Behavior and Mood Disorders in Focal Brain Lesions

Since Phineas Gage first had his untimely encounter with a tamping iron (1), physicians have recognized that focal brain lesions may create relatively specific alterations in emotion and personality. As the editors of this multiauthored text note, however, the neuropsychological consequences of focal brain lesions have been much more thoroughly explicated than associated changes in mood, affect, and behavior. This work addresses that failing, not merely by providing extensive and well-referenced reviews of behavioral changes associated with specific lesions in frontal and temporal lobes, basal ganglia, and the thalamus, but also by articulating the standards by which behavior is best quantified and highlighting the methodological problems inherent in studying secondary disorders of mood and behavior.

Approximately half of the chapters focus on behavior rather than neuroanatomical location as the independent variable and examine the variety of lesions that can be associated with mania, obsessions and compulsions, violence, change in sexual behavior, loss of motivation, psychosis, and change in self-awareness or emotional perception and expression. There is much to admire and little to critique. The bibliographies are exhaustive and timely (through 1997), and the benefits of editing are obvious in that redundancy is kept to a minimum. Illustrations and tables are generally limited to situations in which they are most useful, and the book is mercifully free of florid positron emission tomography images competing with the logic of written discourse.

A particular pleasure for clinicians is the inclusion of a section on possible therapeutic interventions in each of the designated chapters, as well as a clinical vignette whenever relevant. A case in point is that of Spyder Cystkopf, a 65-year-old historically docile man who strangled his wife in a domestic dispute and then threw her body from their 12th-floor apartment window in an attempt at disguising her death as a suicide. He was eventually able to describe his involvement in the incident accurately and in detail, but without apparent emotion. In the course of an extensive neuropsychological, neurophysiological, and neuroimaging workup, he was found to have an arachnoid cyst that occupied most of the left middle fossa. How the legal system responded and what happened to Mr. Cystkopf are unfortunately left unaddressed, but the complexities of cause and effect and of free will and determinism are not. One disappointment is the relative absence of neurochemistry in the discussion of circuits and lesions; neurogenetic disorders that have uniquely intriguing behavioral phenotypes, such as velocardiofacial syndrome, are also missing. What remains, however, is valuable enough in its own right, a book that Wilder Penfield or MacDonald Critchley would have been keen to contribute to and that any psychiatrist should have.