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International J. of Healthcare and Biomedical Research, Volume: 03, Issue: 03, April 2015, Pages 82-84
Case report
Frontal Lobe Syndrome- A case report
Dr. Cijo Alex, Dr. Anoopa Benny, Dr. Venkatarangan
Department of Psychiatry, SMVMCH, Madagadipet, Pondicherry - 605107
Name of the Institute/college: SMVMCH, Madagadipet, Pondicherry - 605107
Corresponding author: Dr. Cijo Alex
Abstract:
A 45 year old male, presented with recurrent outbursts of aggression, disinhibited behavior, altered speech, and
suspiciousness following a head injury, sustained after a fall from a flight of stairs, under intoxication. He had
undue suspiciousness over his wife for an extra marital affair. His premorbid personality was described as
authoritative, organized, cheerful and helpful. Cognitive functions were intact. Physical and detailed
neurological examination was essentially normal. He lacked insight into his problems. This case illustrates the
need for a multidisciplinary approach to the assessment, management and rehabilitation of such cases.
Keywords: Disinhibited behavior, Frontal lobe syndrome, Jocularity, Dysexecutive syndrome
Introduction:
head injury followed by loss of consciousness for
Frontal lobe is the phylogenetically most developed
around half an hour. This was followed by bouts of
part of the brain and lies anterior to the central
vomiting,
sulcus or the rolandic fissure. General functions of
reduced activity. He was taken to a government
frontal lobe include planning, programming and
hospital (JIPMER) after 5 days. There he was
execution of motor action, motivation, inhibition of
advised totake a CT Brain plain.
impulses, social behavior, motor speech, judgment
The scan showed resolving right frontal contusion
and abstract ability, insight, working Memory.
with a small left parietotemporal contusion. No
Frontal lobe syndromes arise after injury to specific
surgical intervention was advised. Patient started to
parts of the frontal lobe. Most of them manifest as
develop alterations and changes in his behavior and
executive dysfunction or personality changes.
personality. Premorbidly, the patient was very well
Phineas Gage, a rail worker who sustained a frontal
mannered, cheerful, organized and respected
lobe injury by penetrating iron rod is considered the
personnel in his village with a political background.
classical example for frontal lobe syndromes.
He was a fatherly figure to the people of his
Case report:
village. However, post-trauma, he began to behave
A patient was brought to the Psychiatry OPD by his
disinhibited noted by incidents such as passing
brother with complaints of altered behavior
urine in public, using abusive and vulgar comments
inappropriate talk, disinhibited behavior and undue
around women. On one instance, he even
suspiciousness for the past 6 months. The
physically abused a lady police officer and was
symptoms were acute in onset following a head
taken to the police station, following which his
trauma. Patient was under intoxication with alcohol
family was notified and he was released on account
when he had a fall from the stairs. He sustained a
of his medical condition. Patient would become
irrelevant
speech,
drowsiness
and
82
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ISSN: 2319-7072
International J. of Healthcare and Biomedical Research, Volume: 03, Issue: 03, April 2015, Pages 82-84
excessively agitated for small issues unlike before.
•
Orbitofrontal cortex
Gradually the wife noticed that he was suspicious
•
Dorsolateral cortex
about her, assuming she had an extra marital affair.
Orbitofrontal cortex is concerned with response
Patient’s mode of speech was altered and was often
inhibition, emotional lability. The affected patients
found to be beating around the bush in answer to a
will have a disinhibited behavior. Thus,in pseudo
question suggestive of circumstantiality. Patient
psychopathic disorder
would often crack jokes irrelevantly suggestive of
impulsiveness, jocularity, sexual disinhibition and a
increased jocularity. Patient’s family members
complete lack of concern for others is noted.
were worried if he had developed a mental illness
Patients with injury at this location exhibit
due to which his whole personality was affected
stimulus-driven behavior with poor impulse control
and he had transformed into a completely different
diminished social insight, explosive aggressive
person.
outbursts, emotional lability, inappropriate verbal
On examination, patient’s speech was occasionally
lewdness, distractibility, jocularity and lack of
irrelevant and over-inclusive. The patient even
interpersonal sensitivity. 3
cracked a few jokes during the interview, his
The dorsolateral frontal cortex is concerned with
memory was intact. The patient was not aware of
planning,
changes in his behavior. He was started on low
function. Patients with dorsolateral frontal lesions
dose Risperidone (1 mg). He was asked to come for
tend to have apathy, personality changes, abulia,
regular follow up.
and lack of ability to plan or to sequence actions or
The patient reported to OPD irregularly. His
tasks.
relatives reported improvement in behavior. His
The process of recovery following brain injury can
suspicions regarding his wife were also controlled.
roughly be divided into three stages which are
Patient was lost on follow up after 3- 4 visits.
characterized by the changing and overlapping
Discussion:
patterns of disturbance of sexual behaviors. They
Uchikava et al. correlated, reduced cerebral blood
include early (acute), middle (post-acute) and late
flow to frontal lobe in subarachnoid haemorrhage
(re-entry) stages. 4, 5
and dysexecutive syndrome.1
Rommel et al. state that frontal lobe syndrome
Eghwrudjakpor PO et al. state that hypersexuality
comprises a variety of different clinical syndromes
is a rare but well recognized sequel of brain injury.
produced by focal lesions involving the prefrontal
There
of
cortex. Based on the site of lesion prefrontal lobe
controlover sexuality and increased need or intense
dysfunction may be divided into a disorganized
pressure for sexual gratification. Damage to the
type, caused by lesion of the dorsolateral prefrontal
orbital parts of the frontal lobes is believed to cause
lobe and its connections, a disinhibited type that
deviant sexual behavior as a result of removal of
can
moral-ethical restraints.2
orbitofrontal
Duffy and Campbell et al. pointed out that injury to
following lesions affecting the functional balance
the orbitofrontal area gives rise to disinhibition. 3
between the cingulum and the supplementary motor
The prefrontal cortex of the frontal lobe has three
area.6
parts:
Two main strategies (pharmacologic and non-
is
subjective
•
experience
of
loss
Ventro medial cortex
strategy
be observed
cortex,
or
orbital
formation
personality,
and
following lesions
and
an
executive
of the
apathetic
type
pharmacologic) are generally adopted in the
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ISSN: 2319-7072
International J. of Healthcare and Biomedical Research, Volume: 03, Issue: 03, April 2015, Pages 82-84
management of patients with hypersexual behavior.
Non
pharmacological
psychoeducating
the
methods
family
include-
members
about
behavioral changes in the patient, psychotherapy,
changes in the patient’s environment, cognitive
behavioral modification and a multidisciplinary
approach for the rehabilitation of such cases. 7, 8
Pharmacological
management
includes
anti-
androgenic drugs, SSRI, GnRH analogues and
neuroleptic drugs. 9, 10
Conclusion:
Frontal lobe syndromes need to be managed by a
multidisciplinary approach,
also
by
creating
awareness, about the prognosis of the condition,
Figure 1- Plain CT- Brain showing resolving right
among the family members or caregivers. Recent
frontal contusion with a small left parietotemporal
advances have lead to the development of disease
contusion.
modifying therapies which aim to ameliorate the
social and behavioral deficits
References:
1.
Uchikawa K, Inaba M, Kagami H, Ichimura S, Fujiwara T, Tsuji T, Otaka Y, Liu M. Executive dysfunction
is related with decreased frontal lobe blood flow in patients with subarachnoid haemorrhage. Brain Inj.
2014;28(1):15-9.
2.
Eghwrudjakpor P, Essien A. Hypersexual behavior following craniocerebral trauma an experience with five
cases. Libyan J Med. 2008 Dec 1;3(4):192-4.
3.
Duffy JD, Campbell JJ. The regional prefrontal syndromes: a theoretical and clinical overview. J
Neuropsychiatry ClinNeurosci. 1994;6(4):379–387.
4.
Limbert J. Head injury and sexuality: A literature review.
5.
Blackerby W. Disruption of Sexuality Following a Head Injury.
6.
Rommel O, Widdig W, Mehrtens S, Tegenthoff M, Malin JP. ['Frontal lobe syndrome' caused by severe
head trauma or cerebrovascular diseases]. Nervenarzt. 1999 Jun;70(6):530-8.
7.
Jensen B. Treatment of hypersexuality patients.
8.
Sebit MB, Acuda W, Chibanda D. A case of the frontal lobe syndrome following head injury in Harare,
Zimbabwe. Cent Afr J Med. 1996 Feb;42(2):51-3
9.
Levitsky AM, Owens NJ. Pharmacologic treatment of hypersexuality and paraphilias in nursing home
residents. J Am Geriatr Soc. 1999;47(2):231–234.
10. Salloway SP. Diagnosis and treatment of patients with "frontal lobe" syndromes. J Neuropsychiatry
ClinNeurosci. 1994 Fall;6(4):388-98.
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ISSN: 2319-7072