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BACKGROUND
Neuropsychological research is aimed at a comprehensive assessment of the state of higher mental functions: various types of praxis and gnosis, speech and counting, attention and memory, spatial functions and thinking. The place of neuropsychological research in the clinical and instrumental diagnostic complex is determined by the fact that the quality of life and social readaptation of patients who have undergone TBI, to a decisive extent, depends on the preservation of the mental sphere.Neuropsychological research is based on the concept of A.R. Luria, who considers mental functions as complex functional systems, consisting of hierarchically interconnected links. This methodological premise allowed A.R. Luria to formulate the theory of cerebral systemic dynamic localization of higher mental functions. According to it, any mental function is provided by the joint integrative work of various brain zones, each of which makes its own specific contribution to the implementation of a certain link in the functional system.
Abnormal functioning of certain parts of the brain due to its traumatic injury can lead to a deficit in mental processes, affecting various levels and links of their support. The method of syndromic analysis of disorders of higher mental functions in case of local brain lesions is based on these theoretical concepts. Even during the Great Patriotic War A.R. Luria laid the foundations for its application in patients with TBI, with the aim of topical diagnosis of brain damage and the development of methods for restoring impaired functions.
The use of the neuropsychological method makes it possible to solve the following main tasks in neurotraumatology.
One of the first and main tasks of neuropsychology in a neurosurgical clinic was topical diagnostics in the clinic of local brain lesions. In this sense, neuropsychology can be called “the neurology of higher mental functions”. Almost two-thirds of the cerebral cortex (secondary and tertiary zones) from the point of view of classical neurology, which studies relatively elementary sensory and motor functions, are "mute", since their defeat does not lead to any impairment of sensitivity, reflex sphere, tone and movements ... At the same time, the lesions of these zones lead to disturbances in various forms of perception, memory, speech, thinking, voluntary movements, etc. Developed by A.R. Luria and his followers, the methods of studying these disorders in the clinic of local brain lesions have become widely known as "Luria diagnostic methods", the high accuracy of which has been confirmed by many years of practice.
The introduction into wide clinical practice of modern advances in the field of diagnostic techniques, such as computed tomography and magnetic resonance imaging, to some extent reduced the importance of neuropsychological research in determining the localization of traumatic lesions. Nevertheless, it can be successfully used for the purposes of topical diagnostics in our time. With the help of neuropsychological research, the tasks of topical diagnosis of TBI can be significantly expanded. The high sensitivity of the method makes it possible to detect not only defects caused by the destruction of the brain substance, but also subtle, mildly expressed changes associated with a decrease in the functional state of various brain structures. Comparisons of neuropsychological data with SPECT results show their significant mutual correlation: the presence of neuropsychological signs of dysfunction in those parts of the brain in which, according to radiological methods, there was a decrease in cerebral blood flow and metabolism.
Taking into account that the ultimate goal of all therapeutic and rehabilitation measures in a neurotraumatological clinic is the most complete restoration of the patient's physical and mental potential, the main task of neuropsychological research is a thorough and detailed description of the existing mental disorders and their dynamics. In this case, the main importance is acquired by a qualitative analysis of the detected disorders, aimed at identifying the main factor underlying the deficiency of a particular mental process, i.e. - qualification of defects.
Traumatic brain damage leads to disruption of the work of individual brain zones or the interaction between them, in connection with which mental processes do not suffer globally, but selectively, within the limits of individual components. It is important to emphasize that in this case there remain intact links provided by the work of intact brain zones or systems. Following the principle of qualifying a defect (i.e., clarifying the mechanisms of dysfunction) and the principle of identifying primary and secondary symptoms, a neuropsychologist receives information about defective and intact links of the functional system. This information is the basis for the development of rehabilitation programs aimed at recovery after TBI based on intact links in the structure of the affected function.
The addition of the method of syndromic qualitative analysis with modern methods of quantitative processing of the obtained data made it possible to significantly expand the scope of application of the neuropsychological method in the clinic of traumatic brain injury. The standardized neuropsychological research methodology with a specially developed quantitative assessment system successfully serves as an accurate and sensitive tool for assessing the effectiveness of surgical treatment, pharmacotherapy and rehabilitation measures.
Thus, a comparison of the results of neuropsychological studies before and after shunting operations for post-traumatic hydrocephalus makes it possible to judge their effect on mental defects, which often come to the fore in patients. Using a neuropsychological method, we analyzed the factors influencing the success of surgical intervention (closed external drainage of the hematoma cavity) in patients with chronic post-traumatic subdural hematomas.
The application of a quantitative neuropsychological approach to assessing the comparative effectiveness of drug therapy and targeted pharmacological effects on mental defects is especially fruitful.
The successes of neuropsychopharmacology in recent years have led to a significant increase in the role of neurotropic drugs in the rehabilitation system of patients with TBI. The variety of available tools makes it difficult to make the right choice. The data accumulated to date show that various drugs can selectively affect certain components in the structure and dynamics of mental functions and, accordingly, various brain formations. In the clinical aspect, it is important to take into account the possibility of multidirectional action of the same drug on different parameters within the same function. Analysis of the action of more than 10 neurotropic agents using a standardized technique of neuropsychological research with a quantitative assessment system showed that each of them is characterized by a certain range of effects on the state of mental processes in patients with traumatic brain injury.
According to the type of influence on higher mental functions, psychopharmacological agents can be divided into 3 main groups:
1) nonspecific action - positively affecting all parameters of mental processes; Nootropil possesses this type of action;
2) selectively improving the course of certain types of mental activity or their individual components; as an example, we can cite 2 drugs - amiridine and L-glutamic acid, the positive effect of which reaches a maximum in relation to the components of higher mental functions, in the provision of which the leading role belongs to the left and right hemispheres of the brain, respectively;
3) multidirectionally influencing various components of mental functions, selectively improving the condition of some and at the same time aggravating the defectiveness of others; a representative of this group is bemitil, whose spectrum of action is a "mosaic" set of positive and negative effects affecting only certain links of certain types of mental activity.
Studies have shown that drug therapy is most effective in cases where the "neuropsychological spectrum" of the drug used corresponds to the structure of the patient's neuropsychological syndrome. Thus, when prescribing neurotropic drugs in order to correct defects in higher mental functions, it is necessary to conduct a neuropsychological examination to clarify the structure of the disorders and select the most appropriate drug for the patient's syndrome.
METHOD
Neuropsychological research is carried out with the degree of restoration of consciousness and vital functions, which provides the possibility of a sufficiently expanded and prolonged contact with the patient. The optimal interval between neuropsychological examinations of patients observed in dynamics is 5-10 days in the acute period and 3-6 months in the long-term.The psychologist receives information about the general condition of the patient with a thorough acquaintance with the history of his illness, which in the clinical practice of the A.R. Luria has a special place. Objective data provide a lot of information necessary for the organization of neuropsychological examination and the choice of techniques that are adequate to the state of the motor and receptor systems. The tactical tasks of constructing a neuropsychological examination include the selection of more or less sensitized samples or the creation of special conditions. The methods of sensitizing the experimental conditions include an increase in the rate of delivery of stimuli and instructions, an increase in the volume of stimulus material, and its presentation in noisy conditions.
It must be emphasized that the examination of the patient should be sparing in relation to him. In this sense, not every patient should and can go through a complete and thorough study of all mental functions. The selection of techniques, the choice of symptoms of disorders of mental processes for their subsequent psychological qualification is determined by the patient's condition, the period that has passed since the moment of injury, and the data of an objective anamnesis. The serious condition of the patient serves as an indication for the dosed examination, the use of breaks, and the examination within two to three days.
Neuropsychological examination begins with a preliminary conversation with the patient in order to compile a general description of his condition, after which an experimental study of various types of mental activity is carried out. It includes an assessment of the patient's level of activity, his ability to navigate in place, time, personal situation, peculiarities of emotional and personal status, adequacy of the research situation, focus on performing the proposed tasks, the ability to assimilate and maintain the test program, the degree of exhaustion, criticality in relation to the results of his own activities - the possibility of correcting errors.
With the help of special experimental tests, the state of higher motor functions (kinetic, dynamic and spatial praxis) is specified; gnosis (visual, auditory, tactile, visual-spatial); attention; speech, writing, reading; counting operations. various types of constructive activities (independent drawing, copying, etc.); the most varied aspects of the mnestic function; thinking (comprehension of plot pictures, the ability to make generalizations and analogies, problem solving, etc.).
Depending on the main purpose of the study, the data obtained are subjected to qualitative syndromic analysis with the identification of factors underlying deficiency and functional rearrangements, and a quantitative analysis of the data obtained.
NEIROPSYCHOLOGICAL SEMIOTICS
The variety of primary structural changes in the brain tissue occurring at the time of injury, concomitant pathophysiological reactions, intra- and extracranial complications determine the complexity and extreme variability of neuropsychological syndromes in traumatic brain injury. Nevertheless, it is possible to outline in general terms the nature of disorders of higher mental functions in this contingent of neurosurgical patients.The neuropsychological picture in TBI has its own characteristics. In the acute period of trauma, as a rule, nonspecific disturbances in the normal course of mental processes come to the fore, manifested in a slowdown in the pace of all types of activity, increased exhaustion, and a lack of motivation. The severity of such disorders is determined by the severity of the injury. The described changes in the background components of the mental activity of a patient with TBI often complicate the identification of defects caused by focal traumatic lesions.
As the compensatory mechanisms of the brain become more active, neuropsychological syndromes of a focal nature are differentiated and become most distinct. With the predominant interest of the posterior parts of the hemispheres (of course, taking into account a right-handed or left-handed patient), there are aphasias, apraxia, agnosia, memory impairment of a modal-specific nature, disorders of the spatial component of various types of mental activity, which can occur both in isolation and in the most various combinations with each other.
The neuropsychological picture with a predominant lesion of the left and right hemispheres has its own distinctive features. In cases where foci of traumatic brain damage are localized in the left (right-handed) hemisphere, speech disorders often occur.
When the parietal lobe is involved in the pathological process, afferent motor aphasia occurs, due to a violation of the kinesthetic basis of speech function. It manifests itself in the difficulties of differentiating sounds close in articulation, in the pronunciation and perception of speech addressed to the patient, which is reflected in independent speech, writing, reading.
Localization of the focus in the lower parts of the premotor region leads to the emergence of efferent motor aphasia - a violation of the kinetic link in the organization of the speech act. As a result of the difficulties arising in switching from one article (syllable, word) to another, speech perseverations are observed.
A consequence of the defeat of the upper parts of the temporal lobe is sensory aphasia, which is based on a violation of phonemic hearing. The central symptom is a violation of understanding of the speech addressed to the patient. The phenomenology of sensory aphasia also includes disorders of active spontaneous speech (in severe cases, the patient's speech turns into a "verbal salad"), reading, writing.
If the traumatic lesion captures the middle parts of the temporal lobe, speech deficit takes the form of acoustic-mnestic aphasia. The main symptoms: violation of naming, narrowing of the volume of auditory speech memory, difficulty in choosing words in spontaneous speech, verbal paraphasias.
Amnestic aphasia is associated with damage to the parieto-temporal-occipital region, i.e. difficulties in nomination, and semantic aphasia, which is a disorder of understanding of logical-grammatical speech constructions that reflect spatial or "quasi-spatial" relationships between objects.
Isolated forms of aphasia are rare in TBI. As a rule, violations are complex and include elements of different types of speech impairment. The severity of speech disorders depends on the severity of TBI. In some cases, it can reach total aphasia: a complete absence of speech production, combined with a lack of understanding of the addressed speech.
Traumatic injury to the right hemisphere leads to the formation of specific neuropsychological syndromes, the most typical of which are the following. The syndrome of unilateral spatial ignorance is a difficulty or complete inability to perceive stimuli entering the left half of the perceptual field. This phenomenon can both be limited by the framework of one modality (auditory-verbal, visual, kinesthetic, tactile), and cover the entire sensory sphere. Violations can manifest themselves not only in perception defects, but also in various types of patient activity: movements, drawing, constructive praxis, etc. Another somatosensory disorder characteristic of lesions of the posterior parts of the right hemisphere is a violation of the body scheme - a defect in recognizing parts of one's own body, their location in relation to each other.
Some forms of visual agnosia are found mainly when the foci of traumatic lesions are located in the right hemisphere. These include facial agnosia (a special violation of visual gnosis, which consists in the fact that the patient loses the ability to recognize real faces or their images) and simultaneous agnosia (a sharp narrowing of the volume of visual perception, with a gross expression of up to 1 object). And finally, the well-known phenomenon of "anosognosia", i.e. non-perception, ignorance of one's own defects, is specific for right-hemispheric brain damage. Widespread in the TBI clinic is the involvement of the anterior parts of both hemispheres of the brain in the pathological process, which leads to a violation of programming and control of mental activity in general (aspontaneity, inertia, reduced criticism of one's condition).
The characteristic features of neuropsychological syndromes in TBI: their multifocal nature, a combination of disorders typical for damage to both the right and left hemispheres of the brain, and the frequent reversibility of disorders of higher mental activity.
Neuropsychological studies have shown that the structure of neuropsychological syndromes changes over time and depends on the period of traumatic brain injury. For clarity of these changes, neuropsychological symptoms can be conditionally divided into three main groups:
Group I - a nonspecific decrease in mental activity in general, represented by the phenomena of aspontaneity, inactivity, pathological exhaustion, inertia, lethargy or impulsivity. They manifest themselves in the form of a lack or suppression of spontaneous activity, difficulties in being included in the performance of experimental tasks and switching from one form of activity to another, and a decrease in the productivity of all types of mental activity.
Group II - represented by disorders of consciousness of the type of disorientation in place, time, self, situation, as well as emotional and personal defects, including violations of the motivational sphere.
Group III - includes specific disorders of cognitive functions: primary defects of attention, praxis, gnosis, speech processes, visual-spatial synthesis, memory, thinking.
In the acute period of traumatic brain injury, the symptoms of a nonspecific decrease in general mental activity caused by brainstem and subcortical lesions, as a rule, come to the fore. They are usually combined with mental disorders such as disorientation and amnestic confusion. The most relevant during this period are neurotropic drugs that provide nonspecific activation that increases the energy level of mental processes.
The intermediate period of traumatic brain injury is characterized by a decrease in the proportion of disturbances in the background components of mental activity and the formation of neuropsychological syndromes characteristic of local lesions of the cerebral cortex with a more pronounced manifestation of aphasia, apraxia, agnosia, optical-spatial, mnestic and intellectual defects. In this period, emotional and personal changes can be most vividly and distinctly. The specific structure of the neuropsychological syndrome is determined by the severity of the injury and the localization of the main focus of brain damage. The most effective in this period are drugs that have a more selective effect on higher mental functions.
And, finally, in the long-term period of traumatic brain injury, the failure of patients is due to reduced neuropsychological syndromes, which have a very specific structure and require a very selective correction. This determines the choice of neurotropic agents with the most selective action.
The severity and qualitative nature of neuropsychological syndromes depends on the age and individual characteristics of patients. Nevertheless, the form and predominant localization of the lesion are, to a large extent, the main features of the picture of violations of higher mental functions and the patterns of its development in time.
Brain lesions of a diffuse nature lead to the most gross and persistent defects in higher mental functions. First of all, such patients are in serious condition for a long time due to loss of consciousness and disorders of vital functions, which significantly postpones the time of neuropsychological research from the moment of injury. In some cases, contact with the patient throughout the observation period did not expand so much that a detailed examination became possible. Nonspecific disorders of mental activity appear most rudely and vividly in the study: patients are aspontaneous, inactive, adynamic, slow, demonstrate pronounced inertia and exhaustion of mental processes.
Against this background, a variety of emotional-lineage and motivational changes are found. Defects of higher motor, perceptual functions, speech, visual-spatial sphere, attention, memory, thinking for a long time remain blurred for a long time, which will complicate their differentiated assessment. Only in the presence of massive targeted rehabilitation measures, the noted defects to some, often insignificant extent, lend themselves to reverse development. Patients with this form of traumatic injury in some cases remain deeply disabled.
Clinical observation No. 1. Patient M., 16 years old.
Diagnosis: Closed severe head injury. Diffuse brain damage of severe degree / DAP /.
Coma after injury lasted 4 days, the dynamics of coming out of a coma was characterized by undulations of consciousness: deep stunning - 2 days, stupor with episodes of motor excitement - 5 days, vegetative state - 5 days, occasional execution of elementary instructions - 4 days, stupor - deep stunning - 4 days ... On the 25th day, gaze fixation, tracking, understanding of the addressed speech, the implementation of instructions appeared, on the 26th day, speech production appeared.
Only on the 34th day after the injury the patient became accessible to verbal contact, which, however, is sharply limited by the gross violations of the background components of mental activity by the type of spontaneity, increased exhaustion and pathological inertia of mental processes. The latter clearly appears in perseverations in the motor sphere, speech, writing and graphic tests (Fig. 8-1). These defects are accompanied by pronounced motivational changes, as a result of which the patient is practically unable to form an orientation towards performing test tasks.
The patient is completely disoriented in place, time, personal situation, confabulations are revealed. The picture is aggravated by the insufficiency of the speech sphere: there are signs of impaired understanding of the addressed speech, elements of "alienation of the meaning of the word", the patient's speech is "polluted" with literal and verbal paraphasias, echolalia, perseverations. These violations make it impossible both to conduct a neuropsychological examination and to interpret the results obtained.
In 10 days, on the 44th day after the injury, a detailed neuropsychological study becomes possible. The patient is still completely disoriented in place, time, personal situation, confabulations remain. There is absolutely no criticism of one's condition and the experience of illness. However, the phenomena of increased exhaustion and inertia of mental processes persist, to a lesser extent. It is difficult to include in test tasks, assimilation and retention of the program, criticism to the mistakes made is reduced.
Against this background, an experimental neuropsychological study reveals:
bilateral postural dyspraxia, impaired spatial praxis; while introducing complex types of tactile sensitivity - elements of ignoring tactile stimuli on the left hand; violation of non-verbal auditory gnosis in the form of a persistent overestimation of simple single and serial rhythms, as well as difficulties in reproducing accentuated rhythmic structures according to the auditory pattern; violation of visual gnosis, manifested in defects in recognition of object images in sensitized conditions, erroneous interpretations of plot pictures, in addition, a clear tendency to ignore the left half of the visual field is revealed; violation of optical-spatial gnosis: erroneous orientation in a schematic clock and a geographical map, graphic activity (Fig. 8-1); a complex of speech disorders, including an insufficiency of the sensory component of speech function and elements of efferent motor aphasia, and manifests itself in speaking, writing and reading;
Gross violations of counting operations, reaching the degree of acalculia; gross modal-nonspecific memory disorders, impaired recording of current events, lack of actualization of knowledge, consolidated before the injury; complex violations of verbal and visual memory: a narrowing of the volume of both direct and delayed reproduction with a violation of its selectivity; attention is drawn to contamination and introduction, as well as a confabulatory shade in the retelling of a semantic passage;
Pronounced defects in various aspects of intellectual activity. After another 10 days, on the 55th day after the injury, further recovery of higher mental functions is noted. Until now, such violations of the background components of the course of mental processes, such as increased exhaustion and inertia, persist. The orientation in one's own personality was restored, an incomplete and unstable orientation in the place, situation appeared, at the same time, the orientation in time remains grossly disturbed. The patient is still uncritical to her condition.
The behavior in the research situation became more adequate, the difficulties of assimilating and maintaining the program decreased, and there was some interest in the results. The following objective changes have been registered:
- in the motor sphere, there remain a slight insufficiency of the praxis of the posture on the left hand and elements of impulsivity and specularity when performing tests for spatial praxis; decreased tendency to ignore tactile stimuli on the left hand; overestimation of simple rhythms is noted in isolated cases and can be corrected when prompted, however, inertia should be noted when reproducing rhythmic structures according to an auditory pattern; visual impairments persist; defects of visual-spatial gnosis regressed to some extent; in the speech sphere - a clear positive dynamics: there are almost no paraphasias, "amnestic depressions" in naming, difficulties in understanding the addressed speech; recovered writing (Fig. 8-1), alphabetic gnosis; memory impairments still remain very gross; only a slight recovery of memory for current events and the facilitation of updating the consolidated knowledge can be noted.
Rice. 8 - 1. Samples of writing and graphic activity of patient M. A - on the 34th day after the injury. B - on the 44th day after the injury. B - 55 days after injury.
It should be noted that the above dynamics of the state of higher mental functions was observed against the background of massive drug treatment using targeted neurotropic effects.
Follow-up observation showed that orientation in this patient recovered only 4 months after the injury, and a significant part of the noted disorders of higher mental functions persisted even a year after the injury.
Focal lesions turned out to be less traumatic in relation to mental activity. Patients with a predominantly cortical localization of the localization of the focus in a relatively short time after trauma reach the degree of recovery of consciousness and vital functions, which makes them available for neuropsychological research. They quickly recover all types of orientation, background and neurodynamic parameters of the course of mental processes. Emotional and personality disorders are rarely severe and persistent.
The identified defects, as a rule, do not have a general global character, but selectively affect individual links of higher mental functions. These symptoms are generally reversible, and by the time of discharge, in most cases, they largely regress. Follow-up observation (1, 2 and more years after the injury) shows that the defects of higher mental functions arising from this form of traumatic brain damage, lend themselves well to reverse development and are almost completely compensated. Remains erased traces of previously existing focal disorders against the background of mild asthenic symptoms.
However, with a subcortical or cortical-subcortical location of the focus and in those cases when brain contusion is accompanied by edema or intracranial hematoma, aggravating the clinical picture of traumatic brain injury, focal neuropsychological symptoms are more pronounced and less effectively regress in the acute period. Violations may be more persistent and retain a noticeable degree of severity a year or more after injury.
Clinical observation No. 2. Patient G., 17 years old.
Diagnosis: Severe closed head injury. Heavy. Brain contusion. Epidural hematoma in the frontobasal region on the left. Fracture of the temporal bone with the transition to the base.
The operation was performed: Removal of acute EDG (80.0) of the frontotemporal-basal region on the left. 3 days after the operation was in a coma. On the 4th day he came out of a coma, on the same day he began to follow simple instructions. I spoke on the 8th day. For about a week he was disoriented in place and time, confabulated, did not remember current events, and was periodically agitated.
On the 15th day after the injury, the patient is in contact, available for neuropsychological research in full. Oriented in place, personal situation, time (there is only a slight inaccuracy in the assessment of time intervals). No gross emotional and personal changes. It should be noted, however, that in a situation the research is not completely adequate: does not maintain a distance in communication with a doctor. Criticism to their condition is reduced. In an experimental study, he is included without difficulty, learns the program, retains, but rather quickly depletes. Against the background of exhaustion, signs of inactivity and inertia appear.
An experimental study reveals the following neuropsychological symptoms:
- slight insufficiency of kinesthetic praxis on the right hand (in tests for posture transfer according to the kinesthetic model with closed eyes), lagging of the right hand in reciprocal hand coordination, mild disturbances of spatial praxis;
- pronounced violations of tactile gnosis (Foerster's feelings) on both hands;
- mild violations of auditory gnosis by the type of overestimation of simple single rhythms, the structure of accented rhythms according to the auditory pattern;
- visual gnosis without disturbances;
- in the speech sphere - single difficulties in nomination, facilitated by a hint;
- the optical-spatial functions are relatively intact, only a slight tendency towards specularity, which manifests itself in sensitized conditions, and the insufficiency of the spatial component of the pattern can be noted (Fig. 8-2);
- gross mnestic disorders, clearly manifested at the clinical level, primarily in the difficulties of capturing current information (for half an hour, the patient cannot keep the doctor's name and patronymic, against the background of exhaustion he does not remember not only the presented words, but also the very fact of their presentation); complex polymodal mnestic disorders are experimentally revealed - a narrowing of the volume and order of stimulus reproduction with gross violations of selectivity in the form of impurities and contamination, a defect in strength;
- pronounced defects of thinking, mainly of its verbal-logical link.
In 2.5 months after the injury, there is a significant positive dynamics in the patient's condition. Violations of the background components of mental activity completely regressed. In the emotional-personal sphere, there remains some relief in assessing one's condition. Figure 8-2 shows examples of writing and graphic activities.
Motor, gnostic, speech and visual-spatial functions were fully restored. Non-gross mnestic disorders persist in the form of a decrease in verbal memory in the delayed reproduction link, as well as very mild intellectual impairment (a tendency towards situational thinking).
A neuropsychological study of patients with concussion and minor bruises revealed that they had a significant preservation of higher mental functions. At the same time, nevertheless, almost all patients nevertheless reveal a deficiency in one or another area of mental activity, most often in the form of a decrease in the neurodynamic indicators of the course of its individual components. The most vulnerable in this contingent of patients are mental processes that have the most complex psychological structure and cerebral organization - optical-spatial and mnestic functions.
Rice. 8 - 2. Samples of writing and graphic activity of patient G. And - on the 15th day after the injury. B - 2.5 months after the injury.
Rice. 8 - 3. Samples of writing and graphic activity of patient S. on the 7th day after injury.
Clinical observation No. 3. Patient S., 34 years old.
Diagnosis: Light closed craniocerebral injury. Mild brain contusion.
Short-term loss of consciousness immediately after injury (several minutes). On the 7th day, a full detailed neuropsychological study is available. The patient is communicative, fully adequate in the research situation.
Emotionally-personally unchanged. However, it should be noted a slight ease in assessing their own condition. All types of orientation are preserved. Easily assimilates and retains the program, shows interest in the results, is critical to errors made during the survey. Moderately depleted by the end of the study.
Experimental research reveals:
- slight impulsivity in motor tests;
- Coarse bilateral decrease in tactile gnosis;
- insignificant insufficiency of mnestic function in the form of non-gross violations of verbal memory in the link of delayed reproduction.
The rest of the higher mental functions do not show deviations from the standard indicators. Samples of writing and graphic activities are shown in Figure 8-3.
These disorders completely regressed by the time the patient was discharged from the hospital.
Thus, neuropsychological research significantly enriches the diagnostic complex used in the clinic for traumatic brain injury. The use of the neuropsychological method for the development of rehabilitation measures and the assessment of their effectiveness in post-traumatic recovery of higher mental health significantly expands the scope of its application.
Author Teremova M.N.
Introduction
Neuropsychology is the only discipline of psychology that studies the relationship between mental phenomena and processes with the physiological structures of the brain. In other words, neuropsychology studies the mental activity of a person in a normal and pathological state from the point of view of its cerebral organization. Hence follows the main function of a neuropsychologist: to consider any psychological phenomenon (it does not matter whether it is normal or pathological) in a specific gender, age and sociocultural aspect from the standpoint of its cerebral support.
Neuropsychological examination allows you to establish the degree of impairment of cognitive functions, and how this leads to a violation of daily activity, as well as identify the likely causes of the changes that have occurred. In the future, the obtained data will help the specialists of the NDC of Clinical Psychiatry to monitor the course of treatment, focusing on the severity of cognitive impairments and their changes during pharmacotherapy, as well as to choose behavioral methods for correcting cognitive disorders.
Chapter 1. Neuropsychological diagnostics
1.1 Definition, purpose of neuropsychological examination
Neuropsychological diagnostics is the study of mental processes using a set of special tests in order to qualify and quantitatively characterize disorders (states) of higher mental functions (HPF) and to establish a connection between the identified defects / features with the pathology or functional state of certain parts of the brain or with the individual characteristics of the morpho-functional the state of the brain in general.
With the help of neuropsychological diagnostics, it is possible to determine:
- a holistic syndrome of HMF disorders caused by a breakdown (or a special condition) of one or more brain factors;
- features of energy, operational and regulatory components of mental processes, as well as different levels of their implementation;
- predominant lateralization of the pathological process;
- damaged and intact links of mental functions;
- various violations of the same mental function with damage to different parts of the brain.
First of all, before studying the actual techniques, it is necessary to familiarize yourself with the anatomy of the nervous system and the basics of neuropsychology. Then you need to understand the theoretical and methodological foundations of neuropsychological diagnostics; imagine the big picture, survey; principles of constructing neuropsychological diagnostic techniques. In the future, it is necessary to master specific knowledge and skills in the use of neuropsychological methods for studying various higher mental functions, as well as methods for studying interhemispheric asymmetry and interhemispheric interaction. Finally, it would be useful to have an idea of modern trends in neuropsychological diagnostics in Russia and abroad.
The main block of neuropsychological diagnostic techniques, without a doubt, was created in the 1940-1960s. A.R. Luria (Luria, 1962). However, it should be borne in mind that a number of techniques were borrowed by him from other authors. For example, the test for reciprocal coordination belongs to the famous Soviet psychiatrist N.I. Ozeretsky (Gurevich, Ozeretsky, 1930). Samples for spatial praxis were created by G. Head. In addition, neuropsychology has always been a dynamically developing branch of knowledge, therefore, new methodological techniques were constantly developed in it, and the closest students of A.R. Luria - L.S. Tsvetkova, N.K. Korsakov (Kiyashchenko), E.G. Simernitskaya and others (Tsvetkova, 1985; Kiyashchenko, 1973; Simernitskaya, 1978). As an example, we can cite methods aimed at studying disorders of speech and memory. In connection with the emergence of new directions of neuropsychological research, the arsenal of neuropsychologists was constantly replenished with original methods developed by foreign scientists. Complex (complex) figures of Rey and Osterreich (Rey, 1941; Osterrieth, 1944) were often used to study visual-constructive activity, and D. Kimura's method of dichotic listening (Kimura, 1961; 1973) was used to study interhemispheric interaction. Currently, in Russia and abroad, modifications of the classical neuropsychological examination carried out by L.S. Tsvetkova, E. D. Chomskoy, A.V. Semenovich and others (Tsvetkova, 1998; Neuropsychological diagnostics, 1994; Neuropsychology of childhood, 1998; Tsvetkova, Akhutina, 1981; Pointe, 1998; Golden, 1981).
First of all, this is A.R. Luria and the method of syndromic analysis of their disorders (Luria, 1962, 1973). Neuropsychological diagnostics is also based on modern ideas about the psychological structure and cerebral organization of mental functions. An important role in understanding the genesis and structure of the HMF is played by L.S. Vygotsky, theory of the activity of A.N. Leontiev, the theory of the stage-by-stage formation of mental actions by P.Ya. Halperin, the ideology of a systematic approach to the study of mental phenomena. Finally, neuropsychological diagnostics was developed and applied taking into account the fundamental concepts of neurophysiological and biochemical patterns of the integrative activity of the brain (I.P. Pavlov, P.K. Anokhin, etc.)
1.2. Principles, stages of neuropsychological diagnostics
The basic principles are as follows:
- The principle of the predominant orientation of a specific method to study a certain mental process or a certain link in this mental process ("functional test").
- The principle of focusing neuropsychological techniques primarily on the identification of impaired links of mental functions ("provocation").
- The principle of research of any mental function (factor) using a set of techniques, the results of which complement and clarify each other ("cross control").
- The principle of compulsory analysis of not only the final result of the activity, but also the process of performing the task in its various components (neurodynamic, motivational, regulatory, operational).
- The principle of combining a qualitative analysis of identified disorders with a quantitative assessment of the severity of symptoms.
- The principle of learning - in the course of performing a specific methodology, the neuropsychologist, if necessary, fixes the possibility of the subjects mastering the method of action and its application in similar tasks.
- The principle of comparing the data obtained during neuropsychological examination with the data of anamnesis, objective clinical and paraclinical studies.
- The principle of taking into account the age and premorbid characteristics of the subject.
- Note that most of the above principles are important not only for neuropsychological diagnostics, but also for solving diagnostic problems in other areas of clinical psychology, for example, in pathopsychology (Zeigarnik, 1986; Workshop on pathopsychology, 1987).
On the one hand, there are general rules for constructing and conducting neuropsychological examinations in general and individual techniques in particular. The survey should be carried out individually, take a certain amount of time, include tasks of different levels of complexity, aimed at studying the main mental functions. There are fairly strict rules for presenting instructions and stimulus material to neuropsychological techniques. On the other hand, each neuropsychological examination is unique: the set of techniques used, the sequence and pace of their presentation, even the nature of the instructions can vary depending on the objectives of the examination, its hypothesis, and the characteristics of the patient's condition. Note that any neuropsychologist should be able to quickly and competently make a decision on the choice of tactical nuances of the examination.
The survey should be compact enough and take no more than one and a half hours. Its duration, as a rule, depends on the condition and age of the subject. For example, a neuropsychological examination of primary school children should not exceed 30–40 minutes. If the subject complains of fatigue, and the quality of his activity as a result of this noticeably deteriorates, the neuropsychologist must interrupt the examination and finish it at another time.
Almost all neuropsychological techniques are very compact, and mentally healthy adults can take from a few seconds to several minutes to complete them. However, when we examine patients with brain lesions, some (or most) techniques take longer to complete. In general, we can say that the implementation of the technique should continue until its procedure is completed and / or the neuropsychologist has not decided for himself what are the qualitative features of the disorders and the degree of their severity.
Techniques can be aimed at studying a certain factor (i.e., the principle of operation of any part of the brain), the mechanism of occurrence of disorders, or at identifying the phenomena observed when certain areas of the brain are affected. The mechanisms of occurrence of some phenomena have not yet been sufficiently studied. For example, a number of motor, speech, tactile tests are aimed at studying the kinesthetic factor. Along with this, there are tests for the detection of facial or color agnosia in lesions of the posterior parts of the right hemisphere, about the factorial neuropsychological causation of which only assumptions are made so far.
Neuropsychological examination is carried out individually. Any mental function (or its components) is not simply investigated using a set of methods, but is assessed at different levels of complexity, arbitrariness and with a different composition of afferent links (for example, only based on the leading afferentation). There are special techniques for complicating (sensitizing) neuropsychological techniques: accelerating the pace of execution, excluding visual control, increasing the volume of activity, complicating the characteristics of the stimulus material, minimizing speech mediation, etc.
Chapter 2. Client case
2.1. Conducting a neuropsychological examination, writing an opinion
Neuropsychological examination was carried out according to N.Ya. Semago's diagnostic album.
F.I. child: Barbara.
Age: 6 years 8 months (b. 17.10.2008)
Examination date: 09.06.2015
The girl's mother applied for a consultation with complaints of reading difficulties and low self-esteem.
As a result of the survey, the following features of psychological development were identified.
The girl makes good contact, understands and learns instructions for tasks from the first presentation, begins to work hastily, often not listening to the question, during a conversation, hesitation in speech periodically appears. Emotional reactions and behavior are adequate to the survey situation.
The stock of general knowledge and ideas is slightly below the age norm: he cannot give his full name, address of residence.
The predominant dominance of the left hemisphere is revealed, in the processing of incoming information, the right hand, right eye, right ear, right leg prevail, which is evidenced by the performance of tests for the study of manual and sensory preferences.
Lack of dexterity of fingers and hands is noted in the sphere of movements and actions. The test for reciprocal coordination is performed with a knock, cannot change the movement of both hands at the same time, the fist wraps up. Kinetic praxis was impaired when entering the activity; after changing the stereotype, the errors were insignificant. At the beginning of the activity there was an expansion of the activity program.
In visual-object perception, the inversion of the vector of perception is manifested. Scanning items is chaotic. Difficulties are observed in recognizing both superimposed and crossed out figures (uses perceptually close substitutions).
The weakness of the spatial factor causes a mirror perception and performance of movements, graphic tasks, makes it difficult to understand prepositional structures ("in", "on", "for", "under", etc.).
Perception of rhythms and their reproduction in the norm, there were isolated disturbances in rhythm reproduction due to impulsivity. The perception of household noises outside the window recognizes. Confuses sounds (B-P, D-T, Z-S, G-K - reproduces, BPB, DTD, ZSS - changes places, can insert another letter).
Auditory-verbal memory complies with age standards. Learning curve for words: 6,7,6,6,7. Single substitutions of similar words (cat-cat, brother-son).
The child has access to basic mental operations, summarizes and excludes based on categorical signs, consistently composes a story based on a series of plot pictures, knows how to build an independent coherent story with the highlighting of the main idea.
A pronounced violation of expressive speech - limited vocabulary development, the use of a small set of formulaic words, the fluency of speech is impaired, against the background of this, stuttering could appear, in particular in anxious situations. Understanding speech is not difficult. Characterized by the adequate use of non-verbal cues, gestures, the desire to communicate.
The girl's self-esteem level is normal, but we can talk about anxiety, emotional dependence, a feeling of discomfort, which was especially manifested at the beginning of the activity.
Against the background of the deficit in the work of these factors, well-developed functional systems are revealed, which are compensatory in relation to the weakened:
- the factor of "images-representations" allows the girl to recognize the essential features of objects well enough and to be guided by visual images.
- the factor of auditory-speech memory and the volume of acoustic perception, is characterized by good opportunities to memorize a sufficiently large amount of information, to correctly differentiate it by ear.
- mental features are developed within the age norm, the girl has access to operations of generalization and comparison based on categorical features, she understands connections and relationships by analogy.
Output: against the background of good development of intelligence and emotional-personal sphere, insufficient development of the following factors is revealed:
- insufficient spatial factor;
- deficiency of kinetic and kinesthetic factors.
- Deficiency of the energy component of mental activity.
1) psychological and pedagogical correction, including activation of the sensorimotor level, the development of spatial representations, speech and self-regulation;
2) classes with a speech therapist.
BIBLIOGRAPHY
1. Balashova E.Yu. , Kovyazina M.S. Neuropsychological Diagnostics in Questions and Answers 2012.
2. Semago N.Ya., Semago M.M. Diagnostic album for assessing the development of cognitive activity of the child. Preschool and primary school age.
The advances in psychology, neurophysiology and medicine (neurology, neurosurgery) at the beginning of the 20th century paved the way for the formation of a new discipline - neuropsychology. This branch of psychological science began to take shape in the 20-40s of the XX century in different countries and especially intensively in our country.
The first neuropsychological studies were carried out in the 1920s by L. S. Vygotsky, but the main merit of the creation of neuropsychology as an independent branch of psychological knowledge belongs to A.R. Luria.
Vygotsky's work in the field of neuropsychology was a continuation of his general psychological research. Based on the study of various forms of mental activity, he was able to formulate the main provisions:
* about the development of higher mental functions;
* about the semantic and systemic structure of consciousness (L. S. Vygotsky, 1956,1960).
The early works of LS Vygotsky on neuropsychology were devoted to systemic disorders of mental processes resulting from the defeat of individual parts of the cerebral cortex, and their characteristics in children and adults. Vygotsky conducted his first neuropsychological studies together with A.R. Luria.
The research of LS Vygotsky (1934, 1956, etc.) laid the foundation for the development of neuropsychological ways to compensate for the mental dysfunctions arising from local brain lesions. On the basis of these works, he formulated the principles of localization of the higher mental functions of a person. L.S.Vygotsky was the first to express the idea that the human brain has a new principle of organizing functions, which he designated as the principle of "extracortical" organization of mental processes(with the help of tools, signs and, above all, language). In his opinion, the forms of social behavior that have arisen in the process of historical life lead to the formation of new "Inter-functional relations", which make possible the development of higher forms of mental activity without significant morphological changes in the brain itself. Later this idea of new "functional organs" was developed by A. N. Leont'ev (1972).
The position of LS Vygotsky that "the human brain has a new localization principle in comparison with the animal, thanks to which it became a human brain, an organ of human consciousness" (L. S. Vygotsky, 1982. T. 1. - P. 174), completing his well-known theses "Psychology and the doctrine of the localization of mental functions" (published in 1934) is undoubtedly one of the most fundamental provisions of Russian neuropsychology.
Vygotsky's ideas about the systemic structure and systemic cerebral organization of higher forms of mental activity are only part of the important contribution that he made to neuropsychology. No less important is his concept of the changing significance of the brain zones in the process of intravital development of mental functions.
Observations of the processes of mental development of the child led L.S.Vygotsky to the conclusion on the sequential (chronological) formation of the higher mental functions of a person and the sequential lifetime change in their cerebral organization(due to changes in "interfunctional" relations) as the main laws of mental development. He formulated the provision on the different influence of the focus of brain damage on the higher mental functions in childhood and in an adult.
The idea of an unequal effect in the defeat of the same areas of the cortex at different stages of mental development is one of the most important ideas of modern neuropsychology, which has been really appreciated only recently in connection with the development of research in the field of neuropsychology of childhood.
Both during the Great Patriotic War and in the subsequent time, the formation and development of neuropsychology were closely related to the success neurology and neurosurgery, which made it possible to improve its methodological and conceptual apparatus and to test the correctness of hypotheses in the treatment of patients with local brain lesions.
Research in the field of pathopsychology, conducted in a number of psychiatric clinics in the Soviet Union. These include the work of the psychiatrist R. Ya. Golant (1950), devoted to the description of mnestic disorders with local brain lesions, in particular with damage to the diencephalic region.
The Kiev psychiatrist A. L. Abashev-Konstantinovsky (1959) did a lot to develop the problem of general cerebral and local symptoms that arise with local brain lesions. He described the characteristic changes in consciousness that occur with massive lesions of the frontal lobes of the brain, and highlighted the conditions on which their appearance depends.
B.V. Zeigarnik and her colleagues made an important contribution to Russian neuropsychology. Thanks to these works:
* thought disorders were studied in patients with local and general organic brain lesions;
* the main types of pathology of thought processes are described in the form of various violations of the very structure of thinking in some cases and violations of the dynamics of mental acts (defects
motivation, purposefulness of thinking, etc.) - in others.
Of unconditional interest from the standpoint of neuropsychology are works Georgian School of Psychologists, who studied the features of a fixed installation in general and local brain lesions (D. N. Uznadze, 1958).
Important experimental psychological studies were carried out on the basis of neurological clinics. These primarily include the work of B.G. Anan'ev and his collaborators (1960 and others), devoted to the problem of interaction of the cerebral hemispheres and which made a significant contribution to the construction of modern neuropsychological concepts of the cerebral organization of mental processes.
Of great value for the development of neuropsychology are neurophysiological studies, which have been and are being carried out in a number of laboratories in the country. These include the studies of G.V. Gershuni and his collaborators (1967), devoted to the auditory system and revealed, in particular, two modes of its operation: the analysis of long sounds and the analysis of short sounds, which made it possible to approach the symptoms of damage to the temporal lobes of the cerebral cortex in a new way. in humans, as well as many other studies of sensory processes.
A great contribution to modern neuropsychology was made by the research of such major Russian physiologists as N.A. Bernstein, P.K.Anokhin, E.N.Sokolov, N.P. Bekhtereva, O.S. Adrianov, etc.
The concept of N.A. Bernstein (1947 and others) on the level organization of movements served as the basis for the formation of neuropsychological ideas about the cerebral mechanisms of movements and their disorders in local brain lesions.
The concept of PK Anokhin (1968, 1971) about functional systems and their role in explaining the expedient behavior of animals was used by A.R. Luria to construct a theory of systemic dynamic localization of higher mental functions of a person.
The works of E.N.Sokolov (1958 and others), devoted to the study of the orienting reflex, were also assimilated by neuropsychology (together with other achievements of physiology in this area) to build a general scheme of the brain as a substrate of mental processes (in the concept of three brain blocks, to explain modal-nonspecific disorders of higher mental functions, etc.).
Of great value for neuropsychology are the studies of N.P. Bekhtereva (1971, 1980), V.M.Smirnov (1976, etc.) and other authors, in which, for the first time in our country, using the method of implanted electrodes, the important role of deep brain structures in implementation of complex mental processes - both cognitive and emotional. These studies have opened up new broad prospects for the study of the cerebral mechanisms of mental processes.
Thus, Russian neuropsychology was formed at the junction of several scientific disciplines, each of which made its own contribution to its conceptual apparatus.
The complex nature of the knowledge that neuropsychology relies on and that is used to build its theoretical models is determined by the complex, multifaceted nature of its central problem - “the brain as a substrate of mental processes”. This problem is interdisciplinary, and progress towards its solution is possible only with the help of the common efforts of many sciences, including neuropsychology. To develop the proper neuropsychological aspect of this problem (i.e., to study the cerebral organization of higher mental functions, primarily on the basis of local brain lesions), neuropsychology must be armed with the entire amount of modern knowledge about the brain and mental processes, gleaned from both psychology and from other related sciences.
Modern neuropsychology develops mainly in two ways. The first one is Russian neuropsychology, created by the works of L. S. Vygotsky, A. R. Luria and continued by their students and followers in Russia and abroad (in the former Soviet republics, as well as in Poland, Czechoslovakia, France, Hungary, Denmark, Finland, England, the USA, etc. .).
The second is traditional western neuropsychology, the most prominent representatives of which are such neuropsychologists as R. Reitan, D. Benson, H. Ekaen, O. Zangwill and others.
Methodological framework Russian neuropsychology are the general provisions of dialectical materialism as a general philosophical system of explanatory principles, which include the following postulates:
About the materialistic (natural science) understanding of all
mental phenomena;
· About the socio-historical conditioning of the human psyche;
· About the fundamental importance of social factors for the formation of mental functions;
· About the mediated nature of mental processes and the leading role of speech in their organization;
About the dependence of mental processes on the methods of their formation, etc.
As you know, A.R. Luria, along with other domestic psychologists (L. S. Vygotsky, A. N. Leontiev, S. L. Rubinstein, A. V. Zaporozhets, P. Ya. Galperin, etc.) foundations of domestic psychological science and on this basis he created a neuropsychological theory of the cerebral organization of higher mental functions of a person. The successes of Russian neuropsychology are explained primarily by its reliance on general psychological concepts scientifically developed from the standpoint of materialistic philosophy.
Comparing the development paths of Russian and American neuropsychology, A.R. Luria noted that American neuropsychology, having achieved great success in the development of quantitative methods for studying the consequences of brain damage, actually does not have a general conceptual scheme of the brain, a general neuropsychological theory that explains the principles of the functioning of the brain as a whole.
The theoretical concepts of Russian neuropsychology determine the general methodological strategy of research. In accordance with the concept of the systemic structure of higher mental functions, according to which each of them is a complex functional system, consisting of many links, violations of the same function proceed differently depending on which link (factor) is affected. That's why the central task of neuropsychological research is to determine the qualitative specificity of the disorder, and not only to establish the fact of a disorder of a particular function.
It should be noted that at present, both theoretical positions and methods of domestic neuropsychology are gaining more and more popularity among Western researchers. The methods developed by A.R. Luria are subject to standardization, are widely used, and are discussed at special conferences.
The rich scientific heritage left by A.R. Luria determined the development of domestic neuropsychology for a long time and significantly influenced the development of neuropsychology abroad.
At present, Russian neuropsychology is an intensively developing branch of psychological science, in which several independent directions, united by common theoretical concepts and a common final task, states in the study of cerebral mechanisms of mental processes.
Main directions:
1.clinical neuropsychology, the main task of which is to study neuropsychological syndromes arising from damage to one or another part of the brain, and to compare them with the general clinical picture of the disease.
2. experimental neuropsychology, whose tasks include the experimental (clinical and instrumental) study of various forms of mental disorders in local brain lesions and other diseases of the central nervous system.
A.R. Luria and his collaborators experimentally developed the problems of the neuropsychology of gnostic processes (visual, auditory perception), the neuropsychology of intellectual activity.
3. psychophysiological the direction was created in experimental neuropsychology on the initiative of A.R. Luria. In his opinion, this direction of research is a natural continuation of experimental neuropsychology by methods of psychophysiology.
4.rehabilitation direction, dedicated to the restoration of higher mental functions, impaired due to local brain damage. This direction, based on general neuropsychological ideas about the activity of the brain, develops the principles and methods of restorative education for patients who have suffered from local brain diseases. This work began during the Great Patriotic War.
During these years, it was nominated the central position of the concept of neuropsychological rehabilitation: restoration of complex mental functions can be achieved only by restructuring the disturbed functional systems, as a result of which the compensated mental function begins to be realized with the help of a new "set" of psychological means, which also presupposes its new brain organization.
5.neuropsychology of childhood(70s of the XX century on the initiative of A.R. Luria) The need for its creation was dictated by the specifics of mental disorders in children with local cerebral lesions. There was a need for a special study of "children's" neuropsychological symptoms and syndromes, description and generalization of facts. This required special work to "adapt" the methods of neuropsychological research to childhood and to improve them.
The study of the features of the cerebral mechanisms of higher mental functions in children with local cerebral lesions makes it possible to identify the patterns of chronogenic localization of these functions, which Vygotsky wrote about in his time (1934), and also to analyze the different effects of the lesion focus on them depending on age ( "Up" - for not yet formed functions and "down" - for already established ones).
One might think that over time will be created and neuropsychology of old age(gerontoneuropsychology). So far, there are only a few publications on this topic.
6. neuropsychology of individual differences(or differential neuropsychology) - the study of the cerebral organization of mental processes and states in healthy individuals on the basis of theoretical and methodological achievements of Russian neuropsychology. The relevance of neuropsychological analysis of mental functions in healthy people is dictated by both theoretical and practical considerations. The most important theoretical problem arising in this area of neuropsychology is the need to answer the question of whether it is possible in principle to spread the general neuropsychological concepts of the cerebral organization of the psyche, which developed in the study of the consequences of local brain lesions, to the study of the cerebral mechanisms of the psyche of healthy individuals.
Currently in the neuropsychology of individual differences has developed two lines of research.
The first is study of the features of the formation of mental functions in ontogenesis from the standpoint of neuropsychology,
The second is study of the individual characteristics of the psyche of adults in the context of the problem of interhemispheric asymmetry and
inter-hemispheric interaction, analysis of the lateral organization of the brain as a neuropsychological basis for the typology of individual psychological differences
7. neuropsychology of borderline states of the central nervous system, which include neurotic conditions, brain diseases associated with exposure to low doses of radiation ("Chernobyl disease"), etc. Research in this area has shown the existence of special neuropsychological syndromes inherent in this contingent of patients, and great possibilities of using neuropsychological methods to assess the dynamics of their states, in particular for the analysis of changes in higher mental functions under the influence of psychopharmacological drugs ("Chernobyl trace", 1992; E. Yu. Kosterina et al. 1996,1997; E. D. Khamskaya, 1997, etc.).
Neuropsychology is a young science. Despite a very long history of studying the brain as a substrate of mental processes, which dates back to the pre-scientific ideas of ancient authors about the brain as a receptacle of the soul, and the huge factual material about various symptoms of brain damage accumulated by clinicians around the world, neuropsychology as a system of scientific knowledge developed only in 40-50s of the XX century. The decisive role in this process belongs to the Russian neuropsychological school. Her successes and high international prestige are primarily associated with the name of one of the most prominent psychologists of the 20th century - Alexander Romanovich Luria.
3.3.3. Neuropsychological research methods.
Neuropsychology studies the structure and functional organization of higher mental functions, psychological processes and emotional regulation from the standpoint of a systems approach. The basis of modern neuropsychology is the theory of the systemic organization of higher mental functions, the concept of which is that any mental function is carried out due to the functional interaction of different areas of the brain, each of which makes its own "specific contribution."
Neuropsychological research is aimed at assessing the state of higher mental functions, the peculiarities of the functioning of the asymmetry of the hemispheres and cognitive processes.
Assessment of the lateral organization of functions
Assessment of right-, left-handedness consists of anamnesis data, observation of the subject and relatively objective research using special tests.
Questionnaire M. Annette
Which hand do you prefer to throw objects with? Which hand do you write with? Which hand are you drawing with? Which hand do you play tennis? Which hand do you hold the scissors in? What hand are you combing your hair with? With which hand do you shave (paint your lips)? Which hand do you hold your toothbrush in? In which hand do you hold the knife while eating or sharpening a pencil? In which hand do you hold the spoon while eating? Which hand do you hold the hammer in? Which hand do you hold the screwdriver in?
Lurievsky samples
1. Interlacing of fingers. 2. Pose "Napoleon". 3. Hands behind your back. 4. Applause. 5. Fist to fist. 6. Cross-legged.
Visual asymmetry:1 .Leading eye. 2. Aiming.
Auditory asymmetry:Dichotic listening.
Neuropsychological analysis of higher mental functions
Orientation in time
1. What date is today? (day month Year).
2. What day of the week?
3. What time is it now? (without looking at the clock).
4. How long did the examination take?
5. Count a minute to yourself (individual minute).
Motor functions
1. Kinesthetic praxis:
a) praxis of the posture (reproduction of the posture of the fingers) according to the visual sample. Right hand - O 1-2, O 1-4, 2-3, 2-5. Left hand - O 1-2, O 1 - 4, 2- 3, 2-5;
b) praxis posture according to the tactile model. Right hand - O 1-2, O 1-4, 2-3, 2-5. Left hand - O 1-2, O 1 - 4, 2- 3, 2-5;
c) posture transfer according to the tactile pattern. Right hand-left hand (2-3, 2, 2-5). Left hand-right hand (2-3, 2, 2-5).
2. Kinetic (dynamic) praxis (repetition of a given sequence of movements):
a) reciprocal coordination;
b) rib-fist-palm; fist-rib-palm;
c) graphic samples;
d) oral praxis (blow, puff out the cheeks, grin, stick out the tongue, clatter, click the tongue ...).
3. Spatial praxis (repetition of spatially oriented movements).
b) hand horizontally in front of the chest;
c) palm horizontally under the chin;
d) left hand - right cheek;
e) right hand - left ear;
f) left fist under the right palm with an edge;
g) right hand - left ear, left hand - right cheek.
Actions with imaginary objects: Stir tea. Light a match. Thread the needle.
Symbolic actions: Threaten. Beckon. Salute.
4. Constructive praxis (folding from sticks according to the pattern, drawing according to a verbal task, sketching volumetric geometric figures).
Praxis disorders:
Akinetic (psychomotor) apraxia due to a lack of motivation to move.
Amnestic apraxia- violations of voluntary movements while maintaining imitative.
Ideatorial apraxia - impossibility to outline a plan of sequential actions that make up a complex motor act while maintaining the possibility of their random execution.
Constructive apraxia- the impossibility of composing a whole object from its parts.
Spatial apraxia - violation of orientation in space, primarily in the direction "right - left".
Somatosensory gnosis (perception)
Tactile Gnosis:
Localization of touch. Right hand. Left hand.
Teuber test(simultaneous touch on the left and right hand).
Dermolexia(definition of shapes and numbers written on the skin).
Naming the fingers(without visual control):
Right hand - 5 1 3 2 4 5 1 4 2. Left hand - 2 4 1 5 3 4 2 3 1.
Stereognosis (recognizing objects by touch with closed eyes):
Tactile agnosia (astereognosis) - violation of the ability to recognize presented objects by touch in the absence of distinct defects in elementary types of sensitivity (superficial and deep).
Tactile subject agnosia - violation of recognition by touch with closed eyes of the size and shape of an object, determination of its functional purpose.
Tactile agnosia of object texture - inability to determine by feeling the quality of the material, the nature of the surface of the object, its density.
Auditory gnosis. Auditory-motor coordination
1) Research on auditory perception- recognition of familiar noises (rustle of paper, jingle of keys).
2) Rhythm identification(how many beats?).
3) Playing the presented rhythm sequences(according to the instructions, according to the sample).
4) Recognition of popular melodies.
Auditory agnosia - violation of musical abilities that the patient had in the past.
Motor amusia - violation of the reproduction of familiar melodies. Sensory amusia - violation of recognition of familiar melodies.
With auditory agnosia, the identification of the voices of animals and birds, a variety of household noises can be impaired.
Body outline
Study of the right-left orientation(asked to show his own left hand, the right hand of the experimenter, sitting with crossed arms).
Evaluation of digital gnosis by verbal instructions, naming fingers.
Somatoagnosia (body pattern disorders) - violation of recognition of parts of one's own body, assessment of their condition, location in relation to each other.
Allocate: anosognosia of hemiplegia, blindness, deafness, aphasia, pain.
Autotopagnosia - ignoring half of the body or not recognizing its parts.
Orientation in space
Orientation in real space(recognition of your ward, location).
Spatial relationships(they offer to draw a plan of your room indicating the location of doors, windows, furniture), parts of the world(according to a conditional geographic point set by the experimenter on a sheet of paper).
Recognition of time on a "blind" dial, setting the "hands" of the clock according to verbal instructions.
Visual gnosis
1) Recognition of real objects. 2) Recognition of realistic images. 3) Recognition of superimposed images of objects. 4) Recognition of images of objects with “missing” features, in “noisy drawings” (crossed out images, Poppelreiter's figures, conflicting figures). 5) Recognition of letters. 6) Storytelling pictures ("Ice-hole", "Broken window"). 7) A story based on serial, plot pictures. 8) Identification and classification of colors by shades.
Facial gnosis - recognition of familiar faces, identification of photographs of unfamiliar faces according to a given sample, portraits of writers.
Visual gnosis disorders: subject agnosia- difficulty in recognizing individual objects and their images with preserved peripheral vision. Tactile identification of objects is not impaired.
Prosopagnosia - agnosia on faces, inability to recognize familiar people, to determine the individual belonging of a person by the image, to distinguish between men and women, features of facial expressions. The ability to recognize one's own face in the mirror is rarely impaired.
Color agnosia - violation of color classification, selection of identical colors and shades.
Simultant agnosia - violation of the ability to recognize and understand the content of plot pictures with the correct identification of individual objects and details of the picture.
Mnestic functions
Auditory-verbal memory:
a) Memorizing a series of words(up to 4 presentations).
Examples of tasks:
fish-seal-firewood-hand-smoke-lump;
bubble paint scoop leg bread ball;
star-thread-sand-squirrel-dust-silk.
Direct full reproduction of words from the third time, with the same reproduction order, is normative. After heterogeneous interference (other activity for 10-20 minutes) - delayed reproduction of memorized words. Delayed playback allows 2 errors;
b) Memorizing two series of words(up to 4 presentations).
Examples of tasks:
1) house-forest-cat night-needle-pie;
2) whale-sword-circle ice-flag-notebook;
3) crane-pillar-horse day-pine-water.
The performance standards for the test are the same as in point a). It is imperative to maintain the reference word order.
v) Memorization of phrases.
Apple trees grew in the garden behind a high fence // At the edge of the forest, a hunter killed a wolf.
G) Memorizing stories.
Jackdaw and Pigeons.
Jackdaw heard that the pigeons were well fed. She turned white and flew into the dovecote. The pigeons accepted her. They fed. But she could not resist and screamed at the checkmark, then they kicked her out. She wanted to return to her own, to the jackdaws, but they also did not recognize her and kicked her out.
Visual memory
a) Memorizing 6 geometric shapes.
The performance standards for the test are the same as in the study of auditory speech memory. It is imperative to maintain the reference order of the figures. The storage strength of visual information is examined after 30 minutes without additional presentation of the standard. With delayed playback, 2 errors are permissible (forgetting the figure, its incorrect image, loss of the playback order);
b) Memorizing 6 letters.
Examples: EIRGKU; DYAVSRL; NYUBKIB; OUZTSCHCH;
v) Replaying complex geometric shapes from memory(Taylor , Rhea - Osterritsa).
Speech functions
Expressive Speech Research
a) Spontaneous conversational speech.
Questions are presented that provide a short, monosyllabic answer (such as "yes", "no", "good", "bad") and detailed. Questions touch on everyday life.
When analyzing the answers received, the ability to understand the questions addressed, to maintain a dialogue is taken into account. The character of facial expressions and gestures is noted. In the answers, their monosyllabic or unfolding, features of the pronunciation side of speech, the presence of echolalia, the speed of answers, differences in answers to emotionally significant and indifferent questions for the subject are considered;
b) Automated speech.
They are asked to list the number series (from 1 to 6, from 7 to 12, from 15 to 20), list the months in the year.
The possibility of a smooth enumeration of automated rows, omissions of constituent elements, perseveration, paraphasia are taken into account;
c) Narrative (monologue) speech.
Retelling short stories aloud after being read by the experimenter, making sentences or a short story for any plot picture.
When analyzing narrative speech, attention is paid to the extent to which the key elements of the text are reflected in the retelling, the necessary sequence of the narrative, the proximity of the retelling to the text, and understanding of the meaning of the story are preserved.
The possibility of independent reproduction of a story without leading questions, activity, development, fluency or abruptness of speech, searches for words, agrammatisms, the predominance of verbs, introductory words or nouns in speech, the nature of paraphasia, their variability are noted;
d) Research of reflected speech:
Repetition of isolated vowel sounds (a, o, y, u, e, u);
Isolated consonants (uh, er, re, s, d, k);
Trigram syllables (liv, ket, bun, shom, tal, gis);
A series of three complex vowel sounds (aow, wao, oa, woa, owa, auo);
A series of opposition syllables (ba-pa, pa-ba, ka-ha, sa-za);
Distinguishing between isolated vowel sounds and their series (a-y-y-a-y-a);
Differentiation of syllables, words and sound combinations that are close in sound (da-ta-da-da-ta-ta);
Repetition of simple and complex words (home, work, plumbing, commander, stratospheric balloon);
Repetition of sentences and series of words that are not related in meaning (house-forest, ray-poppy, sleep-run, night-plan-list);
Repetition of a series of trigram syllables (bun-lec, ket-lash, zuk-tiz, rel-zuk-tiz);
Repetition of a series of words, the name of real objects, body parts, images of objects;
Action name (ax-chop, scissors-cut, pistol-shoot);
e) Research on comprehension of addressed speech and understanding of verbal meanings.
To do this, they ask to explain the meaning and meaning of individual words:
Simple commands (close your eyes, show your tongue, raise your hand);
Flexive relations (key-handle, handle-key, handle-key, key-handle);
Understanding the relationship between objects expressed by one preposition and the adverb of a place (put a pen under the book, above the book, to the right of the book);
Two pretexts (put the notebook in the book, but under the handle);
Understanding the constructions of the genitive case (brother's father and father's brother, sister's son and son's sister);
Introverted designs (I had breakfast after reading the newspapers. What did I do before?);
Head's Probe (Show your left ear with the index finger of your right hand);
f) Evaluation of phonemic analysis. Determination of the number of letters in words, the first and last letters in a word, analysis of the word by one or two phonemes (if a word is pronounced in which there is a sound "s" or "s" and "p", raise your hand).
Speech disorders:
Speech pressure- pathological speech arousal with a continuous need to speak.
Pretentious speech - the use of unusual, obscure, often inappropriate words, accompanied by mannered gestures and grimacing.
Mirror speech (echolalia) - involuntarily repeated words heard from others.
Monotonous speech - a speech disorder in which there are no (or extremely insignificant) changes in intonation.
Detailed speech - slow speech, with an overly detailed presentation of unimportant and unimportant details.
Oligophasic speech - impoverishment of vocabulary, grammatical structure and intonation.
Paradoxical speech - predominance of statements that are contradictory in meaning.
Perseverative speech - repeated repetition of the same word or turn of speech, the inability to find the necessary words and turns to continue the speech.
Pueril speech in an adult, it resembles babbling, burr and intonation features of children's speech.
Rhymed speech - filled with all sorts of rhymes, which are often used to the detriment of meaning.
Chanted speech - is a speech disorder in which one speaks slowly, pronouncing syllables and words separately.
Based on the above methods of neuropsychological research, it is possible to identify the following syndromes of disorders of higher cortical functions:
Efferent (verbal) motor aphasia - speech defect in the form of disturbances in the smoothness of articulatory speech, rough perseveration, inability to analyze the words heard or spoken, non-retention of the speech-hearing row, alienation of the meaning of words. Often these violations are accompanied by a loss of fluidity of speech with difficulty in attacking a word, tension, stammering, blurred pronunciation.
Localization of the focus in case of efferent motor aphasia is predominantly in the posterior-lower parts of the premotor region of the left, dominant in speech, cerebral hemisphere ("Broca's zone").
Dynamic aphasia manifests itself in a meager, curtailed, stereotyped speech without pronunciation difficulties. Speech initiative turns out to be sharply reduced in combination with the tendency to use speech stamps. Automated speech is only slightly impaired or, more often, not impaired. The nominative functions of speech are also slightly impaired, but they are clearly manifested in dialogical and spontaneous speech in the form of a search for the desired word. Reflected speech usually remains intact, but reproduction of polysyllabic sentences may suffer. Comprehension of speech and complex grammatical structures does not suffer or is slightly impaired.
There are 3 levels of speech lesions:
At the 1st (design level) spontaneous speech can be absent ”, dialogical speech is carried out only with support from a question;
Violations of the 2nd level are clearly manifested in monologue speech, drawing up sentences for plot pictures, retelling the text, composing a story on a given topic, the impossibility of interpreting proverbs, idiomatic expressions. Errors are caused by syntax defects, verbal substitutions and even perseveration (at the 1st and 2nd levels of dynamic aphasia, the communicative function of speech is grossly disturbed - patients do not ask questions and do not seek to talk about themselves);
The 3rd level is characterized by expressive agrammatisms: errors in the agreement of words in gender and case, verbal weakness and misuse of verb forms, lack of prepositions, general poverty of speech utterance.
Dynamic aphasia, as an independent form of speech pathology, occurs with foci of brain damage anterior to the "Broca's zone" (posterior gyrus and medial surface of the left hemisphere).
Afferent (articulatory) motor aphasia characterized by kinesthetic apraxia, leading to a systemic defect at the articulatory, lexical and syntactic levels.
Clinically, this is manifested by the absence of all types of expressive speech with a relatively intact understanding of addressed speech and reading to oneself.
The lesion is localized in the left hemisphere (in right-handed people) in the lower parts of the posterior-central region with more or less involvement of the anterior parts of the parietal lobe.
Acoustic-gnostic (sensory-acoustic) sensory aphasia- violations of expressive and impressive speech. Spontaneous and conversational speech, depending on the severity, is disturbed from the degree of "verbal okroshka", which is a set of words that are inarticulate in sound composition, to relatively intact, but lexically impoverished speech. Logoria and a tendency to speech disinhibition are often observed.
Expressive speech without pronunciation difficulties, intonationally expressive and emotional. Changes in the grammatical structure of speech are noted. The speech of patients is replete with verbal forms, introductory words, adverbs, with a relatively small representation of nouns. Reflected speech is grossly disturbed - repetitions of individual sounds, words and sentences are noted. Understanding of situational speech is totally violated only with a gross degree of aphasia. In most cases, you can still understand individual words and simple commands.
The lesion is localized mainly in the posterior-upper parts of the 1st temporal gyrus of the left hemisphere ("Wernicke's zone").
Acoustic-mnestic (sensory-amnestic) aphasia- violations of the nomination. The naming function can be violated to a greater or lesser extent, and there is no clear difference in the naming of objects and actions. Difficulties in naming are expressed by an increase in the latency period of recall, verbal substitutions, less often literal substitutions, or refusal to answer. Sometimes the naming is replaced by a description of the purpose of the item or the situation in which it occurs. Often, the specific name of the image of objects is replaced by their generalized concept. There are difficulties in finding the right words or expressions. Pronounced speech disorders are not noted.
In the classification of A.R. Luria identified two forms of aphasia associated with damage to the temporo-parietal region of the left hemisphere (in right-handed people): amnestic and semantic. If the lesion spreads in the caudal direction and covers the parieto-occipital region, then specific disorders of reading and writing (optical alexia and agraphia) may occur.
Semantic aphasia in contrast to acoustical-mnestic and amnestic aphasia, it is characterized by the presence of rough selective impressive, less often - expressive agrammatism, which manifests itself in a violation of understanding and operating with complex grammatical categories. Patients do not understand well the prepositions and adverbs of the place, reflecting the spatial relationships between objects, comparative and transitional constructions, temporal relations, constructions of the genitive case. At the same time, the ability to read and write is retained.
The predominant localization of lesions is the area of the supra-marginal gyrus of the parietal lobe of the left hemisphere.
Study writing:
Cheating short phrases.
Dictation of letters, syllables, words and phrases.
Recording of automated engrams (speech stereotypes). Examples: Own name, patronymic, surname, address.
Agrafia- violation of the ability to write correctly in meaning and form while maintaining the motor function of the hand.
Reading Research:
Reading syllables, words, ideograms, made in different fonts.
Reading simple sentences and short stories, newspaper text.
Reading "noisy" letters.
Alexia- reading disorder due to impaired understanding of the text.
Allocate: Verbal alexia - violation of understanding the meaning of phrases and individual words. Literal Alexia- violation of recognition of individual letters, numbers and other signs.
Account research:
Reading, naming, writing the proposed numbers.
Automated counting operations (multiplication table).
Addition and subtraction of single and two-digit numbers.
Written invoice.
Solving simple tasks. Example: A hostess spends 15 liters of milk in 5 days. How much does she spend in a week?
Serial count (from 100 to subtract 7, from 200 to 13; alternately subtract 1, then 2 from 30).
Akalculia - violation of the ability to perform arithmetic operations. Occurs with damage to the parietal and occipital lobes of the dominant hemisphere of the brain.
Optical acalculia - associated with impaired visual perception and reproduction of numbers similar in graphic structure. It occurs when the occipital region of the cerebral cortex is affected.
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