The Case of JP - Effects of Frontal Lobe Damage on Personality
JP was born in December of 1912, the 11.5-pound product of a normal pregnancy and gestation, followed by a 22-hour labor and a difficult delivery requiring instrumentation. He developed normally through age 2. At 2 1/2, JP developed a tendency to wander blocks from home, entirely without fear. Often, he was returned to his parents by police. This behavior was undeterred by his father’s scolding or corporal punishment. JP’s wandering continued. During young adulthood he would travel thousands of miles, ascribing his meanderings to impulse.
At age 4, JP fell off a bed and struck his head on the floor. About an hour later, he began to “say queer things,” and talk “like a smart alec.” He then lost consciousness and, simultaneously, developed left-sided convulsive movements that abated spontaneously several hours later at the hospital just before he was to have had an exploratory craniotomy. By the next morning, reportedly, he was fully recovered.
JP’s intelligence appeared normal. When he applied himself, JP apparently learned his school-work rapidly, though his reading skills far exceeded his arithmetic skills. However, his behavior in school was incorrigible. He defecated on classmate's possessions and exposed himself to the little girls in the class. JP “denied it vigorously, saying haughtily, ‘I beg your pardon, Sir!’” JP’s manners were described as “Chesterfieldian,” “distinguished by an over-politeness and a smooth ingratiating manner toward adults.” Even as a preschooler he appeared shallow and superficial. JP was boastful, bossy, and unphased by the disdain in which he was held by his classmates.
At age 13, after stealing money from a little girl and repeated episodes of masturbating in school, JP was transferred to the Day School for Defective Children which referred him to the Louisville Mental Hygiene Clinic for evaluation. His intake note included the following observations: “he has no friends; lies; steals; and is known in his neighborhood as having bad sex habits.” JP attributed his social isolation to the malevolence of others. His IQ was measured at 92 on the Stanford-Binet, his mother described his excellent memory for facts in the stories he’d read and the movies he’d seen. However, “his planning ability and capacity to modify behavior by experience” were described as “not equal to that of the average 7-year-old child.”
During the ensuing 6 years JP was transferred to private, public and parochial schools, and finally to an out-of-state military school. There he stole a teacher’s car and served 2 years in reform school. After his release, JP continued to wander widely and steal cars, his father making good on any damages and thereby helping him to avoid arrest. In 1933, at age 19, JP was arrested for yet another car theft. This time he faced the possibility of prison, and the family lawyer arranged for him to see Dr. Spafford Ackerly, a psychiatrist at the University of Louisville.
JP’s parents and lawyer were hoping that Dr. Ackerly could find mitigating circumstances that might keep the patient out of prison. JP had had a long history of stealing cars, but in a most peculiar fashion. Seeing keys in the ignition, he would take a car and drive in whichever direction it happened to be facing until it ran out of gasoline. Then he would abandon the car, find a telephone, and call his parents to pick him up.
The physicians who had previously evaluated JP believed that he was sociopathic. Ackerly, working with the neuropsychologist, Arthur Benton, noted that JP had a well-developed sense of right and wrong in the abstract or with regard to the actions of others, although JP’s own moral judgment was impaired and his behavior antisocial. Ackerly and Benton found JP to be irresponsible, impulsive, a spendthrift, completely free of anxiety, and unable to hold a job for more than a few months. Everybody knew there was something radically wrong, but no one could put his finger on it.
Ackerly’s evaluation of JP included a brain scan that revealed severe bifrontal damage, thought to be consistent with an old brain abscess. Exploratory surgery confirmed that in the place of JP’s atrophic right prefrontal lobe there was a large arachnoid cyst and that bands of chronic arachnoiditis were compressing his left prefrontal cortex. Although it was impossible to tell with certainty, Ackerly believed this damage to have been present from birth.
Ackerly continued to follow JP and published a follow up report in 1964. He describes 50-year-old JP as “the same refreshingly simple, uncomplicated, straightforward, outrageously boastful or indignant little boy.” However, JP had gradually become unable to recall events as recently as five minutes in the past, the only exception being that he could retain anything having to do with automobiles, driving, and highway distances up to at least a day later. JP’s father had died 5 years earlier; JP remained at home, “lording it over his mother and taking no responsibility for helping out.” He appears to have ceased his incessant wandering by that time.
Importance of this case:
Despite uncertainties about the etiology of JP’s pathology, through their study of JP, Ackerly and Benton were able to postulate the role of the prefrontal cortex in social learning. The case of JP demonstrated that early childhood or congenital prefrontal damage could produce lifelong behavioral changes that might not be manifest until increasing social demands bring the behavioral pathology into focus. This was in contrast to individuals with extra-frontal lesions sustained during childhood in which elemental functions tend to recover. Ackerly and Benton’s conclusion that individuals do not seem to be able to compensate for early, severe frontal damage has been borne out by subsequent authors.
JP became the index case of the behavioral sequelae of early life prefrontal dysfunction in contrast to those with more posterior brain damage. Although there is evidence that JP had extensive frontal lobe injury, the precise extent, timing and etiology are unknown. The case of JP clarified that the timing of injury to frontal brain regions influences the patient’s capacity for adaptation.
Excerpted from: “Six Landmark Case Reports Essential for Neuropsychiatric Literacy”
Authors: Sheldon Benjamin, M.D., Lindsey MacGillivray, M.D., Ph.D., Barbara Schildkrout, M.D., Alexis Cohen-Oram, M.D., Margo D. Lauterbach, M.D., Leonard L. Levin, M.S. L.I.S., M.A.