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Home , Amnesia, Organic brain syndrome

Practical in Medicine Part 11. Organic

Organic brain syndrome (OBS) components of may be af­ patient. These personality changes refers to those conditions charac­ fected in varying degrees in OBS. may be extremely distressing and terized by changes in mental func­ Each component of cognition is bewildering to the patient’s family. tioning, particularly cognition, functionally related to every other Finally, part of the clinical pic­ which result from diffuse or local component. For example, ture presented by the patient with destruction of brain tissue or from underlies all of the highest integra­ OBS is a function of the patient’s an alteration of metabolism that af­ tive functions of the brain. To rea­ psychologic reaction to his own fects all or part of the brain. These son; to establish orientation in cerebral deficit, especially when are etiologically asso­ time, place, or person; to decide on confronted with an environmental ciated with a wide variety of disor­ a goal and keep it in mind; to exer­ challenge that highlights an intel­ ders: trauma, intoxication, cise judgment (which requires as­ lectual deficit. metabolic disorders, , sessment of the present in the light Classification of OBS vascular insufficiency, , of past experience); to speak coher­ degenerative neurologic , ently; all require the constant use A time-honored system of and occult . In view of memory. classification considers the organic of the extremely broad range of Disorders of memory are ex­ brain syndromes as falling into two etiologic factors, diagnosis and tremely common in OBS and can groups: brain syndrome and management rest upon the physi­ generally be classified into two chronic brain syndrome. The es­ cian’s knowledge of general types: anterograde and re­ sential difference between these medicine and . In this trograde amnesia. The former re­ two groups is that the former is re­ chapter, we will describe the mental fers to impairment in the ability to versible and the latter is irreversi­ and behavioral characteristics of acquire new , ie, learn­ ble. The simplicity of this the various types of OBS and some ing. refers to classification scheme and its em­ broadly applicable principles of difficulty in recalling information phasis on the critical issue of re­ management. that has already been learned, ie, versibility (and hence treatability) memories from the past. In retro­ are its major virtues. However, not General Considerations grade amnesia it is common for more all brain syndromes that have an In most organic brain syn­ recently acquired information to be acute mode of onset are reversible, dromes, the cognitive functions of lost before older information is for­ nor are all brain syndromes that the mind are the most severely af­ gotten, ie, “ recent memory” is develop slowly over a long period fected. Cognition refers to all those usually affected more than is “re­ of time irreversible. Further, this mental processes involved in the mote memory.” Most patients with simple dichotomous scheme does acquisition and utilization of OBS with memory impairment not do justice to the various sub- knowledge: conscious awareness, have a combination of anterograde types of organic brain syndromes. interpretation of sensory stimuli or and retrograde amnesia. Lipowski6 has proposed a tenta­ , , concentra­ Affect and various aspects of tive classification of OBS which tion, memory, reasoning, and behavior are also commonly af­ makes allowance for the diversity judgment. Any one or all of the fected in OBS. In fact, it is not rare of syndromes encountered by the for an early manifestation of or­ clinician. While early assessment ganic brain to consist of a of potential reversibility and slowly progressive change in per­ treatability is of the greatest impor­ the following chapter has been selected tance, it is nonetheless true, as hy the Publisher from its forthcoming sonality associated with emotional hook, Practical Psychiatry in Medicine, by blunting or indifference, apathy, Lipowski has commented, that re­ John B. Imboden, MD and John Chapman versibility can only be established Oroaitis, MD, in the hope that it will have and inappropriate social behavior 'mmediate usefulness to our readers. which is “out of character” for the with certainty retrospectively, that

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there are degrees of reversibility, associated with visual and auditory and insidiously when it is etiolog- and therefore the use of that one , often of a frighten­ ically associated with such condi­ characteristic as the basis for ing nature, and fragmented, chang­ tions as slowly progressive hepatic classification is of dubious validity. ing paranoid . The patient or renal failure; hypothyroidism; Lipowski groups organic brain may talk excitedly and in a ram­ chronic intoxication with barbitu­ syndromes as follows: bling, incoherent manner. rates, bromides, or lead; a slowly 1. OBS with global cognitive im­ Delirious patients, whether ex­ growing intracranial ; pairment cited, quiet, or in between these normal pressure hydrocephalus: 2. OBS with selective psychologic two extremes, may pose consider­ and so forth. The syndrome may deficit or abnormality able danger to themselves be­ follow an acute organic affection of 3. Symptomatic functional syn­ cause of their disorientation and the CNS such as that produced by dromes poor judgment. The panicky, ex­ trauma, , intracranial The last group includes psy­ cited, confused patient is a particu­ hemorrhage, cerebrovascular oc­ chotic states in which there is a lar danger to himself and some­ clusion, and intracranial neo­ toxic factor and which may resem­ times to others. The patient may plasma. ble functional emotional disorders, disconnect intravenous tubing, The syndrome is characterized an example being the ­ walk off the ward, or jump out the by diffuse impairment of cognitive like syndrome sometimes seen with window. function: patients do poorly in amphetamine intoxication. Delirious states characteristi­ tasks of memory, especially of re­ cally wax and wane during the 24- cent events, learning new facts, OBS with Global Cognitive Impair­ hour period, tending to get worse at orientation, abstract reasoning, ment night. This fluctuation in the pa­ concentration, and comprehension, The three syndromes in this cat­ tient’s condition may be fairly Unlike , the course is egory have in common an impair­ marked, so that if he is seen during usually protracted. ment of many cognitive functions. one of his better periods (which Of great importance is the po­ may occur in midday) the diagnosis tential, sometimes complete, re­ may be missed. If there is a history versibility of subacute amnestic- Delirium (usually from the evening nursing confusional states. Therefore the In delirium, a rapidly developing staff) that the patient has been irri­ timely diagnosis of this syndrome is confusional state, the basic fea­ table, unreasonable, or otherwise of considerable importance, since tures of impaired cognition are typ­ has exhibited periods of trou­ effective treatment of the underly­ ically present, namely, defective blesome behavior, it is wise to ing disorder can reverse some orall memory (retrograde and antero­ suspect delirium and to examine of the mental deficit and can grade), disorientation, faulty judg­ the patient at various times in the prevent the progression to irrever­ ment, and difficulty in concentra­ 24-hour cycle, especially in the sible . tion, comprehension, and reason­ evening. ing. The causes of delirium are man­ Dementia Some delirious patients, though ifold and include intoxication, Dementia refers to organic brain quite confused, may remain rela­ drug or withdrawal, head syndromes associated with cere­ tively quiet, inactive, and depend­ trauma, infections, vascular dis­ bral cortical damage and charac­ ing upon the nature and progres­ ease, and metabolic disorders. terized by widely varying degrees sion of the underlying disease of impairment of cognitive func­ process, may slip into deeper levels Subacute Amnestic-Con- tion. The condition usually, but not of impaired consciousness, stupor, fusional State always, has a slow and insidious or coma. The EEG of this type of Subacute amnestic-confusional onset. Depending upon the nature patient is apt to show high state, sometimes referred to as of the underlying disorder, the state amplitude, slow background activ­ “ reversible dementia,” is in­ of dementia may be static or pro­ ity.4 termediate between delirium and gressive. Most patients withdemeO' Other delirious patients exhibit dementia. The mode of onset is re­ tia, even those in whom the condi­ marked excitement and hyperac­ lated to the underlying cause; the tion is progressive, show a consid­ tivity. These features are apt to be condition is apt to develop slowly erable fluctuation in intellectual

1126 THE JOURNAL OF FAMILY PRACTICE, VOL. 6, NO. 5,1978 ORGANIC BRAIN SYNDROME

functioning, having moments of pathologically identical with senile friends and relatives may react to relative lucidity and periods in dementia and is arbitrarily distin­ these “personality changes” with which cognitive functions are par­ guished from it by its onset before irritation but as the patient’s con­ ticularly severely impaired. the age of 60 years. Pick’s disease dition worsens they become dis­ In considering etiology of the is a rare form of presenile dementia mayed and seek ways to obtain it is necessary to bear in which produces distinctive changes medical attention for the patient. In mind that the intellectual process­ in the cortex, but is clinically indis­ other cases, the dementia initially es, which Hughlings Jackson called tinguishable from Alzheimer’s dis­ manifests itself not by personality “the highest integrative” func­ ease.12 changes but by memory loss, es­ tions, cannot be precisely localized Since the demonstration of a pecially for recent events, which in the cerebral cortex. The degree “ slow virus” infection in kuru, a may be first noticed by the patient of impairment of memory and other dementia-producting disease affect­ himself. cognitive functions in the demen­ ing the natives of eastern New Impairment of Cognitive Func­ tias is better correlated with the Guinea, three other dementias have tions. Usually the earliest intellec­ amount of cortex involved by the become suspected of being the re­ tual loss involves memory. Almost disease process than with the sult of chronic viral infection, invariably recent memory is more precise location of the . namely, progressive multifocal leu- severely affected than is memory Chapman and Wolff* reported that koencephalopathy, inclusion body for events of the remote past, but loss of as little as 30 gm of cerebral , and Creutzfeld-Jakob the latter also deteriorates as the tissue from neurosurgery could re­ disease. disease progresses. Anterograde sult in measurable deficits on for­ amnesia is present also and as this mal psychologic testing. Patients Clinical Characteristics and Course progresses the patient loses his who had lost 30 to 60 gm of cerebral The clinical features of dementia ability to learn new facts, concepts, tissue were slowed down, tended to are the result of: or skills. As retrograde and an­ avoid new or challenging tasks, and 1. Impairment of cognitive func­ terograde amnesia worsens, the fatigued easily. The same correla­ tions. patient cannot keep track of spatial tion between quantity of tissue lost 2. Behavior related to disinhibition and temporal data; he becomes and loss of mental capacities was resulting from destruction of CNS disoriented, usually first in time observed when the former was es­ centers or systems. and later in place but rarely in per­ timated by measurement of en­ 3. Compensatory mechanisms. sonal identification. Deterioration larged ventricular spaces.3 4. Adverse psychologic reactions of all other intellectual faculties en­ Any process which results in to the disease itself and to inciden­ sues, eg, marked impairment of substantial destruction of cortical tal life events. abstract reasoning, inability to tissue, therefore, can result in some When the disorder develops in­ communicate ideas coherently, and degree of dementia; if the destruc­ sidiously, as is typically the case faulty judgment. tive process is progressive, the de­ with senile or presenile dementia, Disinhibition Phenomena. Be­ mentia also will be progressive. the initial manifestations may con­ havior resulting from poor control The dementias are thus associated sist of changes in personality which of impulses may occur early in the with a wide variety of causative may or may not be subtle. Friends course of dementia or may not be factors, including head trauma; and relatives note that the patient observed until the disease is more space-occupying intracranial le­ no longer seems like himself; he advanced. It is often difficult in a sions; and condition producing sus­ lacks a certain sparkle or involve­ particular instance to determine if a tained anoxia such as vascular nar­ ment with life or concern and inter­ given behavior is due to lack of in­ rowing or occlusion, apnea, pro­ est in others that he customarily tact inhibitory neural systems, or if found shock, and carbon monoxide possesses; perhaps his personal it is related to emotional blunting poisoning; CNS infections; occult habits begin to deteriorate so that (lack of concern) or to grossly im­ hydrocephalus; and degenerative he is careless about dress and paired judgment secondary to cog­ neurologic diseases. Among the lat­ grooming, is late for appointments; nitive loss. It may be that all three ter group, the most common disor- and does not show his usual sense of these factors operate together in 'ter is senile dementia. Presenile of responsibility, acumen, and most cases. The sorts of behavior dementia or Alzheimer’s disease is judgment. At first the patient’s to which we are referring are those Continued on page 1131

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Continued from page 1127 which are inappropriate for the in­ visual, may occur. The demented alcohol withdrawal and with intox­ dividual patient in the light of his patient’s may buttress his ication from such as particular personality and his situ­ denial of intellectual deficit, such cocaine, bromides, and hallucino­ ation in life. Thus newly acquired as was the case with a forgetful gens. syndromes can oc­ vulgarity of speech, uninhibited older woman who accused the casionally give this, and optic and inappropriately displayed sex­ shopkeeper of cheating her when nerve or auditory nerve compres­ ual behavior, open expressions of actually she had forgotten that she sion may lead to hallucinations in in unusual degree or fash­ gave only a $5 bill and not a $10 the respective sensory channel. A ion, spending money “ foolishly,” one. , either in reaction further distinction relates to the disregarding the sensitivities or to the loss of intellectual function patient’s insight, or belief in the needs of others, all of these and or to some other loss in the pa­ reality of his hallucinatory experi­ more reflect, at least in part, a mark­ tient’s life, may occur and may ences. Some patients acknowledge edly decreased ability to control substantially intensify impairment the hallucinations as a disease social behavior in a manner cus­ of cognitive function. process, and therefore would not tomary and appropriate for the pa­ be considered psychotic. Other pa­ OBS with Selective Psychologic Def­ tient. tients firmly believe that the hal­ icit Compensatory M echanisms. lucinations represent reality; they Patients compensate for cognitive OBS with selective psychologic are by definition psychotic. loss in many ways. Early in the ill­ deficit is the result of focal rather ness, the patient may openly accept than diffuse and is Frontal Lobe Syndromes his memory loss and attempt to characterized by relatively re­ Frontal lobe damage probably help himself by writing things stricted rather than global impair­ has to be bilateral to produce the down. As the illness progresses, ment of mental functioning. classic picture. The symptoms in­ many patients tend to avoid situa­ clude poor modulation of mood tions in which the memory loss is Amnestic Syndromes with , indifference, apt to be revealed and to avoid In amnestic syndromes memory euphoria, depressionlike inactivity changes and new or unfamiliar ex­ loss is the predominant symptom. or apathy, loss of motivation and periences. The patient’s range of These syndromes may or may not goal-directed behavior, poor con­ activities thus becomes narrowed be accompanied by unawareness of trol of impulses, and lack of initia­ and he becomes more isolated so­ the memory loss and confabula­ tive or spontaneity. The patient cially. It is not uncommon for pa­ tion. In the Wernicke and Kor­ may have difficulty in maintaining tients with organic brain disease to sakoff syndromes the memory dif­ attention during the interview and be seemingly unaware of their intel­ ficulty is characterized by both an­ in abstract thinking. Recent mem­ lectual deficits, as if they are able terograde and retrograde amnesia; ory may be impaired. to deny (to some extent) the reality this condition, which is sometimes A basic deficit according to Op- of their condition. reversible, is associated with bilat­ penheimer7 is that the patient with Adverse Psychologic Reactions. erally symmetric in the frontal lobe damage cannot see into The brain-damaged patient, when diencephalon. Anterograde am­ the future, ie, cannot anticipate the confronted (especially repeatedly) nesia, without significant retro­ consequences of his behavior. This with an intellectual task in which he grade amnesia, is associated with concept can account for such silly cannot succeed, may lose emo­ bilateral lesions of the hippocam­ behavior as that of the man who put tional control and exhibit tantrum­ pus.11 a slice of bread smeared with jam like behavior. Some patients, into a toaster, and was totally sur­ whether at home or in the hospital, Hallucinosis prised by the resulting mess. Simi­ develop paranoid ideas as they be­ Hallucinosis refers to an organic lar lack of foresight may have more come more demented. Paranoid brain syndrome with recurrent or serious results. Oppenheimer men­ ideas in dementia are usually frag- persistent hallucinations in a pa­ tions a man who decided to retrieve mented and changeable rather than tient with clear consciousness and the cigar he had just dropped from systematized and fixed as in no other evidence of a functional a window; he sustained a leg frac­ Paranoid schizophrenia. Halluci­ (loosened associations, ture after jumping out to catch the nations, more often auditory than ). It can be seen in cigar. He later said: “ I just wanted Continued on page 1135

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, disease, as Continued from page 1131 burger a “ham sandwish.” Further history indicated that the actual well as neurotic or psychotic illnes­ to get it, I couldn’t see what would problem at work was that he could ses. The patient feels an uncanny happen to me.’ not tell the other men which tool to sense that things are not quite right, use for a particular operation, not real, and that he may be a Temporal Lobe Syndromes though he could show them what to changed person or even someone Temporal lobe dysfunction can do. He subsequently received ir­ else. Apparently what is lacking is lead to various deficits. Bilateral radiation for a large parietal lobe a sense of participation, as if there amputation of temporal lobes in glioma, and much of his is a failure to integrate cognitive man or other primates results in the and apraxia abated. and affective aspects of experi­ Kliiver-Bucy syndrome with loss of Body image representation also ence. Most patients who experi­ appropriate and , con­ requires the parietal lobes, and le­ ence depersonalization describe it tinuous , com­ sions of the nondominant parietal as strangely alien, and they retain pulsive oral behavior, and indis­ lobe lead to disregard of the oppo­ insight in the sense that the experi­ criminate sexual activity. site side of the body. A 57-year-old ence is regarded as a symptom of Irritative lesions from any cause woman was admitted to psychiatric some sort even though its origin is may give rise to psychomotor sei­ hospital for depression; in the ward not understood. In schizophrenia, zures (“” ). she put on a sweater, leaving her however, depersonalization may These are characterized by (1) var­ left arm out of the sleeve, and de­ lead to delusional explanations of ious subjective manifestations such nied anything was amiss when the phenomenon. Depersonaliza­ as feelings of depression, ; asked about it. She had a menin­ tion usually is a transient or distortions of perception, eg, mac- gioma compressing her right paroxysmal symptom. ropsia and micropsia; depersonali­ parietal area. zation and deja vu or jamais vu ex­ periences; auditory and gustatory Anosognosia hallucinations; abdominal pain and Symptomatic Functional Syndromes other sensations; and (2) various Anosognosia refers to a particu­ motor manifestations such as repe­ lar type of deficit in ­ Symptomatic functional syn­ titive activities or automatisms in­ representation. Denial of illness, dromes include psychoses which cluding lip-smacking, chewing, or especially denial or disregard of arise in the course of an organic engaging in som£ other action re­ such neurologic conditions as brain disorder, improve as the or­ peatedly; rarely there are outbursts hemiplegia or hemianopsia, can be ganic condition resolves, and of aggressive behavior. There is extremely disturbing to family and which closely resemble or are even amnesia for the events of the sei­ to nursing-medical staff caring for clinically indistinguishable from zure and often there is impairment the patient. This denial or, more schizophrenic, paranoid, and af­ of for events of the preictal properly speaking, disregard, may fective syndromes. There may or and postictal periods. represent a neurologic deficit, and may not be accompanying cogni­ should be given serious attention. tive deficits. Anosognosia is not a localizing An occult abdominal neoplasm Parietal Lobe Syndromes symptom, as the condition may re­ such as carcinoma of the pancreas Parietal lobe syndromes involve sult from lesions in frontal, or carcinoma of the colon may be language function, with the patient parietal, or other areas.13 associated with severe depression; unable to name objects (aphasia) or the explanation for this phenome­ to know how to use them (apraxia) non is not known. It is also noted or both. A man was brought to the that depression can be associated emergency psychiatric unit by his Depersonalization with a variety of drugs such as re- wife who insisted he was depressed Depersonalization may be due to serpine and methyldopa. Mood al­ since he was no longer able to per­ psychologic causes or may result teration of a manic or depressive form as a foreman in a sheet metal from organic brain dysfunction. works. On careful examination, it Again, it is not a localizing was noted that he called a ham­ symptom, but may accompany Continued on page 1138

1135 THE JOURNAL OF FAMILY PRACTICE, VOL. 6, NO. 5, 1978