4. Neuropsychological syndromes with lesions of the frontal brain.

The frontal portions of the brain are a complex formation both in their structural organization and in the functions they provide in the integral psyche system, in the complex of mechanisms ensuring self-regulation of mental activity in its components such as goal-setting due to motives and intentions, program formation (choice means) of achieving the goal, monitoring the implementation of the program and its correction, comparing the result of the activity with the original task. Speaking about the complex, multifunctional and supmodal functions of the frontal lobes in general, A.R. Luria emphasized their role in organizing movements and actions. What is the reason for separating movements from the general notion of action in a neuropsychological context? This is due to the direct connections of the anterior parts of the brain with the motor cortex and allows us to consider the frontal systems in combination with the motor and premotor zones as cortical parts of the motor sphere.
The complexity of the structure of the frontal divisions, their connection with other cortical divisions, with subcortical structures, with the limbic-reticular complex and diencephalic structures, on the one hand, give grounds for a conclusion about the integral function of the anterior brain regions, on the other hand, they require a differentiated approach to the assessment of private functional contributions to the organization of mental processes on the part of individual subsystems in the overall structure of the anterior sections of the brain. The analysis of clinical variants of mental disorders in local brain pathology allows us to distinguish the following syndromes: posterolate (premotor) syndrome; prefrontal syndrome; basal frontal syndrome; syndrome of lesion of the deep parts of the frontal lobes.
a) Syndrome of disturbance of the dynamic (kinetic) component of movements and actions in case of affection of the posterior plots of the brain.
Many mental functions can be considered as processes developed in time and consisting of a series of successively alternating links or subprocesses. Such, for example, is the memory function, consisting of the steps of fixing, storing and updating. These are many of the processes in the structure of speech activity. When solving an arithmetic problem, the operations of the program of the solution follow one after another; motor skills generally imply such a clutch of links deployed in a time sequence of execution, when the end of the previous operation is the beginning, the starting signal of the transition to the next. The movements as a whole most clearly represent their consistently temporary character, the successive principle of realization. At the same time, it is important not only the deployment of the movement itself in time, but also the deployment condition necessary for a perfect motor system - a smooth transition from element to element. This component in movements and actions in neuropsychology has received the name of the kinetic (dynamic) factor and is provided by the activity of the posterior plots of the brain. Describing the kinetic factor, we emphasize once again that it contains two main components: a change in the process links (deployment in time) and a smooth ("melody") transition from one link to another, which implies timely deceleration of the preceding element, stealth transition and the absence of interruptions. Finally, speaking of the syndrome of the lesions of the subnormal parts of the brain and the factor provided by them, it should be noted that this area includes the highest level of representation of one of the efferent systems that ensure the execution of movements - extrapyramidal. Moreover, the latter is intimately associated with an extensive group of subcortical nuclei, as a result of which the lesion syndrome of the premotor region itself often appears in conjunction with the subcortical component.
Efferent or kinetic apraxia, which in the clinical and experimental context is assessed as a violation of dynamic praxis, is the central disturbance in the lesions of the posterior region. When memorizing and executing a special motor program consisting of three successively alternating movements (“fist-edge-palm”), there are clear difficulties in its execution with proper memorization of the sequence at the verbal level. These difficulties are presented in the form of isolated execution of each of the parts of the program with constant random control (de-automatization), simplification or shortening of the sequence. With more massive lesions observed pathological inertness, "stuck" on one of the elements in a series of movements, making it difficult to move to the next link in the program.
Such phenomena can be seen in any motor acts, especially those where the radical of a smooth change of elements is most intensely represented. So, for example, with this localization of the pathological process, violations of the letter are found in the form of its de-automatization, the transition to separate writing of letters, the loss of the individual features of handwriting. It is known that in adults, automated writing relies heavily on the kinetic component. With the defeat of the posterior area of ​​the letter (as well as other motor skills) not only loses the property of speed, but also goes on to the level of an arbitrary deployed performance.
Violation of the kinetic factor in the organization of movements can be detected when patients perform other motor tasks, for example, in samples for the reproduction of rhythmic structures. Serial tapping becomes as if broken; in them appear superfluous beats seen by the patient, but difficult to obtain corrections; the transition from one part of the accentuated rhythm to the other (two slow strokes - three fast ones), inert reproduction of one of the rhythmic cycles.
As follows from the above, the change in the neurodynamic parameters of the brain in the form of pathological inertness, noted during the performance of all motor tasks, is obviously an important determinant in the formation of the posterolate syndrome. This is especially pronounced with a massive severity of the syndrome by the phenomenon of motor elemental perseverations. Forced, perceived by the patient, but inaccessible to slowing down the reproduction of an element or cycle of movement prevents the continuation of the motor task or its end. Thus, in the task of “drawing a circle,” the patient draws a repeatedly repeated image of a circle (a “skein” of circles). Similar phenomena can be seen in the letter, especially when writing letters consisting of homogeneous elements ("Mishin machine").
The defects described above can be seen when performing motor tasks both with the right and with the left hand. At the same time, the left hemisphere foci cause the appearance of pathological symptoms in both the contra- and ipsilateral foci of the hand lesions, while the pathology in the posterior pterygomas of the right hemisphere of the brain appears only in the left hand. This fact indicates the dominant role of the left hemisphere of the brain in ensuring the kinetic factor in praxis. Symptoms that are characteristic of lesions of the backside area can be seen in the organization of another sphere of motor acts - speech motor skills. The localization of the pathological process in the lower parts of the premotor zone of the left hemisphere (Broca's zone) leads to the emergence of efferent (kinetic) motor aphasia. Pathological inertness is manifested here in the difficulties of slowing down the already uttered speech sounds during the transition to subsequent ones. A.R. Luria describes how a patient, who correctly began to utter the word "fly", cannot denervate the syllable "mu" and says "mu ... m ... m ... ma". It should be noted that kinetic difficulties in speech motor skills can be observed only when speech is included (mild syndrome), or in perseverator replacement of unfolded speech with a single speech stereotype, the so-called speech embolus, in coarse speech disorders. In cases of relative preservation of speech utterances, patients with efferent motor aphasia are characterized by chanting, lack of smoothness, reducing the role of intonation, emotional and mimic components, general impoverishment, especially by reducing verbs (telegraphic style), insufficient speech initiative. As well as movement, the patient's speech loses its individual characteristics, resembles the speech products of mechanical devices. In the defect system, not only the expressive side of speech suffers, but also understanding, especially with the rapid pace of speech facing the patient, because its perception requires an appropriate adjustment of the perceptual speech motor that is violated. These difficulties are exacerbated by the directional influence on the subtle movements of the speech apparatus by the instruction “clamp the tongue between the teeth” or “clamp the pencil between the teeth”. It is characteristic that the same technique helps to identify the speech defect in afferent motor aphasia.
The violation of the dynamic component of the movements correlates with the violation of the dynamics of the flow of intellectual and mnestic processes, i.e. is a syndrome-forming radical in the formation of a wider, than only motility, spectrum of symptoms of mental deficiency. In the structure of the syndrome, it is possible to see the difficulties of solving arithmetic problems in the form of jamming the patient on the actions initially performed, preventing the transition to subsequent ones; in the form of the inability to change the wrong decision algorithm to the correct one. With the available actualization of the sequences fixed in the individual experience in direct order (January, February, March ..., December; Monday, Tuesday ..., Sunday), patients find it difficult to reproduce them in the reverse order (December, November, ... January; Sunday, Saturday, ... Monday), begin the task correctly, but gradually slide down to the automated straight line. Error correction takes place, but does not lead to success, after correction the patient again updates the sequence in direct order. Similar difficulties arise when performing counting operations (especially with a serial account) with a "reverse vector": subtraction and division are replaced by addition and multiplication. In tasks of arbitrary memorization in patients of this group, the phenomenon of proactive inhibition is observed, consisting in the fact that memorization and reproduction of the preceding material negatively affects memorization and reproduction of subsequent stimuli, replacing them in the case of grossly expressed pathological inertness.
Thus, the defeat of the posterior portions of the brain leads to the complex syndrome of motor, speech, intellectual and mental disorders in connection with the violation of the factor of dynamic organization of activity in its temporary, successive deployment. All these symptoms are most clearly associated with the left hemispheric localization of the pathological process, which indicates the dominant function of the left hemisphere in relation to the successively organized mental processes.
b) Syndrome of violation of regulation, programming and control of activity in case of lesion of the prefrontal divisions
The prefrontal regions of the brain belong to tertiary systems, which are formed late in phylogenesis and ontogenesis and reach the greatest development in humans (25% of the total area of ​​the cerebral hemispheres). According to A.R. Luria, the frontal cortex, as it were, builds up over all the formations of the brain, providing regulation of the states of their activity.
In addition to being directly involved in ensuring the working mode of the cortical tone in solving various tasks, the prefrontal divisions, as shown by clinical and psychological data, are directly related to the integrative organization of movements and actions throughout their implementation and, above all, at the level of arbitrary regulation. What does arbitrary regulation of activity imply? First, the formation of intentions, in accordance with which the purpose of the action is determined and, based on past experience, an image of the final result that corresponds to the goal and satisfies the intention. Secondly, the selection of the means necessary to achieve the result is carried out in their sequential connection, i.e. program. Thirdly, the execution of the program should be monitored, since the conditions for achieving the result may change and require correction. Finally, it is necessary to make a comparison of the achieved result with what was supposed to be obtained and, again, to make a correction, especially in case of a mismatch between the forecast and the result. Thus, the arbitrarily planned execution of a task in itself is a complex, multi-part process, during which the correctness of the chosen path to the realization of the original intention is constantly checked and corrected.
One of the features of the "frontal syndrome", usually associated with dysfunction of the prefrontal regions, complicates both its description and clinical neuropsychological diagnosis - a variety of options for the severity of the syndrome and its member symptoms. A.R. Luria and E.D. Chomsky (1962) point to a large number of determinants that determine variants of the frontal syndrome. These include the localization of the tumor within the prefrontal regions, the massiveness of the lesion, the addition of cerebral clinical symptoms, the nature of the disease, the age of the patient and his premorbid features. It seems to us that the individual-typological features of a person, the level of the psychological structure that LS. Vygotsky designated as the "core" of the individual, in many respects determines the possibilities of compensation or masking of the defect. We are talking about the complexity of the stereotypes formed during the life, the breadth and depth of that "buffer zone", within which there is a decrease in the overall level of regulation of mental activity. It is known that a high level of established forms of behavior and professional characteristics, even with severe pathology of the prefrontal divisions, determines the availability of patients performing fairly complex activities.
All that has been said about variants of the frontal syndrome, the riddle of the function of the frontal lobes (according to G. L. Toyber) to some extent can serve as an excuse for the lack of clarity with which the syndrome of prefrontal brain lesions will be described in this paper. Nevertheless, we will try to systematize the main components of this form of local pathology, based on the ideas of A.R. Luria.
One of the leading signs in the structure of the frontal syndrome, in our opinion, is the dissociation between the relative safety of the involuntary activity level and the deficiency in the arbitrary regulation of mental processes. This dissociation can take an extreme degree of severity, when the patient is practically inaccessible to perform even simple tasks that require minimal arbitrary activity. The behavior of such patients is subject to stereotypes, stamps and is interpreted as a phenomenon of "responsiveness" or "field behavior." Such cases of "field behavior" are described: when leaving the room instead of opening the door, the patient opens the doors of the cabinet next to the exit; when performing the instruction, light a candle, the patient takes it in his mouth and lights it like a cigarette. A.R. Luria often said that it is better to judge the state of mental processes and the level of achievements in neuropsychological examination of a patient with frontal syndrome, if one does not examine this patient, but his roommate. In this case, the patient is involuntarily included in the examination and can detect a certain productivity when involuntary performing a number of tasks.
The loss of the function of arbitrary control and regulation of activity is especially pronounced when the instructions of tasks are fulfilled, which require the construction of an action program and control over its implementation. In this regard, patients form a complex of disorders in the motor, intellectual and mnestic areas.
In the frontal syndrome, a special place is occupied by the so-called regulatory apraxia, or apraxia of the target action. It can be seen in such experimental tasks as the performance of conditioned motor reactions. The patient is invited to perform the following motor program: "when I hit the table once - you raise your right hand, when twice - raise your left hand." Repetition of the instruction is available to the patient, but its implementation is grossly distorted. Even if the initial implementation can be adequate, then when a sequence of stimulus strokes is repeated (I – II; I – II; I – II), the patient develops a stereotype of arm movement (right – left, right – left, right – left). When changing the sequence of stimuli, the patient continues to implement the stereotypical sequence that has taken shape, ignoring the change in the stimulus situation.In the most rude cases, the patient may continue to actualize the prevailing stereotype of hand movement when the stimuli are stopped. So, following the instruction “squeeze my hand 2 times”, the patient shakes it repeatedly or simply squeezes once, for a long time.
Another variant of the violation of the motor program may be its initial direct subordination to the nature of the presented stimuli (ecopraxia). In response to one stroke, the patient also performs one tapping, two knocks - knocking twice. In this case, a change of hands is possible, but there is an obvious dependence on the stimulus field, which the patient cannot overcome. Finally (as an option), when the instruction is repeated at the verbal level, the patient does not perform the motor program at all.
Similar phenomena can be seen in relation to other motor programs: mirror uncorrected performance of the Head test, echoprax performance of the conflict conditional reaction ("I will lift a finger, and you will raise a fist in response"). Replacing the motor program with an echopraxia or a stereotype formed is one of the typical symptoms in the case of pathology of the prefrontal regions. At the same time, the actualized stereotype that replaces the real program may refer to well-established stereotypes of the patient’s past experience. As an illustration, refer to the above example with the ignition of the candle.
The description of the symptoms characteristic of apraxia of the target action will be incomplete if you do not touch on another feature in the impairment of the motor programs, which, however, has a broader meaning in the structure of the prefrontal frontal syndrome and can be singled out as the second leading symptom. This violation is classified as a violation of the regulatory function of speech. If you again turn to how the patient's motor programs perform, you can see that the speech equivalent (instruction) is absorbed and repeated by the patient, but does not become the lever by which the control and correction of movements are carried out. The verbal and motor components of the activity seem to come off, split off from each other. In the roughest forms, this can manifest itself in the replacement of motion by the reproduction of verbal instruction. So,the patient, who is asked to squeeze the examining hand twice, repeats "squeeze twice", but does not perform the movement. When asked why he does not follow the instructions, the patient says: "squeeze twice, already done." Thus, the verbal task not only does not regulate the motor act itself, but is also not a trigger mechanism that forms the intention to perform the movement.
Both the violation of an arbitrary regulation of activity and the violation of the regulatory function of speech are in close connection with each other and in conjunction with another symptom, the inactivity of a patient with a prefrontal lesion.
Inactivity as a lack of intention in the organization of behavior in the implementation of movements and actions can be represented at various stages. At the stage of forming intentions, it is manifested in the fact that the instructions and tasks offered to the patient are not included in the internal plan of his activity, whereby the patient, if included in the activity, replaces the task required by the instruction with a stereotype or echoxia. With the safety of the activity at the first stage (the patient accepts the instruction), the inactivity can be seen at the stage of the formation of the program of execution, when a properly started activity is eventually replaced by an already established stereotype. Finally, the inactivity of the patient can be identified at the third stage - the comparison of the sample and the result of the activity.
Thus, for the prefrontal frontal syndrome is characterized by a violation of the arbitrary organization of activity, a violation of the regulatory role of speech, inactivity in behavior and when performing tasks of neuropsychological research. This complex defect is especially clearly manifested in the motor, intellectual mnestic and speech activities.
The nature of movement disorders has already been considered. In the intellectual sphere, as a rule, purposeful orientation is violated in terms of the task and program of actions necessary for the implementation of mental operations.
A good model of verbal-logical thinking is counting serial operations (subtraction from 100 to 7). Despite the availability of single subtraction operations, in the conditions of the serial account, the execution of a task is reduced to replacing the program with fragmentary actions or stereotypes (100 - 7 = 93, 84, ... 83, 73 63, etc.).
More sensitized breakdown is the solution of arithmetic problems. If the task consists of one action, its solution does not cause difficulties. However, in relatively more complex tasks, it is violated, as shown by A.R. Luria and L.S. Tsvetkova (1966), and the general orientation in the conditions (especially the question of the problem, which is often replaced by the patient due to the inert inclusion of one of the elements of the condition into it), and the solution itself, which does not comply with the overall plan, program.
In visual-cogitative activity, the model of which is the analysis of the content of the plot picture, similar difficulties are observed. From the general “field” of a picture, the patient impulsively snatches out any detail and further suggests the content of the picture, not comparing the details with each other and not correcting his assumption according to the content of the picture. So, having seen the inscription "Caution" in the picture depicting a skater who had fallen through the ice and a group of people attempting to save him, the patient concludes: "High Voltage Current". The process of visual thinking is being replaced here again by the actualization of the stereotype caused by a fragment of the picture.
Mnestic activity of patients is disturbed first of all in the link of their arbitrariness and purposefulness. So, writes A.R. Luria, these patients lack primary memory disorders, but the ability to create strong motives for memorizing, maintain active tension and switch from one set of tracks to another is extremely difficult. When memorizing 10 words, a patient with frontal syndrome easily reproduces 4-5 elements of a sequence that can be memorized directly at the first presentation of a series, but when presented again, the playback performance does not increase. The patient inertly reproduces the originally captured 4-5 words, the learning curve has the character of a "plateau", indicating the inactivity of mnestic activity.
Of particular difficulty for patients are mnestic tasks, requiring the successive memorization and reproduction of two competing groups (words, phrases). In this case, an adequate reproduction is replaced by an inert repetition of one of the groups of words, or one of 2 phrases.
Defects of arbitrary regulation of activity in combination with inactivity are also manifested in the speech activity of patients. Their spontaneous speech is depleted, they lose their speech initiative, echolalia predominate in the dialogue, speech production is replete with stereotypes and cliches, meaningless statements. Also, as in other activities, patients can not build a program of self-narration on a given topic, and when reproducing the story proposed for memorization, they slide into side associations of the stereotypical-situational plan. Such a speech disorder is classified as speech spontaneity, speech weakness or dynamic aphasia. The question of the nature of this speech defect is not fully resolved: whether it is actually speech or goes into the syndrome of general inactivity and aspiration. It is obvious, however, that common radicals,violations of goal-setting, programming, and control for the defeat of the prefrontal brain, which form the syndrome, are clearly expressed in speech activity.
In the characterization of the prefrontal syndrome, its lateral features remained unexamined. Given that all the symptoms described are most clearly manifested in bilateral lesions of the anterior parts of the frontal lobes of the brain, the unilateral location of the focus introduces its own characteristics. With the defeat of the left frontal lobe, the violation of the regulatory role of speech, the impoverishment of speech production, and the decrease in speech initiative are especially pronounced. In the case of right-hemispheric lesions, disinhibition of speech, an abundance of speech production, and the patient's readiness to quasi-logically explain their mistakes are observed. However, regardless of the side of the lesion, the patient's speech loses its meaningful characteristics, includes stamps, stereotypes, which, with right hemisphere foci, gives it a color of “resonance”.More rudely with the defeat of the left frontal lobe inactivity manifests itself; decrease in intellectual and mnestic functions. However, the localization of the lesion in the right frontal lobe leads to more pronounced defects in the field of visual, non-verbal thinking. Violation of the integrity of the assessment of the situation, narrowing of the volume, fragmentation, characteristic of the right-hemispheric dysfunctions of the previously described brain zones, are fully manifested in the frontal localization of the pathological process.fully manifested in the frontal localization of the pathological process.fully manifested in the frontal localization of the pathological process.
c) Syndrome of emotional-personal and mental disorders with the defeat of the basal parts of the frontal lobes.
Localization of the pathological process in the basal parts of the frontal lobes leads to a number of emotional-personal disorders. Considering the emotional processes in this context, we can distinguish the following components to be analyzed: the general emotional background of the patient's mood, situationally conditioned emotional reactions, attitude to one's disease, stability or lability of affective processes, a variety of emotional reactions.
The assessment of one's disease and its experience, the cognitive and emotional components of the internal picture of the disease in patients with lesions of the basal areas of the frontal lobes take a dissociated nature, although each of them does not have an adequate level. So, knowledge of some of the symptoms of their disease, their formal transfer to patients with lesions of the right hemisphere of the brain is combined with the lack of a holistic view of their disease and its experience (anosognosia). Explaining complaints in response to questions, the patient says, as it were, not about himself, while ignoring the significant symptoms. The general background of the mood is characterized by complacency, euphoria, and in a number of cases by the disinhibition of the affective sphere.The stability of a benign mood background is also manifested in emotional reactions to failure when performing various tasks. Patients make attempts to explain their insufficiency due to external factors, the lack of necessary skills in the past. Such a “quasi-logical” (according to A.R. Luria) argument creates the appearance of an adequate comprehension of the situation of failure. Superficial, formal naming of disease symptoms in combination with their ignoring, the lack of a holistic internal picture of the disease suggests that the disease is not included in the system of semantic parameters, is not a component of self-awareness.Luria) the argument creates the appearance of an adequate comprehension of the situation of failure. Superficial, formal naming of disease symptoms in combination with their ignoring, the lack of a holistic internal picture of the disease suggests that the disease is not included in the system of semantic parameters, is not a component of self-awareness.Luria) the argument creates the appearance of an adequate comprehension of the situation of failure. Superficial, formal naming of disease symptoms in combination with their ignoring, the lack of a holistic internal picture of the disease suggests that the disease is not included in the system of semantic parameters, is not a component of self-awareness.
The lesion of the basal parts of the left frontal lobe is characterized by a general depressive background of behavior, which, however, is not due to the true experience of the disease, the cognitive component of the internal picture of which the patient is absent. Complaints are either not spontaneously presented to the patient at all, or are presented undifferentiated in the general (very depleted) stream, where intestinal insufficiency is noted in the same row with an indication of headaches. Separate emotional reactions to failure can take place in the form of negativism, aggression, and violent crying. Such emotional manifestations are labile in nature.
In general, the emotional world of patients with fronto-basal pathology is characterized by the impoverishment of the affective sphere, the monotony of its manifestations, the insufficient criticality of patients in a situation of neuropsychological examination, and the inadequacy of the emotional response. Against this background, there are no distinct disorders of gnosis, praxis, and speech. The functional insufficiency of the basal areas of the frontal lobes affects intellectual and mnestic processes to a greater degree. The operational side of thinking remains intact, but it can be disrupted at the level of systematic monitoring of activities. Performing a sequence of mental operations, patients find an impulsive slide on side associations, move away from the main task, show rigidity if the algorithm needs to be changed.In general, a specific violation of the neurodynamic parameters of activity characterized by a seemingly paradoxical combination of impulsiveness (disinhibition) and rigidity, which give the syndrome of plasticity disorder, is characteristic of this localization of the lesion. This radical is also found in the implementation of the mnestic function, the level of achievement in which fluctuates, and not so much due to changes in productivity, but rather due to the predominance of one or the other part of the stimulus material in the product.This radical is also found in the implementation of the mnestic function, the level of achievement in which fluctuates, and not so much due to changes in productivity, but rather due to the predominance of one or the other part of the stimulus material in the product.This radical is also found in the implementation of the mnestic function, the level of achievement in which fluctuates, and not so much due to changes in productivity, but rather due to the predominance of one or the other part of the stimulus material in the product. A.R.Luria figuratively described this variant of violations as “the tail pulled out - the nose stuck, the nose pulled out - the tail stuck”. So, for example, recalling the story, consisting of two concentres, the patient impulsively reproduces his second half, the closest in time to the time of actualization. Repeated presentation of the story may, due to the correction by the patient, ensure the reproduction of its first half, hindering the possibility of transition to the second part.
In conclusion of the description of the syndrome of mental disorders in the defeat of the basal parts of the frontal lobes of the brain, it should be noted that its features are due to the connection of the latter with the formation of the "visceral brain." That is why the foreground in it are changes in emotional processes.
d) Syndrome of impaired memory and consciousness in the defeat of the medial regions of the frontal lobes of the brain.
Medial regions of the frontal lobes included A.R. Luria in the first block of the brain - the block of activation and tone. At the same time, they enter into a complex system of the anterior parts of the brain; therefore, the symptoms that are observed at the same time acquire a specific color in connection with those disorders that are characteristic of the defeat of the prefrontal regions. With the defeat of the medial regions, there are two main sets of symptoms - impaired consciousness and memory.
Disturbances of consciousness are characterized by disorientation of the patient in a place, in time, in his illness, disorientation in his own personality. Patients can not exactly name their place of residence - a geographical point, hospital. Often, this may cause a “train station syndrome”, as an uncritical reflection of the temporality of the place of stay, frequent movements associated with various surveys. In the orientation in the place, random signs acquire a special role, when the patient interprets the situation of his place of residence by the type of "field behavior". So, lying under the net (due to psychomotor agitation), the patient answers the question where he is, that in the tropics, because "very hot and mosquito net". Sometimes there is a so-called dual orientation,when the patient does not feel at the same time the contradictions, replies that he is simultaneously in two geographical locations. One of the patients described by A.P. Luria, said that she is in Moscow and Novosibirsk, and that "the speed of movement and the wonders of modern technology provide such an opportunity." (It is characteristic that information about the place of stay had its source in the past patient's experience: she, who was on a permanent job in Moscow, very often had to fly to work for a long time in Novosibirsk).that the information about the place of stay had its source in the past patient's experience: she, who was on a permanent job in Moscow, very often had to fly to work for a long time in Novosibirsk).that the information about the place of stay had its source in the past patient's experience: she, who was on a permanent job in Moscow, very often had to fly to work for a long time in Novosibirsk).
The orientation in time is no less disturbed, both in terms of knowing the date and in the current immediate time. Patients cannot name the year, month, day, time of year, their age, the age of their children or grandchildren, the duration of the disease, the time spent in the hospital, the date of surgery or the length of time after it, the current time of day or the period of the day (morning, evening, and .d.) Orientation in objective values ​​of time (date) and its subjective parameters were called, respectively, chronology and chronognosia.
The described symptoms of disorientation in the most pronounced form are found in bilateral lesions of the medial regions of the frontal lobes of the brain. However, they also have specifically lateral features. With the defeat of the right hemisphere of the brain, a dual orientation in a place is more common, or absurd answers about the place of their stay associated with confabulatory interpretation of environmental elements.
Disorientation in time according to the type of violation of chronognosy is also more characteristic of right-sided patients. The chronology may remain intact.
Memory impairment in case of damage to the medial regions of the frontal lobes is characterized by three features: modal non-specificity, impairment of delayed (under interference) reproduction compared with relatively preserved direct and impaired selectivity of reproduction.
According to the first two signs, mental disorders are similar to the memory disorders described above with lesions of the medial regions of the temporal region (hippocampus), as well as its defects, which will be characterized further in connection with the defeat of the hypothalamic-diencephalic region. Violation of the mnestic function applies to memorizing material of any modality, regardless of the level of semantic organization of the material. The volume of direct memorization corresponds to the norm indicators in their middle and lower boundaries. However, introducing the interval between memorizing and reproducing an interfering task has a retroactive inhibitory effect on reproducibility. With the similarity of these signs of a mnestic defect at different levels of the first block of the brain, the lesion of the medial regions of the frontal lobes introduces its features in amnesia:violation of the selectivity of reproduction associated with a lack of control during updating. In the reproduction product, "contaminations" appear (contamination) due to the inclusion of stimuli from other memorized series, from the interfering task. When the story is reproduced, confabulations take place in the form of the inclusion in it of fragments from other semantic passages. Consecutive memorization of two phrases "Apple trees grew in the garden behind a high fence." (1) "At the edge of the forest, a hunter killed a wolf." (2) Forms the phrase "In the garden behind a high fence, a hunter killed a wolf". Contamination and confabulations can also be represented by extra-experimental fragments from the patient's past experience. In essence, we are talking about the inability to slow down uncontrollably pop-up side associations.associated with a lack of control during updates. In the reproduction product, "contaminations" appear (contamination) due to the inclusion of stimuli from other memorized series, from the interfering task. When the story is reproduced, confabulations take place in the form of the inclusion in it of fragments from other semantic passages. Consecutive memorization of two phrases "Apple trees grew in the garden behind a high fence." (1) "At the edge of the forest, a hunter killed a wolf." (2) Forms the phrase "In the garden behind a high fence, a hunter killed a wolf". Contamination and confabulations can also be represented by extra-experimental fragments from the patient's past experience. In essence, we are talking about the inability to slow down uncontrollably pop-up side associations.associated with a lack of control during updates. In the reproduction product, "contaminations" appear (contamination) due to the inclusion of stimuli from other memorized series, from the interfering task. When the story is reproduced, confabulations take place in the form of the inclusion in it of fragments from other semantic passages. Consecutive memorization of two phrases "Apple trees grew in the garden behind a high fence." (1) "At the edge of the forest, a hunter killed a wolf." (2) Forms the phrase "In the garden behind a high fence, a hunter killed a wolf". Contamination and confabulations can also be represented by extra-experimental fragments from the patient's past experience. In essence, we are talking about the inability to slow down uncontrollably pop-up side associations.contamination "(contamination) due to the inclusion of incentives from other memorized series from the interfering task. When playing the story, confabulations take place in the form of including fragments from other meaningful passages. Sequential memorization of two phrases" Apple trees grew in the garden behind a high fence. "( 1) “At the edge of the forest, a hunter killed a wolf.” (2) Forms the phrase “In the garden behind a high fence, a hunter killed a wolf.” Contamination and confabulation can also be represented by non-experimental fragments from the past that of the patient. In essence, we are talking about the impossibility of ottormozit uncontrolled pop-side association.contamination "(contamination) due to the inclusion of incentives from other memorized series from the interfering task. When playing the story, confabulations take place in the form of including fragments from other meaningful passages. Sequential memorization of two phrases" Apple trees grew in the garden behind a high fence. "( 1) “At the edge of the forest, a hunter killed a wolf.” (2) Forms the phrase “In the garden behind a high fence, a hunter killed a wolf.” Contamination and confabulation can also be represented by non-experimental fragments from the past that of the patient. In essence, we are talking about the impossibility of ottormozit uncontrolled pop-side association.When the story is reproduced, confabulations take place in the form of the inclusion in it of fragments from other semantic passages. Consecutive memorization of two phrases "Apple trees grew in the garden behind a high fence." (1) "At the edge of the forest, a hunter killed a wolf." (2) Forms the phrase "In the garden behind a high fence, a hunter killed a wolf". Contamination and confabulations can also be represented by extra-experimental fragments from the patient's past experience. In essence, we are talking about the inability to slow down uncontrollably pop-up side associations.When the story is reproduced, confabulations take place in the form of the inclusion in it of fragments from other semantic passages. Consecutive memorization of two phrases "Apple trees grew in the garden behind a high fence." (1) "At the edge of the forest, a hunter killed a wolf." (2) Forms the phrase "In the garden behind a high fence, a hunter killed a wolf". Contamination and confabulations can also be represented by extra-experimental fragments from the patient's past experience. In essence, we are talking about the inability to slow down uncontrollably pop-up side associations.In the garden behind the high fence, the hunter killed the wolf. ”Contamination and confabulations can also be represented by non-experimental fragments from the patient’s past experience. In essence, this means that it is impossible to slow down the uncontrolled pop-up side associations.In the garden behind the high fence, the hunter killed the wolf. ”Contamination and confabulations can also be represented by non-experimental fragments from the patient’s past experience. In essence, this means that it is impossible to slow down the uncontrolled pop-up side associations.
Lateral differences in memory impairment manifest here as follows. Right-sided lesions, firstly, are characterized by more pronounced confabulations, which correlates with speech disinhibition. Secondly, violations of selectivity relate to the updating of past experience. We have described a patient who, while enumerating the characters of the novel "Eugene Onegin", constantly attached to them the characters of the novel "War and Peace". Thirdly, it is precisely with right-hemisphere foci that the so-called “amnesia to the source” arises, when the patient can involuntarily reproduce previously memorable material by random prompting, but is not able to arbitrarily recall the fact of the memorization that took place. Mastering the motor stereotype "to raise one’s right arm by one stroke and the left one by two”,after interference, the patient cannot arbitrarily recall which movements he performed. However, if you start tapping on the table, he quickly updates the old stereotype and begins to raise his hands alternately, explaining that by the need to "move in conditions of hypokinesia." Fourth, the interfering task can lead to alienation, refusal to recognize the products of its activities as patients with right-hemispheric lesion. Often, showing the patient his drawings or the text written by him after some time, one has to see his bewilderment and the impossibility of answering the question: "Who does this draw?"explaining this by the need to "move in conditions of hypokinesia." Fourth, the interfering task can lead to alienation, refusal to recognize the products of its activities as patients with right-hemispheric lesion. Often, showing the patient his drawings or the text written by him after some time, one has to see his bewilderment and the impossibility of answering the question: "Who does this draw?"explaining this by the need to "move in conditions of hypokinesia." Fourth, the interfering task can lead to alienation, refusal to recognize the products of its activities as patients with right-hemispheric lesion. Often, showing the patient his drawings or the text written by him after some time, one has to see his bewilderment and the impossibility of answering the question: "Who does this draw?"
Mnesthetic defect in left-sided lesions of the medial-frontal, departments, characterized by all the above common symptoms, including violations of the selectivity of reproduction, looks less pronounced in terms of contamination and confabulation, which is apparently due to the general inactivity and unproductive activity. At the same time, there is a predominant deficit in the memorization and reproduction of semantic material.
e) Syndrome of lesion of the deep parts of the frontal lobes of the brain.
Tumors located in the deep parts of the frontal lobes of the brain, exciting subcortical nodes, manifest as massive frontal syndrome, central in the structure of which are a gross violation of purposeful behavior (aspontovannost) and the replacement of actual and adequate performance of activities with systemic perseverations and stereotypes.
Practically, with the defeat of the deep parts of the frontal lobes, there is a complete disorganization of mental activity. The aspontane of the patients is manifested by a gross violation of the motivational-need sphere. Compared with inactivity, where the initial stage of activity is still present and patients form an intention to complete the task under the influence of instructions or internal motives, aspirationism characterizes primarily the violation of the first, initial stage. Even biological needs for food, water do not stimulate spontaneous reactions of patients. Patients are untidy in bed, the associated bodily discomfort also does not cause attempts to get rid of it. The core of the personality is broken, interests disappear. Against this background, the indicative reflex is disinhibited, which leads to a pronounced phenomenon of field behavior.Replacing a perceived action program with a well-established stereotype, which has nothing to do with the main program, is most typical for this group of patients.
In the clinical and experimental study of these patients, despite the difficulties of interaction and cooperation with them, it is possible to objectify the process of stereotypy. By the way, speaking of stereotypes here, we would like to emphasize their violent nature, the deep impossibility of slowing down once updated stereotype. The basis of their occurrence is not only the pathological inertness, which is also observed in the lesion of the premotor region, but the obvious stagnation, rigidity, and torpidity of those forms of activity that could be brought about in a patient.
Deep-seated processes in the frontal regions of the brain capture not only the subcortical nodes, but also the frontal-diencephalic connections, providing ascending and descending activating influences. Thus, in essence, with this localization of the pathological process, we have a complex set of pathological changes in the brain, leading to the pathology of such components of mental activity as goal-setting, programming and control (the frontal sections of the cortex itself), tonic and dynamic organization of movements and actions (subcortical nodes) and energy supply of the brain, its regulation and activation (fronto-diencephalic connections with both vectors of activating influences).
It cannot be ruled out that such a combination of structural and functional zones of damage and associated mental disorders simply does not leave the intact areas in the nervous system, with the help of which even minimal compensation of the defect would be possible, since the latter implies the presence of spontaneously controlled rearrangements adoption of external regulation of activity. The cooperation of a person with himself (LS Vygotsky) disintegrates, the patient becomes helpless. Only sensory input remains open for interaction with the outside world, when a stimulus that enters it causes, through a direct closure, the usual forms of activity. The latter, however, cannot adequately unfold and, in fact, embark on the path of multiple repetition of themselves (perseveration and stereotypy).
It is characteristic that elementary perseverations arising from the defeat of the premotor-subcortical zone, in this syndrome, become particularly pronounced. Simultaneously, systemic perseverations also appear, like the forcible reproduction of either the pattern of the method once (in the study) of the performed action, or the stereotyping of the content of the latter. So, for example, A.R. Luria describes a patient who, after performing the letter action during the transition to a task to draw a triangle, draws it, but includes elements of written task execution in the outline. Another example of systemic perseverations is the impossibility of executing the two circle and cross instruction, which is replaced by drawing a circle four times. The stereotype that is rapidly forming at the beginning of execution ("two circles") turns out to be stronger than verbal instructions. A variety of systemic perseverations; paradoxically, their complexity is most fully described by A.R. Luria in the book "Higher cortical functions of man."
Finishing the presentation of the main symptoms of the defeat of the deep parts of the frontal lobes of the brain, it is impossible not to note the imaginary contradiction that may arise when the text is perceived, between the assedness syndrome described here and the data of a clinical experimental study involving the patient's activity. As with other localizations of the pathological process, the severity of neuropsychological syndromes can be different, and the direction of the influence of the tumor on the anterior or posterior parts of the frontal lobes changes the deficit in the arbitrary regulation of functions. Nor should we forget about the radical depletion characteristic of a particular brain area characteristic of all deep-seated tumors, with an increase in the load on the function, in particular, the duration of work within one system of actions.With regard to the syndrome of deep frontal tumors, this position is important in the sense that both graftness and gross perseveration can occur already in the process of working with a patient.
5. Syndrome of defeat of a hypothalamic-diencephalic area of ​​a brain.
The hypothalamic-diencephalic region refers to the first block of the brain, providing (according to AR Luria) the tone of cortical activity, its energy supply, activation processes in the continuum of sleep-active wakefulness states. With the defeat of this block, there is a deficit in the regulation of brain activity and a related disturbance of consciousness, emotions, attention and memory. This combination of disorders occurs with the defeat of any structures included in the first brain block, but it acquires its qualitative features depending on the localization of the pathological process at various levels in the system of the vertical organization of this block. Earlier it was said about the specificity of memory disorders, consciousness and emotional processes in the defeat of the medial regions of the temporal and frontal regions of the brain, in particularconsidered the main mechanisms that form mental disorders syndromes.
These mechanisms are a fairly stable characteristic of the lack of mnestic activities caused by damage to the brain structures within the first block, but their combination and proportion in the structure of the syndrome of memory disorders may be different.
With the defeat of the hypothalamic-diencephalic region on the background of visual and endocrine-metabolic disorders, the so-called amnesia syndrome is formed. It has a modal and non-specific nature and varying degrees of severity from mild, detectable only in special clinical and experimental conditions, to a massive, similar to the pronounced Korsakovsky syndrome with pathological oblivion by the patient of intersecting events.
It is characteristic that, regardless of the depth of the mnestic defect in patients, there is a setting for memorizing and achieving the required reproduction productivity, as well as the ability to control the implementation of mnestic activity. In other words, the observed decrease in the mnestic function is not associated with defects in the arbitrary regulation of the processes of memorization and reproduction, especially since involuntary memorization also reveals a distinct deficiency. One of the signs testifying to the safety of the higher regulatory components of mnestic activity is the relative accessibility by patients of performing the 10-word memorization procedure. In general, the features of the “learning curve” correspond to the so-called general organic type, when the learning process is extended in time,varies in terms of productivity and does not reach one hundred percent of the final result, limited to a maximum productivity of 7-8 words. Nevertheless, it is important that the task of memorizing patients is accepted, and its implementation is monitored and that the available volume of reproduction productivity seems to contradict the overall gross decrease in memory.
Another sign in the structure of the memory function in patients with localization of the process in the diencephalic-hypothalamic region is the relative safety of direct reproduction, i.e. reproducing directly adjacent to the presentation of stimulus material. It corresponds to the lower limit of the norm and is 5-6 elements. Thus, here, in the link of direct fixation, pathological signs that correlate with the severity of amnestic syndrome are not detected in the memory. The relative preservation of the volume of direct reproduction distinguishes this syndrome from modal-specific memory impairments with the defeat of the analyzer zones of the brain.
There is also the possibility of retaining in memory for two or three minutes (empty, empty pause) material that was reproduced directly, which indicates the relative intactness of the information translation link from short-term to long-term memory.
However, an increase in the pause in excess of three minutes can lead to a decrease in the productivity of reproduction, the number of elements of the stimulus series, which were previously directly updated, decreases. Despite the possibility of an ambiguous approach to the assessment of this phenomenon, today there are no grounds for refusing to interpret it in connection with the mechanism of violation of the very function of trace formation at the stage of transfer of traces to the long-term storage system. It should be noted that this phenomenon, on the one hand, is only observed explicitly in patients with a massive amnestic syndrome, on the other hand, it can also occur in healthy subjects. The latter circumstance allows us to suggest that the so-called extra-experimental (unrecorded, related to the hidden, proceeding "inside"subject to other mental processes at the time of preservation of the trace) sources of interference interfere with mnestic activity. And yet, among the mechanisms that form the amnestic syndrome in expanded form, it should be noted the mechanism of dysfunction of trace formation. This pathological factor is not so decisive in the formation of amnesia, which is characterized by another, the most significant, determining mechanism - the inhibition of reproduction of the formed traces by interfering influences.which is characterized by another, the most significant, determining mechanism - the inhibition of reproduction of formed traces by interfering influences.which is characterized by another, the most significant, determining mechanism - the inhibition of reproduction of formed traces by interfering influences.
The fact is that the introduction to the interval (even shorter than the above two minutes) between memorizing and playing back any side activity negatively affects the productivity of actualization. This phenomenon is associated with the development of retroactive inhibition, arising from the implementation of the interfering task and blocking the possibility of updating the traces of previous learning interference. The removal of interfering influences can lead to the emergence of reminiscences, which is one of many experimental proofs of precisely the inhibitory, rather than destructive action of the interfering task with respect to the trace of the memory.
The mechanism of the negative influence of interference on the recourse to the tracks of the just-held learning leads to the occurrence of forgetting in healthy subjects. But with the defeat of the first block of the brain, the development of diffuse inhibitory states acquires a pathological character, and the disturbance of the neurodynamic parameters of the brain activity forms the phenomenon of pathological forgetting during the amnestic syndrome.
The third mechanism, which determines the structure of a mnestic defect, is a neurodynamic nature - a violation of the selectivity of reproduction, which was considered in connection with memory impairment in foci in the medial-frontal regions.
Returning to the syndrome of mnestic disorders in the defeat of the hypothalamic-diencephalic region, it should be emphasized that the main pathological