Behavioral effects of congenital ventromedial prefrontal cortex malformation

B.W.'s behavior has been characterized through extensive review Patience of clinical and personal records along with behavioral and neuropsychological testing. A central feature of the behavioral profile is severe antisocial behavior. He is aggressive, manipulative, and callous; features consistent with psychopathy. Other problems include: egocentricity, impulsivity, hyperactivity, lack of empathy, lack of respect for authority, impaired moral judgment, an inability to plan ahead, and poor frustration tolerance.The vmPFC has a profound contribution to the development of human prosocial behavior. B.W. demonstrates how a congenital lesion to this cortical region severely disrupts this process.The last twenty years have witnessed a surge of discoveries about the ventromedial prefrontal cortex, a brain region centered at the ventral (orbital) and medial surfaces of the prefrontal lobe. Lesion and functional imaging studies have combined to highlight the critical role of the vmPFC in highly valued human processes, including: decision making [1], emotion regulation [2], moral judgment [3], empathy [4], and impulse control [5]. Dysfunction of the vmPFC has been implicated in certain psychiatric disorders, including pathological antisocial behavior (e.g. developmental psychopathy [6], conduct disorder [7], antisocial personality disorder [8]) as well as mood disorders [9] and impulse control disorders (reviewed in [10]).Much of the foundation for what is known about the vmPFC has come from rigorous characterization of the behavioral profile following adult-onset focal lesions of the vmPFC [11-22]. These individuals typically perform normally on a standard neurological exam (language, memory, general intelligence, sensorimotor), but display dramatic disturbances in personality and real world behavior that are more severe than what is seen after injury to other sectors of the prefrontal lobe [23]. Core deficits include: egocentricity, a lack of empathy, poor decision-making,