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114 MEDICINA (2003) Vol. 39, No. 2 - http://medicina.kmu.lt Mental disorders and their relation to brain lesion location: diagnostical problems Devika Gudienė, Benjaminas Burba Clinic of Psychiatry, Kaunas University of Medicine Hospital, Lithuania Key words: organic cerebral pathology, psychiatric symptoms, cerebral lesion. Summary. Knowledge of symptoms of appropriate brain areas lesion helps to differ psychiatric and neurological disorders. The objective of our work was to find out the situation in scientific research about mental disorder relation to brain lesion location and to except the location of lesions, which are most complicated in differential diagnosis. We discussed the relation of most important mental disorders to brain lesion location. The study of discrete organic cerebral lesions resulting in clearly definable psychiatric disorders may provide an understanding of the underlying pathophysiological basis of these disorders. Different nervous functions need the integrational work of various brain areas. The regions differ from each other by the importance of playing part in corresponding functions. The differential problems appear because various structural brain lesions provide symptoms, similar to mental disorder symptoms. The development of mental disorders and lesion location questions are very urgent. While analyzing the location of lesion, it is important to motivate the theories of development of schizophrenia, organic depression, emotional lability and other disorders. The mass of the brain makes 2 percent of total mass of human body. The brain uses 20 percent of oxygen required for whole body. The brain gets 20 percent of blood output, provided by human heart. This happens because human brain is controlling whole body’s functions and behavior (1). Different nervous functions need the integrational work of various brain areas. The regions differ from each other by the importance of playing part in corresponding functions. Even very difficult cognitive functions have their localization in appropriate areas of the brain. Although the cerebral cortex is critically important, many other brain areas are also involved in higher cognitive functions (2). The study of discrete organic cerebral lesions resulting in clearly definable psychiatric disorders may provide an understanding of the underlying pathophysiological basis of these disorders (9). Knowledge of symptoms of appropriate brain areas lesion helps to differ psychiatric (functional) and neurological (organic) disorders. The major focus of research is on the temporal cortex; its lesion leads to auditory hallucinations, delusions, and thought disorders (3, 27, 29). Even though the scientists have done a lot of research work in neuropsychological branch, it is still important to go further into the understanding of some pathological states dependence on the lesion location. However, the relation between lesion location and psychiatric illness, for example after stoke, remains unclear (4, 7). Does the post-stroke depression, emotional lability development depend on localization of lesion? The depression development association with cerebral pathology in multiple sclerosis is still not understood (5). Even with the advance of new technologies such as enhanced structural imaging (computed tomographicCT or magnetic resonance-MRI-imaging,), functional imaging (positron emission tomographic-PET, single photon emission computed tomographic-SPECT-imaging), questions regarding the damage of which brain regions can result in well-defined psychiatric syndromes, are still not totally answered (6). The scientists pay a lot of attention to research of schizophrenia etiology. The asymmetry and laterality of the brain are very important features while discussing the mental disorders’ relation to the brain lesion location (2, 9). The dominant hemisphere is the one to express language. The left hemisphere is dominant in 96 percent of right-handed Correspondence to D. Gudienė, Clinic of Psychiatry, Kaunas University of Medicine Hospital, Eivenių 2, 3007 Kaunas, Lithuania. E-mail: devika@centras. lt Mental disorders and their relation to brain lesion location: diagnostical problems persons and approximately 70 percent of left-handed persons. In addition to language ability, the left hemisphere has been described as being the rational half of the brain, concerned with analytic, sequencing, abstracting and logistical abilities. The right hemisphere is thought to be more involved with perceptual, visual-spatial, artistic, musical and synthetic cortical activity. (1, 3) The cerebral cortex contains approximately 70 percent of the neurons in the CNS. Because of this, the cerebral cortex has been the main focus of many psychiatric researches and theories (3). The cerebral cortex receives direct or indirect afferent input from almost every other area of brain (2). The cerebral cortex anatomically can be divided into four lobes: frontal, which is 32.5 percent of whole cortex, temporal (25.3 percent), parietal (21.5 percent) and occipital (12 percent) (1-3). Dividing cerebral cortex by modality produces motor, sensory and association areas. There are three major areas of supramodal association cortex: prefrontal, involved in cognitive planning and motor activity, parietal-temporal-occipital, involved in sensory evaluation and language, limbic, involved in memory and emotion (2, 3, 27). Major behavioral and psychological symptoms of cortical injury are described in Table 1. In general, frontal cortex is involved in motor behavior, expressive language, ability to concentrate and attend, reasoning and thinking and orientation in time, place and person (2, 3). The scientists have made the conclusion, that ability to concentrate depends from the functioning of the anterior part of gyrus cinguli, which is in right frontal lobe (8). The prefrontal cortex is involved in planing of movements and evaluation of sensory information (1-3). Two general patterns of symptoms have been related to two different frontal lesions: dorsolateral convexity syndrome and orbitomedial syndrome. The dorsolateral convexity syndrome is described as apathy, decreased drive, poor grooming, psychomotor retardation, decreased attention, and if dominant hemisphere is affected, aphasia. This syndrome is somewhat similar to so-called negative-symptom schizophrenia. Evidence from brain imaging techniques has suggested this area of cortex as a potential lesion site in a subgroup of patients with schizophrenia. Lesion of orbitomedial frontal cortex results in withdrawal, fearfulness, lability of mood, explosiveness, loss of inhibitions and occasional violent outbursts. Some of these patients seem similar to patients with severe bipolar illness (1, 3, 9). The primary functions of temporal cortex include language, memory and emotion. Because lesion of this MEDICINA (2003) Vol. 39, No. 2 - http://medicina.kmu.lt 115 area leads to symptoms similar to hallucinations, delusions, mood disturbances, this area has received particular attention in psychiatric research. Lesions of the dominant temporal lobe lead to euphoria, auditory hallucinations, delusions, thought disorders, decreased ability to learn new material and poor verbal comprehension. Lesion of nondominant temporal lobe leads to dysphoria, irritability and cognitive deficits (1-3, 9, 27). Scientists are also interested in frontotemporal dementia, which is difficult to identify because its major symptoms imitate non-organic psychiatric disorders including mania, obsessive-compulsive disorder, schizophrenia, depression or personality disorder (34). The parietal cortex has associational cortices for visual, tactile and auditory input. The left lobe has a preferential role in verbal processing and the right lobe has a greater role in verbal processing (2, 3). Gerstmann’s syndrome has been attributed to lesion for the dominant parietal lobe and includes agraphia, calculation difficulties, right-left disorientation and finger agnosia. Two symptoms of nondominant parietal lesion are denial of illness (anosognosia) and neglect of the left side. Clinically, a person with a right-sided stroke may deny that he has paralyzed left arm and also may completely ignore the left side of his body (e.g., not washing it) (1, 3, 31). The occipital lobe plays important part in vision. Total destruction of the occipital cortex results in cortical blindness. Subtler dysfunction can result in distortion of images, and loss of depth perception. Some of these symptoms may be similar to those seen in psychiatric conditions and may cause the clinician to miss the diagnosis of a neurologic disorder of the occipital lobes. Anton’s syndrome is associated with bilateral occlusion of the posterior cerebral arteries, resulting in cortical blindness and denial of blindness (1, 3). Frontal, parietal and temporal lobes are involved in the reception and production of language. Patients with frontal nondominant lesion are not able to inflect their speech with affect (1, 3). Limbic system is associated with emotions, sex drive, eating behavior, violence, memory and motivation. The hippocampus is thought to be involved in memory and motivation. The limbic system and amygdala are mostly connected with emotions. Animal experiments showed, that stimulation of amygdala provokes fear. Lesion of the amygdala and anterior temporal lobes has been clinically correlated with symptoms similar to schizophrenia, depression and mania (1-3, 9). The basal ganglia are involved in number of cerebral disorders, including psychosis, depression and 116 Devika Gudienė, Benjaminas Burba Table 1. Major behavioral and psychological symptoms of cortical injury Lobe Functions Disfunctions Frontal Motor, sensory and emotional brain areas Speech (dominant hemisphere) Important for personality, memory, concentration, judgement, abstract thinking ant other higher mental funcions · Frontal lobe syndrome: uninhibited, inappropriate behavior, lability and irritability, depression and flat affect, lack of motivation, memory deficit, attention difficulties, other cognitive deficits · Affective will disorder: apathetic-akinetinisabulic syndrome · Aphasia (dominant hemisphere) · Peculiar facetious sense of humor (Witzelsucht) Temporal Memory (especially hyppocampus ) Sexual and agressive behavior Interpretation of gustatory and olfactory sensations Major part of limbic system · Dominant hemisphere: euphoria, auditory hallucinations, illusions tought disorders, reduced capability to memorize new material, weaker verbal comprehension, afazija, memory impairement · Nondominant hemisphere: dysphoria, troubles in controlling sexual and agressive behavior, impairment of other cognitive functions Parietal Receives and identifies sensory information from tactile receptors · Left hemisphere is important for verbal processing · Right hemisphere is important for visual-spatial processing Praxes · Dominant hemisphere: alexia, agraphia, ideokinetic ir kinesthetc apraxias, dyscalculia, astereognosis right-left disorientation · Nondominant hemisphere: impaired spatial abilities, denial of illness (anosognosia), inability to recognize body parts (autopagnosia) apraxia, astereognosis, left spatial neglect Occipital Visual memory Interpretation of visual images Disturbed spatial orientation (metamorphopsia) Visual illusions Visual hallucinations Blindness Symptoms may simulate hysteria Adopted from: Kėvelaitis E, Illert M, Hultborn H. Žmogaus fiziologija (Human Physiology). Kaunas; 1999; Avižonienė I, Barkauskas E, Bičkuvienė I. Nervų ligos (Neural diseases). Vilnius; 1996; Kaplan HI, Sadock BJ. Clinical Psychiatry. Baltimore; 1988. dementia. The major clinically observed disorders of basal ganglia are movement, thought processes disorders, affect and cognition disorders. Basal ganglia disorders are most associated with symptoms of psychosis. Untreated schizophrenic patients show many subtle movement disorders that imply an involvement of the basal ganglia (2, 3). The scientists say that the functional consequences of cerebrovascular disease may be the causal pathway by which basal ganglia lesions are associated with depressive symptomatology (10). MEDICINA (2003) Vol. 39, No. 2 - http://medicina.kmu.lt Mental disorders and their relation to brain lesion location: diagnostical problems The hypothalamus is involved in appetite and sexual regulation. The destruction of lateral hypothalamus results in anorexia and starvation (1-3, 9, 39). Although we know a lot about thalamus functions, the scientists are doing new researches. Pervasive retrograde amnesia without anterograde memory impairment has rarely been described as a consequence of circumscribed brain damage. Scientists reported this phenomenon in right-handed man in association with the extension in the right thalamus of a previously bilateral thalamic lesion. This case added to the growing body evidence to suggest that world knowledge pertaining to people and events is stored or accessed similarly to autobiographical information and differently from other types of more general factual knowledge. The scientists hypothesized that the right mediodorsal thalamic nucleus and immediately surrounding regions comprise the central processing mechanism as responsible for inducing and coordinating the recall of these sorts of cortically stored memory (11, 28). Anosognosia had a significantly higher frequency of right hemisphere lesions, primarily involving the thalamus, basal ganglia and temporoparietal junction (12, 28, 31). Although the medial geniculate body is a wellknown integration center for the central auditory pathways, auditory symptoms caused by its damage have not been described. Scientists reported the appearance of the auditory illusions of hyperacusis to the patients without previous psychiatric or epileptic illness after a hemorrhagic infarction located mainly in the right medial geniculate body (13). The major focus of research is on the depressive symptoms development in relation with the localization of lesion. Depression, which is starting after the stroke, is frequent subject of discussion. The conclusion of the research work on after stroke depression relation with the lesion location, made in UK (1998), was that depression is significantly associated with larger lesions involving the right cerebral hemisphere. The importance of depression as a consequence of stroke has been clarified by the studies in this area. According to the studies results, the emotional lability development is also related with the stroke. But, this contradicts the psychiatric hypothesis, that lesion of the left hemisphere more often results in depression. However, wide confidence intervals support the possibility that significant results may be due to chance. Other scientists made a research work, but reports by other workers for an association of depressive disorder either with left-sided brain lesions, or with anteriorly placed lesions in the left cerebral hemisphere, were not supported. Neither there was the evidence MEDICINA (2003) Vol. 39, No. 2 - http://medicina.kmu.lt 117 of a correlation between symptom score and proximity of the lesion to the anterior pole of the left cerebral hemisphere. Psychiatric symptom scores were however greater with larger volume brain lesions (14). Although, there were made a lot of studies, proving the correctness of above-mentioned hypothesis, still there are works, which results allow to doubt, if the lesion lateralization is so important for the onset of depression. A systematic review of these studies is now needed if a consensus is to be reached (4). Depression and emotional lability is frequent after stroke condition (4). But exact location of lesion was unknown for a long time. There was a scientific study made in Korea (2000). The aims of this study were to determine the frequency of emotional lability following first ever stroke, and to find out the relation of the location of stroke with post stroke depression and emotional lability. Emotional lability was present in 18 percent of patients (15). The frequency was higher in women than in men and in ischemic rather than hemorrhagic stroke. The presence of post-stroke emotional lability and especially post-stroke depression was related to lesion of anterior cortex part (16). The prevalence of post-stroke depression was 75% and post-stroke emotional lability -100% in location in frontal lobe of anterior cerebral artery territory. When the lesion was in temporal lobe, half of patients had depression, but no one, same as when the lesion was located in occipital lobe, had any emotional lability. When the lesion is in middle cerebral artery territory and in thalamus the prevalence of both states is nearly equal. The prevalence of emotional lability was 22 percent, when the lesion was in cerebellum, but there were no post-stroke depression cases (37). According to these results, the scientists made a conclusion, that the development of poststroke depression and post-stroke emotional lability is strongly influenced by lesion location. This is mostly related to the frontal/temporal lobe-basal ganglia-ventral brainstem circuitry. Post-stroke emotional lability is more closely related to lenticulocapsular strokes than is post stroke depression. (16) Other study declares that emotional lability occurs independently of post stroke depression (15). The relationship between depression and the alterations in the frontal and temporal lobes of the right hemisphere supports, on the contrary, the causative role of organic brain damage. The lack of any significant association between symptoms of anxiety and either MRI abnormalities or clinical variables led to the opinion that anxiety is a reactive response to the psychosocial pressure put on the patients (35). 118 Devika Gudienė, Benjaminas Burba Recent studies indicate a biological origin of poststroke depressive disorders. Only a few studies of poststroke depression report detailed neuropsychological assessments (10). The was study made in Germany (1999), which analyzed lesion configuration in patients in the post-acute stage after first single unilateral stroke, who suffered from depressive disorders. Patients with left hemisphere strokes exhibited a major depression and patients with right hemisphere infarcts – a minor depression. The most prominent lesions were found in frontal lobe. Type and severity of depression were not related to the severity of neurological symptoms. For both major and minor depression the maximal overlap of lesions was found in subcortical areas, including parts of the caudate nucleus, posterior parts of the putamen, and the deep white matter. The findings supported the theory that post stroke depression was related to the dysfunction of (cortico-) striatopallido-thalamic-cortical projections that modulate cortico-thalamo-cortical loop systems. (7) Using patients with a single left- or right-hemisphere stroke, the scientists in 1999 in USA investigated the distinction between major and minor depression after stroke. They find out, that minor depression was associated with younger age, left-hemisphere lesion location, and more caudal hemisphere lesions. But the question about the significance of damage in left-hemisphere posterior portions of the brain for the development of minor depression after stroke is still left for discussion (17). This consecutive multiple case study, done in Canada in 1999, was designed to determine whether cortical lesion sites can predict occurrence of mood or psychomotor disorders in adults and children. However, it is not clear how psychomotor status fits into this picture, or whether children respond to the same lesions in a similar manner. They analyzed cases of school-aged children and adult patients with focal unilateral cortical lesions. The study was based on hypothesis, that left hemisphere lesions result more often than right ones in depression, and that the inverse occurs in mania. The findings of the study supported the neuropsychiatric approach to mood and psychomotor disorder in children and adults. Patients with mania and/or psychomotor agitation had predominantly right hemisphere lesions. Adult and children patients with depression and/or psychomotor lethargy had predominantly left hemisphere lesions (18). In a study of patients with focal epilepsy, the hypothesis was explored that different measurements of psychopathology were related to specific distribution of cerebral perfusion. The results do not support the notion that lateralized epileptogenic lesions are associated with different levels of depression, obsession, or personality traits. They support the view that certain psychopathological symptom patterns are related to specific regional dysfunctions depending on the laterality of a hemispheric lesion (19). Cases of bipolar disorder subsequent to a mild head injury were reported. Review of the literature indicates that these are rare outcomes (32). The concept of a conversion disorder (such as) has always been controversial (20). Although the diagnosis is recognized by current psychiatric taxonomies, many physicians still regard such disorders either as feigned or as failure to find the responsible organic cause for the patient’s symptoms. That’s why thorough analysis of hysterical paralysis was made. The patients had no organic disease or structural lesion. Psychological trauma was associated with the onset. They reported patients with left-sided paralysis (and without somatosensory loss). The attempt to move the paralyzed leg failed to activate right primary motor cortex. Instead, the right orbito-frontal and right anterior cingulate cortex was significantly activated. Based on this, scientists suggested that these two areas inhibited prefrontal (willed) effects on the right primary motor cortex when patients tried to move their left leg (21). These results prove, that not only the lesion localization is important, but appropriate brain areas activity’s changes also play significant part in the development of mental illness. According to Swiss scientists, who revealed with single photon emission computerized tomography using (99m)Tc-ECD a consistent decrease of regional cerebral blood flow in the thalamus and basal ganglia contralateral to the hysterical deficit. Independent parametric mapping and principal component statistical analyses converged to show that such subcortical asymmetries were present in each subject. Importantly, contralateral basal ganglia and thalamic hypoactivation resolved after recovery. These results suggest that hysterical conversion deficits may entail a functional disorder in striato-thalamo-cortical circuits controlling sensorimotor function and voluntary motor behavior. Basal ganglia, especially the caudate nucleus, might be particularly well-situated to modulate motor processes based on emotional and situational cues from the limbic system. Remarkably, the same subcortical premotor circuits are also involved in unilateral motor neglect after organic neurological damage, where voluntary limb use may fail despite a lack of true paralysis and intact primary sensorimotor pathways. These findings provide novel constraints for a modern psychobiological theory of hysteria (36). MEDICINA (2003) Vol. 39, No. 2 - http://medicina.kmu.lt Mental disorders and their relation to brain lesion location: diagnostical problems We already know relation of some mental illnesses with lesion location, but many of them have to be studded more. Swedish scientists decided to analyze the topographical location of obsessive-compulsive disorder. The results appealed to capsulotomy effect. Stereotactic capsulotomy by means of thermo lesions may provide symptomatic relief for patients with otherwise therapy refractory “malignant” obsessive-compulsive disorder. In patients, who fulfilled criteria for good postoperative outcome, all lesion sites overlapped covering a small area within the right anterior limb of the internal capsule. Analyzing this method and results, rather definite lesion location, which can “provide“ obsessive-compulsive disorder, was found (22, 38). Investigations into the neuropathology of schizophrenia have increasingly altered the perception of the illness. Early studies focused on finding consistent and discrete areas of cortical pathology in the brain material of schizophrenic patients. After nearly a half century of study, little evidence emerged from a great body of data suggesting any consistent, discrete neuropathologic finding associated with this illness. This lack of evidence led to obvious frustration on the part of researchers and movement within the psychiatric community towards significantly less brain-based theories of the genesis of schizophrenia. With the advance of new technologies such as enhanced structural imaging (CT, MRI), functional imaging (PET, SPECT), and better neuropathologic methods, the focus of schizophrenia research has again turned towards the brain. Ultimately, hypotheses regarding the cause of schizophrenia will be proved or disproved on neuropathologic evidence (30). Few, if any, modern schizophrenia researchers would make the argument that there is a single, consistent neuropathologic lesion that is responsible for the entire illness of schizophrenia. Current theories tend to interpret the wide variety of neuropathologic changes in this illness as evidence of disturbed nervous system maturation, either acquired or inherent, or perhaps as a response to damage with aberrant neuronal regeneration. Evidence for a neurodegenerative disorder has not proved to be compelling. Furthermore, these theories emphasize dysfunction of elements of distributed neuronal systems, including subcortical systems, not discrete “lesions.” Despite the risks, this approach to investigation promises to offer more than just information pertinent to schizophrenia research; it offers insights into the mechanisms of behavior as a product of integrated brain function (23, 33). Schizophrenia has been the subject of intensive neuropsychological, neuroradiological, neuropathologiMEDICINA (2003) Vol. 39, No. 2 - http://medicina.kmu.lt 119 cal, and neurochemical investigations. The most consistent and reproducible result from all this effort has been the demonstration of a mild degree of enlargement of the cerebral ventricles. The existence of this finding is no longer a subject of controversy, and it clearly occurs independently of psychiatric treatment and chronicity of disease. This finding represents the strongest evidence to date that a structural lesion of the central nervous system underlies schizophrenia. The localization of the lesion responsible for ventricular enlargement and for the clinical findings in schizophrenia is not as clear. With genetic and neurochemical findings pointing to a biological etiology, considerable effort has been devoted to finding direct evidence of brain abnormality in schizophrenia. Schizophrenia is characterized by minor structural abnormality, which, in the case of lateral ventricular enlargement, may be better understood as a risk factor than a causative lesion. The functional imaging findings are not transparent but suggest that as a disorder schizophrenia shows complex alterations in regional patterns of activity rather than any simple deficit (as for example: in prefrontal function) (25). Neurodevelopmental models of schizophrenia imply that a more severe early brain lesion may produce earlier onset of psychotic symptoms (24, 33). The medial temporal lobes have been proposed as possible locations for such a lesion. The authors tested this hypothesis in a group of children and adolescents with childhood-onset schizophrenia who had severe, chronic symptoms and who were refractory to treatment with typical neuroleptics. Patients with childhood-onset schizophrenia had significantly smaller cerebral volumes. With no adjustment for brain volume, no diagnostic differences were observed for any temporal lobe structure. Unexpectedly, with adjustment for total cerebral volume, larger volumes of the superior temporal gyrus and its posterior segment and a trend toward larger temporal lobe volume emerged for the patients with schizophrenia. These patients lacked the normal (right-greater-than-left) hippocampal asymmetry. These findings do not indicate a more severe medial temporal lobe lesion as the basis of very early onset schizophrenia (26). Rather similar results where found by many groups of researchers. Several groups, using both in vivo neuroimaging and postmortem anatomic techniques, have independently identified pathologic alterations in the anteromedial temporal lobe, particularly in the hippocampus. The details and etiology of temporal lobe-hippocampal pathologic states remain to be elucidated (24). 120 Devika Gudienė, Benjaminas Burba Conclisions We discussed relation of the most important mental disorders to the location of brain lesion. Different nervous functions need the integrational work of various brain areas. The regions differ from each other by the importance of playing part in corresponding functions. The development of mental disorders and lesion location questions are talking points now. The differential problems appear, because various structural brain lesions provide symptoms, similar to mental disorder’s symptoms. Since lesion of temporal cortex leads to symptoms similar to hallucinations, delusions, mood disturbances, this area has received particular attention in psychiatric research. Lesion of frontal lobe results in dorsolateral convexity syndrome and it is somewhat similar to so-called negative-symp- tom schizophrenia. Lesion of orbitomedial frontal cortex results in orbitomedial syndrome and some of these patients seem similar to patients with severe bipolar illness. Lesion of the amygdala and anterior temporal lobes have been clinically correlated with syndromes, are still not totally answered. The psychiatric hypothesis, that lesion of the left hemisphere and of anterior part of the brain more often results depression coming is still question of discussion. Modern schizophrenia theories emphasize dysfunction of elements of distributed neuronal systems, not discrete “lesions.” Scientists’ findings represent the strongest evidence to date that a structural lesion of the central nervous system underlies schizophrenia, but more exact location of brain lesion, which results in onset of schizophrenia, is still the question of the day scientific discussions. Psichikos sutrikimų priklausomumas nuo galvos smegenų pažeidimo vietos. Diagnozavimo sunkumai Devika Gudienė, Benjaminas Burba Kauno medicinos universiteto klinikų Psichiatrijos klinika Raktažodžiai: organinė galvos smegenų patologija, psichikos sutrikimų simptomai,galvos smegenų pažeidimas. Santrauka. Žinant atitinkamos galvos smegenų dalies pažeidimo simptomus, galima lengviau diferencijuoti psichiatrinius ir neurologinius pažeidimus. Darbo tikslas – išnagrinėti, kokių yra mokslinių tyrimų duomenų tiriant psichikos sutrikimų priklausomumą nuo galvos smegenų pažeidimo vietos. Taip pat išskirti lokalizaciją tų pažeidimų, kurie sukelia sunkiausiai diferencijuojamus psichikos sutrikimus. Išanalizuotas svarbiausių psichikos sutrikimų pasireiškimas priklausomai nuo galvos smegenų pažeidimo vietos. Tiriant atskirus organinius galvos smegenų pažeidimus, kurie sukelia aiškių psichikos sutrikimų, galima nuodugniau ištirti šių sutrikimų patofiziologinį pagrindą. Įvairioms nervų sistemos funkcijoms reikia daugelio smegenų sričių integracinės veiklos, bet kai kurios sritys dalyvauja vienose funkcijose labiau negu kitose. Diferencinės diagnostikos sunkumus sudaro tai, kad struktūriniai galvos smegenų pažeidimai sukelia simptomų, panašių į psichikos ligų būsenas. 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