Frontal Lobe Damage: Case Study

The frontal lobes play a major role in the regulation of our emotions and behaviour as well as planning, decision making, social conduct, and executive functions. They are vulnerable to damage and many neuropsychological tests have been developed to assess subsequent impairment related to the frontal lobes. The study looks at the case of Mr A who has reported a drastic change in his personal and professional skills and abilities following brain injury. WCST, TEA and TOL tests were used to examine his brain damage. Previous studies have found patients with frontal lobe damage display difficulty and score low on these tests in comparison to normative scores. It is suggested that patients with frontal lobe damage be observed in every day settings as well as examined through tests. Further tests and treatments were suggested to increase understanding of Mr A’s brain damage and help him overcome problems caused by it.

The frontal lobes are thought to be our emotional control centre and home to our personality. The frontal lobe is divided into 3 areas, these are; precentral, premotor and prefrontal regions (Perecman, 1987). The frontal lobes are vulnerable to injury and damage due to their location at the front of the skull and their ample size. Magnetic Resonance Imaging studies have revealed that the frontal area is the most frequent region of damage following brain injury (Levin et al., 1987). Statistics show that there is no other component of the brain in which impairment can cause such a wide array of symptoms (Kolb and Wishaw, 1990).

The frontal lobes are involved in problem solving, spontaneity, memory, language, initiation, judgement, impulse control, social cognition (Benson, 1996) and sexual behaviour. Motor function is also seen to be controlled by the frontal lobes (Leonard et al., 1988). According to Shammi and Struss (1990) the right frontal lobe is also connected with the ability to appreciate humour. They found that patients with frontal lobe damage reacted less, with reduce physical or emotional responses to humour such as laughter and smiling. Other studies have pointed to the role of the frontal lobes in facial expression (Kolb & Milner, 1981). Many studies have established that verbal fluency is connected with frontal lobe damage (Ramier and Hecaen, 1970). Broca’s Aphasia has also been linked with frontal lobe damage (Brown, 1972). It is supported that frontal lobe damage has an effect on memory and attention (Stuss et al., 1985). Patients with frontal lobe damage show impairment in sorting or shifting (Kramer and Jarvik, 1979). Parts of the frontal lobe have been found to be involved in motivated behaviour (Mega and Cummings, 1994) as well as initiation and goal directed behaviour (Devinsky et al, 1995). Frontal lobes enable people to learn from past experiences, organise information, make future intentions, and remain attentive during tasks. It is suggested by Struss and Benson (1984) that frontal lobes are associated with executive functions such as, planning, decision making, error correction, dealing with difficult situations, overcoming and resisting temptation. However, a recent review indicates that executive functions may not exclusively depend on the frontal lobes (Alvarez and Emory, 2006).

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The frontal lobes have also been related with empathy and socially appropriate behaviour (Mega and Cummings, 1994). A famous case which illustrates how damage to this area can affect this is that of Phineas Gage. His case demonstrates personality change and how patients suffering frontal lobe damage can become irritable, unpredictable, disinhibited and unable to adjust to social norms.

Phineas Gage is one of the earliest documented cases of severe brain injury. Gage suffered major personality changes after brain trauma following an accident during railroad construction where he worked. A spark from a tamping iron ignited dynamite and caused an explosion which resulted in the iron to be propelled at high speed straight through Gage’s skull. It penetrated under the left cheek bone and exited through the top of his head; it was later retrieved many yards away from the location of the disaster (Harlow, 1848).

Harlow (1848), the doctor that attended to him recorded the mental and emotional symptoms of Gage’s brain injuries. The damage to Gage’s frontal lobes had resulted in a complete loss of social inhibitions; this led to socially inappropriate behaviour. His wife and loved ones reported dramatic changes in his personality.

The case of Phineas Gage and the publication of Harlow’s 1868 report of Gage’s personality changes is significant, as it confirmed previous findings that damage to the frontal lobe could result in personality changes while leaving other functions unharmed. It is one of the first cases providing evidence that the frontal lobes are involved in personality.

Mesulam (1986) pointed out from his studies, that some people who have suffered frontal lobe damage show impairments in their everyday life; however they show little or no impairment on clinical neurological assessment tests. This was also evident in the case of patient EVR.

EVR underwent surgical removal of a large bilateral frontal meningioma. At the time of his operation EVR was an accountant and a respected member of his community. He was married with children; his siblings considered him a role model and a natural leader. After the operation however, EVR underwent drastic negative changes in his day to life as he was unable to make decisions and plan. Although he was above average on most tests, (EVR had a verbal IQ of 125, a performance IQ of 124 and he displayed no difficulty on Wisconsin Card Sorting Test) EVR was often unable to make simple everyday decisions, such as which toothpaste to buy, what restaurant to go to, or what to wear even after endless comparisons and contrasts Damasio (1985). Eslinger and Damasio (1985) report: “It was as if he forgot to remember short and intermediate-term goals.”(p.g. 1737). This may be characterised as a failure of future memory, the ability to encode delayed intentions, and act on those intentions when the appropriate time arrives.

There have been many neuropsychological tests developed to test patients with brain damage and particularly frontal lobe damage. The study aims to select the appropriate tests that can be used in the identification and assessment of the dysfunction described in the case study of Mr A. It is expected that Mr A will display low scores and difficulty carrying out the tests as previous literature has related frontal lobe damage with low coring in neuropsychological tests measuring executive functions.

Method

Design

A case study design was proposed for the study.

Participants

The case study focuses on Mr. A; A 48 year old male and an architect by profession, Mr A was involved in an accident resulting in brain injury. His family have reported a drastic change in his personality and previously exceptional skills and abilities. He is reported to have become withdrawn, anxious, easily distracted as well as displaying great difficulty organising, managing and planning. This has affected his personal life as well as at a professional level.

Materials

Materials include three neuropsychological tests. These are;

Wisconsin Card Sorting Test (Grant and Berg, 1948): This test consists of 4 stimulus cards differing in colour, shape and number along with 128 response cards. Participants are required to sort the cards according to shape, colour and number. Administration time is 10-15 minutes.

Test of Everyday Attention (Robertson et al, 1994): The study includes 3 subtests which are; Elevator Counting With Distraction – Participants have to count the low tones in the pretend elevator while ignoring the high tones. This measures selective attention; Visual Elevator – Participants have to count up and down as they follow a series of visually presented ‘doors’ in the elevator. This measures attentional switching; Telephone Search Dual Task – Participants must search in a directory while simultaneously counting strings of tones presented by a tape recorder. This measures divided attention. Administration time altogether is 45-60 minutes.

Tower of London Test (Shallice, 1982): This test consists of 2 boards with 3 pegs and 3 beads differing in colour and height. Participants are required to move the coloured beads on the first board until they achieve the exact arrangement presented on the second board. This must be done in as few moves as possible. Administration time is 10-15 minutes.

Procedure

The procedure would involve a referral of the patient Mr A to the neuropsychologist. The researcher would interview the patient in a semi structural manner and take the following details; Descriptive data, developmental history, social history, relevant past medical history, current medical status and the effect of the injury on the everyday life of Mr A (Lezak et al, 2004). The interview is seen as a very important aspect of assessment; it is also essential for evaluation and can guide the researcher in appropriate test selection (Sattler, 2002).

The first test selected for the assessment of Mr A’s brain damage is The Wisconsin Card Sorting Test (WCST) (Grant and Berg, 1948). It is used to evaluate problem solving, strategic planning, use of environmental feedback, goal directed behaviour and inhibition of impulsive responding. The WCST is widely used and has been seen to accurately recognize frontal lobe dysfunctions (Milner, 1963; Robinson et al, 1980; Goldberg et al, 1987; Berman et al, 1988). Mr A has displayed difficulty with supervisory and administrative aspects of his work and also reports a failure to organise and plan his work schedule as well as impaired management skills.

The Test of Everyday Attention (TEA) (Robertson et al, 1994) was developed to improve upon existing methods of assessing attention problems. It consists of eight subtests which measure sustained, selective and divided attention in visual and auditory modalities reflecting current thinking on the fractionation of attention. It is designed to be ecologically valid and the subtests are designed to mimic everyday activities. Mr A’s wife reported him to become easily distracted and unable to hold a conversation since his brain injury, hence this test is relevant to his case.

The Tower of London test (Shallice, 1982) is the third test to be selected for implementation with Mr A as it investigates planning, strategy use, maintenance of attention and problem solving in patients that have sustained damage to the frontal lobes. Mr A has reported to have difficulty with his supervisory and management skills and also seems to be easily distracted, this justifies the test selection.

Results

Wisconsin Card Sorting Test:

Studies have found an association between performance on the WCST and dysfunction of the frontal lobe (Goldberg et al, 1987). Patients with any sort of frontal lobe damage have been found to do poorly at WCST. In particular they make a higher number of repetitive errors than control participants (Milner, 1963).

Another study investigated deficits in planning ability using the WCST. Results showed that deficits were due to a greater likelihood to break the rules of the task, that is, in plan following processes, rather than in planning the strategic approach to solve it (Gouveia et al, 2007). It is therefore expected that Mr A will have difficulty following the rules of the task and will make repetitive errors and score poorly on the test.

Test of Everyday Attention:

Studies have found that brain injured patients generally perform worse than matched control groups in the TEA. Chan (2000) reported scores for subtests of TEA as follows; Elevator with distraction; Patients with brain injury scored 5.52 on average compared to 8.76 for control group. Visual Elevator; Patients with brain damage scored an average of 6.57 compared to the control group score of 8.86 average. Telephone search dual task; Control group scored 5.69 compared to 1.75 average patient scores. It is consequently expected that Mr A will exhibit low scores on the 3 subtests of the TEA.

Tower of London Test:

Shallice (1982) reported patients with damage to the left frontal lobe demonstrated impaired planning and problem solving and therefore needed a greater number of moves for the solution of the test.

Many studies have found that patients with frontal lobe damage showed significantly delayed solution times and made more moves on the TOL test in comparison to control groups (Carlin et al, 2000′ Owen et al, 1990). De Lucia et al (2003) reported 92% of males aged between 30-49 with no brain damage completed the test with maximum moves and made an average of 0.80 excess moves per trial. Hence, it is expected that Mr A will need a greater amount of time before making solutions and will make a higher number of excess moves than normative scores on the TOL test.

Discussion

Results show that patient A would score poorly on WCST as a result of frontal lobe damage. MRI studies have shown a prevalent stimulation of frontal brain areas throughout the duration of the WCST (Berman et al, 1995; Cabeza and Nyberg, 2000; Barceló and Santome-Calleja, 2000). However, several studies have stated that the WCST is incapable of discriminating between frontal and non frontal lobe damage (Anderson et al, 1991; Mountain and Snow, 1993). Successful completion of the test relies upon a number of intact cognitive functions including attention, working memory, and visual processing. Some researchers suggest that poor results from the WCST can also be due to working memory deficits (Barcelo et al, 1977). Moreover, some researchers have suggested that WCST not be associated with frontal lobe damage as other areas in the brain are also involved in abstract thought (Reitan and Wolfson, 1994). These findings imply that these factors should be considered when assessing patients with brain damage.

Results also show that TEA scores would be low in Mr A as a result of frontal lobe damage. The TEA has received praise for having several advantages such as being based upon theoretical framework of attention, having realistic subtests which simulate everyday life situations, having a children’s equivalent and finally showing strong validity in assessing attention in individuals (Chan and Lai, 2006; Robertson et al, 1996). The test has also shown to discriminate between patients with frontal lobe dysfunction and those without (Chan, 2000).

The TOL test would require Mr A to make a higher number of moves due to frontal lobe damage. Morris et al (1993) found a high activation in the left frontal lobe during participants undertaking the TOL test. This implies that the frontal lobe is involved in the planning required for successful performance on the TOL test.

However, a study in which test results of patients with frontal lobe damage compared with that of control subjects found that whereas the WCST discriminated well between patients and control subjects, the TOL test did not (Cockburn, 1995). Further, Shallice (1988) reported a failure to replicate his earlier finding that impaired performance on the TOL task was associated with left frontal lobe damage.

Other tests recommended to examine the extent of Mr A’s deficits are; the Category test (Halstead, 1947) which measures problem solving and abstract reasoning, the Stroop test (Stroop, 1935) which measures executive functions and the Trail Making tests (Reitan, 1971) which measure visual attention, alternation and sequencing.

Interestingly, some patients who suffer from frontal lobe damage often do not show any defects on neuropsychological tests. However, when observed in unstructured real world settings, patients frequently demonstrate cognitive difficulties, neurobehavioral symptoms, and deficits in their executive functions. Therefore neuropsychological tests are poor at assessing these problems and symptoms. Researchers have investigated this issue and found that the neuropsychological test scores of these patients were often either unrelated or poorly related to measures of everyday functioning and their behaviour in real-world settings (Chaytor and Schmitter-Edgecombe, 2003; Chaytor et al.,2006). Consequently Sbordone (2009) has suggested that neuropsychologists should not rely solely on the quantitative test data of these patients since it may provide inaccurate and misleading information.

It is recommended that patients with frontal lobe damage be introduced to rehabilitation strategies to help them overcome the difficulties in their everyday life. Yoga has been seen to facilitate many mental functions, an example being visiospatial memory (Naveen et al, 1997) and attention and concentration (Telles et al, 1993). Studies have found high frontal lobe activation during meditation (Herzog et al, 1990; Lazer et al, 2000). Other studies have found that yoga improves planning and the subsequent performance in the Tower of London test (Rangan et al, 2008; Manjunath and Telles, 2001). This implies that there are strategies available at helping patients overcome the negative effects of their brain damage and improve upon deficits caused by their injury and Yoga is a proven treatment which can bring about positive change to the day to day activities of these patients.

In conclusion frontal lobe damage can have a serious negative effect on the day to day life of an individual as it affects many skills, abilities and processes. Neuropsychological tests have been seen to be useful in identifying damage to the frontal lobe, however should not be solely depended upon. Observations of patients’ problems in everyday life situations must be considered to be fully aware of the extent of the patient’s deficits. Furthermore, strategies for treatment and therapy also need to be considered to help the patient overcome their difficulties and improve their performance in many areas, which in turn can improve their quality of life.