hello everyone my name is annie reyes and for this summer dr casey hewitt and i will be your moderators we're pleased that you could join us for this week lecture in our first seven a week near known your anatomy meaning series that brings you lectures from experts in the field covering different anatomy topics each week this series was created by trainees and early career neuropsychologists to provide free high quality didactic opportunities we would like to recognize our non-anatomy planning group for their hard work pulling this mini series off we would also like to thank our sponsors for their financial support for this series before we start there are disclaimers for the series this training is not meant to replace formal education in neuropsychology and the views of the speakers are their own questions can be submitted via the q a box on the lower left of your screen and a recording of today's lecture will be provided on our website later this week questions will be asked at the end and not during the lecture today's q a is led by dr casey hewitt and that is my pleasure to introduce dr catherine price for today's lecture titled frontal lobes anatomy and function dr price is an associate professor in the department of clinical and health psychology with a joint appointment in the department of anesthesiology at the university of florida in gainesville she's a licensed psychologist for board specialty in clinical neuropsychology she is a director of the preoperative cognitive anesthesia network program for alzheimer's disease and related dementias her primary research aims are to understand the relative contribution of white matter versus subcortical great matter structural integrity on the cognitive profiles of subcortical neurogenetic diseases second her aim is to apply this knowledge towards more collaborative and longitudinal research examining the predictive value of cognitive profiles why in great matter structural integrity on one to this disease cognitive decline as well as vulnerability to accelerated cognitive change after elective medical intervention such as major elective surgery and it's a pleasure to have dr price giving us a lecture on executive functions thank you dr price great thank you so very much for this wonderful introduction and for the invitation i'm really honored i've heard so many wonderful things i haven't been able to watch this on my own so i am so glad to be able to be a part of it and now you have a fan i'll be watching all the time so all right so i'm going to do is i'm going to share my slides here okay can you see the screen okay do you just see the major screen you don't see the yeah it looks perfect thank you it looks fine okay good all right so what i'm going to talk about today we're going to talk about executive function um and we typically talk about executive function we think about the frontal lobes so one thing you're going to learn is that executive function is not just the frontal lobes but one thing we are going to ask is i'm going to ask that you at least know the regions of the frontal lobe because this is going to help you when you are trying to understand executive function and as you're assessing individuals who may have executive dysfunction so here we go today's discussion i'm going to orient you to some anatomy we're going to talk about the basic roles associated with the frontal lobe and then we're going to try a couple of cases for name that lesion for clinical evaluation okay so first let's talk about anatomical boundaries i'm going to talk to you about the prefrontal cortex the three major functional areas and we're going to talk about basal ganglia connections that's the first part all right so first off here now we have to remember the lateral and the medial side of the brain so we're thinking about um the cortex area here and here are the main areas i want you to remember you have your motor strip your pre-motor area and then you have your prefrontal cortex here so this is the lateral side but then there's also a medial side to the frontal lobe that many of us forget and so i'm glad that we're here to have a remember to remember that in practice so you have your motor area the pre-motor because you have to remember the cortex folds in and then you have the medial with your anterior cingulate and then you have your orbital frontal region so this whole area here hopefully you can see my mouse is the prefrontal cortex so now i'm going to give you some quiz a quiz um what is this area here that we talked about so hopefully you're remembering that this is a part of the pre-motor regent okay and this region is related to responding to stimuli um random stimuli for example this region can be partially involved in eye movement particularly through electrical impulses and the pre-motor region here is really important for preparing information from your primary motor cortex and other functions of the brain it's going to send signals to different areas of your body all right and it's divided into different parts you have your dorsal you have a ventral part of your pre-motor cortex you don't need to know all that i just want to make sure that you know that this area is there it's a very essential part of your your motor function in your frontal lobe and so we're going to come back to that in a little bit okay so pre-motor cortex now the next one pretty large we talked about the we talked about this area a minute ago do you remember what the name of this area is okay well this is the prefrontal cortex all right and in the prefrontal cortex you this is a very complicated area multiple regions um here as you can see in this next image this shows you it's a little bit blurry but this is actually not in the human brain you can see here this is in a monkey brain and there are different areas here that are cyto architecturally distinct based on cellular layers as well as different functional regions that you'll know from broadening on broadman's area so you're going to know the prefrontal cortex is complicated because it actually includes multiple regions you have your orbital frontal region and that orbital frontal region is here you can see right here it's this is from the side this is from your ventral view and this is from your mesial view all right um so you're going to want to pay attention to this region we're going to talk about this region as well it's part of the prefrontal cortex that's the orbital frontal specific area of the prefrontal cortex and then here's another area of the prefrontal cortex you need to remember and what area would this be so i want you to think about that particularly if you're a student or a trainee uh to remember what structure this could be because remember we talked about you have the singular cortex you've got this is on your mesial area so this would be your medial prefrontal cortex in the middle of the brain slicing right in the half and you're looking on either side okay and the inside of the hemisphere so this is where the cortex is folding in you might have remembered from when you studied the homunculus from your sensory and the motor system you can tell a lot you have to think about the homunculus running across right right through um providing you with your boundaries of what areas and what type of the body is being stimulated within different areas we're going to talk about that in a second later on in the in the talk i'm going to show you a slide that actually will give you some nice lesion detection okay so what about um this last area this is really fascinating for one reason well multiple reasons but let me back up these regions here the orbital frontal are very cyto architecturally cellular this distinctly uh unique there are different areas here area frogmen 10 and 11 that are associated here um that i want you to remember um overlap with a lot of key sensories or over to frontal etc and then here when we get back to the dorsolateral prefrontal region this has a number of different areas here that are not primarily based on your cytoarchitectural or cellular layers this is your dorsolateral prefrontal cortex and even though it has this nice blue blob on top here right this light this area of the cortex is functionally defined whereas the other two are defined by cellular layers and you can actually see distinctly distinct differences in the cortex in the frontal cortex associated with those regions of interest but for the dorsolateral prefrontal cortex which is this structure here is functionally defined which makes it really unique it's actually very interesting and challenging to study the dorsolateral prefrontal cortex because it's it's individualized based on that on that person so it's been identified with functional resting state or functional studies task based oriented studies and you'll see that the dorsolateral prefrontal cortex is actually different for everybody other things that are interesting is that it's really challenging um to uh do a to segment that area using different types of software if you've ever tried to use free surfer versus other tools you'll see that it'll actually extract different areas and different sizes of the dorsolateral prefrontal cortex so there's lots of challenges and interesting elements within these different regions of the brain you can see how complex the prefrontal regions are all right so those are that's just the basic very basic elements of some of the key regions as neuropsychologists we assess within the frontal lobe okay now i'm going to come back to those regions but i also want you to realize that those structures those cortical structures are connected to important subcortical structures and also specific white matter circuits all right and this is you're going to understand this in a minute so hopefully this is a bit of a review all right so there are five components of the basal ganglia as well as the thalamus that you need to remember when you're thinking of the frontal lobes all right and the reason why is because the frontal lobe is connected to these structures these five components all right you've got the caudate nuclei the putamen the globus pallidus the subthalamic nucleus and the substantia [ __ ] okay now the caudate and putamen combine to make the striatum the putamen and the globus pallidus form the lenticular lentiform nucleus but it looks just like a lens and then the caudate putamen of the globus powders make the corpus striatum so here's a nice uh depiction of this and you have to think about more of a vertical you have to think about the vertical aspect of the brain right and the connections between each of these regions here is another depiction of this relative to the frontal lobe i like to say here this is your coronal slice like you're taking a slice here and you're looking in this slice you're looking this is axial slice so you're taking a slice here and you're looking down all right so here now you can see that you have your caudate nucleus and the putamen here forming your striatum all right these two areas here then you have your the ventral lateral nucleus of the thalamus here and you have your subthalamic nucleus your globus pallidus and substantia [ __ ] now key among here you have your um you have gada gaba you have glutamine you have major neurotransmitters but you also have quite a bit of impact from your dopamine acetylcholine and your serotonergic neurotransmitters and what's happening is that these are providing an input and pathway for activation within the frontal lobe and vice versa and they're going through these white matter fibers here so you can see this connection going from the from these structures these gray matter structures these nuclei the cells here all the way to the external areas of the cortex through these white matter fibers that are crossing one another right sending information back and forth so we have to appreciate this loop and through work of alexander on the long and strict which you can breed and you know this very well of where you are in emory all of their wonderful circuits that were published approximately what now 50 years ago that's really sad um there's been so much work since then but what we still know based on this classic work is that there are three neuroanatomical loops and two motors okay and you can there there's been debate as to whether there are other ones but i really want you to remember if you are going to be a neuropsychologist involved in neuropsychology involved in neurology you have to remember there are three neurobehavioral circuits all right and the basic pathway is the same this is really important because what what happens behaviorally is that you can have a lesion in the cortical area for example a broadband area 10 or 11 and you could present with a certain pattern if you have gut lesion in the striatum you could show the same pattern you could have a lesion here you might show the same pattern so you have to see there's duplication among this among this loop okay so i'm just checking the chat to make sure okay that i'm not missing something okay so for the orbital frontal cortex we're going to start from in a hierarchy we're going to start at the start of the orbit of frontal region all right and you have to think of there's connection for everybody right back up and back up one side i want you to remember there's a connection from the cortical to the striatum to the pelvis to the thalamic regions and all right going back sorry that arrow should be the other way but um one thing that differentiates the different regions of the brain is where in the striatum the cortex is connecting okay so pay attention to that so if you look here at the orbital frontal cortex it goes from the cortical basal um uh broaden areas 10 and 11 to the striatum it's going to the lateral eventual medial caudate when you start to see ventral regions you start to realize okay ventral is actually this is really interesting ventral is getting information that is relaying information more about olympic responses the vagus nerve is there pain responses are in the cottage okay uh in that area um and then also ventral star adam so if we think about orbital frontal when you're going to learn about the orbital frontal is that the orbital frontal region is involved in your a lot of your olympic responses so this makes sense that it's going to this cortical to the striatal then going to the palatal with the globus pallidus internal and substantia [ __ ] cars um particulata and then the thalamus okay and then back so uh-oh if we i have to take this off so if you think about this what happens is when this is involved in our personality our mood and then you're going to hear a term called utilization behavior that i'm going to show you so this is just showing you how this this loop is involved in different types of uh frontal functions typically what we associate with personality okay so that's just a little taste of what we're going to talk about now the next area that i want you to think about because remember we're focusing on the prefrontal cortex all right so the next year i want you to think of is the mesiora the medial region of the frontal lobe where i showed you earlier okay so this area we're still in the pre-motor area but this is now mesial and now it's connecting to the ventral portion of the striatum again but you also have involvement um with the putamen and you have the nucleus accumbens um and then it's going to the paladin and then it's going to the thalamus so here what you often see here is you see a disruption in motivation you see disruption and attention you can see some apathy you can see slowness and i'm going to show you a little bit more we're going to talk about this more this is just a taste of what we're going to talk about then the next one the next day remember how i talked about this was a functional area of the frontal lobe this is the dorsolateral region of the the cortex of the frontal lobe this one you again have you have this area classically we consider area 46 involved and it goes to the dorsal lateral caudate head now remember i showed you earlier how the orbital frontal circuit and the mesial went to the ventral striatum this one's going to the dorsal area of them sorry dorsal area of the striatum and specifically the dorsal portion of the caudate what we've learned through research is that the caudate is also segmented in numerous different areas and where the projection systems are coming in can tell us a lot so what we know is that the caudate the dorsal portion of caudate actually is really important in more of the cognitive aspects of function whereas eventual like i said is more involved in more of the visceral pain fatigue nausea those aspects so you want to think about where the input and the output systems are within the structures okay hold on one second we take this one away too all right so now we're back so typically when we think about damage to the dorsolateral prefrontal cortex we're thinking about that's the area involved in executive dysfunctions what we typically call um damage to this area but i want you to think a little bit more critically about this and i want you to think about really what is executive dysfunction is executive dysfunction really aligned only to the dorsolateral prefrontal region so we're going to talk about that too in a few minutes reason why it's typically associated with executive dysfunction is because individuals who have damage to the dorsolateral region typically those are individuals who are having difficulty searching for different types of information they might have make source memory errors they have difficulty with working memory maintaining clear output you're going to see some hyperkinetic behaviors i'm going to give you some examples of it may be more stimulus bound um and it's just like things jump out and they want to grab them so i'm going to show you a bit of that too all right so the next slide now so that was just basic basic basic anatomy with regard to frontal lobe um areas and their connections to the basal ganglia and the circuits or the three parallel circuits and the one thing i do want you to remember though the takeaway message from that is that those cortical regions are connecting to specific areas and specific um structures within that basal ganglia network and within specific areas of the thalamus and that there's that lovely beautiful parallel circuit and that you can have a lesion in any area of those circuits that can produce a very similar behavior all right so we may think that a behavior is portable but it actually might turn out that it's a lesion within the thalamus all right in a specific area of the thalamus some wonderful work by bruce crossin who was at emory he was at uf too he showed that with language over and over so if you need to if you're interested in that i encourage you to read some of his books and some of his work specifically about um the subcortical uh structures and language it's a really great great textbook um a lot of his research so now let's talk about the functional goals okay of the frontal lobe i'm going to talk about the framework its role in motor output and we're going to just talk about basic definitions and then i'm going to go back over again the functions of those prefrontal regions and what happens if you have a damage okay and then we're going to try two clinical cases oops oops let me back up i hit the end button when i didn't mean to hit the end button so here we are there thank you okay so here we go this slide is one of my favorites this is about frontal lobe and this is this conceptual framework now i want you to we're going to change the word function from frontal lobe function i want you to think of the frontal lobe as a mediator all right what does mediator mean mediator is a person who's in between two types of opposing forces and trying to help create something or some agreement between two types of forces is basically what the frontal lobe is doing all right it's a mediator so look at this figure this is a lovely figure um and this shows you let's check them from the bottom this is your environment the frontal lobe is the mediator between the environment and the rest of the body basically okay and it's in you have to remember that half your brain is sensory the other half is motor you're this in your frontal lobe is your biggest low right it really is huge so what's happening here is you have to humans which is actually really interesting humans um have one of the largest um frontal lobes okay um and what do we do what is one of the biggest things that we do humans we create we are um known for creating we have created uh buildings right everything you have we created we created tools right so and we have thumbs so we've actually we have used things to change our entire world and i'm able to talk to you wherever you are through the power of zoom right and that was created by humans that's because we take the environment and we change it right so that's exactly what the frontal lobes haven't allowed us to do so we have the environment information comes in to our primary sensory areas then our hessial's gyrus think about it our occipital regions our sensory tactilely our frontal lobes take that primary information and they it goes from primary sensory whatever that area is here goes to our unimodal association cortex to figure out what it is right then it goes to okay now let's figure out on multiple information about that object then our prefrontal lobe takes that information and knows what to do with it and then we make a decision somehow that we're going to use this object in some certain way or we hear something and so we're going to respond this way and then we create from that standpoint we make a rule that oh now i want to do x or now we want to do y and so then we produce it so that's what the frontal lobes have done they take the information the sentry in and they create it and reproduce right so now you have to consider it that as a mediator so there's no direct syntactic input right or output from the external environment it comes through the sensory and it comes through the olympic system our emotions also and then we produce an output and that's the motor behavior and it's linked exclusively through the cortex and subcortical regions so it is really is a mediator okay um and it's a dispersed neural network such that you have to think about the fact that um it's not only just a frontal to the subcortical structures that i showed you but the frontal to the parietal regions all right and i didn't even show you those networks but you can see it here the pictures you have your longitudinal particularly that are going back and forth between your frontal parietal and you know now that working memory is frontal and parietal right so we no longer really think of it just as a frontal lobe so as you go through you have to apply the frontal lobe function then to cognition behavior and you have to remember that your higher order thinking right is fused to this whole entire biological drive of what you see in the environment right so when you think about how a person is um engaging on the environment if they're able to you have to kind of think of the best way to tell you um it's not it's your responsiveness to the environment how well you how a person is experiencing the environment and then their ability to take that information and create something from the environment and change their output or respond appropriately so it fuses higher order thinking fuses the biological drive with an external behavior okay all right and then you have to think that the frontal lobe is also helping to regulate that behavior what is it appropriate is it not to change the environment in a certain way so there's always this give and take right between your what you see your internal drives and what you produce um and so the result is a really nicely you know hopefully a goal-directed behavior where a person is able to balance those effective things that are coming through not only the orbit of frontal region sorry someone had to say something no something is coming information is coming through all the different areas of the brain but then there's also the orbital frontal region you have to think about the mesial region you're going to see this a little bit more as we talk about it and then there's the planning component so all different areas of the prefrontal lobes are engaged together as with the whole brain i hope this is making sense okay so in general the main message here is that the executive function is a function rather than a brain region so don't think when you're doing your assessments or you're working with individuals that if there is executive dysfunction that it's primarily in the frontal lobes where the lesions located okay the frontal lobe is a contribute is contributing but it's part of a wider network of brain involvement okay so now we're going to go back and we're going to use this i want you to look at this picture over here to the left we have the the figure and i want you to think about the regions that we talked about from this from the um when we talked about the anatomical pathways to help you understand the behaviors that you see with individuals or with behaviors typically associated with the prefrontal cortex and specifically the orbital frontal or prefrontal cortex so here when we think about the orbital prefrontal cortex what we found through different um stimulation uh studies through lesion studies through animal studies case studies we found that individuals when there is a damaged or we found that the orbital frontal cortex is really important for uh understanding and being able to engage on the environment uh with regard to their internal drives being being able to use your internal information and your internal drives to enact on the entire on the external environment so there's planning with regard to your intrinsic factors there's also a reward and emotional value of stimuli which is highly connected to your amygdala and the connections between the orbital frontal cortex to the amygdala the orbital frontal cortex is really important for your ability to moderate your drives and appetites it's involved in social behavior and it we really think of it with regard to our personality and you probably remember some very famous cases about individuals who might have had a lesion to an area of the orbit of frontal cortex and have had drastic changes in personality and i bet you can name one off the top of your head which would be phineas gage and so you could think of that that individual and if you do then you might remember that when you have damage to the orbital frontal cortex that's when you start to see some of these behaviors so clinically you're going to look for these behaviors here first you might look for reduced decision-making ability or being overly impulsive okay um you might see poor social skills so uh whistle suits which is a inappropriate chocularity or laughing right um maybe euphoria inappropriate sexual advances poor impulse control or sense of self you might see some disinhibition acting impulsively grabbing things there's been some classic stories of individuals putting out glasses and people uh the patient or the individual who's being assessed might pick up the glasses and even though that individual has their own pair of glasses on they put their the other glasses that are on the table right on top of their own glasses all different types of observations i'm going to give you an example in a minute then you might see emotional ability you might see that sometimes they're happy sometimes they're sad aggressiveness reduce self-awareness so that's typically what we associate with personality changes now how would you assess orbit of frontal function what do you do and that's a really good question and i wish i could have it as a group discussion but in general you know there's some wonderful papers out there and one i would love you to look at is as a some there are some classic papers um from lermy that were published on case observations actually observation is probably the best thing you could do as a clinician for observing and understanding orbital frontal behavior so you're watching an individual you're a behaviorist okay so in um larry's papers this is one and this is called utilization behavior and so he has some wonderful papers where he had three different cases that who had different areas of brain damage and he does a lovely review of all the areas of the brain that were damaged in the separate papers but in one paper he summarizes the patients um that he saw and it wouldn't be irb approved today but actually what he did is he put out different situations he brought in this wonderful woman here and he set up different stations for her so for example he took her into the kitchen and there were dishes there that were dirty in the sink and he just let her be and watched her and she went over there proceeded to go ahead and clean the dishes and put the dishes away right um in another example he had brought her into i think um into the bedroom and there had been some needles out there or sewing kit and she had gone ahead and she had begun to she just picked it up and started sewing and fixing and another more drastic approach she actually had a syringe out and uh she told him she filled up the syringe with the fluid there and said told him that she would give him the shot so that was a very clear one uh very interesting case reports now he has a two other cases that he talks about but it's these are very extreme cases of utilization behavior but they did have uh damage within the orbital frontal regions of the brain as well as the dorsal so observation is clearly one way in which you can assess orbital frontal function other ones is you can use tools such as the iowa gambling task where you can really pull on that internal drive response you can see how a person responds uh to external stimuli based on it can they actually make a decision that is going to be useful for them how with regard to do they change their environment and their choose so i would suggest that you look at the iowa gaming task or other tools if you want to assess orbital frontal behave behavior but also the best approach is using your own observation skills okay so what about the medial frontal or the sing or the singular region all right so this structure is involved like we said again in your initiation and your action and your emotional expression okay so here when we think about this structure um this is an area of the brain where you're getting you have this is where you know back here when we're talking about the orbital frontal regions there is a reduced capacity to use internal stimuli to guide behavior based on an external stimulus okay here we're talking about the medial or mesial region this is when there's a lack of internal drive all right and this is more of an endogenous versus an exogenous when we see endogenous it means internally driven exogenous is more externally so um this is the ability to initiate and sustain your interest or your movement all right very clear connections to the basal ganglia structure and we often see in this structure truly engaged in a number of different disorders and i'm sure you can think of some on your own that might have that you can classically think of would be associated with disruption to this structure air or the whole pathway so these individuals would not engage as much on their environment you could put out eyeglasses for them they wouldn't pick them up all right you could try to get them to engaged um to move to a certain area of the room they're not interested even watching television they may not be interested or maybe they sit and watch television all day and they don't do anything so individuals with this structure they typically are damaged to the structure or anywhere along that circuit that i mentioned before they might show uh signs of akinesia which means a is loss right when you have the a preface loss of movement all right or loss of inability for movement of speech of um any physical movement at all uh they may have a bilia apathy action so limited emotional expression limited social activity and one of the classic classic diseases that we typically associate with medial frontal involvement or disruption in that in circuit here this circuit here we typically think of would be parkinson's disease if you haven't thought of it yet okay some measures that you could use to assess medial frontal functions you can look at apathy measurements which is different from depression you could use different scales you could use your behavioral observations and also caregiver reports uh reduced initiation for goal directed behavior impaired activities of daily living just not cleaning taking care of themselves you can see this type of behavior in individuals who are remarkably depressed okay all right so now let's contrast those two regions to the dorsolateral prefrontal region right so the dorsolateral prefrontal region as we know is a very large region okay we talked about the different areas of the dorsolateral prefrontal region and this area is involved in the planning component being able to use external information as well as combining internal to navigate and manipulate the environment now this is where you are processing information online actively so working memory is involved spatial maintaining information in your mind multiple types of information mind whether it be spatial verbal internal modulation as well as external modulation engagement of both the internal and external drives that are there so this is very very complex possibly why it has such a very large area that we think of in the prefrontal cortex it also like i says i said has connections to the subcortical structures but also to the parietal regions very much involved in your sensory awareness and your awareness of your whole uh space okay um we typically think of it with regard to working memory so we think about um an individual you know doing two things at the same time we think about disinhibition of being able to inhibit immediate responses think about attentional control here are some examples so for example if i ask somebody i want you to draw two a three two three two three two three two three and i kept pushing that person right and here's their output a two a three a two a three and they keep going but then they lose set they begin to lose their focus lose their attention they may get distracted due to internal or external reasons and here you see a perseveration here okay so this is an example it's actually a alex it's a test um based off uh alexander luria um some of his work and so that is an example of a loss of set that would be associated with dorsolateral prefrontal disruption another one is you've probably seen is the stroop effect so for example where you have to see different colors and you name the colors and then you read the word but then you have to name the color ink and not read the word so you're having to inhibit all right and so this is the stroke effect this has been linked to also the dorsolateral prefrontal cortex all right and the circuitry area another example we did remember i talked to you about being able to the ability to be able to stop behaviors um uh recognize when there is any type of modulation or disruption in a person's output and being able to modulate their own output that would be linked to dorsolateral prefrontal region disruption here are some examples this is also from luria this is called hyperkinetic behavior you can see this here these are some examples from his books um so here's repeating the circles you can see perseverations here this is hyperkinetic behavior and you'll see this on different types of drawings that you might be doing with your participant or your patients other areas associated or disruptions associated with dorsolateral prefrontal cortex it would be planning an organization one of my favorite tests is a clock drawing test and here you can see that this is a test where you would say you have them do a command and a copy condition and the instructions are i want you to draw the face of the clock put in all the numbers and set the hands to 10 after 11. so if i'd had this you probably would have seen i've had this in real time you would have seen the person probably draw a clock a circle sorry circle um they may have put in the numbers but here you can see the numbers are a bit disorganized just a bit um it's over here is where they have the 12 and the 11 10 and then the one is on top of the two and then you can see that there is some difficulty with the place in the hands and they're connecting the hands with a line going across with the different numbers so the planning and organization is not there at least from the command and the production of that clock themselves without an external stimulus you give them an external stimulus like a copy you can see that they improve they still have some errors but they did improve so there was a response to an external stimulus so this is internally driven and this is externally driven and you can see that there is still a little bit of an error here with the external driven and this individual actually did have a type of disorder involving the region of the dorsolateral prefrontal cortex but providing a comparison between internally driven and externally mediated or external um stimulus for modeling can give you a really nice insight as to whether or not as to the type of behavior a person is or a type of impairment a person might have and where in the brain it can be all right so individuals who have dorsolateral frontal damage they you might see perseveration you might see reduced word fluency loss of output you might see difficulties with working memory like we mentioned disinhibition using hyperkinetic behavior or poor planning so there are a number of things that you could see with dorsolateral regions damage all right so clinical presentations i'm just going to give you a couple of examples in a minute but first let me just remind you you know that the human uh in humans the prefrontal cortex occupies about 35 of the neocortex just like i had told you before it's huge for us right um but it is the newest area of the vortex and it's the latest to grow uh last to grow first to be lost um and you know we have to remember that it's one of the it's still growing through your teen years and so these are things to consider um and it's different with regard to other animals so it's our largest lobe and it's like i said a mediator now when we think about damage to those disorders not only do we have to think about the age of the individual etc but we have to think about all right um what areas and what structures are involved is it the cortex could it be the subcortical could it be neurotransmitter based only could it be white matter structures etc and so there are a number of case number of disorders uh that you might see difficulties with the frontal lobes frontal temporal dementia you can see traumatic brain injury frontal lobe epilepsy attention deficit disorder schizophrenia parkinson's disease you could see stroke and this is a this is from the bloominfeld text with neuroanatomy through clinical cases and i'm sure you remember the anterior cerebral artery the middle and the posterior artery have different um regions that they occupy and provide for fusion to so you could have a damage to these and it could just uh differentially disrupt the frontal lobes from here so you have to think that the frontal lobes really are quite wonderful they provide us with an incredible um source of behavior but really complex for us um let me give you a couple of examples here so this is a an individual who's 64 years old he was referred for a neuropsychological evaluation by his neurologist so his presenting symptoms included increased use of pornography increased spending of money multiple affairs no longer working due to difficulties he was brought in for a neuropsychological eval like i said by his neurologist because they they really wanted to rule out what could be some of the difficulties what could be some of the differential diagnoses they had um i actually saw him he was eating i had to go see him um at a at a clinic and he had brought in food and was repeatedly eating uh pulling out things out of his bag when we did the assessment he had an impairment in working memory recent memory he was having difficulty with set shifting disorganized uh disinhibited he was having some difficulty with word retrieval um now he had progressed a bit i guess you would say i'm probably giving you a little bit of an idea of what kind of ex what kind of disorder he is um but he um uh really was doing fine attentionally and processing speed wise he was walking his gait was fine and he was denying any symptoms of anxiety or depression so for him he actually was diagnosed with what's called a frontotemporal dementia behavioral variant based on his primary symptoms which included the orbit of frontal classic behaviors and he also was having just a progression of the disease so that it involved more of a cognitive symptoms involving now involvement of the dorsolateral prefrontal cortex as well as some of his temporal regions so just due to time i'm going to skip to the next one this is mr m he's a 58 year old man who had come in now he was really interesting he was observed in the waiting room he was hunched over and he's sad he had limited expression during discussions he had um adequate grooming but was slow slow to initiate slow to move somewhat lethargic now here on some testing here's his processing speed measures this is just a t score i'm sorry that they're not all z scores um but this is a t score remember high is good hit this i saw him actually twice these aren't the real dates this is um just put in automatically but here's the average average is up here at 50. here are his scores on trails a stroop test troop color test and you can see that um he's pretty um this is before and this was the second um time i saw him i guess a year later yes so here is he's going a little bit up and down but in general you can see he has a trend towards reducing in his inhibitory functions all right and just processing speed just slightly here's his attention in working memory digit span forwards forward span backward span and letter number sequencing um and you can see they're pretty they're maintaining um slightly lower over the year but still within low average to average although backwards fan and working memory certainly are reduced at that time point particularly both across both ears and here's in his inhibitory and problem solving same pattern now when we get to his depression anxiety and apathy you can see here here's his anxiety higher is bad right and his back depression inventory and geriatric depression scale really high across each of the time points that he's been followed and you can see that here uh moderate to severe depression for him so he was actually diagnosed with um he's just been maintained as intractable depression and so his area would that you would associate with frontal function would be more on the mesial whereas the first case that i showed you would be more orbital frontal all right so overall today this was just a brief discussion of the basic frontal regions of the of the brain how they connect subcortically to remember that the frontal lobe is a mediator it's in uh it's its goal is to help us to regulate our internal drives with the environment and to help us produce and act on the environment all right i also went over two basic clinical cases now the one thing i really want you to do is just to keep reading read on the frontal lobes there are so many wonderful books out there on the frontal lobes i just encourage you to do that and like i said just remember it's a mediator for behavioral profiles and i want to thank you so much for letting me be here today thank you dr price we really appreciate the talk that he gave us today so informative i think something too is we've had so many q and a's in today for our lecture i would like to say there's so many on here so we'll start off with some of the fun ones you ended with case presentations which i think is great in all of training so for this one they wanted to thank you for providing the case examples but then when working with people with frontal lobe dysfunction and formal frontal disorders do they realize something is wrong for example when drawing a clock are they able to see the clock is drawn incorrectly oh that's a great question so sometimes many times individuals are not able to provide you with feedback that what they notice is any that anything is wrong um and so that's a really interesting observation it's a really great question in in your clinical work what do you do do you point it out to them that it is incorrect or do you ask them to compare no typically not that's a great question so you are taking that information in and you move on to the next task at that point so for example i'd say well do you see that this is can you tell me do you think this is a an accurate drawing of the clock and you wait to see what they say then you would give a copy condition see how they do on the copy or you move on to the next task to get more updates today together exactly i think it speaks to not just do our tests give us so much information but also behavioral observations that can be very important for the feedback session thank you i agree so i think another question we have here is can you speak more to the connections between the cerebellum and the frontal lobe oh that's a great question oh my gosh the cerebellum choose a frontal lobe so there's cerebellum has been so underappreciated with regard to executive function and behavioral output um so we have to remember processing speed elements are also involved with cerebellar we know that there are celeb cerebellar regions involved in planning um so you know you do have to think about that but also from a neurotransmitter standpoint um you have to remember that that significant amount of dopamine impulse and then also you have um regions associated with acetylcholine production so um there's some wonderful work i'm sure as you know um being done on the cerebellum with regard to executive function um it's just an area that you have to be aware of and you have to appreciate uh i'm trying to think anybody else can chime in with regard to structure is just something you have to you have to be aware of and read the literature and know that that is it's a whole brain system understood i think that's the whole point too this lecture is trying to understand it's a whole brain system and it's hard to break it down sometimes we really appreciate you trying to talk to us i felt like for me personally i thought you were personally giving me a lecture today and i wanted to chime in sometimes but with this too you speak to that it may be difficult to learn about all the different structures what are some of the best resources that you give students to start learning all of this information ah one of the best resources okay so a reading lease resource or a reading resource or sure um okay above dr price yeah i'm trying to think um so one of some of the best resources i would encourage you to read colbin wishaw text is awesome uh also of course the lesac text those are um perfect but i really always go back to coleman wish off those texts are it's just perfect and they have numerous iterations now i'm not i don't have the most recent version but i encourage everyone i i always go back to the one that my first one it's just fabulous yeah i think it's great too using those resources we talked a little bit about feedback before so some people had some feedback questions with this if somebody does have a frontal lobe disorder how do you explain it to them in a feedback session oh that's a great question well um very carefully and i love feedback sessions typically i what i do when i'm discussing things i try to make it more simple for me i do a lot of drawings i like to make it i try to talk about the brain in a very simple way so for example one of my approaches is i talk about the brain as an apple so i'll say you know how we have an apple apple is a can visualize an apple and i'll talk to them about okay so the apple has an outside you have your skin of the apple and then you you know if you cut the apple in half then you have you have the core you also see the white and you have the seeds and so the outside of the apple the skin is just like the cortex and then you have the the core of the apple if you can visualize cutting it in half that is your uh those are your ventricles right so that's your your the core then you have the seeds those are your subcortical nuclei and then you have the whites we'll actually will draw that out for them and then we can have a discussion about what the white does the white is those are white matter fibers and those are connecting the seeds to the skin and sending information back and forth and then we talk about it we draw and then i talk about the different areas of the brain and the behaviors and kind of link it back to the drawing you have to be very concrete um and uh give information in a very kind um careful manner and then but make it so it has value and so that they understand how that impacts their life and link it back to what they're also indicating what their complaints are so it has to be a give and take between you the information that you have as well as with the um the patient themselves or the client it's a great way of looking at it it has to be very interactive and it's very interactive do that definitely patient quality of life yeah provide something for them yes i'm gonna i'm gonna have to steal the apple description yeah please do drawing skills for that one definitely appreciate your time dr price we love the information that you gave us today and i would like to do a shout out for next week as well so next monday august 23rd we will have mary pat mcandrews from university of toronto presenting on learning the memory so we look forward to everybody joining us next week thank you again dr president thanks so much take care everyone bye-bye stay well you