The Executive Brain
(This column was first published in the May 3, 2001 ArtVoice of Buffalo.)
At the outset, let us be certain that we understand what this book is NOT about. It is NOT one of those treatises by some jackass entrepreneur like Bill Gates or Lee Iacocca telling how he manipulated the world to his personal advantage -- and the disadvantage of all the rest of us. (The bitterness that you detect in that description is at least in part due to my experiences with Microsoft products, those huge overstuffed programs that constantly try to outsmart you -- and too often succeed. As I type this commentary, for example, this latest version of Word insists on changing to its preferred font every five minutes.)
What The Executive Brain: Frontal Lobes and the Civilized Mind by Elkhonon Goldberg (NY: Oxford, 2001) is about is the brain itself. Goldberg is one of this country's foremost neuropsychologists. But let him explain his own title:
"This book is about leadership. The frontal lobes are to the brain what a conductor is to an orchestra, a general to an army, the chief executive officer to a corporation. They coordinate and lead other neural structures in concerted action. The frontal lobes are the brain's command post. We will examine how the leadership role evolved in various facets of human society -- and in the brain....
"Like a large corporation, a large orchestra, or a large army, the brain consists of distinct components serving distinct functions. And like these large-scale human organizations, the brain has its CEO, its conductor, its general: the frontal lobes. To be precise, this role is vested in but one part of the frontal lobes, the prefrontal cortex. It is a common shorthand, however, to use the term 'frontal lobes.'...
"Like the functions of a CEO, the functions of the frontal lobes defy a soundbite definition. They are not invested with any single, ready-to-label function. A patient with frontal lobe disease will retain the ability to move around, use language, recognize objects, and even memorize information. Yet like a leaderless army, cognition disintegrates and ultimately collapses with the loss of the frontal lobes. In my native Russian language, there is an expression 'bez tsarya v golovye,' 'a head without the czar inside.' This expression could have been invented to describe the effects of frontal lobe damage on behavior."
The early chapters of this book tell of Goldberg's escape from Russia where he had a career mapped out for himself working with the internationally renowned Alexandr Luria, to whom this book is dedicated. He even had to give up his completed and even bound doctoral dissertation to flee the country. That he was able to remake his career in the West is testimony to the appreciation scientists have of high quality in an individual.
Then the book turns serious and in places heavy going. But within even the toughest sections are case studies that give us insight into the functions of these pre-frontal lobes. Here are sections taken from two:
"Vladimir was a promising engineering student in Moscow in his mid-twenties. He was standing on the platform of the Moscow subway, the famous, bombastically imposing 'metro,' Stalin's great pyramid built with the labor of Gulag slaves. When the soccer ball Vladimir was tossing around fell on the rails, he jumped down to get it. He was hit by an approaching train, suffered severe head injury, and was rushed to the Bourdenko Institute of Neurosurgery, where I did my research at the time under Luria's supervision. I first encountered Vladimir two or three months after his injury. By that time Vladimir was medically stable, his life no longer in danger.
"Vladimir was particularly interesting because, as a result of his injury, he had to undergo surgical resection of both frontal poles.... Conveniently, I was one of the few males on Luria's largely female staff and thus could be relied on to deal with Vladimir's clinical antics....
"Vladimir spent most of his time in bed staring blankly into space. He ignored most attempts to engage him in any kind of activity. Persistent attempts could provoke a trickle of profanities, and a particularly vigorous intruder ran the risk of being hit with a chamber pot.... The nurses would call on me to help coax Vladimir out of bed to go for a medical procedure or to give him an injection (the surest way to encounter Vladimir's chamber pot). I reasoned with Vladimir in a casually profane, locker room-style banter, and it usually had a calming effect. A friendship of sorts developed between a brain-damaged student and a student of brain damage. As a result, I was able to engage Vladimir in all kinds of little bedside experiments with relative ease, despite his general inertia. He would follow my instructions in a detached, stone-faced, zombie-like fashion.... The most conspicuous feature of their behavior is an inability to initiate any behavior. Once engaged in a behavior, however, the patient is equally unable to terminate or change it on his own.
"Vladimir's inertia, so striking in his everyday behavior (or lack thereof), could also be elicited experimentally. Asked to draw a cross he would first ignore the instruction. I had to lift his hand with mine, place it on the page, and give it a little push, and only then would he start drawing. But having started, he could not stop and continued to draw little crosses until I took his hand in mine and lifted it off the page. Such combined inertia of initiation and termination is seen in various disorders affecting the frontal lobes, including chronic schizophrenia.
"When the task was to listen to a story and then recall it, Vladimir would start slowly and then carry on in a monotonous voice. He would go on and on and when asked to finish, he would say 'Not yet.' The never-ending monologue was an expression of 'reverse inertia,' an inability to terminate activity....
"A simple experiment illustrates Vladimir's severely impaired ability to follow plans. I asked Vladimir to listen to a story, 'A Hen and Golden Eggs,' and then recite it from memory. The story goes as follows: 'A man owned a hen that was laying golden eggs. The man was greedy and wanted to get more gold at once. He killed the hen and cut it open hoping to find a lot of gold inside, but there was none.'
"Vladimir repeated the story as follows: 'A man was living with a hen -- or rather the man was the hen's owner. She was producing gold. -- The man -- the owner wanted more gold at once -- so he cut the hen into pieces but there was no gold. -- No gold at all. -- he cuts the hen more
no gold -- the hen remains empty -- So he searches again and again -- No gold -- he searches all around in all places.
"'The search is going on with a tape-recorder -- they are looking here and there, nothing new around. They leave the tape-recorder turned on, something is spinning there -- what the hell are they recording there -- some digits -- 0, 2, 3, 0 -- so they are recording all these digits -- not very many of them -- that's why all the other digits were recorded -- turned out to be not very many of them either -- so, everything was recorded -- [monologue continues]
"The sheer length of Vladimir's monologue is out of proportion to the original story. This is his inability to terminate an activity -- the inertia in reverse that we have already discussed. He also perseverates, as he continues to rehash the phrases and themes of the story. But at a certain point new content is introduced, a spinning tape-recorder. All of a sudden, Vladimir's story is a complete non sequitur: it is no longer about the golden eggs, but about a tape-recorder.
"The explanation for this strange behavior lies in the environment. I am sitting in front of Vladimir with a portable tape-recorder in my lap, taping the very monologue that we are discussing here. Vladimir's task is to recall the story. The tape-recorder is completely incidental to this task. But its mere presence in the environment is sufficient to derail Vladimir's ability to follow the task at hand....
"Being at the mercy of incidental distractions and displaying an inability to follow plans are common features of frontal lobe disease.... A frontal lobe patient will drink from an empty cup, put on a jacket belonging to someone else, or scribble with a pencil on the table surface, merely because the cup, the jacket, and the pencil are there, even though these actions make no sense....
"I recall the indignation of the nurses on the university hospital neurology service where I used to consult many years ago. A few patients on the unit invariably kept wandering into the other patients' rooms, inciting the wrath of the nurses, who accused the patients of every conceivable malicious intent. The reality was much simpler and sadder. The wandering patients were entering through the doors just because the doors were there. They were patients with frontal lobe damage suffering from field-dependent behavior....
"The most striking feature of Vladimir's condition was his complete unawareness of his disorder and of his drastically changed life circumstances. Vladimir suffered from anosognosia, a devastating condition which strips the patient of the capacity for insight into his own illness. A patient with anosognosia may be severely impaired, yet he will have no inkling of it and will continue to claim that everything is fine. This is different from being 'in denial,' when it is assumed that the patient has the capacity to comprehend his own deficit but 'chooses' to look the other way. Following frontal lobe damage the cognitive capacity for insight into one's own condition is genuinely lost."
And the second case: "Kevin...was a fabulously successful entrepreneur and entertainment executive, a happy husband and father of three. An all-round athlete, he was an accomplished equestrian, but that day he was riding an unfamiliar horse in New York's Central Park and was thrown on hard basalt rock, hitting his head against a tree in the process. He was rushed to the nearest hospital, where Dr. Hughes performed emergency surgery. Kevin had been comatose for two days and was slowly recovering.
"I first saw Kevin briefly approximately two months after his accident. He was disoriented, confused, and overwhelmed by his surroundings. His general demeanor was panic-stricken, and if there ever was an embodiment of the expression 'shell-shocked,' Kevin was that embodiment. He was severely aphasic and responded to every question addressed to him by saying 'Thank you, thank you, thank you.' That was his only utterance. There was something extremely childlike and pleading in his demeanor and his 'thank you' -- he was a man who had lost his core, defenseless like a child.... He wandered aimlessly on the unit walking through any open door -- just because the door was there.... Nothing in this fragile visage was evocative of the supremely confident, buoyant, and physically imposing persona that the old Kevin was supposed to have been.
"Kevin was discharged from the hospital, and three months later I was asked to see him again. He was a different person, his wavy hair regrown into a rich mane, his weight regained, with a broad smile on his face and gregarious manners returned. His language was fluent and his mood relaxed. Dressed in one of his expensive suits, his hair blown dry, Kevin appeared the epitome of a palpably successful dweller of New York's Upper East Side. Superficially, his demeanor of a man in control of his environment had returned, and one could imagine the old Kevin -- a self-confident, charismatic, and slightly glib, upper-crust New Yorker.
"In reality, Kevin was far from recovered. He still had significant memory impairment, which affected both his ability to learn new information (anterograde amnesia) and his ability to recall information learned well before his accident (retrograde amnesia). His language, while generally fluent and even articulate, revealed slight word-finding difficulties, maybe not likely to be noticed by the uninitiated, but certainly apparent to me.
"As I continued to observe Kevin, I was particularly struck by the severity of his 'frontal lobe syndrome.' Kevin was perseverative; that is, his behavior invariably fell into repetitive stereotypes. Every evening, he would arrange his clothes for the following day and the clothes were always the same. As winter passed and spring began, and well into the summer, Kevin continued to prepare his sheepskin jacket to wear the following day and could be found walking around the Upper East Side of Manhattan clad in his sheepskin on a sweltering July day. It took a lot of persuasion to get him to wear anything else. Despite his superficial flair, any conversation with Kevin rapidly deteriorated into a rather vacuous activity such as simple card games. He had a small repertoire of rehearsed stock topics, and the conversation would predictably and quickly drift toward one of them, say, discussion of some of his friends. Having run through his repertoire of half-a-dozen topics, Kevin would start from the beginning, repeating everything almost verbatim again and again.
"Kevin was not only perseverative, but he was also field-dependent. Accompanied by a family member or an aide, Kevin occasionally ventured into a neighborhood restaurant for lunch. In the restaurant he tended to order every item on the menu, 10 or 20 items in all. He did so not because he was that hungry, but because the items were there. He spent most of his time, though, languishing in his apartment, occasionally asking people to play simple card games and backgammon with him. His behavior during the games was childlike. He would clap his hands with joy after winning and throw temper tantrums after losing. He was not above cheating.
'Kevin's affect was constantly oscillating between euphoria and superficial rage. These mood swings were abrupt, extreme, and could be precipitated by the most trivial events -- like a waitress in a restaurant asking him if he wanted more coffee.
"His personality took on childlike characteristics in virtually every respect. He related to his wife like a 12-year old and competed with his children for her attention. In many ways he interacted with his children as an equal. Like a little child, he demanded instant gratification, although his needs were not those of a child. On several occasions he approached his female acquaintances with rather explicit propositions, an odd combination of the old charming Kevin and the socially inappropriate frontal patient.
"Kevin had no insight into his condition. When questioned about the effects of the accident, he would mention his physical injuries but maintained that his mind was sound. He was convinced that he was ready to go back to work. When asked why he had not done so, he would say that he did not feel like it, or that he had been busy doing other things. Eventually Kevin was encouraged to spend a few hours a day in his old office, engaged in various cognitive exercises designed to help his recovery. He enjoyed going to the office and chatting with his old colleagues. His sense was that he was 'back to work' -- despite the fact that the way he spent his time in the office bore little similarity with his activities before the accident.
"Kevin's mind was astoundingly concrete. When I once said that it was time to repeat the CAT (computerized axial tomography) scan, this was met with genuine puzzlement. Why the CAT scan, Kevin marveled, if after all he had been hurt by a horse, not a cat?"
There are great insights here into more general behavior as well. Here is how Goldberg begins his right-on-target discussion of attention deficit disorder: "If one were to run a 'disease of the decade' contest, attention deficit disorder (ADD) and attention deficit/hyperactivity disorder (ADHD) would be among the plausible contenders. At the close of the twentieth century and the beginning of the twenty-first, the diagnosis is made generously and casually, often with little understanding of the underlying mechanisms, and sometimes with none at all. Parents actively seek the ADD diagnosis for their children to explain their school failures, and adults seek it for themselves to explain their life failures. It is not uncommon for a patient to ask the doctor 'to diagnose my ADD.' The proposition, of course, is utterly oxymoronic, about as sensible as asking: 'What is the color of my green sweater?' But many doctors oblige, and those who do not often run the risk of losing their patients to those who do (it happened to me). It is not unheard of for a patient to shop for a doctor until the magic diagnosis is obtained.
"When a diagnosis is not merely suffered but sought, clearly we have more than a clinical disorder. We have a social phenomenon."
And here is a little of what he has to say -- good news and bad -- about senility: "A preordained, inexorable progression toward 'senility' is a myth. This is the good news. The bad news is that while not inevitable, dementias are very common. Alzheimer's type dementia is the most common among them, accounting for more than 50% of all dementias. By the age of 65, more than 10% of the population is afflicted with one form of dementia or another. According to the American Medical Association, by the age of 85, some 35% to 45% of people have it to at least some degree. It is estimated that dementias are likely the fourth or fifth most common cause of death in the United States.
But Goldberg offers support for the idea that stimulation of the brain is good for us -- that old concept of the brain as a kind of muscle to be trained that was long discharged as nonsense by behavioral psychologists: "Animal studies show that improvement of 'brain power' through cognitive activation is more than a fantasy. Scientists at the famed Salk Institute for Biological Studies in southern California examined the effects of enriched environment in adult mice. They found that mice placed in cages filled with wheels, tunnels, and various toys developed up to 15% more neural cells than the mice left in standard cages. The 'stimulated' mice also did better than their 'unstimulated' counterparts on various tests of 'mouse intelligence.' They were able to learn mazes better and faster...."
And we too gain: "British neuroscientists reported a finding that, even a few years earlier, would have been dismissed as a neurological impossibility. They scanned the brains of 16 London taxi drivers and compared them with the brains of 50 control subjects. The taxi drivers, who in the course of their work develop an intricate mental map of their huge metropolis, had larger posterior hippocampi. Furthermore, the greater the number of years spent on the job, the larger the hippocampi were in individual drivers. Not surprisingly, the hippocampi are presumed to be involved in spatial learning and memory. This may very well be the first direct demonstration of a relationship between the size of a brain region and the environmental factors contributing to its use."
As I read this book, my mind kept harking back to that terrible end of "One Flew over the Cuckoo's Nest" with those patients sitting on a bench staring off into space after being subjected to supposedly curative pre-frontal lobotomies. This book represents a very different and certainly more balanced and instructive alternative to that early medical misdirection.-- Gerry Rising