There are three areas of the frontal lobes of the brain. First is the "Motor" area which is responsible for controlling our movements. The "Premotor" area selects movements, selection and direction of motor sequences, chooses your behavior in response to clues and controls our fronal eye fields. Lastly, the "Prefronal cortex" controls the cognitive processes so that appropriate movements are selected at the correct time and place.
This article discusses the Prefrontal Complex from the viewpoint of a attending Physician.
The prefrontal cortex (pfc) is the most evolved part of the brain. It occupies the front third of the brain, underneath the forehead. It is often divided into three sections: the dorsal lateral section (on the outside surface of the pfc), the inferior orbital section (on the front undersurface of the brain) and the cingulate gyrus (which runs through the middle of the frontal lobes). The cingulate gyrus, often considered as part of the limbic system, will be covered in its own chapter. The dorsal lateral and inferior orbital gyrus are often termed the executive control center of the brain and will be discussed together in this chapter. When necessary, I'll distinguish what is known about their function.
Overall, the pfc is the part of the brain that watches, supervises, guides, directs and focuses your behavior. It contains "executive functions," such as time management, judgment, impulse control, planning, organization and critical thinking. Our ability as a species to think, plan ahead, use time wisely and communicate with others is heavily influenced by this part of the brain. The pfc is responsible for behaviors that are necessary for you to be appropriate, goal directed, socially responsible and effective.
North Carolina neuropsychiatrist Thomas Gualtieri, MD succinctly summarized the human functions of the pfc, ".the capacity to formulate goals, to make plans for their execution, to carry them out in an effective way, and to change course and improvise in the face of obstacles or failure, and to do so successfully, in the absence of external direction or structure. The capacity of the individual to generate goals and to achieve them is considered to be an essential aspect of a mature and effective personality. It is not a social convention or an artifact of culture. It is hard wired in the construction of the prefrontal cortex and its connections." (In The Neuropsychiatry of Personality Disorders, 1996, Edited by John Ratey. MD.)
The pfc helps you think about what you say or do before you say or do it (especially the inferior orbital pfc). The pfc helps you, in accordance with your experience, select actions between alternatives in social and work situations. For example, if you are having a disagreement with your spouse and you have good pfc function you are more likely to give a thoughtful response that helps the situation. If you have poor pfc function you are more likely to do or say something that will make the situation worse. Likewise, if you're a check out clerk in a grocery store and a difficult, complaining person comes through your line (who has poor pfc function) and you have good pfc function you are more likely to keep quiet or give a thoughtful response that helps the situation. If you have poor pfc function you are more likely to do or say something that will inflame the situation. The pfc helps you problem solve, see ahead of a situation and, through experience, pick between the most helpful alternatives. Effectively playing a game such as chess requires good pfc function.
This is also the part of the brain that helps you learn from mistakes. Good pfc function doesn't that mean you won't make mistakes. Rather, it generally means you won't make the same mistake over and over. You are able to learn from the past and apply its lessons. For example, a student with good pfc function is likely to learn that if he or she starts a long term project early, there is more time for research and less anxiety over getting it done. A student with decreased pfc function doesn't learn from past frustrations and may tend to put everything off until the last minute. Poor pfc function tends to be involved in people who have trouble learning from experience. They tend to make repetitive mistakes. Their actions are not based on experience, but rather on the moment, and immediate wants and needs.
The pfc is also involved with sustaining attention span (especially the dorsal lateral pfc). It helps you focus on important information while filtering out less significant thoughts and sensations. Attention span is required for short term memory and learning. The pfc, through its many connections within the brain, helps you keep on task and allows you to stay with a project until it is finished. The pfc actually sends quieting signals to the limbic and sensory parts of the brain. When there is a need to focus, the pfc decreases the distracting input from other brain areas. It helps to inhibit or filter out distractions. When the pfc is underactive there is less of a filtering mechanism available and distractibility becomes common (this will be discussed in detail under attention deficit disorder).
The pfc is also the part of the brain that allows you to feel and express emotions; to feel happiness, sadness, joy, and love (especially the dorsal lateral pfc). It is different from the limbic system, which is a more primitive part of the brain. Even though the limbic system controls mood and libido, the prefrontal cortex is able to translate the feelings of the limbic system into recognizable feelings, emotions and words, such as love, passion or hate. Underactivity or damage in this part of the brain often leads to a decreased ability to express thoughts and feelings.
Thoughtfulness and impulse control is heavily influenced by the pfc. The ability to think through the consequences of behavior is essential to effective living, in nearly every aspect of human life. Common examples of the need for forethought include: choosing a good mate, interacting with customers, dealing with difficult children, spending money and driving on the freeway. Without proper function in this part of the brain it is difficult to act in consistent thoughtful ways and impulses can take over.
The pfc has many connections to the limbic system. It sends inhibitory messages that help keep it under control. It helps you "use your head along with your emotions." When there is damage or underactivity in this part of the brain, especially on the left side, the pfc cannot appropriately inhibit the limbic system, causing an increased vulnerability to depression if the limbic system becomes overactive. A classic example of this problem occurs in people who have had left frontal lobe strokes. Sixty percent of patients with these strokes develop a major depression within a year.
When scientists study the prefrontal cortex with neuroimaging studies like SPECT, it is often done twice. Once in a resting state, and again during a concentration task. In evaluating brain function, it is important to look at a working brain. When the normal brain is challenged with a concentration task, such as math problems or sorting cards, the pfc increases in activity. Much like when you flex a muscle, the muscle produces more energy. In certain brain conditions, such as attention deficit disorder and schizophrenia, the prefrontal cortex decreases its activity in response to an intellectual challenge.
Problems in the dorsal lateral prefrontal cortex often lead to decreased attention span, distractibility, impaired short term memory, decreased mental speed, apathy and decreased verbal expression. Problems in the inferior orbital cortex often lead to poor impulse control, mood control problems (due to its connects with the limbic system), decreased social skills and overall decreased control over behavior.
Overall, when there are problems in the pfc the organization of daily life becomes difficult and internal supervision goes awry. People with pfc problems often do things they later regret, exhibiting problems with impulse control. They also experience problems with attention span, distractibility, procrastination, poor judgment and problems expressing themselves. Test anxiety along with social anxiety also may be hallmarks of problems in the pfc. Situations that require concentration, impulse control and quick reactions are often hampered by pfc problems. Tests require concentration and the retrieval of information. Many people with pfc problems experience difficulties in test situations because they have trouble activating this part of the brain under stress, even if they have adequately prepared for the test. In a similar way, social situations require concentration, impulse control and dealing with uncertainty. Pfc deactivation often cause a person's mind to "go blank" in conversation which lead to being uncomfortable in social situations.
When men have problems in this part of the brain, their emotions are often unavailable to them and their partners complain that they do not share their feelings. This can cause serious problems in a relationship because of how other people interpret the lack of expression of feeling. Many women, for example, blame their male partners for being cold or unfeeling, when it is really a problem in the pfc that causes a lack of being "tuned in" to the feelings of the moment.
ADD occurs as a result of neurological dysfunction in the prefrontal cortex. When people with ADD try to concentrate the pfc decreases in activity rather than increasing as it does in normal control groups. As such, people with ADD show many of the symptoms discussed in this chapter, such as poor internal supervision, short attention span, distractibility, disorganization, hyperactivity (although only « the people with ADD are hyperactive), impulse control problems, difficulty learning from past errors, lack of forethought and procrastination.
ADD has been a particular interest of mine over the past 15 years. Of note, two of my three children have this disorder. I tell people I know more about ADD than I want to know. Through the SPECT research done in my clinic, along with the brain imaging and genetic work done by others, we have found that ADD is basically a genetically inherited disorder of the pfc, due in part, to a deficiency of the neurotransmitter dopamine.
Here are some of the common characteristics of ADD that clearly relate this disorder to the pfc.
Research has shown that the more people with ADD try to concentrate, the worse things get for them. The activity in the pfc actually turns down, rather than turning up. When a parent, teacher, supervisor or manager puts more pressure on a person with ADD to perform, he or she often becomes less effective. Too frequently when this happens the parent, teacher or boss interprets this decreased performance as willful misconduct and serious problems arise. I treat a man with ADD who is a ship welder. He told me that whenever his boss puts intense pressure on him to do a better job, his performance becomes worse (even though he really tries to do better). When the boss encourages him to do better in a positive way, he becomes more productive. In parenting, teaching, supervising or managing someone with ADD, it is much more effective to use praise and encouragement, rather than pressure. People with ADD do best in environments that are highly interesting or stimulating and relatively relaxed.
A short attention span is the hallmark symptom of this disorder. People with ADD have trouble sustaining attention span and effort over prolonged periods of time. Their attention span tends to wander and they are frequently off task, thinking about or doing other things than the task at hand. Yet, one of the things that often fools inexperienced clinicians assessing this disorder is that people with ADD do not have a short attention span for everything. Often, people with ADD can pay attention just fine to things that are new, novel, highly stimulating, interesting or frightening. These things provide enough of their own intrinsic stimulation which activates the pfc so they can focus and concentrate. An ADD child might do very well in a one-on-one situation and completely fall apart in a classroom of 30 children. My son with ADD, for example, used to take 4 hours to do a half and hour's worth of homework, frequently getting off task. Yet, if you gave him a car stereo magazine he would quickly read it cover to cover and remember every little detail in it. People with ADD have longstanding problems paying attention to regular, routine, everyday matters such as homework, schoolwork, chores or paperwork. The mundane is terrible for them and it is NOT a choice. They need excitement and interest to kick in pfc function.
I have had many adult couples tell me that in the beginning of the relationship the person with adult ADD could pay attention to the other person for hours. The stimulation of new love helped focus. But as the "newness" and excitement of the relationship became more routine (as it does in nearly all relationships) the ADD person has a much harder time paying attention and their listening ability falters.
As mentioned above, the pfc sends inhibitory signals to other areas of the brain quieting intake from the environment so that you can concentrate. When there is not enough activity in the pfc it doesn't adequately dampen the sensory parts of the brain which cannot then filter out distractions, too much stimuli bombards the brain as a result. Distractibility is evident in many different settings for the ADD person. In class, during meetings, while listening to a partner the person with ADD tends to notice other things going on and has trouble staying focused on the issue at hand. People with ADD tend to look around the room, drift off, appear bored, forget where the conversation is going and interrupt with extraneous information. The distractibility and short attention span may also cause them to take much longer to complete their work than would be expected in the situation.
The lack of impulse control gets many ADD people into hot water. They may say inappropriate things to parents, friends, teachers, supervisors, other employees or customers. I once had a patient who was fired from 13 jobs, because he had trouble controlling what he said. Even though he really wanted to keep several of the jobs, he would just blurt out what he was thinking before he had a chance to process the thought. Poorly thought out decisions also relate to impulsivity. Rather than thinking a problem through, many ADD people want an immediate solution to the problem and act without the necessary forethought. In a similar vein, the impulsivity causes these people to have trouble going through the established channels at work. They often go right to the top to solve problems, rather than working through the system. This may cause resentments from their co-workers and immediate supervisors. Impulsivity also may lead to such problem behaviors as lying (saying the first thing that comes into your mind), stealing, having affairs and excessive spending. I have treated many ADD people who have suffered with the shame and guilt of these behaviors.
In my lectures I often ask the audience, "How many people here are married?" A large percentage of the audience raises their hands. I then ask, "Is it helpful for you to say everything you think in your marriage?" The audience laughs, because they know the answer. "Of course not," I continue, "relationships require tact." Yet because of impulsivity and a lack of forethought many people with ADD say the first thing that comes to mind. And, instead of apologizing for saying something hurtful, many ADD people will justify why they said the hurtful remark, only making the situation worse. An impulsive comment can ruin a nice evening, a weekend, even a whole marriage."
Many people with ADD unconsciously seek conflict as a way to stimulate their own pfc. They do not know they do it. They do not plan to do it. They deny that they do it. And yet, they do it just the same. The relative lack of activity and stimulation to the pfc calls out or craves for more activity. Hyperactivity, restlessness and humming are common forms of self-stimulation. Another way I have seen people with ADD "turn on their brains" by causing turmoil. If they can get their parents or their spouses to be emotionally intense or yell at them that might increase activity in their frontal lobes and help them to feel more tuned in. Again, this is not a conscious phenomenon. They do not know that they do this to get turned on. But, it seems many ADD people become addicted to the turmoil. They repeatedly get others upset with them even though there is no conscious benefit to their behavior. This is "Pavlovian," or conditioned behavior.
I once treated a man who would quietly stand behind a corner in his house and jump out and scare his wife when she walked by. He liked the charge he got out of her screams. Unfortunately for his wife she developed an irregular heart rhythm because of the repetitive scares. I have also treated many ADD adults and children who seemed driven to get their animals upset by playing rough or teasing them.
The parents of ADD children commonly report that the kids are experts at getting them upset. One mother told me that when she wakes up in the morning, she promises herself that she won't yell or get upset with her 8-year-old son. Yet, invariably, by the time he is off for school, there have been at least three fights and both of them feel terrible. When I explained the child's unconscious need for stimulation to the mother, she stopped yelling at him. When parents stop providing the negative stimulation (yelling, spanking, lecturing, etc.) these children decrease the behaviors. Whenever you feel like screaming at one of these kids, talk as softly as you can. At least in that way you're breaking their addiction to turmoil and lowering your own blood pressure.
Another self-stimulating behavior common in people with ADD is worrying or focusing on problems. The emotional turmoil generated by worrying or being upset produces stress chemicals that keep the brain active. I once treated a women who had depression and ADD. She started each session by telling me she was going to kill herself. She noted that this would make me anxious and seemed to enjoy telling me the gruesome details of how she would do it. After about a year of listening to her I finally figured out that she really wouldn't kill herself and she used my reaction as a source of stimulation for her. After getting to know her well, I told her, "Stop talking about suicide. I do not believe you'll kill yourself. You love your 4 children and I can't believe you would ever abandon them. I think you use this talk as a way to keep things stirred up. Without knowing, your ADD causes you to play the game of `Let's have a problem.' This ruins any joy you could have in your life." Initially, she was very upset with me (another source of conflict I told her), but she trusted me enough to at least look at the behavior. Decreasing her need for turmoil became the major focus of psychotherapy.
The problem with using anger, emotional turmoil and negative emotion as a way to stimulate yourself is that it ruins your immune system. The high levels of adrenaline produced by conflict driven behavior decreases the immune system's effectiveness, increasing vulnerability to illness. I have seen this scenario over and over.
As noted, many ADD folks tend to be in constant turmoil with one or more people, at home, work or school. They seem to "unconsciously" choose people who are vulnerable and begin to pick verbal battles with them. I have had many mothers come into my office and feel as though they want to run away from home. They cannot stand the constant turmoil in their relationship with the ADD child. They say the children are driven to turmoil and seem to look for a problem or fight. Many ADD children and adults have a tendency to embarrass others for little to no good reason, distancing themselves from others. They may be the class clown in school or be the wise-cracker at work. Witzelsucht is a term in the neuropsychiatric literature that relates to "an addiction to making bad jokes." It was first described in patients who had frontal lobe brain tumors, especially on the right side. Many people who have ADD clown excessively.
Disorganization is another hallmark of ADD. It often includes disorganization of physical space, such as rooms, desks, book bags, filing cabinets and closets; and disorganization of time. Often when you look at an ADD person's work area, it is a wonder they can work in it at all. They tend to have many piles of "stuff;" paperwork is often hard for them to keep straight; and they seem to have a filing system that only they can figure out (and only on good days). Many people with ADD are chronically late or put things off until the last possible minute. They are often late to work because they have significant problems waking up in the morning. I've had several patients who have bought sirens from alarm companies to help them wake up. Imagine what their neighbors thought! They also tend to lose track of time, which contributes to lateness.
The energy and enthusiasm of people with ADD often pushes them to start many projects. Unfortunately, their distractibility and short attention span impairs their ability to complete them. One radio station manager told me that he had started over thirty special projects the year before, but only completed a handful of them. He told me, "I'm always going to get back to them, but I get new ideas that get in the way." I also treat a college professor who told me that the year before he saw me he started 300 different projects. His wife finished the thought by telling me he only completed three.
Many people with ADD tend to be moody, irritable and negative. Since the pfc is underactive it cannot fully temper the limbic system and it becomes overactive, leading to mood control issues. In another subtle way, as mentioned, many people with ADD worry or become overfocused on negative thoughts as a form of self-stimulation. If they cannot seek turmoil from others in the environment they seek it with themselves. They often have a "sky is falling" attitude which tends to distant themselves from others.
Through the years I have heard many people say ADD is a fad or it is a disease made up by teachers or parents who want to control children with drugs. This popular "fad notion" has prevented many people from getting the help they need. In fact, ADD was first described at the turn of century by a pediatrician who called hyperactive, impulsive and inattentive children morally defective. He didn't understand that when you enhance the pfc with medication they often have a conscience as good or better than most.
ADD used to be thought of as a disorder of hyperactive boys who outgrew it before puberty. What we now know is that most people with ADD do not outgrow the symptoms of this disorder and that it frequently occurs in girls and women. It is estimated that ADD affects 17 million Americans.
Brian was 24 years old when he first came to see me. He came for help because he had gone to a junior college six straight semesters. He wasn't able to finish one of them! He wanted to go to medical school. Everybody told him he was nuts! How could he go to medical school if he couldn't even finish a junior college semester? Then his mother read my book "Windows Into The ADD Mind". She wondered if Brian didn't have attention deficit disorder.
After I took Brian's history, it was clear he had suffered from an undiagnosed lifelong case of ADD. From the time he was in kindergarten, he had problems staying in his seat, he was restless, distractible, disorganized and labeled as an underachiever.
Brian's father wanted to be convinced about ADD and requested we do a brain SPECT study to look at his brain. He wanted to make sure Brian wasn't just looking for another excuse as to why he was failing in life. His brain SPECT study at rest was normal. When Brian tried to concentrate, however, the prefrontal cortex of his brain turned off.
After the results of the clinical examination and brain SPECT studies, I put Brian on Ritalin, a stimulant medication that has been used to treat symptoms of ADD for over 40 years. Brian had a remarkable response. He completed all of his classes at school the next semester. In 18 months he got his Associates of Arts Degree and three years later he finished his Bachelor's Degree in biology. He has been accepted to medical school! I did a follow up study on Ritalin several months after starting the medication. As you can see in the illustration, not only did he have a positive clinical response he also had significant increased activity in the prefrontal cortex.
It's amazing how much his father's attitude has changed towards him. He told me, "I thought he was just lazy. It makes me sad to think of all those years that he had a medical problem and I just hassled him for being lazy. I wish I could have those years back."
I understood how Brian's father felt. I adopted my oldest son, Antony, when he was two-and-a-half-years-old. He was an intelligent child who was tested as gifted in the second grade. By fourth grade, he complained of being bored in school. A half an hour of homework would take him three or four hours to do. He was often distracted, restless and off task. He began to slip a little in school in seventh grade, and by ninth grade he fell apart and did terrible in school. I took him to see a colleague of mine who evaluated him. He said that my son was very bright, but that he had trouble concentrating and was easily distracted. He felt that my son might have ADD. Yet, Antony was never really a hyperactive child. In fact, if anything he was spacy, daydreamy, and a little sluggish. Approximately half the children, teens and adults who have ADD are not hyperactive; in fact they may be hypoactive. I decided to do a SPECT study on Antony. I had tears in my eyes as I looked at his SPECT study. Like Brian, he had good activity in his prefrontal cortex at rest, but when he tried to concentrate his prefrontal cortex completely shut down. For years I had been telling him to try harder. Boy, did I feel like a fool. Medication has helped Antony a lot. He's now in college and making a remarkable turnaround from where he had been 5 years earlier.
I have one man in my practice that has 10 businesses, because that's what he needed in order to keep himself turned on! When the brain is underactive, it's uncomfortable! Unconsciously, people learn how to turn it on, either by conflict, coffee, cigarettes (both mild stimulants), anger, a fast paced life, or doing highly stimulating activities, such as bunje jumping. Bunje jumpers need to be screened for this problem!
Many psychiatric disorders are now thought to have significant genetic influences. ADD is no exception. Here's a family case example: Paul, age 20, first came to see me because he was having trouble finishing his senior year at a Northern California university. He was having trouble completing term papers, he could not focus in class and he had little motivation. He began to believe that he should drop out of school and go to work for his father. He hated the idea of quitting school so close to graduation. He came to see me on a referral from a friend who had a younger brother whom I had helped. In his history, Paul also told me about bouts of depression that had been treated with Prozac in the past with little benefit. Paul's brain SPECT study was consistent with both depression and ADD. The SPECT study showed increased activity in his limbic system (consistent with depression) and deactivation of his prefrontal cortex during a concentration task (consistent with ADD). He had a wonderful response to a combination of an antidepressant and stimulant medication. He finished college and got the kind of job he wanted.
When Paul's mother, Pam, saw what a nice response he had to treatment, she came to see me for herself. As a child, she had trouble learning. Even though she was very artistic, she had little motivation for school and her teachers labeled her as an underachiever. As an adult, Pam went back to school and earned her degree in elementary school teaching. In order to student teach, however, she had to pass the National Teacher's Exam. She had failed the test on four occasions. Pam was ready to give up and try a new avenue of study when she saw Paul get better. She thought maybe there was help for her. In fact, her brain SPECT studies were very similar to Paul's studies and she responded to the same combination of medication. Four months later, she passed the National Teacher's Exam.
With two successes in the family, the mother then sent her 19-year-old daughter, Karen, to see me. Like her brother, Karen was a bright child who had underachieved in school. At the time she came to see, me she lived in Los Angeles and she was enrolled in a broadcast journalism course. She complained that learning the material was hard for her. She was also moody, restless, easily distracted, impulsive and had a quick temper. Several years earlier she was treated for alcohol and amphetamines abuse. She said that the alcohol settled her restlessness and the amphetamines helped her to concentrate. Karen's brain SPECT studies were very similar to her brother's and mother's. Once on medication, she was amazed at the difference. She could concentrate in class and she finished her work in half the time as before. Karen's level of confidence increased to the point where she could go and look for work as a broadcaster, something she had been unable to do previously.
The most reluctant member of the family to see me was the father, Tim. Even though Pam, Paul and Karen told him that he should see me, he balked at the idea. He said, "There's nothing wrong with me; look at how successful I am." But his family knew different. Even though Tim owned a successful grocery store, he was reclusive and distant. He got tired early in the day, he was easily distracted and he was scattered in his approach to work. He was successful at work, in part, because he had very good people who took his ideas and made them happen. He also had trouble learning new games, such as cards. This caused him to avoid many social situations. Tim enjoyed high stimulation activities and he loved riding motorcycles, even at the age of 55. Looking back, Tim had done poorly in high school. He barely passed college even though he had a very high IQ. He tended to drift from job to job until he was able to buy the grocery store from a widow whose husband had recently died. Tim's wife finally convinced him to see me. She was getting ready to divorce him, because he would never talk with her in the evening. She felt that he didn't care about her. He later told me that he was physically and emotionally drained.
During my first session with Tim he told me that he couldn't possibly have ADD because he was a success in business. But the more questions I asked him about his past, the more lights went on in his head. His nickname was "Speedy" as a child. He often didn't do his homework. He was often distracted or bored in school. His energy was gone by the end of the morning. When I asked about his organization at work, he replied her name was Elsa, his assistant. At the end of the interview, my comment back to him was that, "If you really do have ADD, I wonder how successful you could be given what you've already accomplished." Tim's brain SPECT studies showed the classic pattern for ADD. When he tried to concentrate the prefrontal cortex of his brain turned off, rather than on. When I told him this, it really sunk in. "Maybe that is why it is hard for me to learn games. When I'm in a social situation and I'm pressed to learn or respond, I just freeze up. So I avoid these situations."
Tim had a remarkable response to Ritalin. He was more awake during the day, he accomplished more in less time and his relationship with his wife dramatically improved. In fact, they both said they couldn't believe that their relationship could be so good, after all the years of distance and hurt.
Psychotic disorders, such as schizophrenia, are serious disorders that affect a person's ability to distinguish reality from fantasy. These disorders are complex and involve several brain areas, but at least in part, they affect the function of the prefrontal cortex.
Schizophrenia is a chronic, long-standing disorder characterized by "psychotic symptoms" that significantly impair functioning and involve disturbances in feeling, thinking, and behavior. Delusions, hallucinations, and distorted thinking characterize this disorder. When I first started ordering SPECT studies on schizophrenic patients, I began to understand why they distorted incoming information. Julie is a good example:
Julie was 48 years old when we met. She was divorced and she had a history of multiple hospitalizations for paranoid thinking, hearing voices, feeling electrical blasting in her head, along with delusional thinking. Her main delusion centered around being assaulted by someone who put an electrical probe inside of her head which "blasts her with electricity." She had been on multiple medication trials without success. Due to her lack of responsiveness to standard treatments I ordered a brain SPECT study.
In a sense, Julie was right. She was being blasted with electricity (note the multiple hot spots across her brain), but because she had such poor prefrontal cortex activity she was unable to process the physiological nature of her illness and developed delusions in order to explain the pain she experienced. With the information from the SPECT study, Judith was placed on a high therapeutic dose of Depakote that lessened her pain and anxiety. For the first time, she was willing to entertain the possibility that symptoms were the result of abnormal brain activity rather than from an outside attacker. A repeat SPECT study 8 months later showed a marked decrease in the hot spots in her brain along with subsequent increased activity in her prefrontal cortex.
In another case, Derrick, a 13-year-old boy came to see me because he was severely anxious. He was displaying psychotic symptoms, feeling that other children were talking about him behind his back and that they were out to embarrass him in front of the whole school. He started to avoid all contact with his peer group. He would hide in the middle of clothes racks at the mall if he saw people he knew, for fear that they might start to laugh at him or talk about him to others. He was petrified by his thoughts and he stopped going to school. He even seriously entertained suicide as a way to rid himself of the awful thoughts. He had crying spells, sleeplessness and intense anxiety. No one was able to rationally discuss these feelings with him and he was unable to entertain other alternatives for his thoughts. I saw him for months in psychotherapy and tried him on several antidepressant and antipsychotic medications without a therapeutic response. His psychological testing, especially the inkblot test, revealed psychotic thinking. A SPECT scan was done when he was off all medication to help us understand what was going on.
Derrick's SPECT study showed marked decreased activity in his prefrontal cortex at rest, which is a common finding in psychotic disorders. It is also a finding in some psychotic depressions. The study led me to try alternative medications that were more effective. Within two months there was a dramatic clinical improvement in his condition. His mood was better, there were no suicidal thoughts, he was less sensitive to others and he was more able to entertain alternatives to his distorted thoughts. Seven months later, he was much more like a normal teenager. A repeated SPECT study was performed 6 months later with normalization of prefrontal cortex activity. Six years later, I see Derrick every 6 months. He is an honors student at Stanford University.
The SPECT study was very important in the treatment process. It clearly showed Derrick's parents that his problems were based on brain abnormalities and that he couldn't help what he thought or felt. They were able to react in a more understanding and helpful manner, changing the level of stress at home.
Due to its location, the pfc is especially susceptible to head injuries. Many people do not fully understand how head injuries, sometimes even "minor" ones where no loss of consciousness occurs, can alter a person's character and ability to learn. This is particularly true when the head injury occurs in the brain's executive director or pfc. Your brain is very soft. Your skull is very hard. Your brain sits in a closed space that is not smooth, and has many sharp edges. Unfortunately for the pfc, the inferior orbital cortex sits on top of several sharp bony ridges and the dorsal lateral prefrontal cortex lies just beneath the place where many blows to the head occur.
It is important to note that many people forget they had a significant head injury in their lifetime. In our clinic we ask patients 4 or 5 times whether or not they had a significant head injury. Our intake paperwork asks the question, "Have you ever had a head injury?" The historian, who sees patients to gather history before they see the physician, asks patients about head injuries. The computer testing we have patients complete asks about head injuries. If I see no, no, no to the question of head injuries I'll ask again. If I get a fourth no I will then say, "Are you sure? Have you ever fallen out of a tree, fell off a fence or dove into a shallow pool?" I am constantly amazed at how many people remember significant head injuries which they have long forgotten or felt were too insignificant to remember. One patient, when asked the question for the fifth time, put his hand on his forehead and said, "Oh yeah! When I was 5-years-old I fell out of a second story window." That was important information for me to have. Likewise, I have had other patients forget they went through windshields, fell out of moving vehicles or were knocked unconscious when they fell off their bicycles.
Head injuries are very important. I often tell my patients that their brain is more sophisticated than any computer we can think of designing. You cannot drop a computer without the potential of causing serious damage. In the same way, the brain is fragile and if trauma occurs in sensitive parts of the brain it has the potential to alter one's ability to function.
Phineas P. Cage provided scientists with an extreme example of pfc dysfunction secondary to a head injury. This was one of the first cases in the medical literature about what occurs when the prefrontal cortex is damaged. In 1848, at the age of twenty-five, Cage was an up-and-coming railroad construction foreman in Vermont working for the Rutland and Burlington Railroad. His job involved using explosives to forge a path for the railroad. He used a long tamping iron to ignite the explosive. One day a horrible accident occurred where the explosion sent the tamping iron, which was 3.5 feet in length, 13.5 pounds in weight and 1.25 inches in diameter, through the front part of Cage's skull. It went through his left eye, left prefrontal cortex, and out the top front part of his skull, leaving a circular 3.5 inch opening, destroying his left prefrontal cortex and surrounding areas of the brain. Initially the interest in the case was about Cage's ability to survive the accident. It was called "unprecedented in surgical history." Later, in 1868, his physician turned his attention to the personality changes that occurred. Before the accident Cage was considered to be an honest, reliable, deliberate person and a good businessman. After the accident, even though he did not appear to suffer any intellectual impairment, he was described as childish, capricious and obstinate, showed poor judgement, used profane language and was inconsiderate of others. In short, his physician concluded that "Gage was longer Gage." In many ways, the pfc contains our ability, in a personality sense, to be ourselves.
Zachary and James provide two modern day examples similar to Cage. Zachary, age 10, was a fun loving, active boy who was loving, sweet and liked to please. He did well in kindergarten and was liked by the other children. One summer, between kindergarten and first grade, at dusk Zachary was riding in the front seat of a car with his mother on a trip to his grandparents house. All of a sudden a drunk driver swerved into their lane causing the mother to quickly jerk the car to the side of the road. She lost control and the car hit a tree. The mother broke her leg in the accident and Zachary, thankfully in a seat belt, hit his head against the side window. Zachary was unconscious, but only for about 10 minutes.
Initially, they were glad to just be alive and Zachary and his mother became even closer than before. About six weeks later, however, Zachary's behavior began to change. He exhibited aggressive behavior, breaking his own toys and hurting his younger brother. He began swearing, which was a new behavior for him. He blurted out statements at inappropriate times and interrupted frequently. He became rude, contrary, argumentative and conflict seeking. He lost his friends at school the next year because he would say things that would hurt their feelings. He started to tease the two cats at home, so much so that they started to avoid him whenever he came into the house. Six months after the accident his mother knew that there was something seriously the matter. She brought him to a counselor who thought the problem was psychological, as a result of the accident. The counselor thought that Zachary and his mother were too close and developed strategies to help Zachary become more independent. That only seemed to make things worse. After two years of counseling, which didn't seem to help much, the mother consulted Zachary's her pediatrician. He diagnosed Zachary with ADD and put him on Ritalin. But it didn't help very much. In fact, it only seemed to make him more aggressive. When Zachary was brought to see me at age 9, I thought he might have a chronic post concussive syndrome, secondary to the accident. His brain SPECT study revealed marked decreased activity in the left pfc and decreased activity in the left occipital cortex, indicating both a front and back injury (common in head injuries). In addition, he had decreased activity in his left temporal lobe. Given this constellation of findings I put him on a combination of medication (an anticonvulsant, to stabilize his aggressiveness and help his temporal lobe function, and amantadine [Symmetrel] to help with focus, concentration and impulse control). He was also placed in a special class at school and given cognitive retraining exercises. Over the next several months his behavior began to improve and he was able to live at home.
Tim, age 15, was a high school sophomore at a high school in Connecticut. From the time he was young he exhibited severe conduct problems. He had already been arrested for shoplifting, he frequently cut school and was defiant and abusive toward his parents. He did not get along with other teens at school and seemed to "never fit in." He smoked a pack of cigarettes a day and frequently used both marijuana and cocaine. He had already been in one treatment program and was on his way to a second program when his parents brought him to our clinic. From an early age, Tim was hyperactive, impulsive, moody and frequently angry, especially whenever someone would tell him no. His temper flared quickly and often, often over minor or trivial incidences. He had tried numerous medications without success. His parents had heard about my clinic and decided to come across the country to see us.
His brain SPECT study showed severe damage to his left prefrontal cortex. It was one of the most severe cases I have ever seen. When he was 18 months old he fell down a flight of stairs. His mother said he was never quite the same since then. She could just tell there was a difference in his personality. Given the level of functional damage to Tim's brain I decided to put him on a combination of an anticonvulsant medication and a stimulant. It helped lessen the rage and improve his impulse control. Given the level of damage, his chances for having full executive function are not very promising. The goal of treatment is to utilize every prescription available to help Tim develop auxiliary internal supervision mechanisms. Otherwise, legal authorities will have to impose external supervision in some form of a contained setting, basically through no fault of Tim. He doesn't have the capacity for internal supervision that is housed in the prefrontal cortex.