NEUROBEHAVIORDISORDER

Diatri Nari LastriNeurobehavior Division Neurology DepartmentFKUI-RSCM

Introduction Brain – Behavior relationship

Specific Localization / longitudinal specific function has specific localization (lobe syndrome)

Lateralizationsome function are predominantly mediated by one hemisphere or the other

Specific localization (lobe syndrome)

Lateralization

Parallel Distributed Processing Integrated neuronal circuits that are widely

distributed in the brain and have the capacity to change their response bias with learning

Any point in the circuit may interconnect with other circuits

There can be multiple potential effects from a single lesion

Similar effects could emerge from lesions in different parts of the same circuit

Terminology Organic (??) and Functional (??)

“Organic” illnesses ex: Epilepsy functional alterations with or

without structural abnormalities“Functional” illnesses

ex: Psychosis and Depression are products of

neurologic disorders (tumor, stroke) Idiopathic

Psychiatric disorders whose etiologies and pathophysiology have yet to be revealed

Neurologic and Toxic-MetabolicSpecifics types of brain disorders have beenidentified that account for behavioral changes

NeurobehaviorCognitive Function Attention Language Memory Visuospatial Executive Function

Non CognitiveFunction Neuropsychiatric

symptoms Depression Delusion Hallucination Apathy Mania Dysinhibition Psychomotor

Behavior,etc Sleep, Eating, sexual

disorder

Pseudodepression•Outward apathy and indifference

•Loss of initiative

•Reduced sexual interest

•Little overt emotion

•Little or no verbal output

Dysfunction in Orbitofrontal Cortex

Pseudopsychopathy•Immature behavior

•Lack of tact and restraint

•Coarse language

•Promiscuous sexual behavior

•Increased motor activity

•General lack of social graces

ATTENTION

ATTENTION/CONCENTRATION

•Focus attention•Sustain attention•Shifting attention

Attention is the ability to focus on a particular sensory stimulus to the exclusion of others.Concentration is ability to sustain attention over an extended period.Alertness is respond to any stimulus in the environment

Attention

Cortical areas

Thalamus - Limbic

ARAS (Brain Stem)

Simplication of Brainstem, Thalamic, and Cortical Circuits Important for Mintaining Conciousness.

Hemispheric asymmetry in attention

The most common cause of decreased attention : Diffuse brain dysfunction

• Metabolic disturbance• Drug intoxication• Systemic infection

Extensive bilateral cortical damage• Atrophy• Multiple infarcts• Encephalitis• Head trauma

Right hemisphere lesions unilateral neglect Mood alterations

• Anxiety• depression

Attention (Examination) Observation Serial 7 substraction Digit reversal (20 – 1) Month in reverse order (Dec - Jan) Digit span

LANGUAGE

Language The essential elements of language

are: Fluency Comprehension Repetition Naming Reading Writting

Speech is the motor activity that is final step in the expression of language

Language

Process of language

Process of Language

Site Function Abnormality1. Ear and auditory nerve

Hearing deafness

2.Wernicke’s area Understanding Fluent aphasia3.Arcuate fasciculus Repetition Loss of repetition

( Conduction aphasia)

4.Broca’s area Language production

Non-fluent aphasia

5.Motoroutput,central:cerebellum, corticobulbar tracts

Articulation of speech

Dysarthria

6.Motor output peripheral:facial,hypoglossal,, face and tongue

Articulation of speech

Dysarthria

7.Larynx, vagus nerves Voice production Dysphonia

Case 1 A 74 year old right handed woman

was brought to the emergency room because of sudden inability to speak and right sided weakness.

Good comprehension at bedside testing, only a few words and numbers in production, could not repeat “wati”, “beruang”, named no objects, unable to read.

Broca’s Aphasia

Case 2 An 57 year old right handed woman with

a history of hypertension, suddenly “unable to communicate properly”, speaking with words and sentences that did not make any sense.

On exam: spontaneous speech was fluent but

meaningless normal prosody could not repeat even single words could not naming object

Wernicke’s Aphasia

A 64 years-old woman, suddenly had difficulties with reading

At the clinic, she was completely unable to read, but was able to write normally. She wrote “it is a rainy day in Jakarta”, but she was unable to read her own writing a few minutes later

MEMORY

Memory Structure (Squire & Knowlton, 1994)Memory is the ability to register, store, and ultimately retrieve information

Hippocampus This structure was once thought to

be the most essential structure for memory

Removal of one doesn’t do much but removal of both disrupts the ability to form new memories

No disruption of old memories

HM

HM – severe anterograde amnesia

HM

HM working memory

HM Procedural Memory

Case

Normal Brain AD

Memori Klinik

Lama rentang waktu antara stimulus dan recall Immediate memory (detik) Recent memory (menit, jam ,hari,

bulan, tahun) Remote memory (tahun, seumur

hidup)

MemoriStimulus

detik atensiImmediate memory

menit, jam, konsolidasi, ulang, hari, bln, thn simpan

Recent memory thn, seumur hidup konsolidasi lebih

kuat

Remote memory

Memori Amnesia

● Ketidak mampuan untuk mempelajari informasi baru (Recent memory terganggu)● Atensi / immediate memory, remote memory, dan fungsi kognitif lain masih baik● Recall terganggu● Rekognisi terganggu● Sindroma klinik :

▪ Sindroma Korsakof (diencephalic amnesia)▪ Amnesia Pasca Trauma▪ Transient Global Amnesia▪ Ensefalitis Herpes Simpleks▪ Anoksia dan Hipoglikemia

Memori Retrieval Deficit Syndrome

▪ Recall terganggu▪ Immediate memory, remote

memory masih baik▪ Rekognisi baik▪ Area : Frontal – Subkortikal

Memori Perbedaan Amnesia dan

Retrieval Deficit Syndrome Amnesia RDS

Registrasi intak intak

Recall terganggu terganggu

Rekognisi /

Response Clues terganggu intak

Anatomi Hipokampus- Frontal- bdn mamilaris- subkortikal talamus

Memori (Evaluasi) Immediate memory

● Rentang Digit (Repetisi Digit)● Rentang Digit backward (Working memory)

Recent memory● Verbal :Recall 5 objek (mis : pisang, meja, biru, kucing, kantor) setelah 1 menit● Visual : Recall 3 gambar geometrik setelah 1 menit

Remote memory● Autobiografi, kejadian publik (?)

Semantic memory● Pengetahuan (jml hari dalam 1 bulan, dll)

VISUOSPASIAL

Visuospatial Sensory integration function from parietal

lobe. The disorders are usually the result of

damage to the nondominant (right) hemisphere.

Neglect is manifested by misperception of or inattention to sensory stimuli on the contralateral side of the body.

Constructional apraxia, are difficulties to fill in the numbers on a clock face, copy geometric figures, or build figures with bloc

Skill and abilities mediated asymmetrically by the two hemispheres

Left hemisphere Propositional speech Language

comprehension Repetition Naming Reading Writing Praxis (skilled

movement) Calculation

Right hemisphere Facial discrimination Facial recognition Depth perception Receptive affective

prosody Executive affective

prosody Music Constructional ability Mental rotation of

shapes

Visuospasial Agnosia

Sindroma klinis, dengan gangguan pengenalan objek,namun dapat menangkap stimulus sensorik dengan normal● Prosopagnosia

` Ketidakmampuan mengenal wajah yang sudah dikenal● Agnosia jari, lingkungan, warna, simultanagnosia

Visual object Agnosia

Hemispatial Neglect

Visuospatial (evaluation) Clock Drawing Test

● Visuospatial ● Executive Function (planning, abstracts)

Visuospatial tested and brain damage

Parietal lobe affect copying →

Frontal lobe affect spontaneous →

drawing more than

copying

Sub cortical draw in a piece meal →

segmented fraction

without formulation of

and overall

EXECUTIVE FUNCTION

Fungsi Eksekutif

Frontal (terutama korteks prefrontal) – subkortikal

Fungsi :● Inisiasi● Problem solving● Planning● Perseverasi (shifting of idea)● Abstraksi

Fungsi Eksekutif Verbal Fluency (menyebutkan

nama binatang dalam 1 menit) Set Shifting

Oral trail making test (a-1-b-2-c-3-dst)

Abstraksi (peribahasa) Similarities Luria 3 step Perseverasi

Figure 1. Rey-Osterrieth Figure (complex construction) drawn by a patient with a frontal lobe syndrome (model left, copy right). The figure was drawn in a segmented fashion and exaggerates areas with high stimulus value.

Luria 3 step

Perseverasi (shifting of idea)