Frontal Lobe Disorders

Amity Institute of Psychology and Allied Sciences
FRONTAL LOBE
DISORDERS
PSYC715 Basics of Neuropsychology
OUTLINE
 Introduction
 Functional anatomy of the frontal lobes
 Neurotransmitters in the frontal lobes
 Frontotemporal Dementia
 Frontal lobe syndrome
 Frontal lobe epilepsy
 Schizophrenia & Frontal lobe
 Depression & frontal lobe
 Testing prefrontal cortical function
 Common causes of frontal lobe
syndromes
Complexity of the Brain

… one hundred trillion synapses
in a single human brain
organized into exquisitely complex circuits…
responding to experience, drugs,
disease, and injury…
Complexity of the Brain
•As befits the 3-pound organ of the mind, the

human brain is the most complex structure
ever investigated by our science.
It is useful to think of the brain as containing six or

seven component parts. The largest and most
advanced part consists of the left and right cerebral
hemispheres, which appear to be more or less
symmetrical. They are covered with a layer of gray
matter called the cerebral cortex. Each of the cerebral
hemispheres has traditionally been divided into four
"lobes," which are named after the bones of the skull
that surround them: frontal, parietal, occipital, and
temporal.
The frontal lobe is the largest and least understood, beginning

at the front of the brain and reaching back to the central sulcus
& laterely lateral sulcus. The area between the central and
precentral sulci helps control body movements and is called the
"motor area," while the remainder of the frontal lobe probably
modulates various aspects of thinking, feeling, imagining, and
making decisions.
FUNCTIONAL FRONTAL LOBE ANATOMY
 Largest of all lobes

 SA: ~1/3 of each hemisphere
 3 major areas in each lobe

 Dorsolateralaspect
 Medial aspect
 Inferior orbital aspect

Premotor area Primary motor area

B6 B4
Central sulcus
Supplementary
motor area
(medially)
Frontal eye field

B8
Prefrontal area
B 9, 10, 11, 12
Lateral sulcus/
Sylvian fissure
Motor speech
area of Broca
B 44, 45

Motor cortex Prefrontal cortex
 Primary
– Dorsolateral
 Premotor
– Medial
– Orbitofrontal
 Supplementary
 Frontaleye field
 Broca‟s speech area
MOTOR CORTEX
 Primary motor cortex
 Input:
thalamus, BG, sensory, premotor
 Output: motor fibers to brainstem and
spinal cord
 Function: executes design into
movement
 Lesions: / tone; power; fine motor
function on contra lateral side
MOTOR CORTEX
 Premotor cortex
 Input:thalamus, BG, sensory cortex
 Output: primary motor cortex
 Function: stores motor programs; controls

coarse postural movements
 Lesions: moderate weakness in proximal
muscles on contralateral side
MOTOR CORTEX
 Supplementary motor
 Input:
cingulate gyrus, thalamus, sensory &
prefrontal cortex
 Output: premotor, primary motor
 Function: intentional preparation for movement;

procedural memory
 Lesions: mutism, akinesis; speech is non-
spontaneous
MOTOR CORTEX
 Frontal eye fields
 Input: parietal / temporal (what is target);
posterior / parietal cortex (where is target)
 Output: caudate; superior colliculus;
paramedian pontine reticular formation
 Function: executive: selects target and
commands movement (saccades)
 Lesion: eyes deviate ipsilaterally with
destructive lesion and contralaterally with
irritating lesions
MOTOR CORTEX
 Broca‟s speech area

 Input:
Wernicke‟s
 Output: primary motor cortex
 Function: speech production (dominant

hemisphere); emotional, melodic component of
speech (non-dominant)
 Lesions: motor aphasia; monotone speech
PREFRONTAL CORTEX
 Orbital prefrontal cortex

 Connections: temporal,parietal, thalamus, GP,
caudate, SN, insula, amygdala
 Part of limbic system
 Function: emotional imput, arousal, suppression

of distracting signals
 Lesions: emotional lability, disinhibition,
distractibility, „hyperkinesis‟
PREFRONTAL CORTEX
 Dorsomedial prefrontal cortex

 Connections:temporal,parietal, thalamus,
caudate, GP, substantia nigra, cingulate
 Functions: motivation, initiation of activity
 Lesions: apathy; decreased drive/ awareness/

spontaneous movements; akinetic-abulic
syndrome & mutism
PREFRONTAL CORTEX
 Dorsolateral prefrontal cortex

 Connections: motor / sensory convergence
areas, thalamus, GP, caudate, SN
 Functions: monitors and adjusts behavior
using „working memory‟
 Lesions: executive function deficit;
disinterest / emotional reactivity; attention
to relevant stimuli
NEUROTRANSMITTERS
 Dopaminergic tracts
 Origin: ventral tegmental area in midbrain
 Projections: prefrontal cortex (mesocortical
tract) and to limbic system (mesolimbic tract)
 Function: reward; motivation; spontaneity;
arousal
NEUROTRANSMITTERS
 Norepinephrine tracts
 Origin:
locus ceruleus in brainstem and lateral
brainstem tegmentum
 Projections: anterior cortex
 Functions: alertness, arousal, cognitive

processing of somatosensory info
NEUROTRANSMITTERS
 Serotonin tracts
 Origin: raphe nuclei in brainstem
 Projections: number of forebrain structures
 Function: minor role in prefrontal cortex; sleep,

mood, anxiety, feeding
 Five „frontal subcortical

circuits‟
(Cummings,„93)
1. Motor
2. Oculomotor
3. Dorsolateral prefrontal
4. Lateral orbitofrontal
5. Anterior cingulate
 „Frontal subcortical circuits‟
Globus Pallidus
Striatum & Thalamus
Frontal Caudate & Substantia
cortex Putamen Nigra
FRONTAL SUBCORTICAL CIRCUITS:
1. MOTOR CIRCUIT
Globus
SMA, Pallidus
Hypo-thalamus
Premotor,M Putamen
o tor
Thalamus
 Supplementary Motor & Premotor: planning, initiation &

storage of motor programs; fine-tuning of movements
 Motor:final station for execution of the the movement
according to the design
2. OCULOMOTOR CIRCUIT
Globus
Frontal Eye Pallidus
Central Thalamus
Field
Caudate
Substantia
Nigra
 Voluntary scanning eye movement

 Independent of visual stimuli
3. DORSOLATERAL PREFRONTAL CIRCUIT
Globus
Lateral Pallidus
Caudate Thalamus
Prefrontal
Substantia
Nigra
 Executive functions: motor planning, deciding which stimuli

to
attend to, shifting cognitive sets
 Attention span and working memory
4. LATERAL ORBITOFRONTAL CIRCUIT
Infero-lateral
Globus
prefrontal
Pallidus
Caudate Thalamus
Orbito-frontal Substantia
Nigra
 Emotional life and personality

structure
 Arousal, motivation, affect
 Orbitofrontal cortex: consciousness
5. ANTERIOR CINGULATE
CIRCUIT
Globus
Anterior
Ventral Pallidus
Cingulate Thalamus
Gyrus Striatum
Substantia
Nigra
 Abulia, akinetic mutism

Frontal Lobe Syndromes

The Case of Phineas Gage
 tamping iron blown through
skull: L frontal brain injury
 excellent physical recovery
 dramatic personality change:
stubborn, lacked in
consideration for others, had
profane speech, failed to
execute his plans
FRONTOTEMPORAL LOBE DEMENTIA
 Frontotemporal lobar degeneration (FTLD) is a

neurodegenerative disease that selectively
attacks the frontal and anterior temporal
regions.
 FTLD occurs in 5–15% of patients with
dementia and it is the third most
common degenerative dementia,
following only
Alzheimer‟s disease (AD) and dementia with
Lewy bodies.
 Typical age of onset is between 50 and 60
years, although FTLD can occur as early as the
 In contrast to AD, in which memory loss is

usually the first symptom, the initial symptoms of
FTLD often involve changes in personality,
behavior, affective symptoms, and language
function.
 Most patients with FTLD begin with language (left-
sided cases) or emotional (right-sided cases)
changes. The lack of insight seen in FTLD,leads
patients to ignore or deny their deficits.
 The core features of FTLD as defined by the
Neary criteria (Neary et al., 1998) are early decline
in social and personal conduct, emotional
blunting, and loss of insight.
•  The clinical onset is insidious, with a slow gradual progression. Although the
neuropsychiatric profile for patients with FTLD varies.
•  Behavior problems such as overeating, repetitive compulsive behaviors,
apathy, and agitation and disinhibition, develop in the majority of these patients
as the disease progresses.
•  The estimated duration of the illness is around 6–10 years.
•  SSRI improved a variety of psychiatric symptoms, including irritability,
depression, repetitive behaviors, and hyperorality.
FRONTAL LOBE SYNDROMES
 The dorsolateral frontal cortex is concerned with

planning, strategy formation, and executive
function. Patients with dorsolateral frontal lesions
tend to have apathy, personality changes, abulia,
and lack of ability to plan or to sequence.
patients have poor working memory for verbal
information (if the left hemisphere is
predominantly affected) or spatial information (if
right hemisphere lesion).
 The frontal operculum contains the center for
expression of language. Patients with left frontal
operculum lesions may demonstrate Broca
aphasia and defective verb retrieval, whereas
patients with exclusively right opercular lesions
tend to develop expressive aprosodia.
 The orbitofrontal cortex is concerned with response inhibition.

Patients with orbitofrontal lesions shows disinhibition,
emotional lability, and memory disorders. Personality
changes from orbital damage include impulsiveness, a
jocular attitude, sexual disinhibition, and complete lack of
concern for others.
 Patients with superior mesial lesions typically develop
akinetic mutism.
 Patients with inferior mesial (basal forebrain) lesions tend to
manifest anterograde and retrograde amnesia and
confabulation.
CAUSES
 Mental retardation
 Traumatic brain injury
 Brain tumors
 Degenerative dementias including Alzheimer
disease, dementia with Lewy bodies, Parkinsonian
dementias, and frontotemporal dementias
 Cerebrovascular disease
 Schizophrenia
 major depression
 multiple sclerosis
 It is associated with blood alcohol level and occurs during
acute intoxication with many recreational drugs.
CLINICAL PICTURE
 Profound change in personality.

 Lack of initiation and spontanity.
 Response are sluggish.
 Occasionally patient are hyperactive and
restless.
 Mood is often euphoric and out of keeping with
patients situation.
 Irritability and outbursts are common.
 Loss of finer senses.
 Judgements are impaired.
 Fail to plan and carry through ideas.
FRONTAL LOBE EPILEPSY
 Frontal lobe epilepsy is characterized by recurrent

seizures arising from the frontal lobes.
 Seizures may arise from any of the frontal lobe
areas, including orbitofrontal,dorsolateral,
opercular, supplementary motor area, motor
cortex, or cingulate gyrus.
 In most centers frontal lobe epilepsy accounts for
20-30% of operative procedures involving
intractable epilepsy.
 No significant gender-based frequency.
 In a large series of cases, mean subject age was
28.5 years with age of epilepsy onset 9.3 years for
left frontal epilepsy and 11.1 years for right frontal
epilepsy.
CLINICAL PICTURE
 Patients with frontal lobe seizures may present with a

clear epileptic syndrome or with unusual behavioral or
motor manifestations that are not immediately
recognizable as seizures.
 may be associated with facial grimacing, vocalization,
or speech arrest.
 seizures frequently preceded by a somatosensory
aura.
 Complex behavioral events characterized by motor
agitation and gestural automatisms; viscerosensory
symptoms and strong emotional feelings often
described; motor activity and may involve pelvic
thrusting, pedaling, or thrashing, often accompanied
by vocalizations or laughter/crying; seizures often
bizarre and may be diagnosed incorrectly as
psychogenic
DIFFERENTIAL DIAGNOSES
Absence Seizures
Periodic Limb Movement Disorder
Psychogenic Nonepileptic Seizures
REM Sleep Behavior Disorder
Somnambulism (Sleep Walking)
Temporal Lobe Epilepsy

EXPRESSIVE APHASIA
 Expressive aphasia, known as Broca's aphasia caused by

damage or developmental issues in anterior regions of the brain,
including the left posterior inferior frontal gyrus known as
Broca's area (Brodmann area 44and Brodmann area 45).
 Sufferers of this form of aphasia exhibit the common problem
of agrammatism. For them, speech is difficult to initiate, non-
fluent, labored, and halting. Similarly, writing is difficult as
well. Intonation and stress patterns are deficient. Language is
reduced to disjointed words and sentence construction is poor.
 comprehensionis generally preserved, meaning interpretation
dependent on syntax and phrase structure is substantially
impaired. Patients who recover go on to say that they knew
what they wanted to say but could not express themselves.
 Residual deficits will often be seen.
SCHIZOPHRENIA & FRONTAL LOBE
 some schizophrenic symptoms are found in

frontal lobe disorder, in particular that involving
dorsolateral prefrontal cortex. Symptoms
included are those of the affective changes,
impaired motivation, poor insight. Evidence for
frontal lobe dysfunction in schizophrenic
patients has been noted in neuropathologic
studies like EEG studies, in CT scan, with MRI,
and in cerebral blood flow studies.
Hypofrontality is documented in several studies
using PET. These findings emphasize the
importance of neurologic and neuropsychologic
investigation of patients with schizophrenia.
DEPRESSION & FRONTAL LOBE
 it has been found that the right frontal lobe demonstrated

increased activity in response to negative moods whereas left
frontal activity decreases. repetitive transcranial magnetic
stimulation of the right frontal lobe reduces depressive symptoms
, whereas left frontal activity increase depression as
demonstrated through functional imaging studies.
 Not only reductions in left frontal activity, but injuries to the left
frontal lobe have been consistently associated with depression,
"psycho-motor" retardation, apathy, irritability, and blunted mental
functioning.
 psychiatric patients classified as depressed demonstrate
insufficient left frontal activation and arousal.
 In severely depressed patients demonstrate insufficient activation
and a significant lower integrated amplitude of the EEG evoked
response over the left vs right frontal lobe.
Testing for Frontal lobe function

– Wisconsin Card Sorting Test
• abstract thinking and set shifting; L>R
– Trail Making
• visuo-motor track, conceptualization, set shift
– Stroop Color & Word Test

• attention, shift sets; L>R
– Tower of London Test

• planning
Wisconsin Card Sorting Test
“Please sort the 60 cards under the 4 samples.

I won‟t tell you the rule, but I will announce every mistake.
The rule will change after 10 correct placements.”
Trail Making Test
5 B
A 4
6
1 C
2
3 D
7
Various levels of difficulty:

1. “Please connect the letters in alphabetical order as fast as
you can.”
2. “Repeat, as in „1‟ but alternate with numbers in increasing
Stroop Color and Word Tests
RED BLUE ORANGE YELLOW

GREEN RED PURPLE RED
GREEN YELLOW BLUE RED
YELLOW ORANGE RED
GREEN BLUE GREEN
PURPLERED
“Please read this as fast as you
can”
Tower of London Tests
Various levels of difficulty:

e.g. “Please rearrange the balls on the pegs, so that each peg
has one ball only. Use as few movements as possible”
Diseases Commonly Associated With Frontal Lobe

Lesions
 Traumatic brain injury
– Gunshot wound
– Closed head injury
• Widespread stretching and shearing of fibers throughout
• Frontal lobe more vulnerable
– Contusions and intracerebral hematomas
Diseases Commonly Associated with Frontal Lobe Lesions
 Frontal Lobe seizures

– Usually secondary to trauma
– Difficult to diagnose: can be odd (laughter, crying, verbal
automatism, complex gestures)

Lesions
 Vascular disease
– Common cause especially in elderly
– ACA territory infarction
• Damage to medial frontal area
– MCA territory
• Dorsolateral frontal lobe
– Anterior Communicating artery aneurysm rupture
• Personality change, emotional disturbance

Lesions
 Tumors
– Gliomas, meningiomas
– subfrontal and olfactory groove meningiomas: profound
personality changes and dementia
 Multiple Sclerosis
– Frontal lobes 2nd highest number of plaques
– euphoric/depressed mood, Memory problems, cognitive and
behavioral effects

Lesions
 Degenerative diseases
– Pick‟s disease
– Huntington‟s disease
 Infectious diseases
– Neurosyphilis
– Herpes simplex encephalitis
Diseases Commonly Associated with Frontal Lobe Lesions

 Psychiatric Illness – proposed associations
– Depression
– Schizophrenia
– OCD
– PTSD
– ADHD

Frontal Lobe Disorders

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Amity Institute of Psychology and Allied Sciences

Complexity of the Brain

Complexity of the Brain

•As befits the 3-pound organ of the mind, the

It is useful to think of the brain as containing six or

The frontal lobe is the largest and least understood, beginning

 Largest of all lobes

 3 major areas in each lobe

 Inferior orbital aspect

Premotor area Primary motor area

Frontal eye field

FUNCTIONAL FRONTAL LOBE ANATOMY

 Function: stores motor programs; controls

 Function: intentional preparation for movement;

 Broca‟s speech area

 Function: speech production (dominant

 Orbital prefrontal cortex

 Function: emotional imput, arousal, suppression

 Dorsomedial prefrontal cortex

 Lesions: apathy; decreased drive/ awareness/

 Dorsolateral prefrontal cortex

 Functions: alertness, arousal, cognitive

 Function: minor role in prefrontal cortex; sleep,

FUNCTIONAL FRONTAL LOBE ANATOMY

 Five „frontal subcortical

 „Frontal subcortical circuits‟

 Supplementary Motor & Premotor: planning, initiation &

 Voluntary scanning eye movement

3. DORSOLATERAL PREFRONTAL CIRCUIT

 Executive functions: motor planning, deciding which stimuli

4. LATERAL ORBITOFRONTAL CIRCUIT

 Emotional life and personality

 Abulia, akinetic mutism

Frontal Lobe Syndromes

 Frontotemporal lobar degeneration (FTLD) is a

 In contrast to AD, in which memory loss is

 The dorsolateral frontal cortex is concerned with

 The orbitofrontal cortex is concerned with response inhibition.

 Profound change in personality.

 Frontal lobe epilepsy is characterized by recurrent

 Patients with frontal lobe seizures may present with a

Periodic Limb Movement Disorder

Psychogenic Nonepileptic Seizures

REM Sleep Behavior Disorder

Somnambulism (Sleep Walking)

Temporal Lobe Epilepsy

 Expressive aphasia, known as Broca's aphasia caused by

 some schizophrenic symptoms are found in

 it has been found that the right frontal lobe demonstrated

Testing for Frontal lobe function

– Stroop Color & Word Test

– Tower of London Test

Wisconsin Card Sorting Test

“Please sort the 60 cards under the 4 samples.

Trail Making Test

Various levels of difficulty:

Stroop Color and Word Tests

RED BLUE ORANGE YELLOW

Tower of London Tests

Various levels of difficulty:

Diseases Commonly Associated With Frontal Lobe

Diseases Commonly Associated with Frontal Lobe Lesions