Grief

Frontal Lobe Damage: Treating Patients through Grief, Acceptance and Growth

In this episode of the podcast, I interview Steven Prince, one of my patients who had a rare form of a stroke—in the right orbital frontal cortex. He participated in a psychiatric program that I run. He tells his story of how his function and emotions changed, and how he dealt with it. At the end of the episode, I talk more with Jaeger Ackerman about the science and neurology of his case so other mental health professionals can have a basis for how to think about approaching brain injury.

David Puder, M.D., Jaeger Ackerman

The case of Phineas Gage

The history of the study of frontal lobe damage

Phineas Gage was a railroad construction worker who experienced a massive frontal lobe injury in 1848 in New England. He was efficient, capable, and full of energy prior to his accident. During an explosion at work, a 13 pound iron bar was launched through his face at close range, up through his skull. It entered his left cheek, went through his eye, and came out of the top of his skull, landing 100 feet away. 

Gage was carted to a local doctor where he got out of the cart and walked into the doctor’s office. As the doctor treated him for a few weeks, brain matter and infections, bone particles and tissue were oozing out of his head. Still, Gage survived, with relatively little physical injury after he was healed, with the exception of his left eye.

The main effect of Gage’s injury was in his behavior. He was studied, a medical marvel of survival, and is now reputed to be one of the first, and therefore most important, cases dealing with frontal lobe damage and its effect on behavior. After his accident, Gage was belligerent, fitful and profane. He lost the balance between his emotions and his intellectual ability to function. 

Other symptoms of broad temporal frontal lobe damage can be:

  • Apathy

  •  Depression

    • Anterior (Stuss 1986) and Lateral lobes (Paradiso 1999)

    • Left lesions more likely to lead to depression than right lesions (Rogers 1998)

    • Postmortem neuropathology of depressed patients indicated generalized prefrontal diminution (Cotter 2005)

  • Euphoria (Grafman 1986)

    • Sporadic or recurrent and resembles the affect of the hypomanic state (nervous, irritable, sometimes paranoid)

    • Usually accompanied by compulsive, shallow, childish humor

    • Distractibility and hyperactivity 

  •  Motion and Emotion

    •  Hypokinesia (dorsolateral lesions) (Heilman 1991)

    • Hyperkinesia- aimless/excessive motility (orbitofrontal lesions) (Meyer 1948,)

      • Perseveration (repeating old patterns of behavior even in circumstances that demand change) (Konow 1970)

    • Emotional Lability and disinhibition (orbitofrontal lesions) 

  • Empathy 

    • Large lesions of orbitofrontal/ventromedial cortex impair mainly affective empathic component (Shamay-Tsoory 2004)

    • Inability to interpret and respond to emotional voice or facial expressions (Shaw 2005)

  • Social Behavior

Grief, acceptance and growth

Steven’s story

Steven had five strokes and tinnitus. It was also not physical trauma, and Gage’s was much worse. His decline led him to spend five hours a day researching his health conditions.

He was suffering from anxiety, depression, fear and grief in reaction to his health condition, and Steven did something about it. He came to my outpatient group.  

At his worst, Steven’s tinnitus caused him to lock up the guns in his house so he wouldn’t think of ending his life, and he says he “took xanax like candy.” He felt as if he was mourning and grieving losing who he was. He’d had a successful career previously, but he no longer found the same meaning in his life. 

During his struggles with his mental health, Steven joined the day treatment program that I am the medical director of. When he first came to the program, he didn’t think he would fit in. When he introduced himself on the first day of meetings, he told the others his name, and then described his illness. When the entire room finished introducing themselves, the therapist kindly pointed out that they had all introduced themselves through the lens of their illnesses. “Aren’t you people? Humans? You are not your diagnosis,” the therapist said. Steven said it changed his life to see it that way. 

As he became more comfortable being his “new” self, more comfortable with his emotions and frustrations about his limitations, he became more aware of how he was speaking and thinking about himself. He learned to accept his illness instead of battling it. When he accepted it, he was alright with moving on and being a whole person, just in an entirely different way. He says he became more self confident, healthy, and less stressed. His wife has commented on his increased empathy as well. 

Steven’s diagnosis - Right Side ACA Strokes

After Steven’s stroke, he felt “flooded.” He would become overwhelmed with audio and visual stimulation, which caused him to have to retreat into a dark room for up to 24 hours. 

ACA Stroke/Frontal Lobe Damage symptoms

  1. Accounts for 0.3 to 4.4% of total stroke cases. Males are more commonly affected than females, and most of these strokes occur between the age of 59 and 75. ACA strokes arise on the left hemisphere more commonly than the right. (Kang and Kim 2008, Arboix, Garcia-Eroles et al. 2009)

  2. Most common presentation is motor deficits characteristically involving the contralateral lower extremity; present in 86.3-90% of ACA strokes (Kumral 2002)

  3. Other motor disorders related to ACA infarcts include hypometria, bradykinesia, global akinesia, loss of reciprocal coordination, parkinsonian gait, tremor, dystonia, and motor neglect (Nagaratnam, Davies et al. 1998, Kobayashi, Maki et al. 2011)

  4. Sensory deficits less common; ~25%, and always correlate with weak extremity (Kang 2008)

  5. Abulia (willpower, assertiveness), agitation, motor perseveration, memory impairments, emotional lability, anosognosia are neuropsychological features reported in ACA infarcts (Kang and Kim 2008)

  6. Altered consciousness and speech disorders identified in up to 43.1% of ACA infarcts (Arboix, Garcia-Eroles et al. 2009)

  7. Transcortical motor aphasia and transcortical mixed aphasia (Nagaratnam, Davies et al. 1998, Kumral, Bayulkem et al. 2002)

The main part of the brain that is typically affected by this kind of stroke is the prefrontal cortex region, which makes up 29% of human brain matter. Humans are unique in that the prefrontal cortex is significantly larger than in other species. This region of the brain is responsible for temporal organization, executive memory and executive attention. 

Temporal organization is the most general and characteristic of all prefrontal functions in the primate and enables the organization of actions and thought within the domain of time. This temporal organization facilitates the capacity for elaborate behaviors, speech fluency, higher reasoning, and creative activities.

Executive memory is the idea of taking formed prior experiences and being able to learn from them and make decisions about the future. This ability effectively organizes the present in order to prepare for the future

Executive attention deals with using short term active memory to apply to the immediate here and now. Within executive attention, there are a few main functionalities:

  • The preparatory set is the part of the brain that reconciles sensory cues and coordinates past memories to prepare the body for active response—like a runner gearing up for a race. 

  • Inhibitory interference control enhances contrast to different information. The brain filters out what it needs in the immediate, and is able to dampen down everything else that doesn’t matter. In Steven’s case, this part of his brain was damaged because he had a lack of control over what information was inhibit or processed as important by his brain.

Also in Steven’s case, I opted to focus on increasing his sensorium by lowering his xanax intake to help him increase his executive functioning so he could become more himself. 

The fascinating thing is that the brain can change itself. If you have a loss of movement from a stroke, you want a program that is 5 days per week and really intensive. That’s why partial programs can be helpful to guide the patient in developing the brain in a way that would be most healing for a loss of psychological function. 

The importance of emotional congruency

One of the main things we focus on in the program Steven was part of is implementing the importance of congruence. Congruency is about making sure who you are on the outside reflects who you are on the inside. When people are incongruent, they put undue psychological stress on their personality to perform and feel the need to appease others. Steven adaptively relied on his ability to tell funny stories, and when he felt he could finally just “be” and not “perform” for others to make them feel more comfortable, he felt he could take that part of his personality off. He became more congruent with what his inner state felt like. 

As Steven shed his need to please, he became more assertive. He also learned to handle his tinnitus with self compassion and lower anxiety. Now, he lives with it and it causes him little emotional distress. 

Within the program, doctors helped our patients develop congruence through their writing, drawing and talk therapy. We can often see incongruencies in those different modalities and begin to talk about them. Another way we help them with their mental health is through encouraging them to start doing strength training. 

Moving on

Steven’s passion is now helping connect others who need support through their chronic illnesses. He wanted to find a support group where he lived, but he couldn’t, so he started his own on Facebook. He opened it to more than stroke victims, and he has been successful in creating that group, having guest speakers who are mental health professionals, and building a supportive community within it. He says he wants to bring hope and encouragement to people with chronic illness. 

Watching Steven change and heal has been a pleasure. He has moved through the grief, acceptance, and growth that is possible for many of our patients. 

Treating patients with frontal lobe damage

Other than therapy, I find that optimizing a patient’s sensorium is incredibly important to restore normalcy of life.

You can improve sensorium through improving sleep, diet, and strength training. Also, having meaning and purpose, having friendships and an internal locus of control, can also optimize sensorium.

Consider listening to this one next:

The Process of Grief

On today’s episode of the podcast, I am interviewing Maris Loeffler, LMFT. We cover different types of grief (acute, complicated, traumatic, etc.), attachment styles in relation to grief, and  some helpful things to consider in caring for a grieving patient as a mental health provider.   

An Overview of Grief 

Joseph Wong (MS3), Tyler Rigdon (MS2), David Puder M.D.

This article complements the above podcast, with some research findings we did not talk about in detail, and is written for mental health professionals to understand some of the research behind grief work.

Grief is the multifaceted response—emotional, behavioral, social—to a loss or major life adjustment (like a divorce, loss of a job, etc.). Bereavement is the process of grieving specific to the loss of affection or bond to a person or animal (Parkes & Prigerson, 2013; Shear, Ghesquiere & Glickman, 2013; Shear, 2015). 

Some of the signs and symptoms of grief are: 

  • somatic symptoms (e.g. choking or tightness in the throat, abdominal pain or feeling of emptiness, chest pain) 

  • physiological changes (e.g. increased heart rate and blood pressure, increased cortisol levels)

  • sleep disruption and changes in mood (e.g. dysphoria, anxiety, depression, anger) 

(Buckley et al., 2012; Lindemann, 1944; O’Connor, Wellisch, Stanton, Olmstead & Irwin, 2012; Shear & Skritskaya, 2012; Shear, 2015; Zisook & Kendler, 2007

Medical and psychiatric complications can also arise due to grief and include:

Acute grief begins after a person has learned of the passing of a loved one (Shear, 2015). During acute grief, a person may experience immense sadness, yearning for the deceased, and persistent thoughts of the decreased (Maciejewski, Zhang, Block & Prigerson, 2007; Shear, 2015). Auditory and visual hallucinations are benign hallucinations commonly found in acute grief and involve the person seeing, talking to or hearing the voice of the deceased (Grimby, 1993). 

The process of grief has long been seen through the lens of Kubler-Ross’ 5 stages of grief (denial, anger, bargaining, depression and acceptance). Now, however, it is now more commonly understood that the process of grief is not as linear or predictable as originally posited by Kubler-Ross, and that there may not even be stages of grief that a person has to pass through in their grieving process (Maciejewski, Zhang, Block & Prigerson, 2007; Stroebe, Schut & Boerner, 2017). 

Most bereaved individuals are able to progress from acute grief to integrated grief, in which the individual has adapted to their grief and is able to once again enjoy daily life and activities (Shear & Mulhare, 2008; Shear, Ghesquiere & Glickman, 2013). About 6 months after the loss of the decreased, negative grief indicators (e.g. disbelief, yearning, anger) are in decline (Maciejewski, Zhang, Block & Prigerson, 2007). Thus, this transition from acute grief to integrated grief means that the individual only experiences grief as a temporary period rather than a prolonged chronic state. However, approximately 10% to 20% of people who lose a romantic partner do not transition from acute grief to integrated grief and instead transition to complicated grief (prolonged grief disorder) where the individual experiences grief for a longer period of time than expected to the point where it causes impairment in daily functioning (Bonanno & Kaltman, 2001; Shear, 2015). 

Complicated grief is more common in parents who have lost children, when the loss of the decreased is sudden or violent (e.g. suicide, homicide, accident), and is less common after an expected loss (e.g. chronic illness) (Meert et al., 2011; Mitchell, Kim, Prigerson & Mortimer, 2005; Nakajima, Masaya, Akemi, & Takako, 2012; van Denderen, de Keijser, Kleen & Boelen, 2015; Young et al., 2012). Complicated grief has been found to be most prevalent in women above 60 years old (Kersting, Brähler, Glaesmer, & Wagner, 2011). 

Complications of complicated grief include:

  •  sleep disturbances

  • suicidal ideation

  • substance use disorders

  • decreased immune function

  • increased risk for cardiovascular disease and cancer (Buckley et al., 2012; Shear, 2015). 

Like acute grief, the symptoms of complicated grief involve intense yearning for the decreased and persistent sadness. In complicated grief, these symptoms are accompanied by the fact that the individual is unable to accept the reality of the death of the deceased, and has intrusive thoughts or images of the deceased, and excessive ruminations and recurring negative emotions (e.g. anger, guilt, bitterness) surrounding the death Shear & Mulhare, 2008; Shear, 2015; Simon, 2012). Individuals with complicated grief commonly avoid situations, events or places that remind them of their loss and are fixated by viewing, touching or smelling momentos left behind by the decreased (Shear, 2015). 

Attachment Styles and Grief 

Attachment theory was first established by Mary Ainsworth in the 1960s and 70s and applied to children with 4 attachment styles in children being classified: 

In the 1980s, attachment theory was extended to adults and 4 attachment styles were also classified: 

The anxious attachment style reflects worry concerning the availability of the attachment figure, while the avoidant attachment style reflects a tendency to keep at arm’s length from attachment figures (Shear & Shair, 2005). 

Secure attachment style is characterized by low anxiety and low avoidance. Anxious-preoccupied is characterized by high anxiety and low avoidance, dismissive-avoidant is characterized by low anxiety and high avoidance and fearful-avoidant is characterized by high anxiety and high avoidance (Shear & Shair, 2005). 

It has been well-documented that bereaved individuals with insecure attachment styles are at risk for increased grief symptoms. Insecure attachment styles have been found to put spouses of terminally ill patients at greater risk for traumatic grief symptoms (Van Doorn, Kasl, Beery, Jacobs & Prigerson, 1998). Individuals with an anxious ambivalent attachment style that lost a close friend or family member in the previous year experienced greater levels of grief and depression, while individuals with an avoidant attachment style experienced greater somatic symptoms in comparison to individuals with secure attachment styles (Fraley and Bonnano, 2004; Wayment & Vierthaler, 2002).

Below are the prototypic behaviors and characteristics of the adult attachment styles with respect to grief. 

Anxious Attachment

Typically occupied with fear of abandonment, exhibits hypervigilance and seeking behaviors. Afraid that their partner might leave them. 

Patients with anxious attachment styles latch onto items or articles of clothing; however, people can normally hold onto momentos as part of the grieving process, so further investigation should be done to differentiate the two. 

Avoidant Attachment

Fearful of intimacy and emotional engagement. Prefers to process things alone. They withdraw with signs of emotional neediness from partner. 

How does this attachment style impact the grieving process and hinder healing? 

  • Have trouble with acknowledging the depth/importance of the relationship. 

  • Don’t like to be vulnerable in the relationship.  

  • Avoid fully looking within themselves and processing their grief response.  

  • By pushing down their emotions, it makes it hard to get through the grief process ,as when you grieve, you need to feel emotions, and it makes it difficult to process emotions if you’re not acknowledging them. 

    • Maris’ approach is to work with the body if they can’t put words to what they’re feeling as part of the grief process. People with avoidant attachment styles have more somatic symptoms (headaches, stomachaches), so putting that into words for them can help them better understand their grief process. 

Disorganized Attachment

Kids with disorganized attachment have no organized way of regaining connection. They later will have higher rates of dissociation. Patients with high amounts of dissociation will need to feel grounded and present to process through things, and learning when someone is dissociating will be helpful to help them progress in their emotional development. I (Dr. Puder) often look for microexpressions in the midst of someone dissociating to help me know what emotions are felt but not being allowed to experience.

Other Considerations 

The following are some of Maris’ considerations that have helped her in approaching a patient with grief. 

  • One of Maris’ grounding principles is centered around, “When I bring a person into the room, I need to understand what they need.” This mindset helps her to just let the client speak their story for the first few sessions, after which she will begin formulating her own ideas about the client’s grieving process. In a non-confrontational manner, she will ask questions like the following to dig deeper. 

    • “I’m noticing that it’s difficult for you to talk about the funeral.” 

    • “It feels like you get angry when you notice how your brother is handling the situation.”

  • Realize a patient’s grief hits them after the funeral service. After the deceased has passed and before the funeral, usually family members and friends gather to give support to the grieving. However, after the funeral, those people are no longer there and the patient is left alone. Consider this timeline when helping the patient through their grieving process. 

  • Sometimes it’s difficult to determine the fine line between supporting a friend with grief and exhausting them with your presence. So what are the things to consider in comforting a friend with grief? 

    • Firstly, it depends on your relationship with the person

    • Second, ask them what would be most helpful for them at the moment

      • Right after a loss, everyone comes around, but sometimes people want to be left alone and it can be exhausting for the person in question to feel overburdened with emotional comfort. 

      • Sometimes it’s valuable to check in and reach out. That alone can make an impact, even if you can’t find the right words to comfort the person.

  • The importance of personally going through therapy cannot be understated in this line of work. Even therapists need therapists, and being a patient can help you become a better therapist by allowing you that first-person perspective. 

  • Some patients may be doing really well with therapy for a period of time, but encounter roadblocks associated with life events without the presence of the decreased (first Christmas or the first anniversary after the loss of their loved one). The patient may need to revisit their grief once again, and that’s perfectly fine—grieving is not linear, nor is it the same for everyone. 

  • Every patient has their own way of talking about and processing their grief. Certain patients may even repeat the process of the passing of the decreased over and over. While it may be repetitive to hear the same thing every session, allowing the patient to talk about their experience helps the patient with their process of grieving.

  • Some patients might feel a lot of guilt towards themselves while grieving. Normalize the feeling of guilt, express the difficulty in feeling things, and help them look at the guilt with less judgement. 

  • Some patients may even feel anger towards the deceased, which they might have difficulty acknowledging or getting it out. It is common for people to remember the decreased in terms of their good aspects or attributes, but that may not always be the case for the patient. Allow them the space and time to express their negative emotions, which may not always be apparent on the surface in their grieving process. 


Maybe at some point, you have thought to yourself that you don’t have the ability to process grief with your patients or that it simply isn’t your strong suit. I hope that some of the points brought up in this podcast will be helpful in your own practice and journey as a mental health provider. 

Connect with Maris Loeffler, LMFT on Instagram, Linked In, Psychology Today



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