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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)