I have lost my ego

A SEASONED NEUROLOGIST was caught by surprise when his new  patient, W.R., reported his main symptom quite simply: “I have lost my ego.” (R. T.  Knight & Grabowecky, 1995   ).

A driven child, W.R. decided at an early age that he wanted to become  a lawyer. Focused on this plan, he completed college with an excellent  GPA and took the right classes for a prelaw student. He was accepted  to his fi rst-choice law school and graduated with a solid, if not stellar,  academic record. But then his life derailed: Suddenly, he seemed to have  forgotten his plan to work at a top law fi rm. Four years later, he had yet  to look for a job in the legal profession and, in fact, had not taken the bar  exam. Instead, he was an instructor at a tennis club.
Accompanying W.R. at the neurologist’s offi ce was his brother, who  reported that the family had found W.R.’s behavior odd but not atypical  of the times, perhaps indicative of an early, antimaterialist midlife crisis.  Maybe he would fi nd satisfaction in teaching tennis, his favorite hobby,  or perhaps this was just a temporary diversion before he embarked on  a career in law after all. But no: W.R. eventually gave up on his job and  even lost interest in playing tennis. His nonchalant attitude frustrated his  opponents, as he forgot to keep track of the score and whose turn it was  to serve. Unable to support himself fi nancially, W.R. hit up his brother  with increasingly frequent requests for “temporary” loans.
Clearly a highly intelligent man, W.R. was cognizant that something  was amiss. Though he expressed repeatedly that he wished he could pull  things together, he simply could not take the necessary steps to fi nd a  job or get a place to live. He had little regard for his own future, for his  successes, even for his own happiness. His brother noted another radical change in W.R.: He had not been on a date for a number of years  and seemed to have lost all interest in romantic pursuits. W.R. sheepishly  agreed. If this had been the whole story, the neurologist  might have thought that a psychiatrist was a better  option to treat a “lost ego.” However, during his last  year in law school, W.R. had suffered a seizure. An  extensive neurological examination at the time failed  to identify the cause of the seizure, so it was diagnosed as an isolated event, perhaps related to the fact  that on the night before the seizure, W.R. had been  drinking coffee all night while preparing for an exam.  After hearing about the events of the previous 4 years,  the neurologist decided it was time to reconsider the  cause of the seizure.
A CT scan confirmed the neurologist’s worst fears.  W.R.’s brain had an extremely large astrocytoma that  had traversed along the fibers of the corpus callosum,  extensively invading the lateral prefrontal cortex in  the left hemisphere and a considerable portion of the  right frontal lobe. This tumor had very likely caused  the initial seizure and over the previous 4 years had  slowly grown. The prognosis was now poor, with a life  expectancy of about a year.
W.R.’s brother was devastated on hearing the  news. W.R., on the other hand, remained relatively  passive and detached. Though he understood that  the tumor was the culprit behind the dramatic life  changes he had experienced, he was not angry or  upset. Instead, he appeared unconcerned. He understood the seriousness of his condition, but the news,  as with so many of his recent life events, failed to evoke  a clear response or any resolve to take some action.  W.R.’s self-diagnosis seemed to be right on target: He  had lost his ego and, with it, the ability to take command of his own life.
In this chapter our focus turns to cognitive control  processes, which are essential for the kind of behavior that is uniquely human, be it going to law school,  playing tennis, or recognizing that something is amiss  in one’s actions or those of a loved one. Cognitive control processes give us the ability to override automatic  thoughts and behavior and step out of the realm of  habitual responses. They also give us cognitive flexibility, letting us think and act in novel and creative ways.
To facilitate discussion of these functions, we first  review the anatomy of the frontal lobe and the behavioral problems that are observed when this region of  the brain is damaged. We then focus on goal-oriented  behavior and decision making, two complicated processes that rely on cognitive control mechanisms to  work properly. And deciding on a goal is only the first step toward attaining it. Planning how to attain it and  then sticking with the plan are also complicated affairs  involving different cognitive control processes, which  we examine in the final sections of this chapter.

Cognitive Neuroscience The Biology of the Mind by Michael S. Gazzaniga , Richard B. Ivry , George R. Mangun