Frontal syndrome

Introduction

Disinhibited behaviour is usually caused by an injury to the forehead. There are a few specific brain areas where disinhibited behaviour is seen after a brain injury.

On this page we only discuss the frontal lobe.

 

Vulnerable brain area in the forehead

Because the frontal lobes are located in an extremely vulnerable part of the head, brain damage in this area occurs quickly. For example, after a traffic accident, violence, a blow or a fall. This type of brain injury is called traumatic brain injury.

 

Common causes include:

• A blow to the car's dashboard
• A blow or fall on the handlebars of a bicycle
• Landing hard on the asphalt in a motorcycle or moped accident
• A blow with a blunt object
• Colliding with a hard object, for example while playing sports or hitting a tree in traffic.

 

The consequences are different for injuries on the left side of the forehead, on the right side of the forehead or on both sides. It also matters how extensive the injury is and how many interrupted nerve connections there are. Last but not least, it is important whether the person has compensation options. We have separate pages about that.

 

Frontal syndrome can also be a consequence of another form of brain injury in the forehead, such as a stroke, a brain tumor, inflammation, a hereditary condition, protein clumping or lysosomal changes that lead to frontotemporal dementia.

 

Changed behavior

A common feature of frontal damage is a dramatic change in social behavior and inability to regulate emotions.
A person's personality can undergo significant changes after an injury to the frontal lobes, especially when both lobes, left and right, are involved.
Left frontal damage usually manifests itself as pseudo-depression and right frontal damage as pseudo-psychopathy.

 

It is important to realize that brain injury in combination with the location of the injury in the brain can change behavior.

Complaints can differ per person, also in severity, and can be experienced differently by the person themselves. One person with damage to this brain area may have one or two of the complaints listed, while another may have several or to a greater or lesser extent.
Emotional changes due to physical causes can sometimes be painfully expressed and experienced differently 'from within' by the person affected. Read more....

 

Someone may exhibit apathetic behavior as a result of a frontal syndrome, have disinhibitions in all kinds of areas, be agitated or even be aggressive. Someone may have problems assessing situations and/or think less critically. Social norms my fade. There may be an emotional numbness and a lack of insight into the illness. This is not the person's fault.

It is a consequence of the injury. At the bottom of this page we explain how to deal with this syndrome.

Everything depends on whether someone can still compensate and fall back on other brain areas or learned skills. Sometimes compensation is no longer possible due to a changed situation, or because an illness or second injury occurs.

 

Undesirable behavior or reduced self-insight

The painful thing is that the deviant or unwanted behavior is not (always) experienced this way by the person himself.
Someone may react uninhibited or be compulsive in behavior, i.e. have behavior that is not considered socially acceptable. Self-insight may be lacking. It may also be the case that someone notices that her or his behavior is undesirable, but cannot change it.
Psycho-education (mainly aimed at the environment), behavioral therapy and guidance are the forms of therapy that are used. See bottom of this page.
Unfortunately, desirable behavior is not always feasible or learnable.

 

Impulsiveness

Brain activity can be measured with an MRI scan. During a scientific study the researcher used magnetic impulses to influence the frontal lobe.

During this research it turned out that people became more impulsive. Automatic tendencies could be less well controlled.
People with brain damage in the frontal lobe may also have reduced control over emotions due to brain damage.

 

Sexually altered behavior

Sexual behavior can also be affected by frontal injury. Injury to the eye socket, 'Orbital-frontal injury', can cause abnormal sexual behavior, while 'dorsolateral injury' (slightly further back and to the side) can reduce libido. See image:

The frontal lobes

Located in the forehead, the frontal lobes are the largest lobes of the brain. The front part of the frontal lobe is the prefrontal cortex.
MRI studies have shown that damage in the frontal lobe is the most common damage in mild to moderate traumatic brain injury.

 

They are involved in the so-called executive functions:

• Scheduling
• Organizing
• Memory, working memory
• Impulse control
• Solving problems
• Selective focus
• Decision making
• Controlling behavior and emotions
  

See also the page executive dysfunctioning.

 

Damage to these lobes can lead to damage in:

• Emotions
• Language
• Impulse control
• Memory
• Social behaviour
• Sexual behavior
• Reduced empathy

 

That is not the case with everyone.
Everything depends on whether someone can still compensate and fall back on other areas of the brain. Sometimes compensation is no longer possible due to a changed situation or because an illness or second injury occurs.

 

More specific:

• Loss of simple movement of various body parts (motor function).
• Inability to plan the sequence of a series of complexmovements or actions required for complex tasks, such as making coffee.
• Loss of spontaneity in interacting with others. Loss of flexibility in thinking. Loss of initiative.
• Perseveration (the inability to stop) a single thought.
• Inability to concentrate on a task/attention and this is exacerbated under stressful conditions or distractions. The neurons in the frontal lobe then respond frantically.
• Mood swings (emotionally changing).
• Changes in social behavior and/or personality. For example, lack of initiative, disinhibition or impulsive behavior, less ability to assess danger, reduced empathy, incomprehension for other people's emotions. Changes in behavioral regulation.
• Becoming angry uninhibitedly. Self-insight that may be lacking. Disinhibition in several areas.
• Frontal syndrome due to damage in the frontal lobe (particularly in the orbitofrontal lobe (near the eye sockets).
• Difficulty solving problems
• Inability to express language (Broca's aphasia).

 

Seat of personality and emotional control

The frontal lobes are considered the seat of emotional control and personality. There is no other part of the brain where brain damage causes such a wide variety of symptoms.

 

Random access memory

The prefrontal cortex is vital for working memory.
The brain cells of the prefrontal cortex help store information for short periods of time. Just like what happens in a computer, information can be written in this part of the brain (in these brain cells), and then erased when that information is no longer needed and rewritten with something new.
However, studies show that in case of unexpected stress the information is completely erased. Working memory (part of short-term memory) cannot function under stress and distracting factors.

 

Facial expressions

Disruption of motor skills is characterized by the loss of fine movements and strength of the arms, hands and fingers.
Patients with frontal lobe damage may show few spontaneous facial expressions, indicating the role of the frontal lobes in facial expression. Broca's aphasia, or difficulty speaking, has also been linked to frontal injury.

 

Problem solving ability

Damage to the frontal lobe appears to affect 'divergent thinking', or flexibility and problem-solving skills. There is also evidence that there may be difficulty with attention and memory even after good recovery from a traumatic brain injury.

 

Talk more or less

Scientists have discovered that someone with frontal damage speaks with fewer words (in case of damage to the left frontal lobe) or talks too much (in case of damage to the right frontal lobe).

 

Spatial orientation

The frontal lobes certainly also play a role in our spatial orientation, including the orientation of our body in space.

 

Testing the consequences of frontal damage

With the help of a neuropsychological examination frontal damage can be mapped out. Tests are used that measure, among other things, motor and language skills, but also tests that measure social cognition.
Some common tests for frontal lobe function include:

• Wisconsin Card Sorting;
• Finger Tapping (motor skills);
• Token Test (language proficiency).

See the page on neuropsychological examination.

 

Brain hemispheres (left and right) and behavior

• Frontal damage in the left hemisphere usually manifests itself as pseudo-depression. The left frontal lobe also plays a role in speech and language.
• Frontal damage in the right hemisphere usually manifests itself
  as pseudo-psychopathy. A person's personality may undergo significant changes after an injury to the frontal lobes.
  In general, damage in the right hemisphere of the brain causes 
  more behavioural and personality change than left hemisphere injury.
  
• Frontal damage in both lobes. Especially when both lobes are involved, the greatest changes in a person's personality are seen.

 

Explained per brain area

 

Damage in the center of the frontal lobe:

• dependence on the environment
• without initiative
• loss of willpower
• emotional flatness
• lack of exercise
• apathetic
• paralysis on the other side of the affected part of the brain

 

Possible complaints due to damage in the eye socket area of the frontal lobe:
Frontal syndrome

 

 

• disinhibited
• impulsive
• poor self-correction
• decrease in awareness of what is appropriate and what is not
  
• decrease in critical and careful consideration
  
• little or no attention for others
  
• inappropriate jokes, tactlessness
  
• impaired sense of smell

 

Dealing with someone with frontal syndrome

Because a person with frontal syndrome cannot properly assess the consequences of actions in the present, these people need more boundaries, structure and clarity.
Explain plans, tasks and actions carefully, step by step, but be aware that this person may not be able to remember them, so keep repeating the steps calmly.

Tasks can cause frustration if they don't go well. Realize that fear of failure or shame or fear of anger from others can also play a role and provide support. Try to avoid stress. Studies have shown that working memory (short-term memory) cannot function properly under stress.

Avoid discussions and disputes, stay calm. Try to stay out of your own emotions and stay out of a power conflict. If things get out of hand, take a time out, so that you do not reject the person, but you give yourself and the person some rest and distraction.

Then come back with kindness.

Provide peace in the house, also in terms of noises and other disturbing stimuli. A low-stimulus environment offers more peace and less distraction.

Professional guidance and psychoeducation can be given to partners and family to learn to deal with the sometimes unpredictable behavior of someone with frontal syndrome.

The person with frontal syndrome can also receive guidance, psychoeducation and behavioral therapy, but everything depends on his or her ability to learn.

It is important to realize that the injury and the combination of location in the brain causes this behavior.