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Frontal Lobe Wounds Causing Disinhibition a Study of Six Cases by Hugh F

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Frontal Lobe Wounds Causing Disinhibition a Study of Six Cases by Hugh F J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.17.1.14 on 1 February 1954. Downloaded from J. Neurol. Neurosurg. Psychiat., 1954, 17, 14. FRONTAL LOBE WOUNDS CAUSING DISINHIBITION A STUDY OF SIX CASES BY HUGH F. JARVEE* From the Department ofNeurology, Radcliffe Infirmary, Oxford, anid the Military Hospital for Head Injuries, Wheatley The study of disturbed function following injury however, that subtle changes in this direction not or surgical intervention has yielded a large amount of easy of assessment do occur in many more cases. information about the effects of such injury when it Secondly, when disinhibition is present the degree involves the frontal lobes in man, and certain to which it occurs varies widely. This is because the patterns of reaction have become apparent after disinhibition involves different aspects of the frontal lobe damage. The significance of these personality in different people, so that the aspects patterns as indicators of the part played by the of the personality affected may have a variable guest. Protected by copyright. frontal lobes in the general organization of thought social significance, making the new behaviour more and behaviour is, however, less assured, and their or less offensive when taken within the context of relation to anatomical site within the pre-frontal the special fields of social control involved. area is still a matter of conjecture. In so far as the frontal lobes are concerned with The type of change which appears from case to inhibition, no understanding of their functional role case shows much inconstancy, although cases can in this respect will be complete unless answers can always be identified which show a similar constella- be given to these two questions, Why does disinhibi- tion of symptoms. Of these changes the most tion seem only to occur significantly in a minority impressive are those in which character and tem- of cases ? And why, when it does occur, does it perament are profoundly altered. Thus, the self- involve different aspects of the personality in respecting man becomes irreverent or inconsiderate different people ? of the feelings of others; uninhibited behaviour In the present paper six cases are described in becomes apparent and may be of a degree to bring which clear evidence of disinhibition was found the individual into conflict with society and its laws. following wounds involving the frontal lobes. They These striking changes in personality, which were are taken from a group of 43 penetrating brain first adequately described a hundred years ago by wounds in all sites which have been studied person- Harlow (1848, 1868) in the classic case of Phineas ally and in which changes in behaviour and intellect Gage, are rare but are of such a distinctive quali- have been investigated. The majority of the 43 tative nature that they form perhaps the most cases had frontal lobe involvement. They form a http://jnnp.bmj.com/ characteristic feature of the " frontal lobe syn- part of a series of approximately 900 penetrating drome ". They can all on the whole be regarded as brain wounds in Service personnel from the last war due to " disinhibition ", that is to say, to a distur- and from Korea whose records are preserved in the bance of the mechanisms responsible for the control Head Injury Bureau attached to the Military of behaviour in its social setting. Hospital for Head Injuries. When we come to study the phenomenon of disinhibition after frontal lobe injury two points of Method of Investigation great significance emerge. First, changes in character Personality Studies.-In investigating changes in on September 24, 2021 by and temperament due to disinhibition seem only to behaviour special attention has been given to pre- occur significantly in a minority of cases, and it is traumatic personality studies, and all available not generally possible to establish disinhibition in sources of information have been followed up, every case of frontal lobe damage. It may well be, including interviews with relatives, reports from probation officers, visits by psychiatric social *Beit Memorial Research Fellow. workers, and scrutiny of Army documents. 14 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.17.1.14 on 1 February 1954. Downloaded from FRONTAL LOBE WOUNDS CA USING DISINHIBITION 15 Intellectual Changes.-The estimation of intellec- H.R.V. Matrices H.R.T. median score on each tual changes after brain injury presents special 40 - 20 test for the whole problems, as various types of impairment in group has been super- intellectual functioning may occur. imposed as a thick In the present study the deficits in intelligence line. The median which have been investigated are deficits in con- 15 score on the matrices ceptual activity. Intelligence is thus used in the in the sample is 43, sense in which it is defined by Wolf (1947) as the while Raven's median " mental function of apprehending connexions ", score for this age- and it is the preservation or loss of this ability group is 44, cal- which has been especially studied. 1- culated from the natural scores of Method of Estimating Deficits.-Information with several thousand regard to pre-traumatic intelligence is often scanty. soldiers and civilians Some information can usually be obtained from the 5 (Raven, 1950). scholastic and occupational record of the patient, In this control but this is often unreliable. 10 group, therefore, the Most methods devised to demonstrate intellectual median score on the impairment in organic cases are based on groups of matrices is 43, in the tests, some of which show respectively some 0 4 H.R.V. 26-5, and in resistance or vulnerability to trauma. Thus, when a FIG. 1.-Chart showing distribution the H.R.T. 14. of test scores in 50 normal guest. Protected by copyright. patient with traumatic deterioration is not dysphasic, controls. The thick line The distribution of his ability to reproduce vocabulary is usually represents the position of the the results in these median score on each test. preserved, and this is widely used as an indication 505 normalomlcnrlcontrols of his pre-traumatic intelligence level, because it is shown on the diagram demonstrates a wide scatter generally true that the higher an individual's between the ability to reproduce vocabulary and vocabulary (i.e., the greater the number of words to perform conceptual tests, especially in the he knows) the higher is his intelligence in the lower and medium intelligence levels. It can be conceptual sense. Provided certain limitations are seen, however, that when the higher vocabulary recognized, this method should yield valuable levels are reached the results on the matrices and results, and the tests used in this study are based on H.R.T. tend to equate more consistently with the this principle. The tests are well known, but they vocabulary scores, as shown by the greater number have been re-standardized for the purpose of this of lines going almost straight across. In using such investigation against a group of normal controls. a method as this, therefore, to estimate the presence They are the 1938 Raven Progressive Matrices, the or otherwise of intellectual impairment, it is Hartford Retreat Vocabulary (H.R.V.), and the necessary to avoid drawing conclusions which are Hartford Retreat Test (H.R.T.). These tests have not in view of the range of the normal been administered to the normal controls to justified estimate what levels of vocabulary on the H.R.V. sample. are equivalent to what point scores on the matrices Most of the injured men were enlisted from 1942 and on the H.R.T., the maximum score in each to 1948 and were given intelligence tests as part of http://jnnp.bmj.com/ being: H.R.V., 40; on the matrices, 60; and the the personnel selection procedure, and these results H.R.TL, 20. are still available for some of the cases. In this personnel selection procedure the principal test used Control Tests.-The controls used were 50 was the 1938 Raven Progressive Matrices. soldiers aged 18 to 35 (median age 19) who were In addition, cases treated at the Military Hospital thus in approximately the same age-group as the for Head Injuries in 1944-45 were tested in the early men who had sustained the penetrating brain stages of brain injury by the late W. R. Reynell, wounds. They were a sample of soldiers admitted who used a series of tests of which the 1938 matrices on September 24, 2021 by to the general wards of the Military Hospital for was one. It has thus been possible in certain cases Head Injuries suffering from medical and surgical to demonstrate scores on the same test, i.e., the conditions, the only criterion in their selection being matrices, at different stages in the man's history- that cases with brain damage and psychoneurosis at Army entry, in the early stages after brain were excluded. wounding, and several years after the injury when The results have been plotted on Fig. 1 and the tested by the author. J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.17.1.14 on 1 February 1954. Downloaded from 16 HUGH F. I JAR VIE In the case of men recently wounded in Korea obvious that two types of impairment could be no comparison has been possible between the recognized. In certain cases there was an absolute matrices score before and after wounding. A impairment which was shown by the inability, even comparison has, however, been possible on another H.R.V. Matrices H.R.T. its - test. Since 1948 the Army has used as part of 40 , 60 20 personnel selection procedure a test called the Army Dominoes.
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