The authors are Devinsky, Sacks, and Devinsky - Sacks being neurologist and author Dr. Oliver Sacks. Their anonymous patient, a 51 year old married American man, is currently serving a jail sentence for downloading child pornography. But he's not your average pedophile.
The man's problems began at the age of 19 when he -
first suffered attacks of déjà vu ... They became much more frequent – as many as 20 attacks a day – and much more complex, the déjà vu now being followed by a cascade of other symptoms: sharp pains in the chest and sensations of breathlessness; alterations of hearing; occasional musical hallucinations – he would always hear a particular song ‘as clearly as if it were being played in the next room’...Tests showed that these strange sensations were the result of epilepsy, and that the seizures originated in the right mesial temporal lobe, an area of the brain involved in memory and emotion. Temporal lobe epilepsy is relatively common, and it's a fascinating topic in itself, as the symptoms often include hallucinations and other odd experiences such as a powerful sense of déjà vu.
As time went on the symptoms worsened, and anticonvulsant drugs didn't help, so at age 33, the patient had surgery to remove the part of the brain where the seizures were starting. Tests on the brain tissue removed in the operation showed the presence of a brain tumour (ganglioglioma). However, a few months later, the seizures returned, worse than before. So, at age 39, he had a second operation to take out even more of his right temporal lobe. That's when his real trouble started -
Approximately a month after surgery, behavioral changes of irritability, hyperphagia [increased eating] and hypersexuality (including coprophilia) developed. He became more sexually active with his wife and masturbated more often. Compulsively, he began to watch adult pornographic images and videos on the internet when his wife slept.The unfortunate patient's symptoms are a rare example of Klüver-Bucy Syndrome (KBS) in man. Here's the very first account of it -
He no longer clearly understands the meaning of the sounds, sights, and other impressions that reach him. His food is devoured greedily, the head being dipped into the dish, instead of the food being conveyed to the mouth by the hands. He reacts to all kinds of noises, even slight ones – such as the rustling of a piece of paper – but shows no consequent evidence of alarm or agitation and displays tyrannizing proclivities towards his mate.That's a description of a lab monkey, written in 1888 by British neuroscientists Sanger Brown and E. A. Schaefer. Compare it to the patient's own words about what happened to him -
My appetite for food and sex increased dramatically. I had greater mood swings. I wanted sex constantly. Every day. I was very easily stimulated and began to touch myself regularly. I began to request sex daily from my wife. If I wasn’t having sex with my wife, I masturbated. This behavior increased over time. I became more emotionally labile, obsessive–compulsive... I become distracted so easily that I can’t get anything started or done.It's a classic example of KBS, although the patient only had his right temporal lobe damaged, whereas in monkeys KBS usually follows removal of both the left and the right temporal lobes. Also, it's interesting that the symptoms only started a month after the surgery.
The patient's appetite for sex (and food) was insatiable, and this became his downfall -
Some websites solicited him to view and purchase child pornography. He became obsessed with this and eventually purchased and downloaded pornographic images of prepubescent females engaged in sexual activities from the internet. He was ashamed and secretive about these activities, not discussing the pornography or masturbation with his wife or with anyone else.In 2006, he was arrested. A psychiatrist prescribed an antipsychotic, quetiapine, and an antidepressant, sertraline. His sexual obsessions disappeared, and according to his wife, "he became much warmer and loving but the medications shut off his libido... sex became non-existent."
The patient was subsequently charged with 'knowingly and wilfully possessing material which contained at least three images of child pornography'. He plead guilty. Dr Devinsky told the court that the right temporal lobe damage was the "major contributing factor to the patient’s hypersexuality and viewing of child pornography" and that he was, therefore, not responsible for his actions. Oliver Sacks agreed, saying a letter that he was
. . . a man of superior intelligence and of real moral delicacy and sensibility, who at one point was driven to act out of character under the spur of an irresistible physiological compulsion resulting from his brain injury. A recurrence of such behavior is extremely unlikely given his character and insight... He is strictly monogamous.The prosecution, however, argued that he was in control of actions, because he was able to avoid acting inappropriately in public, and they sought the maximum sentence possible - 20 years. They said that
the patient’s hypersexual behavior in some situations but not others was evidence for volitionally controlled criminal behavior; that it was incompatible with a neurological cause. For example, he downloaded and viewed child pornography at home but not at work.The judge, however, accepted that the patient's medical condition was a mitigating factor in the case. He sentenced him to 26 months imprisonment, 25 months home confinement, and 5 years under supervision - the minimum punishment allowable by law.
Should he have been punished at all? Devinsky, Sacks, and Devinsky don't think so: "Was he criminally responsible? Did his behavioral actions warrant imprisonment? We believe the answer is no to both questions."
But the case raises difficult questions about free will and responsibility. At first glance, it seems as though the man's brain damage didn't directly make him download the child porn, but merely gave him an "urge" to do so. Don't we have the ability to choose whether or not to follow our urges? Isn't that what "free will" is?
On the other hand, damage to the same parts of the brain causes strikingly similar symptoms in monkeys. An alien scientist observing life on earth might well conclude, from cases like this, that all the species of monkeys on this planet are very similar - including humans. You damage a certain part of their brains, and their behaviour changes in a predictable way. Most of us humans would say that other monkeys don't have "free will" - but then how are we so sure that we do?
Links: I've previously blogged about drugs to increase libido and the question of free will. The Neurocritic has a great post on neurology and sex from a few weeks back. Finally, perhaps the most important question raised by this case is what would the Paedofinder General say?
Devinsky J, Sacks O, & Devinsky O (2009). Kluver-Bucy syndrome, hypersexuality, and the law. Neurocase : case studies in neuropsychology, neuropsychiatry, and behavioural neurology, 1-6 PMID: 19927260