A case of frontal lobe syndrome.

Abstract

Frontal lobe syndrome is a broad term used to describe the damage of higher functioning processes of the brain such as motivation, planning, social behavior, and language/speech production.[1] It can occur due to disease, head trauma, or tumor. It is characterized by a change in personality and behavior in a previously normal individual. A 17-year-old boy, educated up to 9th std, living with parents and younger sibling, was brought to the psychiatry outpatient department with complaints of irritability, aggressive behavior, easy distractibility, restlessness, impulsive behavior, inappropriate social behavior, and wandering tendency since 1.5 years. The patient was apparently alright 1.5 years back when he met with a road traffic accident (RTA), sustained closed head injury, and had right ear bleed, following which he had loss of consciousness for 18 days requiring ventilatory support. On regaining consciousness, the patient had memory loss for events a few days prior and multiple days after the RTA, irritability, anger outbursts, impulsivity, abusive behavior, overfamiliarity, jocularity, wandering behavior, disinhibition, and distractibility. He had unprovoked bouts of aggression and would start abusing those around him. He could not sit still for any task and would leave conversations midway, focusing his attention on some other activity. When he got unmanageable at home, he was shown to a psychiatrist a month after the accident and he was prescribed: tablet risperidone 3 mg + tablet trihexyphenidyl 2 mg, tablet olanzapine 5mg BD, and valproate 250 mg BD. The treatment was partially effective in treating his mood and behavioral changes, but symptoms still persisted. There is no significant past medical history, no family history of any psychiatric illness, and no history of substance use. His general physical and systemic examinations were within normal limits. On central nervous system examination, anosmia was present, grip was reduced in the left hand, dysdiadokokinesia showed frequent sequencing errors, and gait was suggestive of frontal ataxia. On the Frontal lobe assessment patient score was: 5/18 (normal score of 15); motor functions: grip strength was reduced on the left side; fine motor speed was reduced in the left hand with errors; premotor functions: sensorimotor integration was slower in the left hand; dorsolateral/ executive functions: complex and directed attention was normal; multiple response alternatives: open set F, A, S beginning words – very poor, behavioral inflexibility: Luria's bilateral hand movements – negative; Wisconsin card sorting test was abnormal; orbital/inhibitory functions: behavioral disinhibition – go no go test was abnormal, Stroop test was abnormal; anosmia was present; abnormal behavior during testing: poor/no insight into deficits, inappropriate social behavior, perseveration present, easily agitated, and hyperactive. From the above tests, we concluded that the patient had loss of executive functions along with disinhibition which is seen in frontal lobe syndrome (dysexecutive syndrome). Mental status examination revealed overfamiliarity, jocularity, and disinhibited behavior. Speech was spontaneous with increased rate, monotonous, nasal voice, unclear words and increased reaction time. His mood was irritable and labile. Delusions/ obsessions/ suicidal ideas were absent. X ray skull showed multiple frontal bone fractures. CT scan of brain showed bilateral frontal bone fractures, orbital and maxillary injuries along with extensive edema. With the diagnosis of frontal lobe syndrome, he was treated with tablet olanzapine 5 mg BD and tablet valproate 500 mg BD. Our case report demonstrates the drastic change in behavior and personality in a patient with traumatic brain injury causing damage to the frontal lobe. He was an above-average student prior to the RTA but could not function normally since then and was unmanageable at home with frequent bouts of unprovoked aggression. He also required supervision to carry out daily activities. Frontal lobe is responsible for higher mental functions including executive functions, voluntary movement, and language and is prone to injury due to its placement. It is also considered the behavior and emotion control center and home to our personality, injury to which can lead to serious consequences. Frontal lobe damage can have devastating consequences on the patient as well as the relatives. Psychotropic medications can be used to an extent to control the behavioral disturbance and rehabilitation could be useful for support, although prognosis is poor for such patients. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.