Early Prefrontal Cortex Insult and Conduct Impairments
William Sheehan and Steven Thurber
Minnesota Department of Human Services, 1701 Technology Drive NE, Willmar, MN 56201, United States.
A case study of an adolescent with pronounced antisocial behaviors is presented. He had been previously seen by multiple mental health professionals in a variety of settings, from outpatient to residential. Ineffective prior treatments were reflective of neglect of the possible effects of early brain trauma (five months of age) in the etiology of antisocial deportment. The results of this case report are congruent with a small number of other studies that suggest early prefrontal cortex damage as a precursor of sociopathy.
The current case presentation can be added to an estimated fewer than 20 other cases reported in the world literature related to behavioral and social functioning following prefrontal cortex damage at an early age. Previous case studies include the initial, remarkable investigation by Ackerly and Benton, begun in the 1940ís and continuing over the subsequent three decades . The subject suffered a head injury at age four, involving damage to the prefrontal area of the brain. Up to that point in development, he showed normal attainment of milestones and age-appropriate social behaviors. Thereafter, he evinced numerous, habitual conduct problems, poor social adjustment and inappropriate deportment that included public masturbation. As an adolescent and young adult, he was a social isolate; he stole cars just for the fun of it; he generally behaved impulsively without regard to the rights or welfare of others, and without a sense of responsibility or compunction. He was an inveterate liar, was financially reckless, stole, and threatened others with occasional physical aggression. This pattern continued into the individualís sixth decade of life. Although this case occurred before the advent of neuroimaging and neuropsychology, exploratory surgery revealed right frontal fossa devoid of cortical tissue .
This historically significant initial case of trauma to the prefrontal area of the brain in a child is analogous to the celebrated adult case of Phineas Gage, with the emotional and behavioral sequelae of childhood trauma appearing consonant with those well documented in prefrontal injuries (like that sustained by Gage) that occur in adulthood, after neural maturation. However, adult onset prefrontal injuries do not affect what has already been acquired relative to factual knowledge in the interpersonal domain or oneís degree of moral development or understanding of abstract moral principles. More recent case research has centered on the effects of brain insults occurring still earlier in childhood. Two subjects, then in their early 20ís, were studied who had sustained prefrontal injuries at ages of less than 16 months; one had been run over by a vehicle at 15 months, the other had a right frontal tumor resection at three months of age . Both displayed behaviors that, like the earlier case study, appeared ìsociopathicî with impaired capacities to learn from experiences, or to regulate actions based on anticipated consequences. They were interpersonally disruptive, physically and verbally aggressive, oppositional, antisocial (e.g., stealing; shoplifting), irresponsible in their sexual behaviors, and emotionally labile. Importantly, despite normal intelligence, both individuals failed to acquire adequate interpersonal knowledge or age-commensurate moral reasoning. Neither displayed guilt or remorse for antisocial actions. Such data suggest that early prefrontal brain insults not only affect mechanisms of impulse control and mood regulation, but also impede or prevent the acquisition of moral rules and understanding of social conventions. Magnetic resonance imaging revealed prefrontal lesions in both patients.
Since only a handful of other instances of early onset prefrontal injuries have been reported, the current case study represents rare occurrence.
The patient, a fifteen year old male, accidentally knocked over a VCR when he was five months old; the VCR reportedly struck him in the forehead, the right of the midline. Subsequently his behaviors were described as ìregressedî in several areas including speech and motor coordination (very slow in learning to walk). Beginning at approximately two years of age he began to evince frequent aggressive episodes and over time alienated others via physical aggression and other forms of hostility. Prior to coming to our attention, he had been living in residential treatment facility. While there, he fashioned a knife out of a tooth brush, and threatened to harm himself and others. He placed a pen in an electric outlet, and shorted out the fuses of staff personís offices and the bedrooms of residents. He destroyed property, threatened personnel and fellow residents with stabbing and burning, and was felt to be too difficult for the facility to handle. These were the precipitating events leading to the current psychiatric evaluation.
In reviewing the history, there had been a significant escalation as he reached adolescence of conduct problems, both in intensity and duration. He exhibited marked mood instability, chronic truancy, and frequent suicidal ideation. There was a history of numerous hospitalizations (one preceded by his setting his house on fire via lighting his pet rat on the stove). He showed a disturbing preoccupation with sharp objects and guns. On one occasion he dropped rocks from a bridge just to hurt people as they walked by. His antisocial behaviors included lying, stealing, being truant from school, etc. These types of actions resulted in several encounters with law enforcement officials, but he seemed fearless of police and indifferent to disciplinary approaches. He seemed alike unresponsive to treatment with medications, hospitalizations, and long-term, and costly, residential programs.
The patient had previously been diagnosed as schizophrenic, conduct disorder, intermittent explosive disorder, bipolar disorder, and ADHD. Not one of his several attending mental health professionals ever considered the possibility that the sociopathic-type characteristics might be related to the TBI sustained in infancy. Not one had elicited that history, despite the fact that it was mentioned by the childís mother who had specifically wondered about it and had even discussed it with pediatricians when she became concerned with his off-kilter developmental trajectory, but they rather airly dismissed with casual reassurance.
In order to follow up on this important lead, we ordered a SPECT scan of the brain, which was performed using 26.1 mCi TC99m Neurolite. The patient was cooperative and the scans were of good technical quality. Axial views showed a complex pattern of perfusion deficits. The most significant of these included a perfusion deficit in the right orbitofrontal cortex, with an area of decreased perfusion between the right orbitofrontal cortex and right temporal lobe. There was also decreased perfusion extending across the midline to include areas in the left parietal-occipital area.
The SPECT results suggest a classic coup-countercoup distribution of deficits. However the pattern is complex, with an overall picture of diffuse and varied deficits. Orbitofrontal lesions are known to concatenate with acquired sociopathy in adults .In addition, perfusion deficits in this area, also demonstrated by SPECT in other patients, have been associated with specific antisocial behaviors such as fire-setting and stealing cars [5-6]. The orbitofrontal cortex seems to be particularly important in the ability to make rapid adjustments in response to environmental challenges and is involved in emotional regulation; problems in the latter domain include dysfunctions in orbitofrontal circuitry in a network with the temporal lobe and can be a precursor of violence .
Because of the definitive findings on SPECT, the patient was reclassified as TBI with appropriate services. The treatments offered were Topirimate, which had been successful in a similar case (see Grant,) and cognitive behavior therapy (CBT). The last contact with the patient was when he had become an adult; by then he was doing well in a group home, and no longer exhibited sociopathic behaviors.
It is noteworthy that this patient had not been correctly diagnosed or treated, despite many assessments, hospitalizations, residential treatments, and psychotropic trials. Information provided by SPECT led to recognition of his underlying neurological deficits and eventual appropriate treatment. Without functional neuroimaging data, further ineffective treatments and escalating antisocial deportment were the probable outcomes.
The results of this case study can be added to accumulating data on the deleterious impact of early prefrontal injuries.
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Copyright Priory Lodge Education Ltd 2012 -
First Published November 2012