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4th Annual Current Concepts in Brain Injury Rehabilitation November 2-3, 2013

Frontal Lobe Syndromes 1

Frontal Lobe Syndromes: Never leave home without your frontal lobes

Hilly Rubinsky, Ph.D.

UPMC Rehabilitation Institute

Brain Injury Rehabilitation Unit

Frontal Lobe Syndromes (FLS)

The term frontal lobe syndrome is no longer useful because it implies damage to a specific region of the brain. The clinical presentations involved reflect dysfunction in several parts of the brain, some of which are in the frontal lobes and some which are not. It is best not to use an anatomical term to describe a clinical syndrome. The common theme is not anatomy but behaviors that reflect dysfunction of the executive system. From Parind, 2008

Frontal Lobe Syndrome

A set of behaviors commonly encountered in certain types of neurologically-impaired patients, namely, disinhibition, stimulus-bound behavior, disorganization, social inappropriateness, over-activity, apathy, perseveration and subcortical dementia

Modified From Parind, 2008



FLS Lack of self-control (i.e., saying "you are really

fat" to an obese person)

Impulsivity

Lack of empathy

Self-obsession (i.e. no interests in people, places or things)

Changes in libido

Obsessive-compulsive behavior.

Frontal Lobe Personality (Modified from Deb, 2010)

Lack of initiative and spontaneity

Placidity: worry, anxiety, self-concern

Psychomotor retardation (abulia - mild form and akinetic mutism - severe form)

Organic driveness: brief but intense meaningless activity

Socially disinhibited

Self-absorbed (driven by immediate personal gratification)

Frontal-Subcortical Circuits (Cummings, 1993)

1. A motor circuit originating in the motor cortex and pre-motor cortex

2. An oculomotor unit originating in the frontal eye fields

3. The dorsolateral prefrontal circuit, which underpins executive functions

4. The anterior cingulate circuit which underpins motivation

5. The orbitofrontal circuit which underpins impulse control and social behavior



The frontal lobe is the only cortical region capable of integrating motivational, mnemonic, emotional, somatosensory and external sensory information into unified, goal-directed action.

From Chatham, 2006

From Pridmore, 2013

From Keifer, 2010



Relevant Brief History

Feuchtwanger (1923) 200 frontal lobe injury cases. Features: lack of initiative, vacillation, euphoria, inattentiveness and normal intellect and memory.

Moniz (1935) - Prefrontal lobotomies in psychotic patients. (We all know how that worked out.)

Jacobson (1935) Premotor lobotomies in primates. Features: Social indifference, tameness, placidity, forgetfulness, difficulty in problem solving.

Luria (1964) Observations from war-related frontal lobe injuries.

Stuss (present day) The leading frontal lobe expert/researcher

Relevant Brief History - Continued

The Case of Phineas Gage

1) Taming iron blown through the left frontal part of his skull in 1848

2) Great physical recovery

3) Marked personality changes: lack of consideration for others, profane speech, impaired execution of his plans



Prefrontal Syndromes

1. Dysexecutive Syndrome (dorsolateral convexity)

2. Disinhibited Syndrome (orbital area)

3. Apathetic-Akinetic Syndrome (medial area)



Dysexecutive Syndrome (Dorsolateral Prefrontal Region)

1. Inability to integrate disparate sensory elements into a coherent whole

2. Stereotyped or limited response repertoire

3. Easy loss of task set

4. Perseverative or inflexible behavior

Dysexecutive Syndrome (Dorsolateral Prefrontal Region) - Continued

5. Lack of self-monitoring of errors

6. Decreased working memory (verbal and spatial)

7. Inefficient learning and failure to make use of active learning strategies

8. Reduced memory for temporal or situational context information

Dysexecutive Syndrome (Dorsolateral Prefrontal Region) - Continued

9. Inefficient free recall despite normal recognition of newly learned information

10. Lack of response flexibility (stuck in set)

11. Impaired self-awareness

12. Decreased planning

13. Impaired goal selection

14. Impaired sequencing

From Smalloy et al., 2006



Disinhibited Syndrome (orbital area)

1. Anosmia

2. Disinhibited personality change

3. Amnesia with confabulation

4. Disruption of inhibitory and emotional mechanisms with resulting impulsivity and inappropriate behavior (can include emotional incontinence, affective lability, and situational inappropriate emotional reactions)

Disinhibited Syndrome (Orbital Area) - Continued

5. Perseveration 6. Stimulus-bound behavior

7. Attentional problems (most common are increased distractibility by irrelevant stimuli and diminished sustained and divided attention)

8. Impaired insight and judgment

9. Miscalculated reward expectations (i.e., errors in anticipation and processing of reward/punishment outcomes) From Smalloy et al., 2006

Other Orbital Characteristics

1) A failure to appreciate the consequences of one's actions

2) Euphoria with a tendency to jocularity, moria (childish excitement), joking and pathological punning

3) Sexual indiscretions and exhibitionism



Apathetic-Akinetic Syndrome (Medial Area)

1. Akinetic mutism (failure to respond to environmental stimuli and remains inert)

2. Diminished responsiveness resulting in difficulty initiating or persisting in behavior (impersistence i.e., failure to maintain a particular response despite reinforcement, feedback, cues or other signals indicating that additional responding is necessary)

Apathetic-Akinetic Syndrome (Medial Area) Continued

3. Unilateral lesions usually transient effects but usually persistent with bilateral lesions

4. Flat/blunted affect, docile, apathetic

5. Alien Hand Syndrome if supplementary motor area and corpus callosum involved

6. Psychosocial consequences (e.g., divorce, job loss, lose friends)

From Smalloy et al., 2006)

Non-focalized Frontal Deficits

1) Frontal release signs (inability to inhibit primitive reflexes such as grasp and snout)

2) Environmental dependency and utilization behavior (believed to be due to a release of parietal exploratory behavior due to absence of frontal inhibition)



Frontal Operculum Area

Center for expression of language

Left-sided lesions may show expressive language impairment (Brocas aphasia)

Right-sided lesions tend to develop expressive aprosodia (impaired emotional expression of language)

Non-focalized Frontal Deficits Continued

1) Reduplicative paramnesia

2) Capgras syndrome

3) Secondary depression and secondary mania

From Smalloy et al., 2006

Executive Functions of the PFC

Set of cognitive processes required to coordinate and direct behavior in a goal-directed way under conditions involving interference or otherwise requiring precise control of response

Chatham, 2006



Executive Functions of the PFC - Continued

1. Initiating and carrying out new and goal-directed patterns of behavior

2. Sustained attention

3. Short-term memory tasks

4. Inhibitory control of interference filtering or gating mechanism of information processing

5. Working memory

Executive Functions of the PFC - Continued

6. Sequencing

7. Planning, shifting set, flexibility

8. Delayed responding

9. Active problem solving

10. Emotional regulation

Neuropsychological Assessment of the PFC

Most of the standardized neuropsychological tests were never designed to assess damage to the frontal lobes. Patients with frontal lobe impairment may look OK on the structured neuropsychological tests but be totally frontal in the real world (e.g., impulsive, disinhibited, distractible and forgetful).



Common Neuropsychological Tests for Assessing PFC

Wisconsin Card Sorting Testing (WCST)

Trail Making Test (TMT)

Stroop Test

Tower of London Test (TOL)

Delis-Kaplan Executive Function System (D-KEFS)

Hayling & Brixton Tests

Common Neuropsychological Tests for Assessing PFC - Continued

Behavioral Assessment of the Dysexecutive Syndrome (BADS)

Frontal Lobe Personality Scale (FLOPS)

Executive Interview (EXIT 25)

Controlled Oral Word Association Test (COWAT)

Halstead Category Test (HCT)

Interventions

Setting limits

Maintaining Structure

Redirecting negative behaviors

Reinforcing positive behaviors

Pharmacologic approaches (e.g., treating associated depression, lability, hypomania, agitation, inattention, memory problems)



Interventions - Continued

Realistically, except for the mild cases, someone other than the patient has to serve as the patients damaged PFC. This means providing a structured and supervised environment 24/7.


For example, this may involve repetitively telling a patient to keep his/her helmet on and having to refasten it 25 or more times during an 8-hour shift.


Goal Management Training (GMT; Robertson, 1966; Levine et al., 2000b, 2007). Goal is to train patients to stop ongoing behavior in order to define goal hierarchies and monitor performance. This is achieved via instructional material, interactive tasks and discussion of real-life deficits. Basically focuses on sustaining attention and keeping goals in working memory until they are achieved.



Questions

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