TBI CLIENTS CAN RETAIN INTELLECTUAL IQ AND EXECUTIVE FUNCTIONS WHILE LOSING "SOCIAL COGNITION" WITH DEVASTATING CONSEQUENCES  [ back to List of Articles ]
Harvey A. Hyman, Esq.

There is a general consensus among cognitive psychologists that there are three distinct types of cognition, intellectual IQ, social IQ and practical IQ. Intellectual IQ, measured by the older Stanford-Binet and newer Wechsler Adult Intelligence tests, refers to a person's capacity for reading comprehension, symbol manipulation, mathematics, deductive logic, analytic reasoning and the like. Social IQ refers to a person's ability to detect, understand and respond in a socially appropriate manner to the mental/emotional states of others. Practical IQ refers to the capacity to solve mechanical problems, and meet physical human needs, through visuo-motor (eye-hand) and constructional skills. Decoding the human genome takes intellectual cognition; mediating a pay dispute between management and labor during a bitter strike takes social cognition; and a lost skier surviving a blizzard on his own while waiting for help to arrive, takes practical cognition.

To some extent, each individual's personality style and coping style under stress are determined by his unique proportion of three IQs and which of them is dominant. The three IQs are rarely, if ever, present to the same degree in any one person. Thus, Socrates had a very high intellectual IQ, but a low social IQ, because he kept humiliating other Athenians with his superior reasoning capacity until they forced him to drink a fatal cup of Hemlock. Einstein was said to have neglected his wives and children to the point of cruelty in pursuit of giant feasts of intellectual cognition. The schizophrenic hero of the movie Sling Blade had low intellectual IQ, but could fix any lawnmower ever made. At its highest and most complete form, social IQ, is coupled with empathy, as in Mother Theresa, who won the Nobel Peace Prize and healed emotional scars in thousands of people. At its lowest, social IQ is displayed by a con man who bilks investors into bankruptcy through misplaced trust, or by a Hitler, a man with a great facility to manipulate others by stirring up their fears and hatred, a man utterly lacking in empathy.

Whether social cognition is used for laudable or deplorable ends, it is critical to getting things done. It may have been less important in the rigidly hierarchical world of feudal times, when the propertied "nobility" owned serfs, where might made right and only a select few could read, write and mold the concepts which explained existence. However, in today's pluralistic democracies with free speech and free press, where information is freely shared across all manner of socioeconomic boundaries, where elected officials govern by consensus, and where people compete on equal footing in a free market of ideas, social cognition is key to a quality existence. To get things done in today's world, people must listen to and learn from others, so they can persuade and motivate one another to accept a position, viewpoint, idea or product. In education, science, technology, manufacturing, advertising, law, medicine, or virtually any other field you care to name, people's work most effectively in groups, and are expected to fully participate in groups. Intellectually "smart" people who lack "social smarts" and cannot get along with others in groups, fare poorly in the workplace.

Social and cognitive psychologists value social IQ very highly. They tell us that intellectual IQ is very important during our school years, but once we leave college, social IQ and practical IQ are much more important, and that social IQ may be the most dominant in success. On reflection, this should not be surprising. Freud said happiness comes from doing well at love and at work. To do well in love, one must be sensitive to, concerned about and focused on one's spouse and children, and take good care of them. To do well in the workplace, one must know how to get along with the boss and co-workers, to avoid offending them and find ways to make them feel included, valued and respected. Think back to high school. Who formed a more complete and rounded life after graduation, the brainy kid with no social skills and no friends, or the highly popular class president with a mediocre grade point average? How come George W. Bush was able to win the Presidency but not an Al Gore or an Adlai Stevenson?

In TBI cases, I have noticed that many neuropsychologists focus so strongly on the intellectual aspects of cognitive functioning as to exclude the social aspects. This group tends to ignore the substantial decrements in social cognition that may play the dominant role in causing a person to lose his job, marriage, or both. They view frontal lobe injury in terms of reduced capacity to perform intellectual work, rather than reduced capacity for successful social interaction. This is a mistake. When jurors find out the plaintiff has gone from an estimated pre-morbid intellectual IQ of 140 down to 120, they may have a hard time identifying with this as a damaging loss, because many of them will have worked all their lives and supported themselves with intellectual IQs a good bit lower than the plaintiff's residual IQ. What they do understand is the importance of having the motivation to get out of bed and get to work, and the importance of getting along with the boss and co-workers. If your neuropsychologist can explain in lay terms that your client's frontal lobe injury has rendered him apathetic and relatively indifferent to the feelings and needs of others, they will know how that would play out in their own lives.

I have had some very memorable clients with frontal lobe injury whose reading comprehension and math skills were reasonably intact, who could never hold a job, because of decreased social cognition. Some of them talked incessantly in a rambling zigzag manner that irritated and alienated everyone. Some burst out crying in a sudden, unpredictable way that made others feel anxious and uncomfortable being around them. Two recent clients had clearly lost the ability to discern when someone else was making a joke, a pun or a witticism. They took everything literally. When someone makes a witty remark, they look for an admiring smile not a blank stare in return.

This brings us to the division between executive function and social cognition. Executive functions are frontal lobe processes that underlie and subserve or potentiate various forms of cognition. A client who has a job interview the next day must select the appropriate attire, lay it out, shower, towel himself dry, put on his clothes, eat breakfast, wipe the milk off his upper lip, find the paper with the interviewer's address, catch the right bus to get himself to the interviewer's building, find his office, announce himself, take a seat and wait to be called. Along the way he may be tempted to dally by the smell of coffee and croissants from the corner cafe or by the sight of a construction area where a crane is wrecking an old building, but he must press on. The ability to create and maintain goal directed behavior and temporally sequenced activities, and to inhibit subconscious responses to stimuli, is executive functioning.

Without intact executive functioning you do not get out the door and arrive at your destination ready to perform what is expected of you. It is highly important; but it is not the whole ball game. Having reasons for going to the job interview, wanting to go and making a decision to go, are equally important. If one neither knows nor cares about why he should go to the job interview, his ability to get there on time in the proper attire means little. Showing up in the right clothes at the right time is not enough. The client must be "plugged into" the process in an effective way that informs, or gives meaning to, the process, and carries him along emotionally. He must care about and desire to engage himself in the process.

TBI to the frontal lobes can rob the survivor of what Freud called "drives," and render him indifferent both to his own fate and to the feeling and expectations of others. This produces a loss of "social cognition," in the sense that the survivor no longer attunes himself to, registers, processes and adjusts himself to the behavioral signals conveyed by others. The frontal lobes are highly complex and heterogeneous with multiple, separate processing centers. They are linked in myriad ways to the limbic system (including the amygdala and hypothalamus) and to the reticular activating system in the brain stem. In The Prefrontal Cortex (Lippincott-Raven Philadelphia, 3rd edition, 1997), Dr. Joaquin Fuster makes the point that while injuries to different parts of the frontal lobes (dorso-lateral, orbito-frontal and medial-cingulate) manifest themselves in slightly different behavioral abnormalities, all pre-frontal lobe injuries damage drives, awareness and personality, and produce problems such as a apathy or impulsivity.

Two recent articles in Brain: A Journal of Neurology (Vol. 124, Part 2, Feb. 2001) support the idea that frontal lobe injury damages social cognition, wholly apart from the damage it does to executive functioning, and loss of social cognition puts the survivor at serious disadvantage. The first article entitled "The Frontal Lobes are Necessary for Theory of Mind" by Donald T. Stuss et al., studied the relative ability of three groups of people to detect the location of a hidden object. In the first phase they could locate the object by their own direct observation, requiring what Stuss called a "modest degree of perception, sustained attention and memory." In the second they had to locate the object (a sponge ball hidden under one of 5 styrofoam cups) by inferring what the examiner's assistants had seen the examiner do while he was blocked from their view. In the third, they could only locate the object (a quarter hidden under one of two cups) by inferring that one of the assistants was intentionally trying to deceive them by lying. The three groups of people consisted of normals, persons with frontal lobe injuries of varying kinds and persons with brain injuries wholly outside their frontal lobes. Stuss found that all three groups did equally well in the first phase, where only executive functions were required. However, the group of patients with frontal lobe injuries did increasingly worse than the other in two groups in phase 2 (where they had to infer the visual experiences of others) and 3 (where they had to detect deception by the examiner's assistants). Stuss concluded that frontal lobe injury interferes with a person's ability to understand, infer and predict the mental states of other people, thus damaging social cognition. He found social cognition to be associated most strongly with the right, frontal lobe.

Stuss says that from the second year of life, human beings practice using a "theory of mind" by which they guess at what others are thinking and feeling, and attempt to predict how others will act based on this information. It is illegal to yell "FIRE" in a movie theatre, based on a prediction of mass panic with increased injuries. Driving instructors tell their students not to flip the "bird" at drivers who recklessly cut them off, out of fear that the other driver may have a gun and use it. Stuss found that frontal lobe injuries (especially orbito-frontal, most especially right orbito-frontal injuries) interfere with the operation of theory of mind. These patients demonstrate a marked inability to accurately infer the mental states of others and to incorporate that knowledge into their future actions. These patients were deceived over and over in the same way by the same assistant, and did not learn from experience. I find this highly ironic, because defense neuropsychologists are on highest alert about being deceived by a plaintiff claiming to have a TBI; yet it is the plaintiff with brain damage, not the neuropsychologist, who is most at risk of being deceived by others.

The second article by C. Fine et al. is entitled "Dissociation between theory of mind and executive functions in a patient with early left amygdala damage." The amygdala is a small almond shaped cluster of neurons lying deep within the temporal lobe just in front of the inferior horn of the lateral ventricle and is continuous with the uncus of the parahippocampal gyrus. Though tiny, the amygdala is extremely important. Work by LeDoux, among others, has shown the amygdala acts on a subconscious level to "appraise" the emotional significance of stimuli, in particular the level of danger posed. The amygdala bypasses the thalamus and can set us in motion, before the thalamus informs the conscious mind what we are looking at. When a hiker spots a curved stick on the ground, he leaps back long before the possibility that this could be a rattlesnake enters his conscious mind. That is the amygdala at work. The amygdale is supposed to "go off" when we meet bad people who want to hurt us or take advantage of us. It is even supposed to sound an alarm when we are about to get creamed in a game of poker, as neurologist Antonio Damasio has shown.

In his article Dr. Fine discusses a patient called B.M. with congenital damage to his left amygdala. B.M. was a caterer who at age 28 was arrested for and convicted of murder and rape. During psychiatric assessment in prison, he was diagnosed with Asperger's Syndrome and schizophrenia. Asperger's Syndrome is a term for an autistic patient who functions at the higher end of the spectrum of that disorder, but still exhibits serious deficiencies in communications and social skills. Dr. Fine saw B.M. when he was 32 years old. He exhibited profound social isolation in prison. He had no visitors, never sent or received mail and spent virtually all his time alone in his cell. Dr. Fine tested B.M.'s intellectual functioning and found he performed at or above average and showed no abnormalities. His full scale IQ was 103. His comprehension subtest on the WAIS-R and National Adult Reading Test were in the superior range. B.M. also performed in the normal range on 16 different tests of executive function including Stroop, Trailmaking and Modified Wisconsin Card Sorting. However, B.M. did very poorly on false belief tests, joke comprehension tests and advanced theory of mind tests. Dr. Fine concluded that B.M. had a significant theory of mind impairment, yet performed well on "control tasks" of comprehension, memory and abstraction. Thus a deficiency in executive functions or intellectual IQ cannot explain his problem. This study furnished evidence that the intellectual IQ cannot explain his problem. It furnished evidence that the amygdala is part of the neural circuitry for theory of I mind, along with portions of the frontal lobe.

What are neurolawyers to make of all this? They must know how to bracket and assess neuropsychological test results in the larger context of social behavior. Always check with the client's spouse, partner, children, boss, co-workers and friends, as to how he is functioning socially. If your client tests well on measures of intellectual IQ and executive function, this does not mean he is OK. He may well have suffered "theory of mind impairment" and decreased social cognition. Note that these losses produce social isolation and its psychological consequences, such as loss of confidence, anxiety and depression. A client with decreased social cognition is likely to endorse the misery items on the MMPI II, leading the defense to conclude wrongly that he does not have a damaged brain, just that he is depressed. Be sure to have your client's competence in theory of mind evaluated, assessed and compared to his estimated pre-morbid level