Frontal lobe dysfunction explains some behaviors, doctors told
As endearing as some of the behaviors may seem to outsiders, the symptoms of "frontal lobe dysfunction" often bring caregivers to tears.
Frontal lobe dysfunction, or executive dysfunction syndrome -- EDS -- or "vulnerable brain," or "Pick's disease" causes changes in personality and behavior and erases inhibitions. Victims make poor decisions and do not anticipate the consequences of their sometimes strange, socially unacceptable actions. "If it feels good, do it," is typical of a victim of frontal lobe dysfunction, Dr. Steven Wengel told a group of McCook doctors when he and Dr. Carl Greiner, of the University of Nebraska Medical Center, stopped in McCook Nov. 8.
"This is not Alzheimer's disease," Dr. Wengel said. Victims' cognition and memory are good, he said; they know what they've done -- they remember doing it. They just don't know it's inappropriate, or that they have frontal lobe dysfunction.
The syndrome has been around for years, Dr. Wengel said, telling the tale of Phineas Gage, not an old gentleman, who in the 1840s, suffered frontal lobe damage when a three-foot-long iron rod was blown through his head. Amazingly, he recovered from that accident, but within weeks he became uncharacteristically obstinate, sexually inappropriate and childlike. Records indicate "he just wasn't himself," Dr. Wengel said. Phineas Gage was unable to hold a job due to his socially-inappropriate behavior, and died 11 years later.
"A patient with executive dysfunction generally does not know that he has it," Dr. Wengel said. "No one ever comes to me and says, 'I think I have bad judgement. Help me with this'."
"We're seeing this now in victims of car accidents and skateboard accidents," Dr. Wengel said, and in soldiers suffering closed-head brain trauma caused by explosions and bombings.
New Mexico Senator Pete Domenici recently announced he will not seek re-election because of this degenerative brain disease.
Normal development of the brain's executive function is a gradual process starting in the pre-teen years through the 20s (" ... or never," Dr. Wengel said. "Not everyone gets here.")
Good frontal lobe function is evidenced by the ability to make decisions, many unconsciously. Even subtle impairment will show in poor decision-making skills and a lack of awareness of consequences.
Abnormal frontal lobe function manifests itself slowly, and early on with a loss of personal and social awareness, insight and disinhibition.
Typical behavioral problems include:
* Socially inappropriate behavior, such as making tactless comments, sexually inappropriate jokes, comments, suggestions and/or requests;
* Aggressive behavior, (for example, becoming easily angered while driving);
* Hoarding; and
Physical signs will include:
* Early, primitive reflexes and incontinence; and
* Late, akinesia (absence or disturbance of motion in a muscle); rigidity; tremor; or low blood pressure.
Treatment includes, "Structure, structure, structure," Dr. Wengel said. "Structure their world, and educate their family." Dr. Wengel recommends setting aside adequate time for tasks and giving concrete, written instructions.
Some medications will help with apathy and with repetitive behavior such as gambling, touching and inappropriate sexual behavior, he said. "Disinhibition doesn't change. That's tough."
"This isn't Alzheimer's," he said, "But Alzheimer's (support) groups can be helpful."
"We can't bring back good frontal lobe function. We can't fix it," Dr. Wengel said. "We can help the family cope."
Dr. Carl Greiner MD, a UNMC professor of psychiatry, practices adult and forensic psychiatry and deals with issues of cognitive impairment and how it can result in legal problems.
Dr. Greiner studies psychiatry and the law, asking, "Is someone with EDS (executive dysfunction syndrome) culpable?"
EDS is hard to recognize, Dr. Greiner said. Victims are, "mentally rigid. The lights are on, but nobody's home. They seem OK, but they're not."
"Victims can get into trouble," he explained, "because their concept of 'the right time and place' is disrupted."
Everyone has a bit of executive dysfunction, Dr. Greiner said, explaining that phonics in the third grade made absolutely no sense to him. But, someone who has had good executive brain function and is now losing it will not function as well as in the past, he said.
"You don't seem like yourself," may be the comment made to an EDS sufferer, Dr. Greiner said.
Someone with EDS is a risk to him/herself, becoming easily befuddled by simple tasks -- such as tripping because they've forgotten to lift their feet to walk up a flight of stairs, or getting burned by forgetting the process of pouring hot coffee, Dr. Greiner said.
The risk is conveyed to others when someone with EDS insists on driving.
Someone with EDS can easily become a victim to predatory practices, Dr. Greiner said. "Attorneys and families can do a lot to reduce harm with good risk management," Dr. Greiner said. "Attorneys and families need to understand EDS to protect the physical, social and financial status of a victim."
"Money, meds and driving" are the three biggest challenges for families dealing with victims of EDS, Dr. Wengel said.
"Early on, symptoms of EDS are illusive ... they're tough to pin down," he said. There is a battery of paper-and-pencil tests that a suspected victim can be put through, including being asked to draw the face of a clock. Planning ahead to fit 12 items equidistance within a circle is a function of good frontal lobe function, he said. An EDS victim often bunches all the numbers together or only makes it half-way around before he/she runs out of numbers. One victim actually drew facial features on a clock, Dr. Wengel said.
Approaching a victim about an EDS diagnosis requires diplomacy, Dr. Wengel said. Oftentimes, a sufferer denies anything is wrong, and will seek the advice of another doctor.
Dr. Greiner said he gently suggests, "You may have an illness ... you may be having small strokes." It's not a case of having to tell someone something repeatedly before he/she understands it. The information, "is just not being integrated," Dr. Greiner said.
He said, "It's not about 'being crazy.' It's about trying to find an illness."
Dr. Wengel said there is at times an overlap between short-term memory loss and frontal lobe disfunction. "On any given day, any one of us can have some degree of frontal lobe dysfunction," he said.
"Frontal lobe dysfunction is a real challenging syndrome to pin down," he said.
A press release from Jo Giles, communications specialist in the Department of Public Affairs, UNMC, indicates:
Frontal lobe dysfunction can occur when the frontal lobes are damaged, such as in a head injury, or in people who are elderly and in the early stages of dementia, or those who suffer from more severe mental disorders, like schizophrenia.
Symptoms include socially inappropriate behavior, financial indiscretions or impaired driving, or a reduction in the ability to solve problems.
Dr. Greiner said people with "vulnerable brains" are more likely to make poor decisions and can be more easily deceived.
"Frontal lobe dysfunction is common, but not well understood. We're interested in sharing how to recognize cognitive impairment early so that the patient gets the necessary health care he or she needs, and to protect them from undue influence and avoid accidents and falls," Dr. Greiner said.
"This is part of our commitment to provide information on important mental health care issues," he said.
Dr. Wengel, chairman of the UNMC Department of Psychiatry, is dedicated to all levels of education. Since 1994, Dr. Wengel has been a consultant for geriatric cases at the Veterans Affairs Medical Center in Omaha. He received his medical degree from UNMC in 1986, then remained to complete a residency in psychiatry in 1990 and a fellowship in geropsychiatry in 1991. Dr. Wengel's research focuses on geriatric mental health issues, such as Alzheimer's disease, anxiety disorders and depression.
Dr. Greiner received his medical degree from the University of Cincinnati where he did his psychiatry residency. He is board certified in psychiatry and neurology with special qualifications in forensic psychiatry. He practices adult and forensic psychiatry, which deals with issues of cognitive impairment and how that can result in legal problems.
UNMC is the only public health science center in Nebraska. Its educational programs are responsible for training more health professionals practicing in Nebraska than any other institution.
Through its commitment to education, research, patient care and outreach, UNMC and its hospital partner, the Nebraska Medical Center, have established themselves as one of the country's leading centers in cancer, transplantation biology, bioterrorism preparedness, neurodegenerative diseases, cardiovascular diseases, genetics, biomedical technology and ophthalmology.
UNMCs research funding from external sources now exceeds $80 million annually and has resulted in the creation of more than 2,400 highly skilled jobs in the state.
UNMC's physician practice group, UNMC Physicians, includes 513 physicians in 50 specialties and subspecialties who practice primarily in The Nebraska Medical Center.
For more information, go to UNMC's Web site at www.unmc.edu.