HUMAN BRAIN
(Anatomy)

When scientists study the prefrontal cortex with neuroimaging studies like SPECT, it is often done twice.  Once in a resting state, and again during a concentration task.  In evaluating brain function, it is important to look at a working brain.   When the normal brain is challenged with a concentration task, such as math problems or sorting cards, the pfc increases in activity.  Much like when you flex a muscle, the muscle produces more energy.  In certain brain conditions, such as attention deficit disorder and schizophrenia, the prefrontal cortex decreases its activity in response to an intellectual challenge.

Problems of the PFC

Problems in the dorsal lateral prefrontal cortex often lead to decreased attention span, distractibility, impaired short term memory, decreased mental speed, apathy and decreased verbal expression.  Problems in the inferior orbital cortex often lead to poor impulse control, mood control problems (due to its connects with the limbic system), decreased social skills and overall decreased control over behavior. 

Overall, when there are problems in the pfc the organization of daily life becomes difficult and internal supervision goes awry.   People with pfc problems often do things they later regret, exhibiting problems with impulse control. They also experience problems with attention span, distractibility, procrastination, poor judgment and problems expressing themselves.  Test anxiety along with social anxiety also may be hallmarks of problems in the pfc. Situations that require concentration, impulse control and quick reactions are often hampered by pfc problems.  Tests require concentration and the retrieval of information.  Many people with pfc problems experience difficulties in test situations because they have trouble activating this part of the brain under stress, even if they have adequately prepared for the test.  In a similar way, social situations require concentration, impulse control and dealing with uncertainty.  Pfc deactivation often cause a person’s mind to "go blank" in conversation which lead to being uncomfortable in social situations. 

When men have problems in this part of the brain, their emotions are often unavailable to them and their partners complain that they do not share their feelings.  This can cause serious problems in a relationship because of how other people interpret the lack of expression of feeling.  Many women, for example, blame their male partners for being cold or unfeeling, when it is really a problem in the pfc that causes a lack of being "tuned in" to the feelings of the moment.

Attention Deficit Disorder (ADD)

ADD occurs as a result of neurological dysfunction in the prefrontal cortex.  When people with ADD try to concentrate the pfc decreases in activity rather than increasing as it does in normal control groups.  As such, people with ADD show many of the symptoms discussed in this chapter, such as poor internal supervision, short attention span, distractibility, disorganization, hyperactivity (although only ½ the people with ADD are hyperactive), impulse control problems, difficulty learning from past errors, lack of forethought and procrastination.

ADD has been a particular interest of mine over the past 15 years.  Of note, two of my three children have this disorder.  I tell people I know more about ADD than I want to know.  Through the SPECT research done in my clinic, along with the brain imaging and genetic work done by others, we have found that ADD is basically a genetically inherited disorder of the pfc, due in part, to a deficiency of the neurotransmitter dopamine. 

Here are some of the common characteristics of ADD that clearly relate this disorder to the pfc.

The Harder You Try, The Worse It Gets

Research has shown that the more people with ADD try to concentrate, the worse things get for them.  The activity in the pfc actually turns down, rather than turning up.  When a parent, teacher, supervisor or manager puts more pressure on a person with ADD to perform, he or she often becomes less effective.  Too frequently when this happens the parent, teacher or boss interprets this decreased performance as willful misconduct and serious problems arise.  I treat a man with ADD who is a ship welder.  He told me that whenever his boss puts intense pressure on him to do a better job, his performance becomes worse (even though he really tries to do better).  When the boss encourages him to do better in a positive way, he becomes more productive.  In parenting, teaching, supervising or managing someone with ADD, it is much more effective to use praise and encouragement, rather than pressure.  People with ADD do best in environments that are highly interesting or stimulating and relatively relaxed.

Short Attention Span

A short attention span is the hallmark symptom of this disorder.  People with ADD have trouble sustaining attention span and effort over prolonged periods of time.  Their attention span tends to wander and they are frequently off task, thinking about or doing other things than the task at hand.  Yet, one of the things that often fools inexperienced clinicians assessing this disorder is that people with ADD do not have a short attention span for everything.  Often, people with ADD can pay attention just fine to things that are new, novel, highly stimulating, interesting or frightening.  These things provide enough of their own intrinsic stimulation which activates the pfc so they can focus and concentrate. An ADD child might do very well in a one-on-one situation and completely fall apart in a classroom of 30 children.  My son with ADD, for example, used to take 4 hours to do a half and hour’s worth of homework, frequently getting off task.  Yet, if you gave him a car stereo magazine he would quickly read it cover to cover and remember every little detail in it.  People with ADD have longstanding problems paying attention to regular, routine, everyday matters such as homework, schoolwork, chores or paperwork.  The mundane is terrible for them and it is NOT a choice.  They need excitement and interest to kick in pfc function. 

I have had many adult couples tell me that in the beginning of the relationship the person with adult ADD could pay attention to the other person for hours.  The stimulation of new love helped focus.  But as the “newness” and excitement of the relationship became more routine (as it does in nearly all relationships) the ADD person has a much harder time paying attention and their listening ability falters.

Distractibility

As mentioned above, the pfc sends inhibitory signals to other areas of the brain quieting intake from the environment so that you can concentrate.  When there is not enough activity in the pfc it doesn’t adequately dampen the sensory parts of the brain which cannot then filter out distractions, too much stimuli bombards the brain as a result.  Distractibility is evident in many different settings for the ADD person.  In class, during meetings, while listening to a partner the person with ADD tends to notice other things going on and has trouble staying focused on the issue at hand.  People with ADD tend to look around the room, drift off, appear bored, forget where the conversation is going and interrupt with extraneous information.  The distractibility and short attention span may also cause them to take much longer to complete their work than would be expected in the situation. 

Impulsivity

The lack of impulse control gets many ADD people into hot water.  They may say inappropriate things to parents, friends, teachers, supervisors, other employees or customers.  I once had a patient who was fired from 13 jobs, because he had trouble controlling what he said.  Even though he really wanted to keep several of the jobs, he would just blurt out what he was thinking before he had a chance to process the thought.  Poorly thought out decisions also relate to impulsivity.  Rather than thinking a problem through, many ADD people want an immediate solution to the problem and act without the necessary forethought. In a similar vein, the impulsivity causes these people to have trouble going through the established channels at work.  They often go right to the top to solve problems, rather than working through the system.  This may cause resentments from their co-workers and immediate supervisors.  Impulsivity also may lead to such problem behaviors as lying (saying the first thing that comes into your mind), stealing, having affairs and excessive spending.  I have treated many ADD people who have suffered with the shame and guilt of these behaviors.

In my lectures I often ask the audience, “How many people here are married?”  A large percentage of the audience raises their hands.  I then ask, “Is it helpful for you to say everything you think in your marriage?”  The audience laughs, because they know the answer.  “Of course not,” I continue, “relationships require tact.”  Yet because of impulsivity and a lack of forethought many people with ADD say the first thing that comes to mind.  And, instead of apologizing for saying something hurtful, many ADD people will justify why they said the hurtful remark, only making the situation worse.  An impulsive comment can ruin a nice evening, a weekend, even a whole marriage.”

Conflict Seeking

Many people with ADD unconsciously seek conflict as a way to stimulate their own pfc. They do not know they do it. They do not plan to do it. They deny that they do it. And yet, they do it just the same. The relative lack of activity and stimulation to the pfc calls out or craves for more activity. Hyperactivity, restlessness and humming are common forms of self-stimulation. Another way I have seen people with ADD "turn on their brains" by causing turmoil.  If they can get their parents or their spouses to be emotionally intense or yell at them that might increase activity in their frontal lobes and help them to feel more tuned in.  Again, this is not a conscious phenomenon.  They do not know that they do this to get turned on. But, it seems many ADD people become addicted to the turmoil.  They repeatedly get others upset with them even though there is no conscious benefit to their behavior.  This is "Pavlovian," or conditioned behavior.