Possibilities of using neuropsychological research in pathopsychological practice. Materials and methods of research What's next? Further actions

Neuropsychology- a specific field of knowledge, where the subject is the study of the brain organization of mental processes, emotional states and personality on the material of pathology, primarily on the material of local lesions of the g/m.

Neuropsychology as a branch of psychological science began to take shape in the 20-40s of the twentieth century in different countries. The successes of psychology, neurophysiology and medicine (neurology, neurosurgery) of the early 20th century paved the way for its formation.

The first neuropsychological studies were carried out back in the 1920s by L.S. Vygotsky, however, the main merit in the creation of neuropsychology as an independent branch of psychological knowledge belongs to A.R. Luria.

Based on the works of Vygotsky (1934,1956), they were formulated the principles of localization of higher mental. human functions. He first expressed the idea that the human brain has a new principle of organizing functions, which he designated as the principle of "extracortical" organization of the psyche. processes(with the help of tools, signs and language).

Observations on mental processes. child development. led Vygotsky to the conclusion about the sequential (chronological) formation of higher mental. human functions and consistent lifetime changes in their brain organization as the basic regularity of psycho. development. He formulated position on the different influence of the focus of brain damage on higher psycho. functions in childhood and in adults.

The central task of neuropsychol. research is to determine the qualitative specifics of the violation, and not just a statement of the fact of the disorder of a particular function.

The main tasks of neuropsychology .

The study of changes in mental processes in local lesions of the brain, which allows you to see what kind of brain substrate is associated with a particular type of mental activity.

Neuropsychological analysis makes it possible to identify those common structures that exist in completely different mental processes.

Early diagnosis of focal brain lesions.

There are two method groups used in neuropsychology. The first should include those methods by which the basic theoretical knowledge was obtained, and the second - the methods that are used by neuropsychologists in practice.

In the first group, there is a comparative anatomical method of research, a method of irritation and a method of destruction.

In the practice of neuropsychologists, the method of syndromic analysis proposed by A. R. Luria, or, in other words, the “battery of Luria methods”, is used. A. R. Luria selected a number of tests, combined into a battery, which allows you to assess the state of all the main HMF (according to their parameters). These techniques are addressed to all brain structures that provide these parameters, which makes it possible to determine the area of ​​brain damage.

These methods, being the main tool for clinical neuropsychological diagnostics, are aimed at studying various cognitive processes and personal characteristics of the patient - speech, thinking, writing and counting, memory.

Currently, there are several areas of neuropsychology that differ in their tasks.

Clinical neuropsychology deals with the study of patients with local lesions of the brain. The main task is to study neuropsychological syndromes in local brain lesions. Research in this area is of great practical importance for diagnosis, preparation of a psychological conclusion about the possibility of treatment, recovery and prognosis of the future fate of patients. The main method is the method of clinical neuropsychological research.

Experimental neuropsychology (Neuropsychology of cognitive processes). Main objective: experimental study of various forms of disorders of mental processes in local brain lesions. Thanks to the work of A. R. Luria and his students, memory and speech are the most studied. In experimental N., on the initiative of Luria, psychophysiological direction - This is a direction whose task is to study the physiological mechanisms of violations of higher mental functions.

Rehabilitation neuropsychology . The main task is to restore HMF in case of local brain lesions. The most developed principles and methods of speech restoration.

Environmental neuropsychology evaluates the influence of various adverse environmental factors on the state of mental functions and on the emotional and personal sphere from the standpoint of neuropsychology.

Developmental Neuropsychology . The task is to identify patterns of brain development.

In recent years, neuropsychology of childhood . This is a new area of ​​neuropsychology that studies the specifics of mental disorders in children with local brain lesions. Research in this area makes it possible to identify patterns of localization of higher mental functions, as well as to analyze the effect of localization of the lesion on mental function depending on age.

Finally, in recent times, more and more begins to assert neuropsychology of individual differences (or differential her ropsychology ), which studies the brain organization of mental processes and states in healthy individuals based on the theoretical and methodological achievements of domestic neuropsychology.

The practical tasks facing differential neuropsychology are primarily related to psychodiagnostics, with the use of neuropsychological knowledge for the purposes of professional selection, career guidance, etc.

Neuropsychology was formed due to the demands of practice, first of all, the need to diagnose local brain lesions and restore impaired mental functions.

In the conceptual apparatus of neuropsychology, one can single out two concept class . The first one isconcepts common to neuropsychology andgeneral psychology; the second one isproper neuropsychologicalnotions, due to the specifics of its subject, object and research methods.

The first class of concepts includes such as:

higher mental function;

mental activity;

psychological system;

mental process;

speech mediation;

meaning;

personal meaning;

psychological tool;

• action;

  operation;

internalization and many others.

The second class of conceptsconstituteproper neuropsychologicalconcepts which reflected the application of general psychological theory to neuropsychology. The basis of this theory is the position on the systemic structure of higher mental functions and their systemic brain organization.

In neuropsychology, as in general psychology, under the highest psi chemical functions are understood as complex forms of conscious mental activities carried out on the basis of compliance motives, regulated by the corresponding goals and programs and subject to all the laws of mental activity.

Higher mental functions have three main characteristics:

* they are formed in vivo under the influence of social factors (consciousness);

* they are mediated by their psychological structure (mainly with the help of the speech system) - mediation;

* they are arbitrary in the way they are carried out (arbitrariness)

Higher mental functions as systems have great plasticity, interchangeability of their components.

The pattern of formation of higher mental functionsis thatinitially they exist as a form of interactioninteractions between people (i.e., as an interpsychological process) and onlylater - as a completely internal (intrapsychological) process.

A functional system in neuropsychology is understood as aphysiological basis of higher mental functions (i.e. aggregatevarious brain structures and the physiological processes occurring in themprocesses) that ensures their implementation.

These provisions are central totheory of systemic dynamic localization of higher mental functions.

The following can be attributed to the second class of concepts - actually neuropsychological ones.

neuropsychological symptom- a violation of mental function that occurs as a result of local damage to the brain (or due to other pathological causes leading to local changes in the functioning of the brain).

Primary neuropsychological symptoms- violations of mental functions, directly related to the defeat (loss) of a certain neuropsychological factor.

Secondary neuropsychological symptoms- disorders of mental functions arising as a systemic consequence of primary neuropsychological symptoms according to the laws of their systemic relationships.

Neuropsychological Syndrome- a regular combination of neuropsychological symptoms, due to the defeat (loss) of a certain factor (or several factors).

Neuropsychological factor- a structural and functional unit of the brain, characterized by a certain principle of physiological activity (modus operandi), the violation of which leads to the appearance of a neuropsychological syndrome.

Syndromic analysis- analysis of neuropsychological syndromes in order to find a common basis (factor) explaining the origin of various neuropsychological symptoms; the study of the qualitative specifics of disorders of various mental functions associated with the defeat (loss) of a certain factor; qualitative qualification of neuropsychological symptoms (synonym - factor analysis).

Neuropsychological diagnostics- study of patients with local brain lesions using clinical neuropsychological methods in order to establish the location of brain damage (topical diagnosis).

Functional system- a morphophysiological concept borrowed from the concept of functional systems by P. K. Anokhin (1968, 1971, etc.) to explain the brain mechanisms of higher mental functions; a set of afferent and efferent links combined into a system to achieve the final result. Higher mental functions different in content (gnostic, mnemonic, intellectual, etc.) are provided by qualitatively different functional systems.

Brain mechanisms of higher mental function(morphophysiological basis of mental function) - a set of morphological structures (zones, areas) in the cerebral cortex and in subcortical formations and the physiological processes occurring in them, which are part of a single functional system and are necessary for the implementation of this mental activity.

10. Localization of higher mental function(cerebral organization of higher mental function) is the central concept of the theory of systemic dynamic localization of higher mental functions, which explains the connection of the brain with the psyche as the ratio of various links (aspects) of mental function with different neuropsychological factors (i.e., the principles inherent in the work of a particular brain structure - cortical or subcortical).

11. Multifunctionality of brain structures- the ability of brain structures (and, above all, the associative zones of the cerebral cortex) to rebuild their functions under the influence of new afferent influences, as a result of which intrasystemic and intersystemic restructuring of the affected functional systems occurs.

Function norm- the concept on which the neuropsychological diagnosis of disorders of higher mental functions is based; indicators of the implementation of the function (in psychological units of productivity, volume, speed, etc.), which characterize the average values ​​in a given population. There are variants of the “norm of function” associated with premorbidity (gender, age, type of interhemispheric organization of the brain, etc.).

Interhemispheric asymmetry of the brain- inequality, a qualitative difference in the "contribution" that the left and right hemispheres of the brain make to each mental function; differences in the brain organization of higher mental functions in the left and right hemispheres of the brain.

Functional specificity of the cerebral hemispheres- the specifics of information processing and brain organization of functions, inherent in the left and right hemispheres of the brain and determined by integral hemispheric patterns.

Interhemispheric interaction- a special mechanism for combining the left and right hemispheres of the brain into a single integrative, holistically working system, which is formed under the influence of both genetic and environmental factors.

These concepts are included in basic pony theoretical apparatus of the theory of systemic dynamic localization of higher mental functions of a person .

Basic provisions of theorii of systemic dynamic localization of higher psychesical functions:

each mental function is a complex functional system and is provided by the brain as a whole. At the same time, various brain structures make their specific contribution to the implementation of this function;

various elements of a functional system can be located in areas of the brain that are quite remote from each other and, if necessary, replace each other;

When a certain part of the brain is damaged, a “primary” defect occurs - a violation of a certain physiological principle of operation inherent in this brain structure;

As a result of damage to the common link included in different functional systems, "secondary" defects may occur.

Currently, the theory of systemic dynamic localization of higher mental functions is the main theory that explains the relationship between the psyche and the brain.

In neuropsychology, based on the analysis of clinical data, a general structural-functionnal model of the brain as a substratum of mental activitysti, according to which the whole brain can be subdivided into three main structural and functional block :

I- an energy block, or a block for regulating the level of brain activity,

II- a block for receiving, processing and storing exteroceptive (i.e., outgoing) information;

III- a block of programming, regulation and control over the course of mental activity.

Each higher mental function (or a complex form of conscious mental activity) is carried out with the participation of all three blocks of the brain that contribute to its implementation.

Energy block includes non-specific structures of different levels:

reticular formation of the brain stem;

nonspecific structures of the midbrain, its diencephalic divisions;

limbic system;

* mediobasal regions of the cortex of the frontal and temporal lobes of the brain.

Non-specific structuresfirst block according to the principle of their action are divided into the following types:

* ascending (conducting excitation from the periphery to the center);

* descending (conducting excitation from the center to the periphery).

Cortical structures of the first block(cingulate cortex, medial cortex)and basal, or orbital, parts of the frontal lobes of the brain)ownedlie in their structure mainly to the crust of the ancient type, withconsisting of five layers.

Functional valuefirst block in providing mental functions is, firstly, in the regulation of activation processes, in maintaining the general tone of the central nervous system, which is necessary for any mental activity (activating function). Secondly, in the transfer of the regulatory influence of the cerebral cortex on the underlying stem formations (modulating function). Due to the descending fibers of the reticular formation, the higher sections of the cortex control the work of the underlying apparatus, modulating their work and providing complex forms of conscious activity.

The first block of the brain is involved in the implementation ofbattle of mental activity, especially in the processes of attention, memory, regulation of emotional states and consciousness in general.

The second block is the block of reception, processing and storage exterocepbeer(t.e.coming from the external environment)information - located in the outer sections of the new cortex (neocortex) and occupies its posterior sections, including the apparatuses of the occipital, temporal and parietal cortex. The structural and anatomical feature of this block of the brain is the six-layer structure of the cortex. It includes primary zones (providing the reception and analysis of information coming from outside), secondary zones (performing the functions of synthesizing information from one analyzer) and tertiary zones, the main task of which is a comprehensive synthesis of information.

A distinctive feature of the devices of the second block is modal specificity and narrow specialization. The first means that the nerve cells of the primary zones respond to excitation of only one modality (one type), for example, only visual or only auditory. The second assumes that these neurons respond only to a single sign of a stimulus of one type (for example, only to the width of the line or the angle of inclination, etc.). Due to this, the apparatuses of the second functional block of the brain perform the functions of receiving and analyzing information coming from external receptors and synthesizing this information.

All major analyzer systems are organized according to a commonprinciple: they consist ofperipheral (receptor) and central departments.

Peripheral departmentsanalyzers analyze and discriminate stimuli according to their physical qualities (intensity, frequency, duration, etc.).

Central departmentsanalyzers include several levels, the last of which is the cerebral cortex.

The processes of analysis and processing of information reach the maximum complexity and fragmentation in the cerebral cortex. Analyzer systems are characterized by a hierarchical principle of structure, while the neural organization of their levels is different.

The posterior cortex of the cerebral hemispheres has a number of common features that allow it to be combined into a single block of the brain. It distinguishes "nuclear zones" of analyzers and "periphery" (in the terminology of I.P. Pavlov), or primary, secondary and tertiary fields (in the terminology of A.V. Campbell). The core zones of the analyzers include primary and secondary fields, and the periphery - tertiary fields.

The third block is a block of programming, regulation and control complex forms of activity is associated with the organization of purposeful, conscious mental activity, which includes in its structure a goal, a motive, an action program to achieve the goal, the choice of means, control over the implementation of actions, and correction of the result obtained. The provision of these tasks is the third block of the brain.

The apparatuses of the third functional block of the brain are located anterior to the central frontal gyrus and include includesmotor, premiumotor and prefrontal regionsbarkfrontal lobes of the brain. The frontal lobes are characterized by great structural complexity and many bilateral connections with cortical and subcortical structures. The third block of the brain includes the convexital frontal cortex with its cortical and subcortical connections.

The anatomical structure of the third block of the brain determines its leading role in programming the ideas and goals of mental activity, in its regulation and control over the results of individual actions, as well as all behavior as a whole.

Various stages of arbitrary, mediated speech, conscious mental activity are carried out with the obligatory participation of all three blocks of the brain:

it begins with the phase of motives, intentions, designs (1 block);

then these motives, intentions, plans turn into a specific program (or “image of the result”) of reality, including ideas about how to implement it (block 3);

* after which it continues as a phase of the implementation of this program with the help of certain operations (block 2);

* psychic activity ends with the phase of comparison of the obtained results with the initial “image of the result”. In case of discrepancy between these data, mental activity continues until the desired result is obtained.

The defeat of one of the three blocks (or its department) is reflected in any mental activity, as it leads to a violation of the corresponding stage (phase, stage) of its implementation.

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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 depend to a decisive extent on the safety 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 individual parts of the brain due to its traumatic injury can lead to a deficit in mental processes, affecting various levels and links of their provision. The method of syndromic analysis of disorders of higher mental functions in local brain lesions is based on these theoretical concepts. Back in the years of the Great Patriotic War, A.R. Luria laid the foundations for its use in patients with traumatic brain injury for the purpose 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 the 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 "silent", since their defeat does not lead to any disturbances in sensitivity, reflex sphere, tone and movements . At the same time, lesions of these zones lead to disturbances in various forms of perception, memory, speech, thinking, voluntary movements, etc. Designed 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 "Luriev's 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 technology, such as computed tomography and magnetic resonance imaging, to some extent reduced the importance of neuropsychological research in determining the localization of a traumatic lesion. 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 medulla, but also subtle, mildly pronounced changes associated with a decrease in the functional state of various brain structures. Comparisons of neuropsychological data with the results of SPECT show their significant mutual correlation: the presence of neuropsychological signs of dysfunction in those parts of the brain in which, according to the data of 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 the 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 existing mental disorders and their dynamics. In this case, the qualitative analysis of the detected disorders is of primary importance, aimed at identifying the main factor underlying the deficiency of a particular mental process, i.e. — qualification of defects.

Traumatic damage to the brain leads to disruption of the functioning of individual brain areas or the interaction between them, in connection with which mental processes suffer not globally, but selectively, within individual components. It is important to emphasize that in this case, intact links remain, provided by the operation of intact brain zones or systems. Following the principle of defect qualification (i.e., clarification of the mechanisms of dysfunction) and the principle of identifying primary and secondary symptoms, the 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 from TBI based on intact links in the structure of the affected function.

Complementing 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 the application of the neuropsychological method in the clinic of traumatic brain injury. A standardized method of neuropsychological research with a specially developed system of quantitative assessment successfully serves as an accurate and sensitive tool for evaluating the effectiveness of surgical treatment, pharmacotherapy and rehabilitation measures.

Thus, comparing the results of neuropsychological studies before and after bypass surgery for post-traumatic hydrocephalus makes it possible to judge their effect on mental defects, which often come to the fore in patients. Using the neuropsychological method, the factors affecting the success of surgical intervention (closed external drainage of the hematoma cavity) in patients with chronic post-traumatic subdural hematomas were analyzed.

Especially fruitful is the use of a quantitative neuropsychological approach to assessing the comparative effectiveness of drug therapy and targeted pharmacological effects on mental defects.

Advances in neuropsychopharmacology in recent years have led to a significant increase in the role of neurotropic drugs in the system of rehabilitation of patients after TBI. The variety of available means makes it difficult to make an adequate 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. An analysis of the action of more than 10 neurotropic agents using a standardized method 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) non-specific action - positively affecting all parameters of mental processes; the specified type of action has nootropil;

2) selectively improving the course of certain types of mental activity or their individual components; as an example, we can cite 2 drugs - amyridine and L-glutamic acid, the positive effect of which reaches a maximum in relation to the components of higher mental functions, in which the leading role belongs to the left and right hemispheres of the brain, respectively;

3) affecting various components of mental functions in different directions, selectively improving the state of some and at the same time aggravating the defectiveness of others; the representative of this group is bemitil, the spectrum of action of which is a "mosaic" set of positive and negative effects affecting only individual links of certain types of mental activity.

The conducted studies show 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 for the purpose of correcting defects in higher mental functions, it is necessary to conduct a neuropsychological examination to clarify the structure of disorders and select the drug that is most appropriate for the syndrome of the patient.

METHODOLOGY

Neuropsychological research is carried out at the degree of recovery of consciousness and vital functions, which provides the possibility of a fairly extensive and prolonged contact with the patient. The optimal interval between neuropsychological examinations of patients observed over time is 5–10 days in the acute period and 3–6 months in the long-term period.

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 school of A.R. Luria is given a special place. Objective data provide a lot of information necessary for organizing a neuropsychological examination and choosing methods 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. Methods for sensitizing experimental conditions include increasing the rate of stimuli and instructions, increasing the volume of stimulus material, and presenting it in noisy conditions.

It must be emphasized that the examination of the patient should be gentle towards him. In this sense, not every patient should and can go through a complete and thorough study of all mental functions. The selection of methods, the choice of symptoms of mental disorders for their subsequent psychological qualification is determined by the patient's condition, the period that has elapsed since the injury, and the data of an objective history. The serious condition of the patient serves as an indication for a dosed examination, the use of breaks, 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 level of activity of the patient, his ability to navigate in place, time, personal situation, features of the emotional and personal status, the adequacy of the research situation, focus on the implementation of the proposed tasks, the ability to assimilate and retain the test program, the degree of exhaustion, criticality in relation to the results of their own activities - the possibility of correcting mistakes.

With the help of special experimental samples, the state of higher motor functions (kinetic, dynamic and spatial praxis) is clarified; gnosis (visual, auditory, tactile, visual-spatial); attention; speech, writing, reading; counting operations. various types of constructive activities (independent drawing, copying, etc.); various aspects of the mnestic function; thinking (comprehension of plot pictures, the ability to implement generalizations and analogies, solve problems, etc.).

Depending on the main goal of the study, the data obtained are subjected to a qualitative syndromic analysis with the identification of the factors underlying deficiency and functional rearrangements, and a quantitative analysis of the data obtained.

NEUROPSYCHOLOGICAL SEMIOTICS

The variety of primary structural changes in the brain tissue that occur at the time of injury, accompanying pathophysiological reactions, intra- and extracranial complications determine the complexity and extreme variability of neuropsychological syndromes in traumatic brain injury. Nevertheless, it is possible to present in general terms the nature of violations 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, non-specific 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 insufficiency of the motivational sphere. The degree of severity of such violations 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 make it difficult to identify defects caused by focal traumatic lesions.

As the compensatory mechanisms of the brain are activated, neuropsychological syndromes of a focal nature are differentiated and become as clear as possible. With the predominant interest of the posterior parts of the hemispheres (of course, taking into account whether the patient is right-handed or left-handed), there are aphasias, apraxias, agnosias, 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 the foci of traumatic brain damage are localized in the left (in right-handers) hemisphere, syndromes of 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 similar in articulation during 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 occurrence of efferent motor aphasia - a violation of the kinetic link in the organization of the speech act. As a result of the difficulties of switching from one article (syllable, word) to another, speech perseverations are observed.

The consequence of damage to 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 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 "word salad"), reading, and writing.

If a traumatic lesion captures the middle parts of the temporal lobe, the speech deficit takes the form of acoustic-mnestic aphasia. The main symptoms are: naming disorder, narrowing of auditory-speech memory, difficulty in choosing words in spontaneous speech, verbal paraphasias.

Amnestic aphasia is associated with the defeat of the parietal-temporal-occipital region, i.e. nomination difficulties; and semantic aphasia, which is a disorder in understanding logical-grammatical speech structures that reflect spatial or "quasi-spatial" relationships between objects.

In TBI, isolated forms of aphasia are rare. As a rule, violations are complex and include elements of different types of speech insufficiency. The severity of speech disorders depends on the severity of TBI. In some cases, it can reach total aphasia: the complete absence of speech production, combined with a lack of understanding of addressed speech.

Traumatic damage to the right hemisphere leads to the formation of specific neuropsychological syndromes, the most characteristic of which are the following. The syndrome of unilateral spatial neglect is the difficulty or complete impossibility of perceiving stimuli entering the left half of the perceptual field. This phenomenon can either be limited to the framework of one modality (auditory, visual, kinesthetic, tactile), or cover the entire sensory sphere. Violations can manifest themselves in this case not only in defects in perception, but also in various types of active activity of the patient: movements, drawing, constructive praxis, etc. Another somatosensory disorder characteristic of damage to the posterior parts of the right hemisphere is a violation of the body schema - 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 in the location of foci of traumatic lesions 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 rough expression to 1 object). And, finally, the well-known phenomenon of "anosognosia", i.e. non-perception, ignoring one's own defects, is specific for right hemispheric brain damage. Widespread in the TBI clinic is the involvement of the anterior sections of both hemispheres of the brain in the pathological process, which leads to a violation of programming and control of mental activity in general (spontaneity, inertia, reduced criticism of one's condition).

Characteristic features of neuropsychological syndromes in TBI: their multifocality, a combination of disorders typical for damage to both the right and left hemispheres of the brain, the frequent reversibility of disorders of higher mental activity.

Conducted neuropsychological studies have established that the structure of neuropsychological syndromes changes over time and depends on the period of traumatic brain injury. To visualize these changes, neuropsychological symptoms can be conditionally divided into three main groups:

Group I - 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 the absence or inhibition of spontaneous activity, the difficulty of including 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 - is represented by disorders of consciousness by the type of disorientation in place, time, self, situation, as well as emotional and personality defects, including violations of the motivational sphere.

Group III - includes specific disorders of cognitive functions: primary defects in attention, praxis, gnosis, speech processes, visual-spatial synthesis, memory, thinking.

In the acute period of traumatic brain injury, symptoms of a nonspecific decrease in overall mental activity due to stem and subcortical lesions, as a rule, come to the fore. Usually they are combined with disorders of consciousness such as disorientation and amnestic confusion. The most relevant during this period are neurotropic drugs that provide non-specific activation, increasing the energy level of mental processes.

The interim 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 distinct manifestation of aphasia, apraxia, agnosia, optical-spatial, mnestic and intellectual defects. In this period, emotional and personal changes can most clearly and distinctly appear. 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 late period of traumatic brain injury, the failure of patients is due to reduced neuropsychological syndromes that have a very specific structure and require very selective correction. This determines the choice of neurotropic agents of the most selective action.

The degree of severity and qualitative nature of neuropsychological syndromes depends on the age and individual characteristics of patients. Nevertheless, the shape 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 over time.

Diffuse brain lesions lead to the most gross and persistent defects in higher mental functions. First of all, such patients are in a serious condition for a long time due to loss of consciousness and impaired vital functions, which significantly delays the timing of neuropsychological research from the moment of injury. In some cases, contact with the patient throughout the entire period of observation does not expand enough to make a detailed examination possible. The most rude and vivid in the study are non-specific disorders of mental activity: patients are aspontaneous, inactive, adynamic, slow, demonstrate pronounced inertia and exhaustion of mental processes.

Against this background, various emotional-linear and motivational changes are revealed. Defects in higher motor, perceptual functions, speech, visual-spatial sphere, attention, memory, thinking remain blurred for a long time, which will make it difficult to differentiate them. Only in the presence of massive targeted rehabilitation measures, the noted defects to a certain, often insignificant degree, are amenable to reverse development. Patients with this form of traumatic injury in some cases remain profoundly disabled.

Clinical observation No. 1. Patient M., 16 years old.
Diagnosis: Closed severe traumatic brain injury. Diffuse brain damage severe /DAP/.
The coma after the injury lasted 4 days, the dynamics of the recovery from the coma was characterized by undulations of consciousness: deep stupor - 2 days, stupor with episodes of motor excitation - 5 days, vegetative state - 5 days, episodic execution of elementary instructions - 4 days, stupor - deep stunning - 4 days . On the 25th day, gaze fixation, tracking, understanding of inverted speech, and the implementation of instructions appeared; on the 26th day, speech production appeared.

Only on the 34th day after the injury, the patient became available for verbal contact, which, however, was sharply limited by the grossest violations of the background components of mental activity such as 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). The listed defects are accompanied by pronounced motivational changes, as a result of which the patient practically fails 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 addressed speech, elements of "alienation of the meaning of the word", the patient's speech is "contaminated" with literal and verbal paraphasias, echolalia, perseverations. These violations make it impossible both to conduct a neuropsychological examination and to interpret the results.

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. Completely absent criticism of their condition and the experience of the disease. True, 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 of errors is reduced.

Against this background, an experimental neuropsychological study reveals:
bilateral postural dyspraxia, violations of spatial praxis; with the preservation of 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 an auditory pattern; violation of visual gnosis, manifested in defects in the recognition of objective 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 insufficiency of the sensory component of speech function and elements of efferent motor aphasia, and manifested in oral speech, writing and reading;

The grossest violations of counting operations, reaching the degree of acalculia; the grossest modal-nonspecific memory disorders, a violation of the imprinting of current events, a deficiency in the actualization of knowledge consolidated before the injury; complex violations of verbal and visual memory: narrowing of the volume of both immediate and delayed reproduction with a violation of its selectivity; attention is drawn to contamination and introduction, as well as confabulatory connotation in the retelling of a semantic passage;

Expressed defects in various aspects of intellectual activity. After another 10 days, on the 55th day after the injury, further restoration of higher mental functions is noted. Until now, there are such violations of the background components of the course of mental processes as increased exhaustion and inertia. Orientation in one's own personality has been restored, an incomplete and unstable orientation in a place, a situation has appeared, at the same time, orientation in time remains grossly violated. The patient is still uncritical to her condition.

Behavior in the research situation has become more adequate, the difficulties of mastering and retaining the program have decreased, and some interest in the results has appeared. The following objective changes have been registered:
- in the motor sphere, there remains 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 at a prompt, however, inertia should be noted when reproducing rhythmic structures according to an auditory pattern; visual disturbances persist; defects of visual-spatial gnosis regressed to some extent; in the speech sphere, there is a distinct positive trend: there are almost no paraphasias, “amnestic lapses” in naming, difficulties in understanding addressed speech; writing was restored (Fig. 8-1), alphabetic gnosis; memory impairments are still very severe, one can only note some restoration of memory for current events and facilitating the actualization of consolidated knowledge.

Rice. 8 - 1. Samples of writing and graphic activity of the patient M. A - on the 34th day after the injury. B — 44 days after 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 with the use of targeted neurotropic effects.

A follow-up observation showed that the orientation of this patient was restored only 4 months after the injury, and a significant part of the noted violations of higher mental functions persisted a year after the injury.
Less traumatic in relation to mental activity were focal lesions. Patients with predominantly cortical localization of the focus in a relatively short time after injury achieve the degree of recovery of consciousness and vital functions, which makes them accessible for neuropsychological research. They quickly restore all types of orientation, background and neurodynamic parameters of the course of mental processes. Emotional and personality disorders are rarely pronounced 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, largely regress. A follow-up observation (1, 2 or more years after the injury) shows that defects in higher mental functions resulting from this form of traumatic brain damage can be easily reversed and are almost completely compensated. Erased traces of previously existing focal disorders remain against the background of mild asthenic symptoms.

However, in case of subcortical or cortical-subcortical location of the focus and in cases where brain contusion is accompanied by edema or intracranial hematoma, which aggravate 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 stable and retain a noticeable degree of severity a year or more after the injury.

Clinical observation No. 2. Patient G., 17 years old.
Diagnosis: Severe closed TBI. Heavy Brain injury. 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 fronto-temporal-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. Spoke for 8 days. For about a week he was disoriented in place and time, confabulated, did not remember current events, was periodically excited.

On the 15th day after the injury, the patient is in contact, available for neuropsychological research in full. Oriented in place, personal situation, time (only a slight inaccuracy in the assessment of time intervals is noted). Without gross emotional and personal changes. However, it should be noted that in the situation of the study it is not fully adequate: it does not keep a distance in communicating with the doctor. Criticism of his condition is reduced. It is included in the experimental study without difficulty, the program assimilates, 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 transferring postures according to a kinesthetic pattern with closed eyes), lag of the right hand during reciprocal hand coordination, mild violations of spatial praxis;
- pronounced violations of tactile gnosis (Ferster's feelings) on both hands;
- mild violations of auditory gnosis by the type of reassessment of simple single rhythms, the structure of accentuated rhythms according to the auditory pattern;
- visual gnosis without disturbances;
- in the speech sphere - single difficulties in the nomination, facilitated by a hint;
- optical-spatial functions are relatively preserved, only a slight tendency to specularity can be noted, which manifests itself in sensitized conditions and the insufficiency of the spatial component of the pattern (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 name and patronymic of the doctor, against the background of exhaustion, he does not remember not only the words presented, but also the very fact of their presentation); complex polymodal mnestic disorders are experimentally revealed - narrowing of the volume and order of reproduction of stimuli with gross violations of selectivity in the form of introductions and contaminations, a strength defect;
- pronounced defects in thinking, mainly its verbal-logical link.

2.5 months after the injury, there is a significant positive trend in the patient's condition. Completely regressed violations of the background components of mental activity. In the emotional-personal sphere, there remains some relief in assessing one's condition. Figure 8-2 shows sample writing and graphic activities.

Motor, gnostic, speech and visual-spatial functions were fully restored. Mild mnestic disturbances remain in the form of a decrease in verbal memory in the link of delayed reproduction, as well as very slight intellectual insufficiency (a tendency to situational thinking).

A neuropsychological study of patients with concussion and light bruises revealed that they had a significant preservation of higher mental functions. At the same time, however, almost all patients still detect deficiency in one or another area of ​​mental activity, most often in the form of a decrease in the neurodynamic parameters 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 brain organization - optical-spatial and mnestic functions.

Rice. 8 - 2. Samples of writing and graphic activity of the patient G. A - on the 15th day after the injury. B — 2.5 months after injury.

Rice. 8 - 3. Samples of writing and graphic activity of the patient S. on the 7th day after the injury.

Clinical observation No. 3. Patient S., 34 years old.
Diagnosis: Light closed craniocerebral injury. Mild brain injury.

Brief 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 not changed. However, it should be noted a slight relief in assessing one's own condition. All types of orientation are preserved. Easily learns and retains the program, shows interest in the results, and is critical of the mistakes made during the examination. Moderately depleted by the end of the research.

An experimental study reveals:
- slight impulsivity in motor tests;
— not rough bilateral decrease in tactile gnosis;
- a slight insufficiency of the mnestic function in the form of mild violations of verbal memory in the link of delayed reproduction.

The rest of the higher mental functions do not show deviations from the normative indicators. Samples of writing and graphic activity 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 of traumatic brain injury. The use of the neuropsychological method for developing rehabilitation measures and evaluating their effectiveness in post-traumatic recovery of higher mental states significantly expands the scope of its application.

- a set of psychodiagnostic methods for assessing memory, attention, perception, thinking, intelligence, speech, praxis, spatial information processing, emotional sphere and volitional qualities of the subject. The study uses screening tests (quick tests to roughly assess the level of deficiency in a particular area) and tests of special functions (methods designed to more accurately assess the state of thinking, memory and other functions). Conducting a neuropsychological examination is recommended for depression, psychopathy, post-traumatic stress disorder, dementia, brain tumors, TBI, stroke, cerebrovascular disease, multiple sclerosis, etc.

Indications

Neuropsychological examination allows you to correlate the violation of the mental process with a certain area of ​​the brain, qualitatively and quantitatively describe the state of higher mental functions (HMF). The results reveal various symptoms of disorders: primary (loss of function), secondary (influence of the primary defect on the psyche) and tertiary (compensatory mechanisms). Therefore, neuropsychological diagnostics is informative for the following pathologies:

• Organic lesions of the central nervous system. The study is indicated for patients who have had a stroke, traumatic brain injury, suffering from epilepsy, vascular and tumor diseases of the brain. The quality of the samples is determined by the degree of morpho-functional disorders, localization of pathological foci, ways to compensate for the defect.
• Mental illness. Neuropsychological examination is prescribed for patients with depression, schizophrenia, bipolar affective disorder, autism. The results make it possible to determine the structure of cognitive deficit, emotional-volitional disorders and personality changes, to identify or refute the presence of a physiological basis for the leading symptoms.
• Features of the development of the central nervous system. Recently, the neuropsychological method has been widely used to examine children of preschool and primary school age. During these age periods, there is an active maturation of brain structures responsible for the formation of arbitrariness and special learning skills. Diagnostics reveals the unevenness of these processes, allows you to draw up a correction program and improve academic performance.

Contraindications

Neuropsychological examination is traditionally performed with children older than 5 years and adults. Adapted variants of diagnostic batteries have been developed for 3-4 years of age, but their information content is limited. Diagnosis is not indicated for children under 3 years of age, as well as those with a deep decrease in intelligence, gross emotional and volitional disorders that prevent establishing contact with a specialist.

A relative contraindication for adults and children is the presence of severe visual impairment and motor functions (tremor, paralysis). In such cases, the use of a number of samples is impossible, which distorts the overall picture of the syndrome. Absolute contraindications for diagnosis: severe psychopathological symptoms, states of clouded consciousness, alcohol or drug intoxication.

Preparation for neuropsychological examination

Neuropsychological examination requires concentration and optimal performance. In order for the diagnostic results to be objective, it is necessary to exclude the influence of such temporary factors as fatigue, drowsiness, a state of emotional stress caused by fear or self-doubt. The study should be carried out after a period of rest or sleep, for children under 7-8 years old - in the morning.

Before testing, it is not recommended to perform hard physical or mental work; children should cancel activities with high emotional involvement - outdoor games, competitions, watching TV. Patients who are taking drugs that affect mental function should discuss with their doctor the possibility of temporarily stopping them a few days before the study.

Methodology

Neuropsychological examination begins with a preliminary study of the anamnesis and medical history, hypothesizing about the violation of the HMF and the existing syndromes. In domestic neuropsychology, the battery of tests developed by A. R. Luria has received the greatest distribution. But diagnostic kits from other authors adapted for childhood can be used. The patient examination consists of the following steps:

1. clinical conversation. The neuropsychologist assesses the possibility of establishing and maintaining contact with the patient, determines the clarity / clouding of consciousness, the parameters of mental activity (lethargy, exhaustion), clarifies complaints. A standardized survey allows you to explore orientation in space, time and your own personality. The state of the emotional sphere is described by the nature of the patient's communication throughout the examination.

2. Performing neuropsychological tests. The neuropsychological examination itself includes several blocks:

• Lateral organization of functions. Patients perform tasks that allow to establish the presence and nature of manual, visual and auditory asymmetry of mental functions (leading hand, leg, eye, ear).
• motor functions. Evaluation of the development/preservation of movements is performed using the study of reciprocal coordination, praxis of posture and fingers, dynamic praxis, and a test for the spatial organization of movements.
• Gnosis. The function of recognition of stimuli of different modality is determined by tests for object, acoustic, somatosensory and visual-spatial gnosis, for auditory-motor coordination.
• Speech. Spontaneous speech in dialogue and during the description of pictures is investigated. A test for naming images of objects, voicing numerical series (automated speech), a test for understanding the logical and grammatical structure of a sentence are being carried out.
• Memory. Mnestic functions are studied by tasks for memorizing words, stories, and visual objects. The direct and delayed memorization is analyzed.
• Intelligence. Tests are used to interpret the meaning of the story and the plot picture, establish analogies, solve arithmetic problems, understand the meaning of proverbs. The function of writing, reading and counting is evaluated.

3. Analysis of results. The neuropsychological examination ends with the identification of HMF disorder syndromes and the drawing up of a conclusion. The number and nature of errors are recorded in the protocol. Syndromal analysis is carried out. In conclusion, the syndrome is formulated, the localization of the brain lesion is indicated, and the features of the brain organization of the HMF are described.

Neuropsychological examination is necessary to draw up a program of neuropsychological correction, and in some cases to decide on the appropriateness of surgical intervention. The patient is assigned a consultation with a neuropsychologist, during which the specialist talks about the results obtained and forms the motivation for further treatment. is carried out in courses with periodic monitoring of dynamics.