BIOLOGICAL BASIS OF BEHAVIOR
Psychology 321
Spring, 2005 HGH 225
Dr. John M. Morgan MWF, 8am to 9:00
Tumors located in the frontal lobe are quite common since this
lobe is the largest in humans. These growths are categorized as
primary, which means they originate in the brain (benign), or
secondary, meaning they have a different origin and it spread to
the brain (metastasized). Primary tumors tend to grow slower and
cause less noticeable damage and behavioral changes. Secondary
tumors, on the other hand, pose a bigger threat because they
grow faster and tend to be malignant. Tumors can be operated,
with low mortality, but it is usually the individual’s behavior,
life, and family that have to change in order to adapt with
these new conditions brought on by these growths.
Neurosurgeon
By Ricardo Agredano
Neurosurgeons will first want to diagnose the individual
complaining of certain complications. Most individuals will
report having seizures and/or recurrent headaches, usually
recurring in the same area. But, other symptoms could occur
depending upon the location. For example, personality changes,
being overactive, trouble paying attention, and a loose,
disconnected feeling. When the complaint is registered, the
neurosurgeon will most likely want to run a couple of tests to
see if what the patient is experiencing is due to a tumor.
To alleviate some of the symptoms in less threatening cases, the
surgeon may prescribe some medicine. Steroids are usually given
to reduce swelling and inflammation from growth. Anticonvulsants
are given to help reduce or stop seizures caused by tumors. And,
to help alleviate hydrocephalus, a shunt is inserted in order to
drain fluids and to reduce that build up caused by the tumor.
But of course these medications could have unwanted side
effects. Steroids like dexamethasone could cause restlessness,
anxiety, and/or depression; antipsychotic medicines usually are
given to subdue those effects. If anticonvulsant drugs’ dose is
too high or too low, it could exhibit aggression, insomnia,
and/or psychosis. They could also have a bad reaction with
chemotherapy and cause sleepiness, depression, confusion, speech
and vision problems, and/or gait problems. This could be solved
by either changing dosage or anticonvulsant.
Modern imaging techniques have allowed neurosurgeons to better
examine the brain and especially locate tumors. The neurosurgeon
could start with some X rays and look for any abnormalities in
the skull and for calcium deposits, but it could be a waste of
time when a Computerized Tomography (CT) could be used. Equally,
positron emission tomography (PET) and magnetic resonance
imaging (MRI) have emerged to provide more detailed and valuable
information on the type of tumor involved. After analyzing the
images taken, the neurosurgeon will move on to a biopsy in order
to make a more conclusive prognosis. The best biopsy technique
would be a needle biopsy in which a burr hole is made and then
the needle is inserted into the brain and guided by a CT scan to
get a small sample of the tissue. If the tissue is cancerous, a
test for cancer elsewhere in the body is also administered.
The tissue analysis and the results from the images will give a
better understanding to what grade it is and whether it is
benign or malignant. Benign tumors may posses less of a threat
because they grow slower, while metastasized tumors usually grow
and destroy rapidly. Either way, removal is usually necessary
through surgery. But before surgery can be suggested, the
individual must have a more positive prognosis based on other
factors. Age is a big factor because the younger the person, the
better survival they have. This is generally for people under 40
years of age. Another important variable to consider is the
amount of neurological deficit the individual possesses. More
leading to a negative prognosis and less would be a better
prognosis.
After the individual has met a good prognosis, the go ahead
would be given for surgery if it were necessary. The operation
site would depend on the location of the tumor. If possible, the
surgeon would be more inclined to seek out natural openings such
as the nose to enter. But, if this is not the case the surgeon
would have to perform a craniotomy, which of course will be as
close as possible to the tumor. Next is a removal of the tumor.
Depending on whether or not the tumor possesses a threat, it
will be fully, partially, or not removed. Usually, however,
there is a complete removal of the tumor followed by a radiation
therapy or chemotherapy.
If the tumor is not very much of a threat, the doctor could
perform other types of operations that could kill the tumor’s
growth. Most common ways of dealing with retarding tumor cell
growth is through radiation therapy and chemotherapy. These
treatments, however, may have some bad side effects that the
patient may not be so willing to deal with to avoid the risks of
surgery. There has been a growing development in new innovative
procedures.
Lasers guided by ultrasound have been increasing in use to
ensure no cells of the tumor are left behind. Another technique
being used to ensure no cancerous cells are left behind is
wafers that contain cancer-fighting drugs are left behind in the
area where the tumor was removed. Stereotactic radiosurgery
sends radiation beams to the exact location and the exact shape
of the tumor using imaging. It is a radiation therapy, but the
idea here is to reduce some of the side effects that come with
normal radiation therapy. Angiogram observations can provide the
routes of blood vessels to the tumor. A tumor usually takes in
much energy and helps them grow. Research is being done to cut
off the blood supply in benign tumors to inhibit their growth.
A neurosurgeon’s next responsibility would be to make sure the
cancer is gone and that the growth doesn’t come back. A
comeback, however, is common and usually treated right away with
surgery or other techniques. The comeback is also the same
reason for why a patient would be put on chemotherapy or
radiation therapy after their surgery. But, follow-ups are
usually done using MRI or CT scans to examine the areas where
the tumor once resided. Usually visits vary with the type of
tumor that was worked with; more severe tumors requiring
frequent follow ups and less sever ones requiring less of the
patient and neurosurgeon’s time.
Neurologist
A neurologist will immediately look at the behavior being
exhibited by his or her patient. Most common complaints about
tumors in the frontal lobe are seizures, recurring headaches, a
change in personality, disorganization, weakness, trouble with
motor movements, language problems, trouble paying attention,
hyperactivity, and loose, disconnected feeling. The frontal lobe
is a large area and it contains many important areas that deal
with the behavior changes patients may undergo.
The frontal portions are responsible for personality changes;
being polite once in life and then changing up to being rude. If
the prefrontal cortex were invaded with a tumor, it would cause
a deficit in organization and planning. A sort of pseudo
depression could arise where the person may act apathetic or
indifferent towards events, and would also show lack of
initiative without the patient feeling actual full on
depression. Similarly, pseudo psychopathology shows symptoms of
psychopathology, such as lack of judgment, maturity, and
restraint, without actually being in the mental state of
psychopathology. If a tumor in the orbitalfrontal arose, the
person would exhibit loss of recent memories or have trouble
making those memories equally.
A tumor near Broca’s area could cause difficulties in language,
especially in the performance of language (Broca’s aphasia).
Patients would have trouble making sense in their speech, make
grammatical mistakes, would have trouble reciting things back
and identifying objects and verbs. The tumor would be close to
motorsensory and somatosensory areas that would inhibit some of
the movements necessary to produce spoken language. Similarly, a
tumor in the same area could cause weakness in other bodily
areas. This leads to praxis, where patients would have
difficulty in skilled limb movements.
Neglect is another symptom that may occur because of a tumor in
the right frontal lobe, and may even persist after operation.
This symptom is often overlooked because individuals may perform
perfect on other tests and the doctor may miss it because
everything looks fine. People who develop neglect, however, will
usually ignore left hemispace. This ignorance of left hemispace
can also carry over into components of motor and sensory
activity, and extinction (visual, audio, motor, somatosensory).
Other neglect symptoms that may arise from tumor damage in this
area is anosognosia, which is a denial of having any illness,
and anosodiaphoria, which is a lack of concern for the illness
without the denial. Misoplegia, a dislike for limbs, could also
occur with a tumor in this area.
Neurologists are also involved in administering several tests in
order to see what behavioral changes occur and if they match up
to what someone with a tumor in the same area exhibits. The
neurologist may administer simple tests involving movement and
recital of words, or even tests in which the patient must fill
out inventories of questions.
The Go, no go task is often used to look for any echopraxia
(response inhibition). This task is done by asking the patient
to hold up two fingers if the psychologist holds up one and one
finger if the psychologist raises two. The antisaccade task is
done by checking where the peripheral sight of the patient goes
when the psychologist causes a stimulus with his/her hands on
the side of his/her head. The eyes should follow to where the
stimulus is otherwise it could signify damage in the
orbitalfrontal cortex.
The Thurstone test looks for letter fluency and word generation
ability by asking the patient to name off as many words,
excluding proper names and word derivates, beginning with the
letter “F” in a minute. Most adults with high school education
can at least name off eight words in a minute. Flaws in this
area would propose that the patient may be suffering from a
tumor in or near the language areas.
Attention and concentration tests are given to test for
cognitive functions. The patient may be asked to count backwards
in digits of 7 from 100 until 65 is reached. Or, they may be
asked to spell words backwards. This is important because if
patients cannot attend to these attention and concentration test
adequately, they cannot be tested with other cognitive tests;
also suggesting damage in the frontal lobe.
Motor reflex ability is usually tested using Luria’s 3 step
method which involves a patient to make a fist, then lie the
palm down flat, and finally putting the hand on edge. If the
patient is unable to follow this sequence, it may suggest that
he/she has damage in the area. Following this test, a
neurologist can further test finer limb movements for apraxia by
asking the patient to pantomime movements of tools such as a
hammer, knife, scissors, or a screwdriver.
Neglect, the most overlooked symptom, is assessed through
various tests. A test for neglect dyslexia is done by having the
patient read a page and have them circle some things or cross
out others. If the patient avoids any of those things on the
left side of the page, he/she could have this symptom and
suggest a tumor in the right frontal lobe. Another way to test
for the same symptom would be to ask the patient to bisect a
well proportioned line in the middle. If the patients mark is
noticeably favoring the right side, the patient may have a
neglect symptom.
There are other tests that are administered that require the
patient to fill out questions or perform other tasks. The Paced
Auditory Addition Test (PASAT) tests for working memory
attention and concentration abilities. Along the same lines is
the Visual Span subtest of the Wechsler Memory Scale and the
Wisconsin Card Sorting Test (WCST). There are also many scales
that look at mood; Beck Depression Inventory, Zung Self rating
Depression Scale, and the Hamilton Depression Scale to name a
few. Aphasia can be assessed using the Western Aphasia Battery
(WAB) or the Boston Diagnostic Aphasia Examination (BDAE).
References
Engelhard, H.H., Stelea, A., & Mundt, A. (2003).
Oligodendroglioma and anaplastic oligodendroglioma: clinical
features, treatment, and prognosis. Surgical Neurology 60. 443-
56.
Feldman, R.S. (2005). Essentials of Understanding Psychology.
McGraw Hill: Boston.
Jacobs, D.H. (2004, October 26). Frontal lobe syndromes.
Retrieved May 6, 2005 from the World Wide Web:
http://www.emedicine.com/NEURO/topic436.htm
Kalat, J.W. (2004). Biological Psychology. Wadsworth/Thompson:
Australia.
The Effects of a Tumor on the Spouse and Other Family Members
By Diana E. Pineda
A tumor that is specifically in the frontal cortex can
cause many changes physically and emotionally which can affect
the way you interact with your family. Some of the functions of
the frontal lobe are attention, abstract thought, problem
solving, intelligence, creative thought, initiative inhibition,
judgment, mood, major body movements, bowel and bladder control,
memory and reasoning (retrieved from www.ect.org. What this
means is that you will not only experience these symptoms
internally but externally as well. Family members may start to
see the decline in your health and become concerned.
When diagnosed with a brain tumor it is important to share
this information with family and friends. Although this can be a
very difficult conversation to have, it is important for loved
ones to be informed. This conversation will not be easy to have
in fact, it can bring up many emotions and questions that are
challenging to discuss (retrieved from www.braintumor.org ).
Understanding what is happening to your loved one is essential
to answer questions and minimize any fears that one can have.
The patients Doctor is definitely a good resource as well as the
internet and the library. If revealing this news seems
impossible for you maybe, you can seek a social worker (many
times hospitals have one on staff), church or a therapist. It
is important to expect dynamics within the family to change.
This change can be due to financial hardships, changes in
schedules, emotions, stress etc.
There are definitely stages of acceptance that your loved
ones may experience. The stages of acceptance are; denial,
anger, resentment, depression, resignation and acceptance
(retrieved from www.cancersurvivors.org). They will not
necessarily experience them in order or even experience them all
but it is a possibility. Denial involves the rejection of even
the possibility that this could be happening. Anger involves
feeling upset at the world, the patient, the Doctor etc.
Acceptance is the emotion that includes excepting the situation
and remaining hopeful towards the future. If some family
members are having an especially hard time coping with the news,
it might be wise to seek family therapy.
Someone in the family might volunteer to help during the
difficult time. The effects of care giving can be rewarding and
stressful. It is important to remember that one person cannot
handle everything. Other family members and friends can assist
with even the smallest situations. Attempting to take on all
the responsibilities can lead to burnout or even anger towards
the person with the illness. As the caregiver, venting can be a
form of distressing yourself. Discussing ones feelings is
imperative, you do not even have to speak to a professional, you
can just speak to good friend (retrieved from www.abta.org ). It
might be helpful to let them know that they do not have to make
everything better but they just have to listen.
Discussing the Tumor with Children
Many people might believe that hiding the illness from
children is the best approach to take. However, children will
notice the differences even if they are very young. Talking to a
child about such a complicated and emotional illness may be
intimidating, but it is necessary.
The age of the child is a good determining factor in the
approach of the conversation. Young children can understand the
concept of having a lump in your head that does not belong there
(retrieved from www.braintumor.org ). You can even draw a
picture or get a book made especially for children. Questions
will undoubtedly arise and it is important to be prepared. It is
not necessary to go into complicated details but a simple
description might be enough. Assure the child that if he or she
has any questions or just want to talk it is okay to do so. Get
the message across that talking will help. Also, explain to the
child that routines might change a little bit. The parents
should attempt to maintain the child’s life as normal as
possible. Maybe the same parent will not pick him/her up after
school or dinner may be a little early. The concept of going to
the hospital and getting surgery is scary for even adults and
children are no exception. Teenagers may begin to act out
because of many emotions they are experiencing.
Returning to the Workplace
Returning to work can be determined by a neuropsychologist.
The type of tumor, side effects of treatment can usually give an
indication as to how soon one will return to a functional state.
A person might want to consider working part time to readjust to
the daily routine. Regardless it is important to be honest about
needs and expectations. If a cancer survivor is “employed at the
time of diagnosis than the rate of return to work varies from
30% to 100%” (retrieved from www.abta.org ). This statistic is
very promising because it signifies the positive side of all the
obstacles. It is important to be aware of the possible side
effects that can affect ones ability to function at the
workplace. The person’s weakness and strengths should be
considered in all areas including cognitive, psychological, and
physical. A patient can easily discuss this matter with the
supervisor to explore accommodations. Maybe a person can take on
simpler tasks to start off with. This can make the transition
easier for the patient, as time goes by one can consider working
more hours.
It is important to consider how much information will be
disclosed to co-workers. Dr. Feuersten a brain tumor survivor
states that for him, working throughout the process of his
chemotherapy was a form of “on the job rehabilitation”
(retrieved from www.abta.org ). It gave him a time to distract
himself from all his troubles. As he described everyone was
understanding to his situation and provided a lot of support for
him. He explains that he did have to modify his duties but
nonetheless, felt as if it helped him with his memory and
energy. It should be noted that not all employers can behave
sympathetically.
The American Disabilities Act of 1990 (ADA) prevents job
discrimination for disabled individuals. If a person can perform
the essential tasks of a job law cannot discriminate against
them. This means that even if a person has apparent disabilities
an employer cannot deny hiring them and should make reasonable
accommodations. In the case of a person with a brain tumor who
may not be able, to recall tasks, they can be accommodated by
making to do list working or repetitious tasks.
There are also Federal and State Disability programs.
There are permanent and temporary benefit programs that one can
apply for financial assistance in. A social worker at the
hospital or at a local agency should be able determine which
program is best for the patients needs. The different programs
include Medicaid, Medicare, Social Security Administration and
Veteran Programs (for more information go to www.cms.gov ).
It is important to acknowledge that this information may
not apply to all individuals. As mentioned previously the type
of treatment and severity of the tumor will determine each
individual capability.
Reference
Bear, J. (1997). Stages of Grief. MSN Cancer Forum.
Retrieved from the Internet on April 28th, 2005.
http://www.cancersurvivors.org/Coping/end%20term/stages.htm
Feuerstain. (2005). Becoming Well Again Through Thriving At
Work. American Brain and Tumor Association, Retrieved
from the Internet on May 1st, 2005.
http://www.abta.org/wellaagain7.php
Thimble, M.H., (1990) Psychopathology of Frontal LobeSyndromes.
Seminars in Neurology. Retrieved from theInternet on April 25th,
2005.http://www.ect.org/effects/lobe.html
The Essential Guide to Brain Tumors. Retrieved from the
Internet on April 25th, 2005. http://wwww.braintumor.org
Frontal Lobe Syndrome
By Katie Holley
Although volumetrically the frontal lobes are the largest portion of the
brain their function remains somewhat elusive (Jacobs, 2005). Even
neuropsychologists have a difficult time creating test that accurately
test frontal lobe functioning. We do know however, that the frontal
lobes are involved in the storage of memories, concentration, abstract
thought, judgment, and self control.
The frontal lobe lies directly behind our forehead (NINDS, 2005) It
contains the primary motor cortex and the prefrontal cortex, which
extend from the central sulcus to the anterior of the brain. The
posterior part of the frontal lobe is the precentral gyrus which is
specialized in the control of fine movements. The very most anterior
portion of the frontal lobe is the prefrontal cortex. The neurons in
this area have up to sixteen times as many dendritic spines as neurons
in the occipital lobe or primary visual cortex. As a result, the
prefrontal cortex is able to integrate a great deal of information
(Kalat, 2004). For most people the left frontal lobe controls language
and the right non-verbal abilities (UNL, 2005).On the left frontal lobe
is an area called Broca’s area which allows thoughts to be transformed
into words. In addition, there are many connections from the frontal
lobe to other parts of the brain that control vision, respiration, blood
pressure and gastrointestinal activity (NBTF, 2005).
Damage to the frontal lobe results a range of behaviors referred to
collectively as ‘frontal lobe syndrome.’ There are numerous ways of
damaging the frontal cortex including lesions, tumors, and strokes.
Lesions damage the frontal cortex when a blow to the head or a sudden
change of motion causes the boney structure underneath the frontal lobes
to tear the axons (as is the case with prefrontal lobotomy or
leucotomy). A stroke can result in ventral and medial frontal lobe
damage. Tumors can damage the frontal lobe by being located on one of
the lobes, or by causing pressure on the frontal lobe, as is the case
with meningioma, subdural hematoma or similarly meningitis (UNL, 2005).
Frontal lobe syndrome results in the impairment of language, motor
functions, social behavior, abstract reasoning, and cognition.
Furthermore, there is often a change in personality (UNL, 2005).
Although language remains fluent and in proper syntax, the overall
amount of talking decreases. Patients have difficulty maintaining
conversations and some even become mute. Motor functions are often
uncoordinated and patients often have difficulty constructing three
dimensional objects. Those who suffer from frontal lobe syndrome often
have difficulty planning, modifying behavior in relation to the context
of the situation and with abstract reasoning. As a result they often
have social responses that are inappropriate. Patients have difficulties
understanding categories of objects, and formulating rules and goals.
Furthermore, both memory and attention abilities are impaired,
specifically the working memory (Kalat, 2005). Patients are often
emotionally instable, while also having an “emotionally flat persona.”
In some cases both hysteria and inhibition are described (Thimble,
1990).
Depending on the area of the frontal lobe damaged both the resulting
change in behavior and cognitive functioning effected can differ
greatly. For example, lesions in and around the Broca area are more
likely to cause aphasia. Constructional apraxia (the inability to draw)
generally localizes in the right hemisphere. Deficits in declarative
memory are most common in orbitofrontal injuries (Jacobs, 2005). The
area of the frontal lobe injured determines the affect in behavior to a
certain extent.
The Role of a Neuropsychologist
Detection of frontal lobe damage is often difficult and misdiagnosed as
many patients have normal neurological testing and an apparently intact
IQ (Thimble, 1990). Consequently, neurophysiologists have created a
variety of test to help identify frontal lobe damage, some of which are
explained below:
Abstract Thinking Task
Ask the patient, “If I have 18 books on two bookshelves, and I want
twice as many books on one shelf than the other, how many books on each
shelf?” (Thimble, 1990)
Cognitive Task
Ask the patient to generate as many words as possible that start with a
given letter in one minute (Normal is around 15, depending on education)
(Frontal Lobe Lesions, 2005)
Thurstone Test
Ask the patient to cross out all of the letter A’s on a page mixed with
other letters. Patients who suffer from frontal lobe syndrome may have
difficulty or only cross out the letters on one side of the page
(Jacobs, 2005).
Understanding
Ask the patient to hold up one finger if the examiner holds up two, and
two fingers if the examiner holds up one. Give ten trials. A failure to
respond correctly suggests a lack of adequate response inhibition.
(F.L.L., 2005)
Wisconsin Card Sort Test (WCST)
In the WCST the patients are presented with a pack of cards with symbols
on them that differ in form, color and number. Four stimulus cards are
available and the patient is asked to place each response card in front
of one of the four stimulus cards. The tester then tells the patient if
he is right or wrong. The patient then has to determine where to place
the next card. Sorting is done arbitrarily by color, number and shape.
The patient’s task is to shift responses based on the information
provided. Patients with frontal lobe syndrome will have difficulty
overcoming prior established responses (Thimble, 1990).
Aphasia Assessment
Both the Western Aphasia Battery (WAB) and the Boston Diagnostic Aphasia
Examination (BDAE) are used to diagnose aphasia (Jacobs, 2005).
Other More Formal Tests
The Paced Auditory Serial Addition Test (PASAT) and the visual span
subtest of the Wechsler Memory scale can be used to assess working
memory and concentration. Mood can be assed using the Hamilton
depression scale, the Beck Depression Inventory, or the Zung Self-rating
depression scale (Jacobs, 2005).
Damage in different areas of the cortex will often result in different
behaviors, further complicating diagnosis. The MRI is generally the most
useful of all measurement tools in diagnosing the location of frontal
lobe damage. It may show lesions, hemorrhage, demyelization or atrophy
in certain areas (Frontal Lobe Lesions, 2005).
The role of a neuropsychologist is not only to diagnose the nature and
extent of the patient’s cognitive impairment, but to offer support for
the patient and their family. They help to arrange appropriate care for
the patient and coordinate appropriate assistance (such as occupational,
speech, and emotional therapy).
What to do as a patient?
There are numerous resources available on the internet explaining
Frontal Lobe Syndrome, such as the National Brain Tumor Foundation,
www.braintumor.org. Seeking the expertise of a neuropsychologist is
especially important, as diagnosis is often quite difficult. Family
education regarding the injury should be one of the primary focuses of
care (Jacobs, 2005). Surgery in frontal lobes is often problematical,
and is only rarely helpful (except in some cases of tumors and
hematomas)(Jacobs, 2005). There are currently no drugs available that
directly affect the frontal lobes (Frontal Lobe Lesions, 2005). Many
with frontal lobe syndrome require residential care although the
prognosis depends entirely on the underlying pathology and varies on a
case-to-case basis (Jacobs, 2005). Both in patient and out patient care
are available. Although many consult a neuropsychologist after treatment
it is recommended by the National Brain Tumor foundation that one
consult a neuropsychologist upon diagnosis. That way an accurate
evaluation before treatment will help to determine the effects of
treatment (NBTF, 2005)
As we have seen frontal lobe damage can have an effect on all aspects of
a patient’s life. Not only is there a change in one’s cognitive ability,
but often times one’s entire personality. As was said, of perhaps the
most famous of all who have suffered frontal lobe injuries- 19th century
railroad worker Phineas Gage after a railroad spike shot through his
head, “Gage was not Gage” (Jacobs, 2005).
References
Frontal Lobe Lesions (2005). www.patient.co.uk/showdoc/40001903/
Jacobs, D.H. Frontal Lobe Syndromes (2005).
www.emedicine.com/NEURO/topic436.htm
Kalat, J.W (2004). Biological Psychology: eight edition, 97-99.
National Brain Tumor Foundation (2005). www.braintumor.org
National Institute of Neurological Disorders and Stroke. Brain
Basics: Know your Brain (2005). www.ninds.gov
Thimble, M.H. (1990). Psychopathology of Frontal Lobe Syndromes.
Seminars in Neurology. www.ect.org/effects/lobe.html
University of Nebraska (2005). Causes of Frontal Lobe Lesions.
www.tbi.unl.edu/savedTBI/frontal.html
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Copyright © 2005, Dr. John M. Morgan, All rights
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This page last edited 1-3, 2005
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