Neuropsychoanalysis

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Revisiting the left convexity hypothesis: changes

in the mental apparatus after left dorso-medial
prefrontal damage

Christian E. Salas & Kenneth S. L. Yuen

To cite this article: Christian E. Salas & Kenneth S. L. Yuen (2016): Revisiting the left convexity
hypothesis: changes in the mental apparatus after left dorso-medial prefrontal damage,
Neuropsychoanalysis, DOI: 10.1080/15294145.2016.1219937

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Neuropsychoanalysis, 2016
http://dx.doi.org/10.1080/15294145.2016.1219937

Revisiting the left convexity hypothesis: changes in the mental apparatus after left dorso-medial
prefrontal damage
Christian E. Salasa,b,c* and Kenneth S. L. Yuend

a
Laboratorio de Neurociencia Cognitiva y Social, LaNCyS. Facultad de Psicología, Universidad Diego Portales, Vergara 275,
Santiago, Chile; bHead Forward Centre, Withington Methodist Church 439, Wimslow Road, Withington, Manchester M20 4AN,
UK; cUnidad de Psicoterapia Dinámica, Instituto Psiquiátrico José Horwitz Barak, Santiago, Chile; dNeuroimaging Centre,
Johannes Gutenberg-Universität Mainz, Mainz, Germany
(Received 1 December 2015; accepted 20 March 2016)

It has been 15 years since Kaplan-Solms and Solms published their Clinical Studies in Neuropsychoanalysis, where
they proposed a neuroanatomy of the mental apparatus. One of their main observations was that damage to certain
areas of the left prefrontal cortex (PFC), particularly those related to expressive language (Broca’s area), did not
generate changes in the mental apparatus. However, a limitation of their model was that it did not include
patients with damage to other areas of the left PFC. The main goal of this paper is to update Kaplan-Solms and
Solms’ model through the description of id, ego and superego changes in a case of left dorso-medial prefrontal
damage (Professor F). Data from a 7-year psychoanalytic psychotherapy with Professor F were collected
through the review of clinical notes and session voice recordings. This material was analyzed under the light of
existing evidence on the neuropsychological functions supported by the left dorso-medial PFC. Results from this
analysis support the hypothesis that damage to other areas of the left PFC, beyond Broca’s area, can in fact
generate deep changes in the mental apparatus. The most remarkable change observed here was a modification
of the dynamic functions of the ego, as an inability to regulate affect via preconscious verbal thinking. This
transformation impacted the baseline arrangement between ego and id, with somatic states becoming more
salient. Finally, changes in the superego were also observed, particularly in relation to its flexibility during
moments of conflict, or the silencing of superego voices outside moments of negative arousal.
Keywords: neuropsychoanalysis; brain injury; emotion; dysexecutive syndrome; frontal lobes; inner speech

work of a growing community of psychoanalytically

The aims of this book are modest but far reaching.
Kaplan-Solms and Solms (2000), Clinical Studies in
Neuro-Psychoanalysis
Thought is not expressed but created in a verbal
process. Vygotsky (1934), Thinking and Speech
Introduction
It has been over 15 years since Kaplan-Solms and Solms
(KS-S) published their Clinical Studies in Neuro-Psy-
choanalysis (2000). In this seminal book, based on the
psychoanalytic treatment of individuals with focal
brain damage, the authors proposed “a general model
of how the human mental apparatus might be rep-
resented in the tissues of the brain” (p. 243). Combining
Freud’s metapsychology and Luria’s dynamic neurop-
sychology, KS-S advanced groundbreaking ideas on
the neural architecture of primary and secondary pro-
cesses, as well as on the “putative neurological organiz-
ation” of the id, ego and superego. During the last
decade, many of these ideas have matured both theoreti-
cally and experimentally thanks to the collaborative
minded researchers and clinicians (for a review, see
Fotopoulou, Pfaff, & Conway, 2012).
The purpose of this paper is to revisit Kaplan-
Solms and Solms’ ideas on the role of the left prefront-
al cortex (PFC) in the normal functioning of the
mental apparatus through a case study of a patient
with left PFC damage, in light of the model proposed
by KS-S. In Clinical Studies, KS-S described one case
with left PFC damage (Mr. J), a man with a circum-
scribed lesion in Broca’s area (in the inferior and
lateral portion of the frontal lobe) who, despite a
marked impairment on expressive language, did not
present drastic modifications of his mental apparatus,
in contrast to other patients studied in the book who
had focal lesions to the posterior areas of the left con-
vexity. As we will discuss below, Kaplan-Solms and
Solms drew some very influential conclusions from
this case.
However, a limitation of KS-S’ model is that they
did not include any observations of patients with
damage to other areas of the left PFC. Evidence accu-
mulated during the last 15 years describing the

*Corresponding author. Email: salasriquelme@gmail.com

© 2016 International Neuropsychoanalysis Society

2 C. E. Salas and K. S. L. Yuen
neuropsychological functions supported by the left
PFC calls for a revision of its potential role in the con-
stitution of the mental apparatus. Thus, the main goal
of this paper is to update KS-S’ model through the
description of id, ego and superego changes in the
case of Professor F., a man who sustained a left
dorso-medial prefrontal damage after a stroke. We
believe that by taking this challenge, we rightly inter-
pret the spirit of Kaplan-Solms and Solms, who
noted that: “In all likelihood, our perspective on
these problems will alter radically as we continue to
test our hypotheses against clinical reality” (p. 243).
The case of Mr. J: impairment of the “motor aspect
of the word” after Broca damage
Let us remind you of KS-S’ case. Mr. J was a 22-year-
old, right-handed male, employed as a junior officer in
the armed forces at the time of his brain injury. Due to
a left middle cerebral artery (MCA) stroke at the age of
20, Mr. J presented with a lesion in the left inferior
frontal and anterior temporal lobes (see Figure 1).
Such damage left Mr. J with a dense right-sided hemi-
plegia and a severe non-fluent aphasia. Twenty months
after the stroke, a neuropsychological assessment con-
firmed a chronic and severe Broca’s aphasia, character-
ized by sparse, telegraphic and agrammatical
spontaneous speech. Performance on repetition tasks
was slightly superior to spontaneous speech and
Figure 1. Lesion reconstruction of Mr. J based on the templates presented by Kaplan-Solms and Solms in the original book.
comprehension was overall preserved – with
occasional difficulty understanding words (alienation
of word meaning). Other language (agraphia, alexia)
and non-language (acalculia, limb-kinetic apraxia)-
related disorders were also present. Interestingly,
according to KS-S, no signs of prefrontal, mesial or
parietal lobe dysfunction were observed.
Based on psychoanalytic observations of a thera-
peutic process twice a week, KS-S concluded that
damage to Broca’s area did not cause changes in
emotion, motivation or personality. In fact, according
to KS-S, the main feature of Mr. J’s presentation was
the “striking integrity of this ego functioning”
(p. 77). Mr. J exhibited adequate levels of awareness
regarding his deficits. In addition, he was able to flex-
ibly adjust his behavior in order to find alternative
ways to communicate his ideas, as well as monitor
whether his efforts were successful or not. His injury
did not appear to compromise the id either, since he
was able to experience, and be moved by, the whole
range of emotions. As for the superego, no dramatic
changes in its function were observed. In fact, some
of the main conflicts related to the elaboration of the
consequences of the brain injury revolved around the
loss of self-worth (in the eyes of his ego ideal).
Based on these observations, KS-S proposed that,
since Mr. J went through a normal process of mourn-
ing, his psychic structures must have been unchanged.
In their own words:

Normal mourning is not possible in the absence of
normal ego and of normal superego functions … His
ego performed its basic tasks – namely, the mediation
between its wishes (the id) and ideals (the superego) on
the one hand, and external reality on the other – more
than adequately. (p. 88)
How is this possible? According to KS-S, the main
reason is that Broca’s area
is associated primarily with the motor element of
speech (…) and the motor element, according to
Freud, was not the component of language that sub-
served the important ego and superego functions (…)
The motor aspect of the word, then, (…) lies at the sen-
sorimotor periphery of the ego. It is little more than an
output channel for the ego’s complex workings; its role
in verbal thinking is superfluous. When the ego is
deprived of this channel of communication with the
outside world, its inner workings are left fundamen-
tally intact. (p. 89, emphasis in the original)
Verbal thinking and the ego
Kaplan-Solms and Solms’ main argument is that
damage to Broca’s area does not generate changes in
the mental apparatus because impairment of the
“motor element” of speech does not compromise
verbal thinking, a core element of ego functioning.
The obvious question then is: what are the neuropsy-
chological components of verbal thinking? And
damage to which portions of the brain alter its func-
tioning? KS-S offer some insights on this matter
when discussing mental changes in two cases (Mrs. K
and Mr. L) of brain damage to posterior areas of the
left hemisphere, in contrast to anterior portions.
They suggest, for example, that damage to Wernicke’s
area (Mrs. K) impairs the auditory component of the
word functional system, thus altering audio-reflexive
consciousness: the ability to attach words to thoughts,
and to bring thoughts to consciousness (p. 108). As it is
to be expected, this type of deficit does compromise
“ego operations” to some extent, specifically by
making the inhibitory influence of the secondary
process “less stable” (p. 114). In comparison, the case
of Mr. L, who exhibited a lesion in the left parietal
cortex – specifically the supramarginal gyrus and
primary sensorimotor cortex – was described by KS-
S as associated with a decrease in mental activity,
due to the absence of constructive thought or active
associations. According to them, this type of impair-
ment does compromise an essential aspect of the ego,
which is its symbolic or representational function, or
the ability to move from concrete perception to
abstract thinking (pp. 145–147). Thus, even though
KS-S’s observations offer valuable insights into the
neuropsychological architecture of verbal thinking
Neuropsychoanalysis 3
and its role in ego functioning, it remains to be
explored whether damage to other areas of the left
anterior convexity can also impair verbal thinking. In
the next sections, we will summarize some old and
recent literature on this matter.
Verbal thinking and inner speech: Luria’s lost cases
Luria was extremely interested in verbal thinking and
its role in problem-solving and the regulation of behav-
ior (Luria, 1959; Luria & Yudovich, 1971). Due to his
friendship and collaboration with Lev Vygotsky, he
came to believe that language did not only have a com-
municative function but, most importantly, it had a
crucial role in the development of thinking itself,
mainly through the transformation of external speech
into inner speech:
The investigations of several authors have shown that
serially organized intellectual operations (writing,
mental arithmetic, complex mental skills) are the
product of prolonged development, passing through
clearly defined stages. Every such operation begins
with an extended cycle of single actions, and is then
transformed into a process taking place with the
close participation of external, extended speech, and
it finally changes to a process linked to inner speech.
This internal speech, based on condensed verbal
kinesthesias, is the mechanism responsible for the per-
formance of complex mental actions. (Luria, 1966,
p. 250)
In Clinical Studies, KS-S also followed a Vygotskyan–
Lurian perspective, by proposing that inner speech
was a key element in the structuralization of the pre-
frontal region and the ego itself. Through this
process, individuals were able to acquire some
“secure form of mental control over their own thinking
and behavior,” by means of distancing themselves
from subjective experience, evaluating thoughts and
behaviors in an abstract way, or planning a sequence
of activities in relation to a non-present goal
(p. 232). Nevertheless, an interesting point that needs
to be made here is that KS-S only described impair-
ments of inner speech after bilateral lesions to the
ventromedial PFC (vmPFC). This contrasts with old
and new literature, which has suggested that inner
speech deficits commonly arise from damage to
dorso-lateral areas of the left anterior convexity.
In 1966, Luria presented a series of cases where
inner speech was differentially impaired after damage
to specific areas of the left convexity. In the first two
cases (patient G1 and L), Luria described how
lesions to the posterior divisions of the left frontal
lobe resulted in the impairment of a specific aspect of
inner speech: verbal kinesthesis, or the “kinaesthetic
impulses flowing from the speech organs to the
4 C. E. Salas and K. S. L. Yuen
cerebral cortex” (p. 295). In both cases, the signature
deficit was
a loss of the smoothness of the course of motor and
intellectual processes, where patients were unable to
perform complex actions organized as a successive
series of a single “kinetic melody” (…) in consequence,
normal, consecutive organized mental actions were
disturbed, and could be performed only with the aid
of extended external speech or auxiliary external
actions in substitutions for it. (p. 355)
The subjective aspect of this impairment was por-
trayed by Luria, who noted in relation to one of
these patients:
his thoughts (patient G1) did not flow as freely as
before, that things that he perceived did not
“connect” and that he had to repeat the problem, or
the text, to be read either aloud or to himself before
the individual parts could be joined into a single
whole and its meaning become clear. (p. 300)
Patients G1 and L could not rely exclusively on the
use of “finely differentiated verbal kinesthesis,” or
internal speech, to organize their thinking process,
thus being forced to use external speech, or “coarse”
verbal kinesthesis, to solve complex cognitive tasks.
Furthermore, when external speech was restricted,
for example by asking patients to grip their tongue
between their teeth, certain operations (e.g. retention
of long successive verbal and nonverbal series; under-
standing logico-grammatical structures; complex
arithmetical calculations) “disintegrated.” According
to Luria, the common element in these complex oper-
ations was that, in order to be performed successfully,
they required the analysis of given material, the mental
transformation of its elements and the development of
plans of actions. In contrast, operations that were not
compromised by the restriction of inner speech (e.g.
reproduction of motor poses, copying of drawings,
making simple geometrical shapes from patterns,
memorizing single words, understanding simple and
familiar sentences) were not taxing on these executive
resources.
According to Luria, lesions to the anterior div-
isions of the speech area in the left PFC could also gen-
erate inner speech impairment. This syndrome,
however, was characterized by a marked impairment
in the dynamics of verbal thinking, where the capacity
to produce spontaneous fluent expressions was lost,
but language abilities (expression, comprehension, rep-
etition and object naming) were relatively preserved.
Using a Vygotskyan framework, Luria proposed that,
in these patients, inner speech, which acts as an inter-
mediate stage between expanded speech and thought,
was altered. As a consequence, a deficit could be
observed in two interrelated processes that are highly
automated in non-brain-injured individuals: the tran-
sition from thought into expanded speech, and the
condensation of narrative speech into thought for the
purpose of grasping its general meaning.
Patients presenting this syndrome often reported,
according to Luria, that “their thoughts will not
move, that nothing enters their head, and they
usually abandon the task or do nothing than to repro-
duce some habitual verbal stereotype, usually taken
from their past experience” (p. 359). They also noted
that, when presented with problems to solve,
“nothing springs up immediately” into their minds.
The key deficit of this syndrome can be appreciated
in patient G2′ s account:
Before I was wounded, my thoughts developed natu-
rally, without demanding any attention, but now my
thoughts will not flow and I cannot think … I
compose one phrase, but can go no further … my
thoughts are not dynamic, I compose a phrase, but it
sticks; if another phrase appears, then I can join it
on somehow, but then come to a standstill again and
I don’t know what to do. (p. 371)
Recent findings on the left PFC, verbal thinking and
inner speech
Since Clinical Studies was published, our knowledge of
the functionality of the left PFC has increased enor-
mously due to human lesion studies exploring the
relation between frontal lobes and specific executive
processes. These findings are interesting for the
purpose of this article, since they point to neuropsy-
chological components that are potentially relevant
to understand the structure of verbal thinking. I
would like to refer here mainly to the work of Stuss
and colleagues (Stuss, 2011; Stuss & Alexander,
2007), who have proposed that damage to different
areas of the left PFC can generate specific impairment
signatures. One of them is task-setting, a process com-
monly disrupted after damage to the ventro-lateral
surface of the left PFC (BA 44, 6). Individuals with
such impairment struggle with setting a new stimu-
lus–response relationship during the initial stages of
learning, thus becoming stuck in old sets of behavior.
Task-setting could be understood as the neuropsycho-
logical component that provides flexibility to verbal
thinking, thus facilitating the shift from one mental
representation to another. This might be particularly
important when verbal thinking is recruited with regu-
latory purposes, and the objects of such regulatory
activity are impulses and feelings that have a prepotent
and perseverative nature.
A second executive component associated to the
left PFC is energization, which refers to the process
of initiating and sustaining a response. Energization

can be disrupted by damage to the left – and also right
– superior and medial frontal cortex (BA 24, 9 and 6),
thus compromising the setting and sustaining of
specific responses, particularly over prolonged
periods of time when there is no external stimulus
reminding the organism to stay engaged on a task.
Energization has a key role in verbal thinking as
well, particularly if we consider verbal thinking not
simply as a problem-solving tool, but also as a spon-
taneous mental phenomenon that occurs when there
is an absence of external demand for thoughts, or
when the mind is wandering (Mason et al., 2007;
Smallwood & Schooler, 2006). When energization is
impaired after brain damage, not only is the capacity
to generate ideas in order to solve problems compro-
mised, but also stimulus-independent thinking is
altered. As we will see with Professor F, in such
cases, moments of mental emptiness are common.
As for inner speech, a growing number of studies
have suggested that the left PFC has a key role sup-
porting this process. A lesion study by Geva and col-
leagues (2011) looked at the neural basis of inner
speech in a sample of individuals with chronic
aphasia. The authors found that inner speech ability
was mainly affected by damage to the left pars opercu-
laris (BA 44) in the left inferior frontal gyrus, and to
the white matter adjacent to the left supramarginal
gyrus (BA 40). The relationship between the left
inferior frontal gyrus and inner speech has also been
Figure 2. 3D reconstruction of Professor F’s lesion. The image shows how the damage compromises dorsal and medial portions
of the left PFC (Salas et al., 2014).
Neuropsychoanalysis 5
supported by a meta-analysis that examined the acti-
vation of cortical areas in self-referential tasks
(Morin & Michaud, 2007).
With this context in mind, we now discuss a clinical
case that illuminates how we should update KS-S’s
original hypothesis about the consequence of left
PFC damage for id, ego and superego functioning.
The case of Professor F1
Professor F is a 72-year-old right-handed male. In
2006, while actively working in academia as a lecturer,
he suffered an ischemic stroke in the territory of the left
anterior and middle cerebral arteries. A later radiologi-
cal examination (2011) suggested a watershed stroke at
the junction of the anterior and middle cerebral
arteries, in the left frontal and parietal lobes. The
damage involved the medial part of the dorsal PFC
and extended into the intra-parietal cortex (see
Figure 2). Even though Professor F’s lesion also
extends into the inferior prefrontal gyrus, thus also
reaching Broca, the extent of such damage is consider-
ably less when compared to Kaplan-Solms and Solms’
case of Mr. J (see Figure 3).
At the moment of the stroke, Professor F exhibited
some minor confusion, severe non-fluent aphasia and
right hemiparesis. Once stable, Professor F was trans-
ferred to a sub-acute rehabilitation unit. Records of
6 C. E. Salas and K. S. L. Yuen

whether he would recover his intellectual capacities,

Figure 3. Overlapping of Professor F’s (light grey) and Mr.
J’s (yellow) lesions. The red circle shows Broca’s area, so
the level of compromise of this area in both cases can be
appreciated.
the initial neurological assessment suggest a quick
recovery, with improved understanding of the immedi-
ate environment, preserved communication abilities –
with some minor difficulties finding words – but high
levels of anxiety. Three months after the injury, Pro-
fessor F returned home and began an outpatient reha-
bilitation program.
When interviewed at arrival, he reported the fol-
lowing problems: difficulties managing time, fatigue,
and high levels of anxiety. When enquired about his
anxiety, he commented that his main worry was
which were essential for his academic job. He reported
that, since the stroke, he had become forgetful, unable
to focus, and with moments when his mind went blank.
A neuropsychological assessment at that time
suggested a profile of dysexecutive impairment charac-
terized by deficits in information-processing speed,
working memory, memory recall, cognitive flexibility,
planning and monitoring. Language assessment by a
speech therapist reported a mild anomic aphasia.
Eight years after the accident, Professor F’s profile
of dysexecutive impairment remained relatively
unchanged, characterized by a marked impairment
in cognitive flexibility and a mild difficulty in initiation
– in the cognitive domain (see Table 1). This profile is
consistent with Stuss’ model, which suggests that
damage to the lateral portions of the left PFC have a
key role in cognitive flexibility (task-setting), while
more dorso-medial lesions impact initiation (energiza-
tion). In everyday life, this profile translates (according
to the Dysexecutive Questionnaire, DEX, Burgess,
Alderman, Wilson, Evans, & Emslie, 1996) into prob-
lems with planning ahead, assessing the magnitude of
difficulties, avoiding distractions, making decisions,
and acting frequently without thinking. At work,
these problems are reflected in his inability to react
to novel or unexpected situations, and his difficulty
organizing ideas for written manuscripts. Nevertheless,
it is important to mention that the impact of these

Table 1. Professor F’s neuropsychological profile eight years after his stroke (adapted from Salas et al., 2014).

Neuropsychological process Task Score Interpretation

Speed processing Processing Speed Index (WAIS III) 88 Low average

Digit symbol-coding (WAIS III) 7ss Low average
Symbol search (WAIS III) 9ss Low average
Language Language comprehension (TOKEN) 26/36 Mildly impaired
Language expression (BOSTON) 3–4 Mildly impaired
Letter fluency (D-KEFS) 9ss Mildly impaired
Category fluency (D-KEFS) 4ss Impaired
Working memory Working Memory Index (WAIS III) 111 Average
Arithmetic (WAIS III) 10ss Average
Digit span (WAIS III) 11ss Average
Letter-number sequencing (WAIS III) 14ss Above average
Memory Free recall (FCSRT) 11 Impaired
Total recall: free and cued recall (FCSRT) 26 Impaired
Recognition (FCSRT) 15 Average
Category generation and set shifting Categories completed (WCST) 4 Impaired
Perseverative errors (WCST) 24 Impaired
Failures to maintain set (WCST) 8 Impaired
Category switching fluency (D-KEFS) 3ss Impaired
Abstraction Similarities (WAIS III) 10ss Average
Matrix reasoning (WAIS III) 12ss Above average
Notes: ss, scaled scores; WAIS, Wechsler Adult Intelligence Scale; D-KEFS, Delis Kaplan Executive Function System; FCSRT, Free and Cued
Selective Recall Reminding Test; WCST, Wisconsin Card Sorting Test.

deficits on everyday life has decreased, since a wide
range of compensatory strategies have been
implemented (for a detailed account of the case, see
Salas et al., 2014).
Since this article is aimed at illuminating Pro-
fessor F’s psychodynamic and emotional changes
that occurred after the stroke, and not to the rehabi-
litation process itself, we will only focus on the
material collected during psychotherapy sessions
(clinical notes and audio-recordings). Psychothera-
peutic work was carried by one of the authors
(CS), and involved 2 sessions a week during outpati-
ent rehabilitation, for a period of 15 months. Once
Professor F was discharged from the program, the
treatment continued privately, once a week, for a
period of three years. Since then, sessions have
been spread to once every fortnight for a period six
years, till the present day.
Clinical presentation and psycho-historical roots of
Professor F’s conflicts
Since the beginning of therapy, Professor F’s profile of
dysexecutive impairment was observed in many ways
during sessions. He could express himself clearly, but
often struggled to find words, or had difficulties pre-
senting thoughts synthetically. It frequently took him
considerable amounts of time to express one thought,
mainly because his thinking process did not pass
smoothly from one idea to another, and was frequently
captured by details. Quite often, in the middle of a
thought, he could find himself stuck, or with a blank
mind, or end up diverting to a side topic. He comments
on this: “My mind goes blank sometimes … it is like I
can’t find what I know, like having gaps, pauses in my
head. My thoughts often drift away. I often can’t make
sense of what is going on.” Consistent with what has
been reported in the literature on executive impair-
ment, this deficit fluctuated according to context. It
was exacerbated in situations when he was asked for
information, or when information was presented to
him and he was expected to elaborate on it – in other
words, when he had to generate, on the spot, an
internal plan to respond to environmental demands.
In contrast, when Professor F was spontaneously
expressing his own ideas, and he was not interrupted,
his thinking process seemed significantly more coher-
ent and fluid. Nevertheless, with time, Professor F rea-
lized that he could express himself better if a list of
“discussion bullet-points” was made prior to each
session. This compensatory strategy has improved con-
siderably his ability to “stay on track,” or his capacity
to “get to the point.” When in the middle of an idea he
gets lost, he immediately returns to his notes and uses
them as a new point of departure.
Neuropsychoanalysis 7
Professor F’s executive impairment has also had an
impact on his capacity to incorporate new information,
integrate information between sessions, and use it in the
outside world. For example, if during one session, a
topic that has been previously discussed comes up, he
is often not able to link it to the previously discussed
material on his own. Furthermore, outside sessions,
he often struggles to connect conflictual events with
themes that have been discussed as part of the
therapy. In a way, the use of therapeutic “insights” to
understand and deal with everyday life is somehow
compromised. However, two things need to be said
here. Firstly, Professor F is very much aware that con-
flictual events “outside” are connected with his brain
injury and also with therapy themes. This is one of the
reasons why he has adhered to treatment for so many
years. He often reports that he has “the feeling” that
“a problem is related to something we have talked
about,” but he simply cannot recall it, or put a finger
on it. Similarly, inside the session, when the therapist
connects external events with “themes” that have been
repeatedly worked on during therapy, Professor F also
appears to emotionally recognize such links.
This profile is similar to memory problems exhibited
by executive patients, where the recognition of infor-
mation previously presented is better preserved than
its free recall. Since this problem has posed important
challenges to the therapeutic technique, compensatory
strategies have also been implemented. The most suc-
cessful one has been the provision of written summaries,
which are sent via email after each session. Professor F
has found this extremely helpful, since whenever some-
thing occurs outside, and he has the “feeling” that there
is something there that is linked to therapy, he goes back
to the notes in order to make sense of it.
With no doubt, this difficulty in learning infor-
mation from sessions has considerably slowed the
mourning process. This is likely because the generation
of new representations of the self and the world, and
the use of those new representations when dealing
with everyday life – what we describe in neuropsychol-
ogy as generalization – has required constant and
extended repetition, as well as the use of many external
aids. With all of this said, however, beyond these
changes, Professor F’s subjective experience of acquir-
ing a brain injury, and the course of the mourning
process, appear to be quite normal.
Since the beginning, his main concern has been
whether he would recover his “intelligence,” or if his
mind will work as before again: I wonder if I will be
able again. How damaged am I? This is something new
to me. I have never felt vulnerable to being damaged
before. Changes in Professor F’s thinking abilities
have been a constant source of anxiety and depression,
since they have imposed limitations on his working
8 C. E. Salas and K. S. L. Yuen
ability, but most importantly, threatened a fragile pre-
existing narcissistic balance: I have never been confident
about myself, I have always doubted my abilities,
whether I am a good teacher or not. I don’t allow
myself to be wrong. But this accident constantly shows
me that I am the exception and that fucks me up.
The roots of this conflict are deeply seated in Pro-
fessor’s F family history. He was born into a very
Catholic family with rigid views on what was right or
wrong. Any deviation from that norm implied some
form of exile from grace. And there were no excep-
tions, even for children. He comments on this:
In my house they were very strict. I am a repressed left-
hander, and they used to hit me on the left hand to stop
me from using it. Since I was little I had to learn to do
what I had to, not what I wanted to. Since then I have
felt that things have been imposed on me. I identify
myself with a naughty child. I have always been like
that, and that was really complicated for my mum. I
believe this is why I feel guilty for not being good, I
feel as if there is something bad deep down in me.
They used to tell me that when I was a kid … my
mum told me I was the only child that gave her
trouble. At Catholic school a priest told me once I
had a demon inside.
This split way of conceptualizing life was somehow
incarnated in his two brothers, who were significantly
older than him, and who became sources of identifi-
cation for Professor F after his father died when he
was a child. His older brother abandoned the house
and moved to a big city where he conducted a licen-
tious life. The other brother, in contrast, stayed at
home in charge of the father’s business and became a
righteous family man. Even though this brother was
the one who helped raising Professor F, he always
felt a deep connection to his “heathen” brother.
The interaction between Professor F’s impairment
and his psychohistory can be summarized in the fol-
lowing way: the cognitive impairment, the inability
to think and solve problems, is unconsciously linked
to his early experience of having something wrong
inside himself. During his life, Professor F has
devoted great amounts of energy to prove to others,
and most importantly to himself, that this is not the
case, that he is not a black sheep like his oldest
brother. On the contrary, by being a “good boy” – a
man who always does what (he thinks) is expected of
him – and by becoming a bright and admired aca-
demic, he has managed to keep those feelings at a dis-
tance. But the consequences of the brain damage have
forced him to face, over and over, this feared and faulty
aspect of himself, thus re-activating a painful conflict:
if you are not able to do what we expect from you, you
are worthless. You are not loved for who you are, but
only for the things you are able to accomplish. It is
this same conflict that has been enacted and elaborated
for years in the transference and countertransference:
he is always careful of not disappointing the therapist,
of being a good patient who never misses a session, is
never late, or never complains because the therapist
forgets to send the session summaries. And when he
is late, or forgets, he becomes very anxious of what
the therapist might think, easily placing the therapist
in the role of a strict and merciless parent.
We hope that, at this point, the reader can get an
idea of Professor F’s impairment and nuclear conflicts.
This has been the focus of our long-term work: to help
him understand his cognitive deficits, but also to bring
some insight on how they interact with his psychody-
namics. In this regard, helping him to elaborate his
over-adaptation, in the Winnicotian sense of the
word, and to soften his harsh superego, in the Freudian
sense of the word, have been key lines of intervention.
But we cannot focus here on those aspects of the
process, since the main goal of this paper is to show
how left dorso-medial damage generates a specific
profile of neuropsychological change that can trans-
form the psychic apparatus.
Changes in the mental apparatus due to left dorso-
medial damage
The hypothesis that we would like to put forward here
is that the type of damage sustained by Professor F
compromised a key component of the thinking appar-
atus, namely preconscious verbal thinking. Professor
F’s deficits in cognitive flexibility and energization con-
tribute to a very specific profile of impairment in verbal
thinking and inner speech. Cognitive inflexibility
makes verbal thinking more perseverative and rigid,
thus impeding the shifting from one idea to another,
while a decrease in energization compromises the acti-
vation of internal verbal thinking. This is particularly
obvious in situations when the act of thinking is not
directed to the outside world (stimulus-independent
thinking), which is the main feature of inner speech,
or speech directed to ourselves. It is important to
acknowledge that this is, however, a rather simplistic
sketch of reality, since clinical experience tells us that
shifting and initiating are two intimately related
processes.
Changes in the ego: verbal thinking impairment and
emotional dysregulation
The first idea that we would like to put forward is that
left dorso-medial PFC damage, and its consequent
deficit in verbal thinking, does modify the ego. In

Clinical Studies, KS-S argued that the frontal lobes
and their associated executive abilities are the “locus
of the ego on its dynamic manifestation,” acting as
the “inhibitory pole of the mind” (p. 269). The
primary task of the ego, according to this view, is to
“constrain the activities and outputs of the mind in
order to make them compatible with the demands
that are imposed by external reality” (p. 113).
Now, the big question here is how such regulatory
or inhibitory process takes place. According to Solms
and Zellner (2012), this process occurs in two steps.
First, stereotyped actions, which would be normally
released under drive/object conditions, are inhibited.
This process, which underlies the “freedom not to
act,” heavily relies on the integrity of the vmPFC, an
area that when damaged compromises behavioral inhi-
bition. The second step depends on this behavioral
inhibition, since when such process is accomplished
successfully, “mental space for thinking is created.”
Mental space, according to Solms and Zellner, is
located anatomically in the dorso-lateral PFC, an
area commonly associated with the manipulation of
mental representations – what we commonly know as
working memory. According to this view, thinking,
considered as an experimental or virtual form of
action, occurs in the mental space of working
memory, thus acting as a buffer between drive and
action. Interestingly, other psychoanalytic authors
have also stressed the relevance of mental space as a
requisite for thinking, or what they call symbolization.
Freedman (2005), for example, has noted that “spatia-
lization” is key in the development of psychic space or
inner space. It is interesting to note here that Solms and
Zellner (2012) considered the dorso-lateral PFC as a
neural substrate of this ego function, thinking. This,
in view that only the vmPFC was acknowledged in
Clinical Studies as playing a crucial role in the
dynamics of the ego. As we shall illustrate with the
case of Professor F, damage to the lateral and dorso-
medial surfaces of the left PFC does compromise the
use of verbal thinking as a tool to regulate the
demands of the id.
In this section, we seek to demonstrate that precon-
scious verbal thinking impairment in Professor F
reduces the ego’s ability to regulate negative affects.
More concretely, in moments of negative arousal, Pro-
fessor F becomes stuck in negative cognitions and is
unable to either shift away from them (to distract
himself), or decrease its intensity via the generation
of positive and soothing verbal representations (to re-
appraise). In his own words:
It is like a peculiar experience, like having something
separated inside, what you think with your head and
what you feel, and that you are not able to master
Neuropsychoanalysis 9
with your head what you feel. That is the problem!
The most important thing here is a sensation of not
knowing what to do, to have your mind blank, or
only scattered images that you cannot coordinate. It
is a sensation of chaos. You are aware of what is
going on but you can’t control it. It is not like I am
not aware that I was thinking stupid thoughts, but I
was simply unable to stop thinking them.
In these situations, Professor F does not become be-
haviorally impulsive, which would reflect some sort
of ventral-frontal disinhibition, but he simply cannot
manipulate thoughts to “manage” feelings (or in
Freud’s language, to “tame” them). In other words,
he is trapped in the concrete experience of his feelings
because the “representational machinery” is
compromised.
If we pay attention to his subjective account, which
is offered a posteriori when things have cooled down,
two ideas need to be considered. First, in moments
of emotional turmoil, his mind becomes blank. As a
consequence, he is not able to generate thoughts that
can be used as regulatory tools. From a neuropsycholo-
gical point of view, this can be interpreted as a deficit in
the generation of ideas, which is consistent with his low
performance on fluidity tasks. Additionally, he also
comments that when negative thoughts appear, he is
not able to shake them off, and they persist in a neurolo-
gically induced rumination. Clearly, there is here an
inability to detach from negative contents and shift to
other mental representations that can facilitate the regu-
latory process. This is also consistent with his low per-
formance on cognitive tasks that measure set shifting.
From a psychodynamic point of view, the ego’s affect
regulatory function is compromised due to impairment
of idea generation and cognitive inflexibility.
This change in the ego has had important conse-
quences for the process of mourning, in the form of
recurrent “micro” crises and depressive feelings. Due
to his high level of functioning, Professor F has
resumed many academic activities, all of them with
great personal effort and external support. However,
every time he begins a new task or project, his dysexe-
cutive syndrome becomes evident, and intense feelings
of frustration and anger (toward life but mostly
himself) emerge. These feelings stay with him some-
times for days, unless he is able to talk to others
about it (usually his wife or his therapist). If he does
not talk to others, he remains feeling “unsettled,”
“turbid,” or “sticky,” thus being unable to make
sense or symbolize his internal states.
Having difficulties walking is something that saddens
me. But then I have this experience that … well … I
know it’s OK to feel sad, but this is not just feeling
sad, this is like a sticky sadness, which makes me feel
10 C. E. Salas and K. S. L. Yuen
sadder than I should. That is really, it is like when you
step in the mud … so you need to make an effort to lift
your foot, and in order to lift your foot you have to
clean it too. I can’t get out of the mud by myself …
it’s not a matter of intensity here, but the sensation
of a weight, of mud, of something that grabs your
foot. I’m afraid of the mud, because it is so sticky
that even my capacity to imagine collapses.
As Professor F acknowledges, he rarely can get out of
these feelings on his own. Usually, he needs to talk to
someone else,2 or write down his thoughts in order to
bring internal order. In other words, thoughts need
to be concretely placed outside his head, and perceived
auditorily (listening to himself or others) or visually
(reading). This is interesting, since it resembles
Luria’s “lost” cases, where patients had to externalize
their thoughts in order to perform complex mental
tasks. It also suggests that Professor F’s capacity to
think to himself inside his head – internal speech – is
compromised, and that in order to “make sense” he
is forced to rely on developmentally earlier forms of
thinking (Vygotsky, 1934). Paying attention to how
and why Professor F uses writing, for example, as a
method to compensate for the inability to internally
generate and organize thoughts,3 offers valuable
insights into the nature of this form of verbal thinking
impairment and how it compromises ego functioning:
Writing is like putting words to the mess. If I don’t
write, everything goes to hell. If I think about it, but
don’t write it, it goes away (…) To think about ideas
does not have the same effect, or the same order. I
can’t think. And if you ask me about repeating some-
thing, it is gone. This is how I work now, and it does
not embarrass me to forget things. Writing helps me
to put order in what I want to say, otherwise, I can’t
repeat it inside my head. It becomes something imper-
ceptible, like waiting for words I do not have. It is as if I
were blind, but conceptually blind. When I write it is
like things emerge … and when I write I can return
to those things. If I don’t write it is like there is
nothing inside my head, or sometimes only the
feeling that there was something. But when I try to
find what was there and I can’t do it – that makes
me feel anxious and powerless.
Changes in the ego-id balance: increased emotional
reactivity
A second idea we would like to put forward is that left
dorso-medial PFC damage alters the balance between
ego and id. KS-S suggest that the id, and its different
sources of arousal – cycles of the hypothalamus, meta-
bolic and humoral processes or stimuli from the
outside world – are influenced by the prefrontal
region and its thinking activity (pp. 266–267). In
other words, and if we are allowed to use some
cognitive concepts here, the bottom-up generation of
emotions and the top-down regulation of emotions
are two highly integrated processes (Lane & Garfield,
2005; McRae et al., 2012). Even though the regulatory
activity of the ego is more prominent during moments
of negative arousal, there is a basal regulatory activity
that appears to occur constantly. However, when the
thinking apparatus is weakened by brain injury,
when it becomes inflexible, or its fluidity decreases,
it is not only the capacity to manage conflict that is
transformed, but also the ego’s basal permeability to
affects. This problem has been described in detail in
a previously published case study of Professor F
(Salas & Castro, 2014; Salas et al., 2014), where an
enhanced experience of both positive and negative
emotions was reported. Evidence for this change
came not only from Professor F’s subjective account
and observed behavior during sessions, but also
from his wife. A very simple way of describing this
change was that Professor F’s positive and negative
feelings were experienced with more intensity after
the injury:
Happy feelings … the accident did not reduce them,
but on the contrary, it augmented them. The capacity
to feel moved, the capacity to cry … now I experience
these things where I am happier, or sadder, or that I
have variations of intensity. That did not exist before.
Because now I feel things … and this is of my life.
The accident made me more sensitive to that.
As discussed elsewhere (Salas et al., 2014), from a neu-
ropsychological point of view, the case of Professor F is
a good example of how the balance between feeling
and thinking can shift after brain damage. This is par-
ticularly interesting, since it has been theoretically
suggested that emotional changes after dorso-lateral
lesions are secondary to the cognitive deficits generated
by such damage (Anderson & Tranel, 2002). In this
case, there is a decrease in the generation of mental
representations: the blank mind.
I have these spaces … that I often call spaces of silence
… quiet spaces, silent ones. And my mind often goes
blank in those moments, without any explicit content
… without any reflexive content … but with truths and
emotional certainties. This often occurs during praying
… with my affection towards my wife, my kids. What I
try to do then is to remain silent and contemplate. If
you ask me, contemplate what? I do not know. It is
some form of empty contemplation, with no images,
but certainly it has reality. They are moments of pure
sensation … I stay there quietly. Then I am just feeling.
Professor F’s case offers supporting evidence to the idea
that mental representations influence the somatic states
from which they have been originated. And when the

representational machinery is damaged (the blank
mind), those somatic states become less constrained
and acquire a heightened quality (“moments of pure
sensation”). This is not a strange thought for psycho-
analysts, who commonly work by attaching words, or
sometimes only by attaching thoughts, to somatic and
affective states in order to contain its energy and
channel it for adaptive purposes. Interestingly, in cogni-
tive neuroscience, there are also data supporting the
same idea. It has been noted, for example, that thinking
and labeling emotions have a dampening effect on
emotional reactivity (Lieberman, Inagaki, Tabibnia,
& Crockett, 2011), apparently via the inhibition of sub-
cortical structures associated with emotion generation
(Payer, Baicy, Lieberman, & London, 2012).
Changes in the superego: “The Greek chorus has
gone quieter”
In contrast to the ego and id, the superego has received
considerably less attention by neuropsychoanalytic
authors. In Clinical Studies, KS-S noted that inner
speech has a key role in the constitution of the super-
ego, through the internalization of parental voices.
Thanks to this process, the child is able to use language
in evaluating his own thoughts and behaviors in an
abstract way (p. 232), thus, acquiring the ability to
look critically upon himself as it if were an external
object (p. 275). More recent neuropsychoanalytic
accounts have also stressed the superego’s represen-
tational nature, which uses virtual internal others, as
sources of reward and punishment that can be
evoked in a variety of simulatory ways (Hopkins,
2012). Interestingly, non-psychoanalytic experimental
approaches to inner speech have incorporated similar
ideas, by suggesting that inner speech has a dialogic
nature, since it reflects the interplay between different
internalized perspectives. These perspectives may rep-
resent voices that embody distinct aspects of the self,
or voices that belong to others which are addressed
to the self (McCarthy-Jones & Fernyhough, 2011).
According to KS-S, “the functions of the superego
are closely bound up with the ventromesial regions of
the prefrontal lobe, which is the point at which the pre-
frontal lobe merges into the limbic system” (p. 275). In
consequence, changes in the superego can be com-
monly observed after damage to this region, where
“the parental voice, a constitutive element of the super-
ego, is destructuralized” (p. 275). It is the authors’ pos-
ition that the vmPFC cortex performs a fundamental
economic transformation that inhibits the primary
process of the mind, what is commonly known as
reality principle (pp. 230–231). However, what seems
to be missing from their model is how damage to
other areas of the PFC, which are not related to
Neuropsychoanalysis 11
behavioral inhibition, but to the generation and
manipulation of mental representations, can alter the
superego’s normal functioning.
Thus, this section attempts to extend KS-S’ ideas
by proposing that the superego can be differentially
modified after damage to different portions of the
PFC. Lesions to the vmPFC, which often alter affec-
tive learning as well as the use of affective signals to
inhibit behavior, appear to compromise the more
“primitive, narcissistic object representations that
form the nucleus of the self-regulatory functions of
the ego and superego” (Kaplan-Solms & Solms,
2000). In contrast, lesions to the left dorso-lateral
PFC, an area commonly associated with cognitive
flexibility and verbal thinking, appear to compromise
representational or language-dependent aspects of
the superego. We will use the case of Professor F to
portray the nature of these changes.
In the case of Professor F, two interesting modifi-
cations in the superego can be observed. The first is a
decrease in its flexibility during moments of conflict,
where it becomes rigid and harsh. In these situations,
when captured by the intensity of negative emotions,
Professor F struggles to shift toward more benign
and soothing internal representations. This harsh
superego often emerges when he is faced with his
impairments, thus experiencing himself as imperfect
and vulnerable. Feelings of powerlessness and anger
– mainly toward himself – are common in the emotion-
al background of these moments. During one session,
he comments on this, in relation to an event where he
fell on the street: “I was pissed at myself, ‘cause I am
not able to do what I think I should. I feel stupid. I get
angry with myself, with my reality, my limitations.” It
often happens that this inner voice that calls him
“stupid” grows into something like a judge: “There is
a judge in my head … who tells me I am insignificant
… and that I should be someone better, someone
important … I should … I should … that word is such
a heavy load to bear.” Other feelings that commonly
emerge when Professor F is not being able to do some-
thing are shame and guilt. On many occasions, these
feelings are associated with inner dialogues with a
voice that represents his former self, Mr. F:
Not being able to explain myself to the doctors is
something that bothers me emotionally, since I need
to ask for help, and I feel embarrassed because of
that. I feel like a little boy and I don’t know what to
do. I have trouble accepting this. Because behind me
is Mr. F, the one I was before. And Mr. F does not
need any help. He does not need people explaining
shit to him. He says to me: How is it possible that
you don’t know? So I feel guilty about this, because I
was not responsible enough and did not take care of
myself properly before the accident.
12 C. E. Salas and K. S. L. Yuen
There is another incarnation of the superego in Pro-
fessor F’s internal world, something he calls the Greek
Chorus. This is quite an interesting imago, since, as
the reader may well know, a Greek Chorus is a group
of individuals who comment with a collective voice on
the dramatic actions that occur during a play. In the
case of Professor F, his Greek Chorus appears to be
the amalgamation of parental and religious figures
with whom he has identified across his life:
I was at the church in a community meeting. Suddenly
I started noticing this fear, fear of not being able to talk
properly, of not being able to express myself and go
silent. I wonder where that comes from? Why am I
so afraid? Then I thought about the Greek Chorus.
The Greek chorus punishes and praises you. But gen-
erally is more about punishing. It has two functions –
punishing and approving.
There is no doubt that Professor F’s harsh superego is a
product of his psychohistory and cannot be explained
simply as a personality change caused by the injury.
However, similarly with his ego, cognitive changes
did impact the superego’s capacity to flexibly shift
between internal representations, or internal voices.
When an external event triggers experiences of
failure or vulnerability, negative cognitions are
immediately attracted, and acquire meaning, by orbit-
ing pre-injury conflict constellations. The influence of
the neuropsychological impairment that can be
observed here is a certain pull, a certain fixation,
which Professor F cannot counteract on his own.
Again, it is often through the intervention of others
(wife or therapist) that he is able to shift away and con-
sider other more positive aspects of himself. And it is
through the influence of others that he can transit
into more caring and compassionate modes of relating
to himself.
The second modification of the superego in Pro-
fessor F appears to be a decrease in its salience –
however, outside moments of negative arousal. As we
have noted above, due to changes in idea generation,
his mind has become quieter (the blank mind). In
these moments, Professor F describes his mind as
empty of mental representations or internal dialogue,
as some form of wordless contemplation. This
change has also impacted the superego’s functioning
since, according to him, “the Greek Chorus has gone
more silent.” Professor F has considered this as a posi-
tive modification brought by the injury, since pre-
viously common internal dialogues along the lines of
“you ought to do this” or “you should be worried
about that” are less frequent. Professor F is not the
first patient to describe such changes after lesions to
the left convexity. Scott Moss, for example, in his auto-
biographical book Recovery with Aphasia (1972),
beautifully portrays how the loss of internal dialogue
generated a fixation on the here and now as well as a
loss of concern and worry for the future:
I had lost the ability to converse with others; I had also
lost the ability even to engage in self-talk. In other
words, I did not have the ability to think about the
future – to worry, to anticipate or perceive it, at least
not with words. Thus, for the first five or six weeks
after hospitalization I simply existed. (p. 5)
Similarly, in her best selling book, My Stroke of
Insight: A Brain Scientist’s Personal Journey (2008),
Jill Bolte Taylor also described how the loss of inner
speech dramatically modified her capacity to guide
her behavior based on past and future virtual
scenarios:
In this altered state of being, my mind was no longer
preoccupied with the billions of details that my brain
routinely used to define and conduct my life in the
external world. Those little voices, that brain chatter
that customarily kept me abreast of myself in relation
to the world outside of me, were delightfully silent.
And in their absence, my memories of the past and
my dreams of the future evaporated. I was alone. In
the moment, I was alone with nothing but the rhyth-
mic pulse of my beating heart. (pp. 42–43)
What is interesting about these cases is that they stress
how the collapse of a key element of the superego,
inner speech, can dramatically alter its represen-
tational function. It is through inner speech that we
detach from immediate experience and project into
the future. This, in order to reflect about the potential
consequences of our acts, as well as the acceptable or
unacceptable versions of us that such actions might
generate. This is what Hopkins (2012) refers to as the
“simulatory” nature of the superego, thus stressing
the intimate link between superego and foresight.
Other psychoanalytic authors have also noted the
future-oriented nature of the superego, by suggesting
that it is “the object that tends to the future” (Bion,
1992) or the “monitor of the future” (Grotstein, 2004).
In sum, evidence from the case of Professor F
suggests that changes in cognitive flexibility and idea
generation can alter the normal functioning of the
superego. This can be observed as an increased “rigid-
ity” or “inflexibility” during moment of conflict, which
compromises the capacity to downregulate negative
feelings via the use of soothing internal dialogues
with benign parts of the self. A decrease in idea gener-
ation, or stimulus-independent thinking, can also
modify the degree of influence that the superego has
outside moments of conflict. The subjective experience
of this change can be, however, positive. When the
internal critical voice is silenced, its evaluative

influence on the ego is weakened, thus generating less
episodes of negative discrepancy between what the
patient is and what he/she should be.
Some final comments on the possibilities and
limitations of neuropsychoanalytic case studies
The main goal of this paper was to extend KS-S’s work
by suggesting that damage to other areas of the left
PFC – beyond Broca – can generate important
changes in the architecture of the mental apparatus.
It is probably no surprise to the reader that we have
proposed changes in the dynamic functions of the
ego in a case of dysexecutive impairment after left
dorso-medial prefrontal damage. Neuropsychologists
have known this link for a long time. However, we
believe that describing changes in the ego’s ability to
regulate affects is something relatively novel, at least
in a field that has tended to exclusively focus on the
importance of ventral areas of the PFC in the regu-
lation of emotions and behavior.
The second idea that we have presented has
perhaps more neuropsychological appeal to the
reader. It suggests that preconscious verbal thinking
impairment generates a change in the balance
between ego and id. As a consequence, the basal
arrangement between emotion generation and
emotion regulation is modified: when the internal
voice is turned silent, somatic experience and feelings
become more salient.
The last observation in this case is perhaps more
novel, since we still know little about the neural basis
of the superego. According to KS-S, the superego
depends on ventromedial regions that act as barriers
of impulses from the id. So, when these areas are
damaged, primary process takes over. But, is this
model enough? Does it account for the less somatic,
and more representational aspects of the superego,
that inner chatter which acts as a commentator in
our daily lives? We believe it does not, and Professor
F’s case offers some preliminary evidence to support
such a claim.
The case of Professor F is an interesting example
of how the observation of brain-injured patients
during psychodynamic treatment can offer valuable
insights about the neural basis of complex aspects
of mental life, such as emotion, motivation or person-
ality. An important advantage of a neuropsychoana-
lytic case approach is that it provides a
methodological solution to bridge the gap between
subjective and objective views of the mind/brain
(Turnbull & Solms, 2004), thus bringing together
first- and third-person perspectives (Salas, Cassassus,
& Turnbull, 2016). This is not a minor accomplish-
ment, since linking first-person subjective data (an
Neuropsychoanalysis 13
individual’s subjective state, or how being a mind
feels like) to third-person objective data (the individ-
ual’s neuronal state) has been a challenging task for
neuroscientists in the last decades (Northoff, Berm-
pohl, Schoeneich, & Boeker, 2007; Northoff &
Heinzel, 2006; Varela & Shear, 1999).
The case of Professor F is a clear example of how
these two perspectives can be linked, since it suggests
that injury to a specific brain area, and the profile of
executive impairment that results from it, correlates
with a particular experience of being a dysexecutive
mind. However, to our surprise, this experience is not
only defined by the many cognitive problems brought
by the injury (the disorganized mind), but most impor-
tantly, by the difficulties experienced in using the think-
ing machinery as a tool to manage “feelings.” As a
consequence, Professor F’s account challenges predom-
inant “cognitivist” views of the mind and forces us to
direct our attention to the problem of how cognition
and emotion interact and influence mutually. It is our
belief that, by using long-term and systematic obser-
vations of how brain injury changes the experience of
being a mind, valuable data on the mind/brain
relationship can be gathered. This information can
then be used to support, challenge or even expand
existing knowledge provided by behavioral or neuroi-
maging studies.
The psychoanalytic observation of brain injury sur-
vivors can contribute greatly not only to researchers
interested in the mind/brain relationship, but also to
rehabilitation clinicians who care about emotional
adjustment. In fact, a neuropsychoanalytic approach
to case studies is highly compatible with the field of
neuropsychological rehabilitation, where a “subjective
turn” has begun to take place during the last decade,
emphasizing the value of patients’ subjective experi-
ence of change as well as patients’ experience of their
rehabilitation process (Ben-Yishay & Diller, 2011;
Wilson, Winegardner, & Ashworth, 2014). Psychoana-
lytic knowledge accumulated for over a century on how
the mind is formed through the influence of attach-
ment relationships, or how the mind copes with nega-
tive emotions like anxiety and grief. This knowledge is
highly valuable in understanding how the meaning of
acquiring a brain injury is constructed by the survivor,
as well as how the survivor relates – or not – to rehabi-
litation professionals as figures of emotional support
(Prigatano, 2008; Salas, 2014). The case of Professor
F is an example here. As it can be appreciated, his con-
servative and religious background is an obvious influ-
ence in the way he developed a narrative about his
dysexecutive impairment, or what he calls the “loss
of intelligence.” A neuropsychoanalytic approach
also has clinical value, since it allows understanding
how cognitive and emotional components interact,
14 C. E. Salas and K. S. L. Yuen

thus contributing to more refined case formulations
and interventions.
Neuropsychoanalytic case studies share most of the
advantages and limitations of traditional case studies
in neuropsychology (for a review of this debate, see
Salas et al., 2016). However, there are two limitations
that are specific to psychoanalytic studies of brain-
injured patients. Firstly, as a methodological approach,
neuropsychoanalytic cases cannot stand alone, but
their evidence needs to converge with data from neu-
ropsychology and neuroscience. The main strength of
neuropsychoanalytic case studies is their potential to
systematically explore the “view from within,” but in
order to guide and interpret such exploration, a solid
knowledge about the neural and neuropsychological
organization of the mind is needed. As a consequence,
such an approach requires “bilingual” clinicians, pro-
fessionals that are “fluent” in both psychodynamic
psychotherapy and clinical neuropsychology. Unfortu-
nately, clinical neuropsychologists are rarely exposed
to psychoanalytic ideas during training, and psycho-
dynamic psychotherapists are rarely interested in a
population that has been wrongly described as non-
analyzable.
There is another common limitation among exist-
ing neuropsychoanalytic studies, which can be
described as a recurrent imbalance between its psycho-
analytic and neuropsychological elements. This imbal-
ance can tilt a case in either way. A study can have a
strong psychoanalytic emphasis, addressing changes
in the mental apparatus, or in specific metapsychologi-
cal processes after a brain injury, but lacking neuropsy-
chological data in the form of an adequate
neuropsychological assessment, or having a very
loose theorization of the neuropsychological processes
compromised by the injury. On the other hand, a study
can have a strong neuropsychological emphasis, with
plenty of neuropsychological data and behavioral
observations, but missing an in-depth and systematic
exploration of the survivor’s internal experience. It is
quite common in these cases to see authors including
very short vignettes of survivors where “snapshots”
of inner experience are portrayed, or what is worse,
simply describing such experience from a third-person
perspective. As the reader may see, in both cases, the
balance between first person perspective and third
person perspective is skewed, thus compromising the
essence of the neuropsychoanalytic enterprise:
The advantage of such an approach [neuropsychoana-
lytic case studies] is that it allows one and the same
thing to be simultaneously studied from both the psy-
choanalytic and the neuroscientific perspectives, so
that the two sets of observations, and the resultant
theoretical accounts, refer to the same reality. Only
this enables us to link the subjective and objective
approaches in mind/brain realities rather than merely
semantic constructs. (Turnbull & Solms, 2004,
pp. 573–374)
Even though the explicit goal of this case study has
been to revise KS-S’ ideas on the role of the left
PFC, our main intention behind writing this article
is to motivate other psychodynamic therapists and
neuropsychologist in using this approach. Despite the
profound impact that Clinical Studies in Neuropsy-
choanalysis has had over the past 15 years, it is still
puzzling why there are so few articles that have fol-
lowed such a path. One possible explanation is that
clinicians who work psychodynamically with brain-
injured patients remain a very small minority. In that
case, a real effort needs to be done to place psychoana-
lysis into clinical neuropsychologists’ curriculums.
Another possibility may well be that clinicians and
researchers are still dazzled by new technologies and
their promise to unveil the darkest nooks of the
mind, or that they only believe in large “N” group
studies as sources of true data. In this case, our job
will be to demonstrate that case studies in general –
and neuropsychoanalytic cases in particular – can
play a key role in contemporary neuroscience, since
they offer a unique possibility to tackle some of the
toughest questions, questions about the neural basis
of what it feels to be a mind.
Notes
1. Some biographical details about Professor F have been
changed in order to preserve his anonymity.
2. See Salas et al. (2014) for a detailed discussion of how
Professor F uses other people as sources of external
regulation.
3. In his book, Restoration of function after brain injury
(1963), Luria also used writing as a compensatory strat-
egy for inner speech problems in cases of dynamic
aphasia.
Disclosure statement
No potential conflict of interest was reported by the authors.
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