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tional system Luria found that when the frontal lobes are injured by disease, there was not only a general psychomotor slowing and easy distractibility but also an erroneous analysis of the abovelisted conditions of the problem The plan of action that is selected quickly loses its regulating in uence on behavior as a whole and is replaced by a perseveration of one particular link of the motor act or by the in uence of some connection established during the patient s past experience Furthermore, there was a failure to distinguish the essential sequences in the analysis and to compare the nal solution with the original conception of the problem Plausible as this scheme appears, like Goldstein s loss of the abstract attitude (the patient thinks concretely, ie, he reacts directly to the stimulus situation), such psychophysiologic analyses of the mental processes are highly theoretical, and the factors to which they refer are not easily measured In modern parlance, the frontal lobe, and particularly its prefrontal components, is said to exert an executive function, referring here to the overall control of other cognitive functions This allows for a type of self-monitoring that guides the selection of strategies to solve problems, the inhibition of incorrect responses, the ability to deal with change in focus and novelty in tasks, and probably to be able to generalize from experience Indeed, all ability to adapt to changes in circumstance requires this executive function Unlike some of the psychic properties mentioned above, these are subject to measurement by testing, but they are observable during the clinical examination as a deterioration in problem solving, by repetitiousness and stereotypies, and by ineptitude in managing simple social situations Probably the trouble all individuals experience in maintaining a stream of thought when interrupted tests this function Other Alterations of Behavior and Personality A lack of initiative and spontaneity is the most common effect of frontal lobe disease, and it is much easier to observe than to quantitate With relatively mild forms of this disorder, patients exhibit an idleness of thought, speech, and action, and they lapse into this state without complaint They are tolerant of most conditions in which they are placed, though they may act unreasonably for brief periods if irritated, seemingly unable to think through the consequences of their remonstrances They let members of the family answer questions and do the talking, interjecting a remark only rarely and unpredictably Questions directed to such patients may evoke only brief, unquali ed answers Once started on a task, they may persist in it ( stimulus bound ); ie, they tend to perseverate Fuster, in his studies of the prefrontal cortex, emphasizes the failure over time to maintain events in serial order (impairment of temporal grading) and to integrate new events and information with previously learned data Placidity is a notable feature of the behavior Worry, anxiety, self-concern, hypochondriasis, complaints of chronic pain, and depression are all reduced by frontal lobe disease, as they are by frontal lobotomy Extensive and bilateral frontal lobe disease is accompanied by a quantitative reduction in all psychomotor activity The number of movements, spoken words, and thoughts per unit of time diminish Milder degrees of this state, associated with only a delay in responses, are called abulia (page 359); the most severe degrees take the form of akinetic mutism (page 305) wherein a nonparalyzed patient, alert and capable of movement and speech, lies or sits motionless and silent for days or weeks on end The localization of this condition is quite imprecise It has been attributed to bilateral lesions in the ventromedial frontal regions or frontal-
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diencephalic connections Laplane found that the lack of motivation of the patient with bifrontal lesions and bipallidal lesions to be the same, though one would expect the latter to be manifest more as a bradykinesia than as a bradyphrenia (slowness of thinking) Benson (and Kleist and others before him) related the syndrome of apathy and lack of initiative to lesions in the sagittal or medial frontal cortex, and a facetious, unguarded, and socially inappropriate state (see below) to orbital and dorsolateral frontal lesions This division has held up only broadly in our experience The opposite state, in a sense, is the hyperactivity syndrome, or organic drivenness, described by von Economo in children who had survived an attack of encephalitis lethargica In our patients, this syndrome has been produced by combined frontal and temporal lobe lesions, usually traumatic but also encephalitic, although exact clinicopathologic correlations could not be made Such patients may also exhibit brief but intense involvement with some meaningless activity, such as sorting papers in an attic or hoarding objects or food Combativeness and extreme insomnia or an otherwise disrupted sleep cycle are often part of the syndrome The hyperactivity of young boys and the mania or hypomania of manic-depressive disease, despite similar symptoms, also lack a known anatomic basis In addition to the disorders of initiative and spontaneity, frontal lobe lesions result in a number of other changes in personality and behavior These, too, are easier to observe in the patient s natural environment for example, by his family than to measure by psychologic tests It has been dif cult to nd a term for all these personality changes Some patients, particularly those with inferofrontal lesions, feel compelled to make silly jokes that are inappropriate to the situation so-called Witzelsucht or moria; they are socially uninhibited and lack awareness of their behavior The patient is no longer the sensitive, compassionate, effective human being that he once was, having lost his usual ways of reacting with affection and consideration to family and friends In more advanced instances, there is an almost complete disregard for social conventions and an interest only in immediate personal grati cation The patient seems to lose an inherent theory of mind, through which the normal individual recognizes the motivations and thought processes of other sapient persons; this results in the inability to incorporate these factors into the patient s responses These changes, observed characteristically in lobotomized patients, came to be recognized as too great a price to pay for the loss of neurotic traits, pain, depression, and tortured self-concern, for which reasons lobotomies were done; hence the procedure raised public outcry and became obsolete The effect of unilateral prefrontal lesions is a question that continues to vex clinicians If the lesions are small, their effects are undetectable; even a large lesion, such as a tumor, may long escape detection Rylander, by careful psychologic testing, has shown that patients with lesions of either frontal lobe manifest a slight elevation and instability of mood, with increased talkativeness and a tendency to joke, lack of tact, inability to adapt to a new situation, and loss of initiative changes that in our experience are more readily recognized if the lesion is on the right Large left frontal lesions have been more prone to cause abulia in our material In general, we agree that the greatest cognitive-intellectual de cits relate to lesions in the dorsolateral parts of the prefrontal lobes and that the greatest personality, mood, and behavioral changes stem from lesions of the medial-orbital parts, although the two types of disorder often merge with one another The diagnosis of lesions in the orbital regions is facilitated by the nding of uni-
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