German by uY1cCm1


									                                 THE MIND AND THE LAW
                        The Relevance of Some Recent Research


                              PROFESSOR G ALLEN GERMAN
                                Professor Emeritus of Psychiatry
                               The University of Western Australia

Both psychiatrists and judges, from different perspectives and backgrounds, have, as a central
concern, human behaviour – what motivates and controls it; what can go wrong with it (and why);
and how it might best be managed. These are huge and daunting areas and are ever-present
concerns for each of us. In this talk, I can only aspire to address a very small, albeit important, part
of such concerns.

My principal focus will be on behaviour and personality, and how these two entwined concepts are
dependent on the functioning of the brain generally and on that of the pre-frontal lobes of the brain
particularly. The pre-frontal lobes are substantial anterior parts of the human cerebrum which lie
immediately behind the forehead, nestled in what might aptly be described as the forward-facing
mezzanine of the cranium – a second storey, as it were, - at the front of the skull, just above the eye-
sockets and the roof of the nasal cavities. The human pre-frontal lobes have been described as being
the most mysterious and complex structures in the known universe.

The pre-frontal neocortex, as developed in the human brain, is the newest, most complex, and
largest of the specialised and phylogenetically new areas of the cerebrum which are generally
highly developed in all primates. Amongst the primates, however, the pre-frontal cortex achieves its
highest complexity, relative size, and sophistication, (and greatest vulnerability to various
traumatic insults) in the adult human being. New in phylogenetic (evolutionary) terms, it is also
new in terms of individual ontogenesis – i.e. in terms of developmental growth and timing in the
individual person. It is, compared with the rest of the brain, significantly immature at birth; is the
last part of the brain to complete its developmental sequences (at about age 25 in the human female
and age 30 in the human male); and, in its massive maturational development in childhood and
adolescence, is almost certainly that cerebral structure which is principally responsible for those
changes in behaviour and personality which mark the passage from the immaturity of the child and
adolescent to the mature behavioural functioning of the healthy adult.

Such sequential developmental patterns in behavioural functioning appear to be identical (in terms
of the emergence of specific functional skills and capacities) in healthy people in all human
cultures. However, despite this functional identity of sequential development, (by this is meant the
timing and manner of brain development and operations), the specific behaviours which diverse
cultures take to be mature differ widely in content and flavour. These content differences reflect
wide variations in cultural and social learning experiences and exposures as between different
cultures and, indeed, as between different families and individuals.

The Mystery of the Pre-frontal Lobes
Before turning to more specific matters concerning the pre-frontal lobes and their functions, it is of
interest to note that up until about 50 years ago these structures were still being referred to as the

silent areas of the brain, a term reflecting the then almost complete lack of knowledge as to what
their function was. In the 1960s and 1970s, increasing physiological information began to accrue
about matters such as the vast oxygen consumption of pre-frontal nerve cells (neurones) in
comparison with other brain cells and, indeed, in comparison with all other cells of the body. Such
observations raised important questions. What on earth were the pre-frontal areas so busily engaged
in doing as to require them to use so much more oxygen than any other group of human body cells?
What was so special about them as to make them so much more capable (than other brain cells) of
dysfunction – and even of cellular death – as a result of developmental and disease-driven
misfortunes in youth; in the face of the metabolic and vascular insults of ageing; and also, always,
in the presence of toxins such as alcohol and various other chemical poisons?

The Executive Brain
Research over the past 30 years has shed considerable light on these questions. It is now known that
the pre-frontal cortex in the human being functions very much like a chief executive in a large and
complex organisation. The brain is made up of many syatems that subserve different functions –
systems for motor behaviour, for sensory behaviour, and for mental phenomena such as memory,
emotion, perception, planning, foresight and judgement, to name but a few. These systems appear to
have their anatomical correlates in widely scattered areas of the central nervous system, but
wherever they may be functionally located they are uniquely linked to the frontal lobes and their
pre-frontal areas by dense networks of fibres (white matter) both going to the pre-frontal brain and
coming from it, extending out to those various modules in their disparate locations. In the absence
of an effectively functioning pre-frontal cortex, these systems seem to be able to function
independently of one another. The human being so afflicted then appears to become a creature of
the moment, reacting to stimuli but remaining unable to co-ordinate and enrich behaviour in an
integrated and effective manner. Tragically, much of the information on this dilapidation of human
behaviour following pre-frontal damage resulted from the practise of lobotomy and leucotomy
carried out on large numbers of mentally ill people during the 1940s and 1950s. The analogy
between the pre-frontal cortex and a chief executive officer in a large organisation is a fairly good
one. It well reflects the role of the pre-frontal brain as presently understood, and it is not difficult to
understand what might go wrong with the cerebral “corporation” in the absence of its executive
component. More and more neuroscientists, neurologists and psychiatrists conceptualise the tasks of
the pre-frontal cortex as being the “executive functions” of the brain.

The Concept of Personality
It is also clear that the pre-frontal cortex is the area of the central nervous system largely
responsible for what we call personality. Again, an analogy may be useful. We can think of
personality as being the behavioural equivalent of physique. Just as with physique, personality is
characteristic of an individual‟s behaviour and is unique to that person. People may have
similarities in personality but there is overwhelming evidence that, even in identical twins,
personality differences exist between every human being on earth.

Not only is personality unique to the individual but it is a constant factor in the individual‟s life.
Once fully matured and formed, usually sometime in the third decade of life, personality, like
physique, does not change in any fundamental way. Physique may alter superficially through the
acquisition of excessive fat, or due to the ravages of illness which can cripple limbs and damage
special senses. So also with personality: basic personality does not change in the healthy individual,
but it may become hung about with the psychic equivalent of adipose tissue such as rigidity of habit
or over-learning of maladaptive behavioural patterns. Or emotional distortions of the basic pattern
may develop resulting from adverse life events. Over years and decades such impacts lead to
changes in personality which, like acquired changes in physique, are often, nevertheless, malleable
and capable of change for the better. Again, as with physique, such changes for the better are easier
to make the earlier in life attempts are made to effect them.

Apart from changes in personality resulting from adverse behavioural styles or adverse life events,
personality also changes in the face of physical damage. Head injury, the presence of pathologies
affecting the pre-frontal lobes of the brain, the effects of long-used poisonous substances such as
alcohol and other drugs, all contribute to deterioration of the mechanisms (cerebral) which lie
behind personality, and all produce effects which range from the highly dramatic to the more subtle
and difficult to apprehend.

To summarise, personality, once developed, is essentially a constant in human behaviour.
Significant changes can result from adverse circumstances and faulty learning, especially during
youth, and these can often be addressed for the better, particularly in younger individuals.
Psychotherapies, social therapies, cognitive and rehabilitative therapies are thus effective before
middle-age, but are less so in older age groups. Finally, personality, like physique, can be damaged
by crippling illnesses or traumatic impacts or poisonous exposure damaging the key brain systems
which underpin it. Such damage, mediated mainly through damage to the pre-frontal cortex and/or
to its incoming or outgoing pathways, may occur as a result of a dramatic illness or injury, but far
more often the provocative pathology is silent, not noticed or even thought about, and is very
difficult if not impossible to reverse. The brain‟s natural healing processes may allow compensatory
behaviour to develop which minimises the effects of damage to a degree, but this generally runs to
completion within 5 to 7 years: after that, one cannot really expect much actual further healing; re-
establishment of normal behaviours may however, through retraining, be progressed to a degree.
Again, age is a vital factor – the younger the brain at the time of damage the more capable it is of
recovering lost functions in a way that is quite impossible in the older subject.

Factors that Shape Personality
Personality is dictated and shaped by various factors. Firstly, one must consider genetic factors,
which are now known to have much more influence on habitual styles of behaviour than was
realised 40 or 50 years ago. The Human Genome Project suggests that there are a surprisingly small
number of human genes – perhaps about 30,000 in all. However, individual genes can have multiple
effects – they are not simple structures but are made up of millions of different molecular

In considering how mature and healthy personality functioning is achieved, an analogy may again
be useful. Let us think of a computer and the various requirements and processes that are vital
before such a mechanism can be expected to function adequately.

Firstly, its designed circuitry must be effective. At the cerebral level, the analogous situation is the
manner in which the brain is shaped and put together as a result of genetic control over the
anatomical design of “cerebral wiring” – such circuitry varies widely with genetic endowment as
between and within species, and within and between individuals within a species. A good design for
a computer or brain, however, is not enough – it needs, secondly, to be developed and put together
properly. The brain may have a splendid genetic blueprint but it is possible for that blueprint to be
inadequately expressed because of adverse biochemical and physiological events during
construction in utero; or in infancy and childhood because of perinatal illnesses causing brain
damage (through anoxia, malnutrition or infectious disease – e.g. measles, chickenpox); or because
of other brain-traumatising events occurring in the first 25 or so years of life during which time the
frontal lobes of the brain are still developing. These may result from injury, or from disease, or,
tragically, through the use of brain-damaging drugs while the brain is still growing. Adolescence, in
consequence, especially given the explosion currently in abusive use of various forms of brain-
influencing drugs, is a period fraught with risk to the developing frontal systems of young people.
From conception to the middle of the third decade of life the pre-frontal cortex specifically is being

manufactured – efficiently or otherwise – and the end-product will represent the best that the given
blueprint can achieve in the face of poor, adequate or superlative “putting together” experiences.

Given then that computers or brains are well designed and have been properly manufactured, they
require, thirdly, to be adequately programmed in order to function. The human brain needs to be
taught and to learn adequately. Throughout its extended period of learning it is vital that abnormal
learning or damaging learning (damaging to intellectual, emotional, social and cultural functioning)
are avoided. It is in this area that the rich fields of psychological, social and psychotherapeutic
intervention theories have been most extensively developed. What we call the psychotherapies or
sociotherapies are largely aimed at retrospectively negating adverse human learning experiences;
they seek to promote, through therapeutic learning, more adaptable and effective behavioural
patterns in the individual. In some cases, psychotherapy has been referred to as “re-programming;”
“de-programming” is a term particularly used for such activity when it seeks to release people from
the influences of odd cult notions, attitudes and beliefs. The use of these terms emphasises the
analogy with the computer – an analogy which can be usefully extended further. How effective is
re-learning in the presence of already damaged systems? To what extent can system repair
(perfectly feasible during the maturational period but less so with aging) be taken advantage of to
allow healthy learning to be resumed in due course?

The development of human personality is a vastly more complex matter than the processes of
producing even the most sophisticated current computing mechanism. Millions of influences go into
the final personality product, and things can go wrong throughout the entire period of development.
There is an enormous range of inputs which, if we are lucky, mostly go in the direction of
promoting good behavioural health. Behind good behavioural health, apart from the quality of the
learning processes that we are exposed to, there must also be good brain health.

I do not intend to look in any detail at these various inputs to human behaviour, but I will draw
attention to just one area which is, I think, of some significance, and which reflects information
gleaned from research undertaken during the past several decades. It is significant because it
demonstrates how those inputs which we think of as non-physical – such as emotional and
interpersonal and social experiences – can powerfully shape the actual physical development of the

Emotional and Environmental Deprivation and Brain Dysfunction
It is not difficult to conceptualise the effect on a developing brain in utero of maternal infection
with, for example, rubella (German Measles), or to understand the damage which can result from
the administration of brain-toxic drugs such as thalidomide. Much more difficult to conceptualise is
the possibility that circumstances which are psychologically and emotionally “toxic” might shape
the physical pattern of brain development. In thinking about this, we suffer from many difficulties
inherent in our dualistic western notions which traditionally separate mind from body – a separation
which, in my opinion, lacks any logical basis.

To exemplify how the metaphysical (or the psychic) and the physical (or the somatic) come
together, critically, in cerebral development, let me briefly mention matters with which most are
familiar and which reflect the impact on the developing central nervous system of impoverished
input from limbs and special senses.

If a mammal is deprived of visual input from birth throughout a period equivalent to approximately
2 years in human terms, then the occipital cortex (that part of the brain which is responsible for
vision) will never thereafter function normally. Nor is it just a functional matter. The cerebral cortex
in such artificially blinded animals fails to show the normal patterns of physical maturation which

should occur as specific brain areas develop in a healthy manner. Similarly, preventing an animal
from using a limb on one side of the body, over approximately the same period of time, will again
lead to abnormalities in both the anatomy and the physiology of the relevant piece of brain. It is
probably not difficult to see that if inputs from the eyes, or from a limb, are prevented, then
essential cellular development in the brain, lacking vital stimulating external inputs, may fail to take
place in an orderly and complete manner.

What is intuitively more difficult to conceptualise, and this is where our ingrained dualistic notions
get in the way, is that deprivation of appropriate and normal emotional inputs at certain critical
stages of brain growth might similarly adversely influence the structure and the functioning of the
developing brain, particularly the pre-frontal cortex and its related cerebral systems. Experimental
work has made it perfectly clear that this certainly happens in mammals and probably also in the

Details of what does occur derive from experimental work with animals, particularly mammals and
primates. Certain primitive cells which are to be found in the cerebral cortices of newborn or very
young mammals should, over the first few months or years of extra uterine life, produce new cells
which progressively mature and migrate to populate the cerebral cortex, producing complex and
sophisticated layers made up of large numbers of matured brain cell bodies (neurones) with
growing numbers of connections and with different functions. This process is usually referred to as
cell differentiation and migration. Cell migration may be thwarted, or may be impoverished, as a
result of diminished or absent normal inputs to the part of the brain in question. Impoverished
emotional and social inputs, particularly in the first few years of life, are considered responsible for
the quite profound “stunted development” of cellular layers and connections reported to be found in
the pre-frontal, temporal and hippocampal cortices rats, dogs, and primates young creatures are
deprived of appropriate emotional and social input. Definitive experiments cannot be carried out in
humans but studies of autopsy material and of the relationship between deprivation and data as to
function and structure from sophisticated neuro-imaging techniques suggests similar mechanisms
operate in homo sapiens.

Before the essentially cerebral underpinning to this was fully understood, it had already become
apparent that so-called “emotional deprivation” in children was more often than not associated with
a variety of psychiatric or psychological abnormalities of personality. Severe deprivation appeared
to be associated with sociopathy or psychopathy, as it used to be called. During the 1960s, an
English psychoanalyst, Dr John Bowlby, wrote extensively about these deprivational syndromes,
attributing them initially to maternal deprivation, although subsequently it was pointed out that the
essential deprivation was of an appropriate adult figure – caring, nurturing, responding, bonding and
interacting. Because of the clarity of the results of these researches, it became practice not to
separate mother and child in paediatric hospitals unless that was absolutely necessary, and
separation between the key adult and the developing child is now regarded as a severely adverse
factor in terms of brain developmental health and, consequentially, personality developmental

Apart from this deprivation of appropriate stimulation, and its effect on brain growth and
development, might there be other factors that can interfere with this crucial migration of cells in
the development of the cerebral cortex? There may, in fact, be genetic factors that serve to inhibit
adequate cellular growth and maturation, or impoverish it in certain areas, and such may be
important factors in the development of what has come to be called „attention deficit hyperactivity
disorder,‟ where there is reason to suspect that there is impairment of maturation of neuronal cells
in the prefrontal and temporal lobes and related parts of the brain.

To these possible genetic factors in impaired brain development, particularly in the areas of our
special interest – viz the pre-frontal cerebral cortex and related structures, we can now add as
discussed above, that significant emotional deprivation in early childhood almost certainly produces
impaired development of cells and their functions in the prefrontal human cortex, and is a factor in
the development of behaviours which are variously described as conduct disorders and, later, as
psychopathic and other personality disorders. Serious mental disorder such as schizophrenia may
also reflect deficits in pre-frontal and temporal development. What we do about these things, or
what we can do about these things, is not at all clear yet. Solutions must await further research on
human brain development and on how maldevelopment can be avoided, mitigated, or compensated
for. But first, if these things are to be achieved, there needs to be much greater understanding of the
key role that early cerebral development has in shaping subsequent behaviour, including criminal

In a very important recent book outlining progress in scientific studies of the human pre-frontal
cerebrum, the distinguished Russian-American neuropsychologist, Elkhonon Goldberg1, discusses
the problem of understanding that brain structures and processes are intimately bound up with

 “This raises” he says “the broad issue of general public awareness of cognitive impairment.
 Although rhetorically, the educated public understand today that cognition is a function of the
 brain, this abstraction often fails to inform specific, real-life situations. As a result, Cartesian
 dualism is alive and well when it comes to everyday encounters with brain-damaged people.
 This naïve dualism is evidenced, even at the level of healthcare policy-making and health
 coverage, when physical health is treated seriously whilst so-called mental health is given short-

 Everyday public attitudes betray a sharp division between physical and non-physical symptoms
 and between physical and non-physical body organs. Problems with vision or hearing, limp
 weakness on one side of the body, will unfailingly be perceived as physical and will engender
 sympathy and readiness to help. The bodily nature of these symptoms will be immediately
 grasped but, curiously, even so, mostly people will be very slow to attribute these problems to
 the brain.

 By contrast, patients with higher order cognitive impairments are often denied the sympathy
 accorded people with physical infirmity, and are treated instead in moralistic, almost
 puritanical terms. Forget the hapless criminals. Consider the common situation of a demented
 elderly individual whose life has been an example of civic responsibility and moral rectitude.
 Now she is old and very forgetful. Having diagnosed early dementia, I am trying to explain the
 implications of my findings to the eager family members. I tell them that their mother suffers
 from amnesia but her forgetfulness is caused by brain shrinkage; that she cannot help it; that
 it’s likely to get worse and that they have to be patient with their loved one. The family members
 listen intently; they nod; they seem to understand – and then comes an irate comment: “But how
 come I give her breakfast in the morning and she comes back asking for her breakfast again?”
 When I encounter this lack of understanding I feel like tipping my hat to my friend Oliver Sacks,
 who has done more than anyone else to enlighten the general public about the effects of
 neurological injury on cognition. I urge people to read “The Man Who Mistook His Wife for a

 But if the neurological nature of impaired memory, perception or language usually can be
 grasped by the general public, the executive deficit caused by frontal lobe injury almost never is
 grasped. Point to the patient’s impulsivity, volatility, indifference, lack of initiative, and the
 common response will be “This is not his brain, this is his personality!” This is total retreat

 three-and-a-half centuries back to Cartesian dualism, as if “personality” were an utterly
 extracranial phenomenon. And the notion of “personality”, of course, is something that, on a
 par with an apple pie and spring water, carries moralistic, righteous connotations. If you were
 born into an honest family and went to a good school, then how dare you not have an upright

 It is my hope that this book will put “personality” and related expressions of the mind where
 they belong, inside the brain, so to speak, in the eyes of the general public. “By helping
 accomplish this, the book will help correct the unintended public insensitivity and sometimes
 outright cruelty, toward the most devastating of all forms of brain damage, the damage to the
 frontal lobes.”

Frontal Lobe Damage – Its Effects and Consequences
So far, we have considered factors which go into the shaping of personality, and have been
particularly concerned with frontal lobe development and some of the more subtle ways in which
such development can be impaired. It has been appropriate to consider the results of recent
researches because of their importance in relating psychological and emotional experience to the
physical growth of the brain and the development of its physical functions. These two domains –
the psychic and the somatic – are clearly inseparable as far as the brain is concerned.

Against that background, let us now look at some of the consequences of pre-frontal lobe damage,
or dysfunction, to the individual, in terms of the various clinical syndromes that result, and end by
noting some further matters which are relevant to all of us in terms of the sorts of damage that can,
in the most insidious way, interfere with the proper healthy functioning of our pre-frontal cortices.

In his book, Goldberg summaries the functioning of the frontal lobes as follows :

 “The frontal lobes are the latest achievements in the evolution of the nervous system. They are
 crucial for all higher order purposeful behaviour, identifying the objectives, projecting the
 goals, forging plans to reach them, organising the means by which such plans can be carried
 out; and monitoring and judging the consequences to see that all is accomplished as intended.”

That is how the system should be and should operate. This is the central role of the frontal lobes – a
role which releases our organism from fixed, instinctual behavioural repertories and reactions, and
allows us to internalise, in subjective consciousness, mental representations of our goals, or of our
alternative goals, and to manipulate these representations in our imagination with the utmost degree
of freedom.

The Orbito-Medial Frontal Lobe Syndrome
This capacity to internalise abstract notions and manipulate them to our advantage, consciously, and
effectively, appears to be a function of the intact and healthy orbito-medial cortex (grey matter) of
the human pre-frontal lobe. This piece of cortex is the area above the eyes, lying on the lower
(hence orbital – above the orbit) and inner (hence medial) sides of the two lobes as they face one
another across the chasm that divides the two hemispheres of the brain. These orbito-medial
structures are known to play a fundamental role in the organisation and management of internal
mental life, permitting creative thought, abstraction, the application of judgement, the capacity to
plan, and the ability to take foresight for the future.

Individuals with orbito-medial frontal cortical damage show certain abnormal features which are
characteristic. Prominent amongst those is an inability to see ahead and to internally represent the

consequences of actions, despite the fact that intellect is intact. The subject may know the
difference between right and wrong in an intellectual sense, but when put into a situation where this
knowledge of distinctions should be put into practice, they may completely fail to do so. Elkhonon
Goldberg‟s famous Russian teacher Luria, who probably did more to advance the understanding of
frontal lobe physiology and psychology than any other individual to date, introduced a test for
frontal orbito-medial damage. He would instruct his patient “I want you to do the opposite of what I
am doing. I am going to hang the desk with my fist and then I am going to wave my finger. I want
you to do the opposite – when I bang the desk with my fist I want you to wave your finger, and when
I wave my finger I want you to bang the desk with your fist”.

This exercise is easy of accomplishment for people with healthy orbito-medial frontal lobes. They
have to concentrate but they can do the test. Persons with orbito-medial frontal lobe damage cannot.
They seem to become so attached to what the tester is doing as to be “stuck”. It is as if the external
pattern of the tester‟s behaviour controls what they do rather than any internalised determination of
their “will” to do the opposite, as instructed.

This test can be taken further. Subjects can be taught to say aloud what they should be doing. Thus
when the examiner bangs the desk with a fist, the subject can be taught to say “I will wave my
finger” – and should do it. Where the orbito-medial frontal cortex is compromised, subjects cannot
do this. They may be able to say that they are waving their finger (they have been taught the verbal
representation) but, in fact, they do not wave their finger!. So they end up doing the exact opposite
of what they say they are doing – and furthermore often are quite unaware of this discrepancy.
Insight has disappeared.

From these sorts of studies it is evident that internalised verbal representations are not, of
themselves, sufficiently potent to influence behaviour in persons with orbito-medial pre-frontal lobe
damage. The “knowing” what they should do is not, of itself, sufficient to detach them from what
Goldberg calls “repertory behaviour,” by which he means behaviour running according to a
preconceived notion, along fixed tracks, which, in this case, is imitation.

Apart from this characteristic deficit, persons with the orbito-frontal syndrome are emotionally
disinhibited. They constantly swing between elation and anger, with poor impulse control, which, in
fact, may be non-existent. They are consumed by the need to satisfy impulses immediately. They
are unable to inhibit this urge for instant gratification and to substitute for it the capacity to delay
gratification until a more appropriate time. As Goldberg puts it “They do what they feel like doing
when they feel like doing it, without any concern for social taboos or legal prohibitions”.
Goldberg‟s final description of this orbito-medial syndrome is worth quoting again :

 “A patient afflicted with the orbital syndrome due to, perhaps, head injury or cerebral vascular
 disease or dementia, will engage in shop-lifting, sexually aggressive behaviour, reckless
 driving, or other actions commonly perceived as anti-social. They are often selfish, boastful,
 puerile, profane and sexually explicit. Their humour is off-colour and their jocularity resembles
 that of a drunken adolescent. Orbital frontal patients are conspicuous for what many people call
 their “ immature personality”‟.

The Dorso-Lateral Frontal Lobe Syndrome
The other classical pattern of disorder in frontal lobe damage is where the upper (or dorsal) and
lateral parts of the pre-frontal cortex have been injured. This produces another characteristic
syndrome called the dorso-lateral syndrome. Patients in this category become indifferent,
withdrawn and apathetic, unmotivated, and respond with difficulty to the stimulation of other
people, other places, and to verbal inputs. The impairment of motivation they experience can be

profound. It is a type of impairment which lends itself very readily to accusations of malingering.
The patient is accused of not wanting to work, and yet the wellspring of motivation in the human
being, which appears to reside in an intact dorso-lateral cortex on both sides of the frontal lobes, has
been damaged or destroyed. If these structures are not functioning, motivation and initiative

Many people who underwent surgical procedures on the frontal lobes in the 1940s and the 1950s,
supposedly to get rid of tension, anxiety and depression, continued to live passionless, unemotional
and retiring lives with gross evidence of dorso-lateral frontal lobe damage. They were quiet,
unmotivated, withdrawn, and relatively unresponsive to others in emotion and in word. They were
usually described by friends and relatives as having become like “vegetables”.

Depression and Frontal Lobe Functioning
To these two syndromes can be added further information at this point in time about certain crucial
functions of the frontal lobe which have become evident from studies of how these structures
actually work in the living, intact human being. Such studies have become possible through the
evolution of various scanning techniques which can examine, amongst other things, the distribution
of blood flow in various parts of the brain under different circumstances. Markedly impaired
cerebral blood flow (hence reduced levels of oxygen use and of functional capacity) in one
particular part of the pre-frontal cortex is found in major depressive illness – and found with a
degree of consistency which suggests that such changes in pre-frontal lobe blood flow are
characteristic of depressive illness. The specific areas in which such reductions in blood flow, and
hence oxygen utilisation, occur, are on the medial (inner) aspect of the dominant (usually the left)
pre-frontal lobe. The role of this part of the brain in emotional life has been partly understood for
some decades now. It is only recently, however, that this specific and consistently reported
pathology relating to depression has been so clearly identified. What this means in terms of
causality and its direction is unclear – is the reduced state of dominant frontal functioning causing
depression? Is it a consequence of depression? Are both reduced frontal functioning and depression
consequences of disorder elsewhere? Answers to such questions are sought and, if found, will,
undoubtedly, deepen our knowledge, not just about depression per se, but also about the roles
played by this extraordinary part of the brain in emotional life.

Concluding Observations
1). An awareness of frontal lobe functioning is important in terms of any attempt to understand
the behaviours of those whom society regards as delinquent or anti-social.

2). Another important area for current research is to endeavour to define the extent to which
frontal lobe impairment damages the behavioural functioning of people, particularly in the last 10
or 20 years of their lives.

The pre-frontal cerebral cortex is not only exposed and vulnerable to injury, but is also affected
significantly by age-related changes. These age-related changes may, in part, represent an
accumulation of toxic damage throughout life to various poisons ingested, inhaled, or otherwise
absorbed. It is known that the pre-frontal cortex is particularly vulnerable to drug effects. Sedative
drugs, which reduce inhibition and relax individuals by diminishing anxiety, appear to function in
part by reducing activity levels in the pre-frontal brain. Many of these drugs, if taken chronically,
appear to eventually cause an acceleration of cell death in the pre-frontal cortex. Alcohol is the
best known of these drugs which are capable of producing frontal lobe atrophy, and its selective
ability to damage the pre-frontal brain is well recognised, both clinically and from studies using

brain-imaging techniques. Much of the personality change invariably described in chronic alcohol
abusers is almost certainly attributable to accelerated pre-frontal lobe damage.

A person who is drunk, depending on the degree of drunkenness, shows a pre-frontal lobe
syndrome as the earliest manifestation of his or her drunkenness – that is probably the simplest
way to describe the condition from a psycho-neurological point of view. As quoted above,
Goldberg talks about a drunken adolescent exhibiting behaviours that may be seen in the orbito-
medial frontal syndrome. Acute drunkenness is, in part, a temporary form of a pre-frontal lobe
syndrome, but if a sub-intoxicating amount of alcohol is taken on a regular, repeated and
consistent basis, maintained over hours, or days, or weeks, or indeed, in the chronic abuser, over
years, then evidence of pre-frontal lobe dysfunction may gradually begin to appear. Dyscontrol of
mood may become increasingly prominent, with rapid fluctuations between fatuous merriment,
rage, irritability, and tearfulness. Jocular comments occur which are inappropriate to situations.
People look at such a person and may decide that he or she is someone they need to shun or move
away from. To a degree, all sedative drugs, taken in a long-term chronic manner, are under
suspicion of having the potential to produce a degree of this type of syndrome.

Many of us actively look for occasional (or perhaps regular) chemical assistance in knocking out
our pre-frontal lobes. This is particularly common in anxious individuals who seem to have hyper-
efficient pre-frontal systems, always alert, always aware, and always experiencing subjective
anxiety and distress. We like to have moments when we can relax, often aided with alcohol, and
during those moments common anxieties are assuaged and depressive feelings tend to be
ameliorated. A distinguished psychotherapist, now dead, visited Perth in the 1970s, undertaking
some postgraduate teaching. At one particular meeting on the subject of frontal lobe impairment,
he suggested to the audience that he did not think such impairment was entirely a bad thing. He
explained that when he was a younger person he was inhibited by anxiety in terms of speaking
publicly at scientific and clinical meetings. However, he had now reached an age where he
believed his frontal lobes were becoming impaired and, as a result, he found himself able to talk
to anyone, anywhere, and about anything, being not at all anxious in saying what he felt he
wanted to say at the moment. “I feel no embarrassment whatsoever – even if people tell me that I
am foolish and am talking rubbish.”

Frontal impairment occurs as we age and does so faster than impairment in the more robust, more
primitive, „other‟ parts of the brain. The most recent cells in evolutionary terms seem to be the
most delicate and the ones with the briefest lives. They are the most susceptible to injury; they are
the most vulnerable to toxic insults from drugs; they are the most readily damaged by metabolic
abnormalities like diabetes or renal or liver failure. Anything that impairs the healthy
biochemistry of the body will first probably affect the pre-frontal cortex. Adequate pre-frontal
lobe functioning is something that is of the greatest importance in any population. This is
particularly so in the world of professionals who normally undertake high-level, meticulous work,
and it is of vital importance that, to the best of our ability, we guard well the functioning of this
most extraordinary system.

                         The seasons form a great circle in their changing and always come
                          back again to where they were. The life of a man is a circle from
                                             childhood to childhood.
                                                                              Black Elk, 19th century Sioux shaman.

    Goldberg, E., “The Executive Brain”, Chapter 9, pp 155-156. Oxford University Press, 2001.


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