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Chapter 26. Higher Cortical Functions

Chapter 26. Higher Cortical Functions

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Published by: Costrut Laur on Jan 28, 2010
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Pridmore S. Download of Psychiatry, Chapter 26. Last modified: March, 20091
CHAPTER 26HIGHER CORTICAL FUNCTIONS
 
Introduction
The HCFs are: 1) memory, 2) orientation, 3) concentration, 4) language, 5)performance of learned skilled movements (examined by tests for apraxia), and 6)recognition of stimuli (examined by tests for agnosia).Only the first four (memory, orientation, concentration, language) are components of the regular psychiatric assessment. Language is a component in so far as we focusparticular attention on the form of thought. It is also a focus of attention in the MiniMental State Examination (MMSE; Folstein et al, 1975, see Chapter 20), the mostwidely used screening test for cognition/HCF. Some additional aspects of languageare listed toward the end of this chapter for reference purposes.Recognition of stimuli (gnosis) and performance of skilled movements (praxis) arenot components of the regular psychiatric assessment, but form part of a morecompleter examination. The HFCs are examined in detail when the clinical findingssuggest an “organic” disorder.The term organic disorder is problematic. It was coined at a time when investigativetechnologies were crude compared to those of the early 21
st
century. At the time, itwas assumed that if no organic basis could be demonstrated (with the technology of the day), none existed. Those conditions for which no physical explanation could befound were termed “functional”, which implied that organs were healthy, but notfunctioning properly.
 
Pridmore S. Download of Psychiatry, Chapter 26. Last modified: March, 20092
 With technological advances, the boundaries of “organic” should be moved.Schizophrenia, for example, was considered to be a functional disorder, but imagingand genetic studies have clearly demonstrated a physical basis. The same applies tomany other psychiatric disorders.The term organic, therefore, says as more about the technology of the day the termwas coined than about pathology. It can be argued that psychiatry is generallyconcerned with pathology at a molecular level (e.g., neurotransmitters) and otherbranches of medicine are concerned with supra-molecular pathology (e.g., abnormalcells, as in tumour), but this is an over-simplification. For example, the ‘neurological’disorder, Parkinson’s disease, is a result of reduced availability of theneurotransmitter dopamine, in the nigrostriatal tract, while the ‘psychiatric’ disorder,schizophrenia appears in large part to be the result of excessive availability of dopamine in the mesolimbic tract.Putting confusing terminology aside: HCF testing is a valuable means of detectingconditions which may present as psychiatric disorders but which require the servicesof other branches of medicine. For example, patients may present with a picturesuggestive of schizophrenia or depression which is secondary to space occupyinglesions, toxic, endocrine or metabolic abnormalities, as in such conditions, HCFtesting frequently reveal abnormalities.In general, if memory, orientation, concentration and language are intact, theperformance of learned skilled movements and recognition will also be intact. Thus,the former may be regarded as a screening test, such that if they are intact, the latterneed not be tested.MMSE deserves special mention. This is a standardised, widely accepted screeningtest of HCF. It examines orientation in some detail and then briefly touches onregistration and recall, attention/concentration, language and constructional abilities.Brevity is its strength (allowing a wide breadth examination) and its weakness (notproviding a comprehensive assessment). This is a screening test which may indicate aneed for more extensive testing.
Memory
 Memory is the ability to revive past thoughts and sensory experiences. It includesthree basic mental processes: registration (the ability to perceive, recognise, andestablish information in the central nervous system), retention (the ability to retainregistered information) and recall (the ability to retrieve stored information at will).Short-term memory (which for this discussion includes what has been calledimmediate memory by others) has been defined as the recall of material within aperiod of up to 30 seconds after presentation.Long term memory can be split into recent memory (events occurring during the pastfew hours to the past few months) and remote memory (events occurring in pastyears).
 
Pridmore S. Download of Psychiatry, Chapter 26. Last modified: March, 20093
 Memory can be influenced by many factors. In addition to physical lesions,intoxication, emotional arousal, psychomotor retardation, thought disorder andmotivation must be considered.Tests of memoryDuring the psychiatric interview some information about memory will be availablefrom the history and initial conversation with the patient. Memory tests are requiredfor quantitative assessment. Three levels of memory are specifically tested.There should be concern for the patient’s comfort and dignity, but there should not beindecision or inappropriate apology. After some general conversation, the examinermay say something like, “Thank you Mr X, I understand what you have been saying. Inow need to test your memory.” Then proceed directly to, “I am going to give youthree things which I want you to remember.......” or similar words, according to thetest the examiner wishes to apply.When a patient who has been treated respectfully refuses cognitive testing, there isprobably cognitive impairment.
 History and conversation
The patient should be able to give a clear account of his/her life from the remote tothe recent past.The presenting complaint is important. Where memory function is the primaryproblem the patient may not be able to remember why he/she is present. The patientshould be able to give details of who made the arrangements for the interview, hows/he was conveyed from home or work, at what time did s/he depart home or work, atwhat time did s/he arrive and how long the journey took. Thus, the history gives theopportunity for a real life test of the recent memory.Assessment of the remote memory may prove difficult as the examiner does not haveconfirmed facts. The internal consistency of the personal history gives importantinformation, that is, matching the dates, ages and events when the patient is describingher/his past life. The names and current ages of children and siblings are often usefulquestions
Short-term (immediate) memory test 
The most common test is to ask the patient to repeat sequences of digits. Three digitsare given first and the patient is asked to repeat them. If this is performedsuccessfully, four digits are given and so on, until the patient makes mistakes. Ahealthy person of average intelligence is usually able to repeat seven digits correctly.(Strictly speaking, this is not memory, as this information is kept in mind and does nothave to be retrieved.)
 Recent memory test 
A common testing method is to ask the patient to learn three or four unrelated words.The patient is advised that s/he will be given some words to remember, and that laterin the interview s/he will be asked to recall them. The words are said (e.g., car, tree,sock, bucket) at the rate of about one second per second. The patient is asked to repeat

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