions were within the average range. Copy of the Rey-Osterrieth complex figure was spatially disor¬ ganized, perseverative, and sloppy. Her construction im¬ proved significantly, however, when it followed a pro¬ grammed format that presented one element at a time.56 Measures of executive and self-regulatory processes in-
significant difficulties in organizing information, utilizing examiner feedback to modify her responses, and planning toward a remote goal. She exhibited significant cognitive rigidity in tasks requiring shifting of response set51 (ie, reactive flexibility) and divergent production49 (ie, spontaneous flexibility). Finally, on a modified cognitive estimation task,9 she had difficulty in making judgments about environmental events. For instance, she reported that 90% of the US population was male; proposed that one dicated
in 6 hours; and Angeles a 5 miles
could drive from New York to Los decided that race horses galloped at hour.
rate
of
per
Personality and Social Behavior The patient presented an austere but sloppy appearance. Her clothing consisted of a simple dress and sandals, with¬ out makeup. She specifically pointed out that her attire, hair¬ style, and omission of makeup were purposely selected to be compatible with the teachings of her religion. However, since our evaluation marked a special occasion, she decided to make an exception and wore a necklace. Assessment of the patient's personality and social and emotional development suggested that she had significant difficulties with managing and expressing strong emo¬ tions, establishing meaningful relationships, and integrat¬ ing multiple aspects of her social and emotional self into a stable and consistent presentation over time. Specifically, the Minnesota Personality Inventory profile was valid, but abnormal (Welsh code 46"98'71230-5: F'LK/). Women generating a similar pattern of responses have been described as excessively demanding and de¬ pendent, unable to profit from experience, and harboring considerable hostility, which they are unable to effectively or directly express. In addition, the patient's responses were similar to those of individuals who experience and demonstrate significant emotional shallowness toward others and have seriously disrupted interpersonal rela¬ tionships. She also generated a very low score on the stan¬ dardized measure of empathy (27:2 SD below the mean), which was confirmed by parental report on an equivalent form. The finding indicates that the patient has unusual difficulty in apprehending the viewpoints and situations of other people. Her analysis of moral dilemmas suggests that she views such complex situations in terms of concrete and Stereo¬ typie notions of "good" and "bad" behavior. In the forefront of her responses are fixed rules. For instance, she decided it would be wrong for a poor young man to steal an expensive drug from a greedy dispenser because, "It's against the law. It's against the Ten Commandments. That's against the Bible. That's against morals." When the genuine plight of the poor young man was pointed out to her, she quickly changed her approach to the problem. She indicated that when laws and rules do not permit a person to do what they want, then the person should change the rules, basing her response on motives of instrumental he¬ donism and interpersonal concordance. The discrepancy between her responses was never resolved. Her approach to these conflicting situations did not adhere to a set of consistent ethical principles or values, but was driven by a varying rationale that would serve to meet immediate needs or to indicate in an absolute inflexible way what was good and bad behavior. Her level of moral reasoning most closely resembled that of early adolescents, 10 to 13 years of age.54
Multiphasic
Downloaded From: http://archneur.jamanetwork.com/ by a University of Manitoba User on 06/16/2015
Fig 1.—Magnetic resonance imaging scan (T2-weighted images) showing deep left prefrontal lobe lesion.
Through retrospective analysis of family and academic records, as well as extensive interviews with the patient's parents, we attempted to gauge the impact of her early frontal lobe lesion on her daily living. During the 3 years immediately following her injury (7 to 10 years of age), she
became a slower learner and a lower achiever in school. In late childhood and early adolescence, significant difficul¬ ties became progressively evident in social and emotional domains. She eventually maintained only one friend, alienating herself from others through noncooperative in¬ teractions and frequent arguments. She became pregnant 1 year after high school graduation by the first man she dated, and was married. After 7 years of marital conflicts, her husband divorced her and gained custody of their child because of the patient's impulsive and immature be¬ unable to regulate her emotions and havior. She unable to learn from her experience as a wife, homemaker, and mother. For instance, while she was able to wipe a ta¬ ble, wash a dish, measure a quantity, and open a can, she could not plan or execute the steps necessary for meal preparation or even cleaning a room. Thereafter, her pro¬ miscuity increased. She proclaimed her love for numerous antisocial and unsavory characters, reporting up to seven boyfriends at a time. She eventually met a self-proclaimed preacher, and after a 2-month courtship decided to marry him because his religion accepted second marriages. This relationship, however, has been marked by conflicts and abnormal sexual activity for several years. She justifies her
appeared
difficult relationship as "obedience to her religion" and cites skewed and concrete biblical references to justify it. Meanwhile, her increasing church involvement appears to provide a structure for her identity and behavior, dictating her dress, interpersonal contacts, and daily activities. Her few friendships are initiated through the church, but are short-lived after repeated overstepping of interpersonal boundaries. She extends her visits beyond the time for which she is welcome and quickly depends on newfound friends to meet all of her emotional needs. The patient's vocational record has also been maladaptive. After high school graduation she attended beautician train¬ ing school for 1 year. However, she was dismissed from her first position because she persistently made hurtful state¬ ments, asked embarrassing questions, and gave impulsive responses. Since that time she has been unable to hold a job for more than a few weeks, although she has the intellectual capacity and physical ability to learn the basic tasks of a semiskilled occupation. Her work is characterized by poor interpersonal skills, by her inability to execute the required activities throughout the course of a day, and by her failure to learn from mistakes. Moreover, she responds to criticism by externalizing blame, becoming obstinate, and telling her employers how they should be managing their business. Despite a poor work record for 12 years, the patient remains naive, and unrealistic rigid in her job-hunting strategies, about her vocational abilities. Her approach is to read the newspaper and apply for positions that "look interesting,"
Downloaded From: http://archneur.jamanetwork.com/ by a University of Manitoba User on 06/16/2015
Fig 2.—Depiction of the lesion seen the left hemisphere.
in
Fig
1
on
the
best-fitting template system and the projection of the lesion onto a lateral and mesial image of
such as an airline stewardess and a store manager. Another aspiration is to open a religious book store in the West, be¬ cause a friend informed her there were none. When asked about these vocational goals, her responses are devoid of any financial or practical planning, as well as anticipation of the various steps leading to employment.
Neuroimaging Results Neuroanatomical interpretation of the magnetic reso¬ nance images revealed damage in the left prefrontal region, involving Brodmann's areas 9, 46, and 32. The le¬ sion extended deep into the white matter, reaching the most superior portion of the left frontal horn and damag¬ ing the white matter underlying Brodmann's areas 45 and 24. No structural abnormality could be detected in the right frontal lobe (Figs 1 and 2). Single photon emission computed tomography with xe¬ non 144 inhalation revealed abnormally low blood flow in
both left and right frontal cortices, suggesting bilateral ab¬ normal function (Fig 3). COMMENT The patient's frontal lobe lesion at 7 years of age occurred during an important phase of matura¬ tion. 13-2
