2. Dimensions of behavior
• COGNITION :
information handling aspect of
the behavior.
• EMOTIONALITY :
concerns feelings and emotions
• EXECUTIVE FUNCTIONS :
related to ‘how behavior is
expressed’
3. ••CharacteristicSx.
Characteristic Sx.
Cognition ••Measureable..
Measureable
••Subtlechanges can be
Subtle changes can be
identified.
identified.
1.Receptive functions – acquire new
information
2.Memory and learning – storage &
retrieval
3.Thinking – reorganize the information
4.Expressive function – means through
4. • What is memory ?
• Types of memory
• Understanding memory – anatomical
and physiological basis
• How to evaluate memory ?
• What are its clinical implications ?
6. Three temporal stages of memory
i. Immediate memory – seconds
ii.Recent memory – minutes to days
iii.Remote memory – years
Memory systems
Short term memory
Working memory
Long term memory
Declarative memory
Non declarative memory
7. • What is memory ?
• Types of memory
• Understanding memory – anatomical
and physiological basis
• How to evaluate memory ?
• What are its clinical implications ?
10. Explict memory Implict memory
( non ( declarative
declarative memory ) memory )
• Factual knowledge of • Involved in training
people, places, things reflexive motor or
and meaning of facts perceptual skills.
• Conscious process and • Builds up slowly
recall requires conscious
through repetition over
search of memory.
many trails
• Expressed mainly in
verbal form • Recalled unconsciously
• Expressed mainly in
1. Episodic - events and form of performance
personal experience
2. Semantic - memory for
facts
11. • What is memory ?
• Types of memory
• Understanding memory – anatomical
and physiological basis
• How to evaluate memory ?
• What are its clinical implications ?
12. H.M patient ( Henry molaison)
• Case of temporal lobe epilepsy
Medial temporal lobes , hippocampus and
amygdyla were removed bilaterally.
• He had –
* normal STM
* normal LTM (events before operation)
* good language and IQ was normal
but he was unable to retain information for > mins ,
mainly about people , places and objects.
He lost the ability to transfer new data from
STM to LTM
extensive bil. lesions of limbic ass. areas of
medial temporal lobe show this defect. (i.e in explict
memory)
13. Understanding memory
Three basic questions
• How does information get into
memory?
• How is information maintained in
memory?
• How is information pulled back out of
memory?
14. Stages of memory process :
1.Reception and registration
2.Storage and retention
3.Recall and retrival
18. • Information is first acquired through
unimodal and polymodal association
areas – prefrontal,limbic and parieto-
occipito-temporal cortex – which
synthesize visual and somatic
information
20. • Therefore entorhinal cortex have dual
functions – both input and output.
# damage causes severe memory loss
and all sensory modalities involved.
# earliest pathological change in AD –
entorhinal cortex involvement and so explict
memory lost early.
• Hippocampus –
right side – spatial memories stored
(lesions cause defect in spatial orientation)
left side – memories for words, objects
and people (lesions cause defect in verbal
memory)
22. • Hippocampus is only a temporary way
station for LTM.
• Unimodal and polymodal association areas
of cortex are concerned with LTM storage.
• Amygdyla – stores component of memory
concerned with emotion. It doesn't store
factual information.
(damage has no effect on explict memory)
23. Association areas are the ‘ultimate repositories’
Association areas are the ‘ultimate repositories’
24. • In hippocampus , it takes days-wks to
facilitate storage of information about the
face initially processed by ass. areas.
• There is relatively slow addition of
information to neocortex, which permits
new data to get stored without disrupting
information.
Their (ie ass. areas) damage l/t
impaired recall of knowledge , aquired
before the damage. Ex- prosopagnosia.
25. Implict memory
• Introduction
• Different forms of implict memory are
aquired through different forms of
learning and involve different regions.
Acquired through fear – amygdyla
(emotional)
Acquired through operant conditioning –
striatum and cerebellum.
Acquired through sensitisation and
habituation – sensory and motor systems.
26. Types of learning
1. Non associative learning : learns
about properties of single stimulus
Habituation – dec response to stimulus,
when presented repeatedly. Ex.-crackers.
Sensitization – enhanced response to any
stimuli , following a first intense stimulus.
this occurs through reflex
pathways.
27. 2. Associative learning :
Operant conditioning (Skinner) – involves
relationship b/w behavior and
consequence of that behavior. Ex.-
Reward .
Classical conditioning (Pavlov) – involves
relationship b/w two stimuli.
PRIMING : effect in which exposure to a
stimulus influences response to a later
stimulus. Ex- Table- ‘tab__’
28. Learning driving
Involves conscious execution (explict)
of specific seq of motor acts necessary to
drive .
with experience driving becomes automatic
and non conscious (implict) activity
29. • What is memory ?
• Types of memory
• Understanding memory – anatomical
and physiological basis
• How to evaluate memory ?
• What are its clinical implications ?
30. EVALUATION OF
MEMORY
• Assess type of memory deficit.
• Degree of memory loss.
• Impact of memory loss on patients
functional ability
• Accurate assessment of memory
requires that any question asked by
examiner be verifiable from a source,
other than pt.
31. • Historic events are commonly used by the
examiners to screen both recent and
remote memory .
But it requires pt.’s premorbid
intellectual capacity & social exposure.
• Most valid and sensitive test for
recent memory –
learning new material and
recalling it over time.
32. • Hinders to the test are –
> inattention .
> disturbances of basic sensory,
motor and language functions.
• Any evidence of aphasia impairs both
verbal STM and LTM. Caution to be taken
while examining these pts.
33. • “Valid memory testing presumes that the
patient is reasonably attentive , can relate
to and cooperate with the examiner , and
has no defect that impairs language
comprehension and expression.”
( Poor memory performance in pts who are
deaf, aphasic , acute confusion,
psychotic, depressed and inattentive –
reflects defect caused by the process
alone )
34. IMMEDIATE RECALL / STM
Tested by digit repetition.
• Repeat digits at rate of one per second.
3-7 *Normal person repeats
2-4-9 five to seven digits.
8-5-2-7
2-9-6-8-3
5-7-1-9-4-6 *< five digits – impaired
8-1-5-9-3-6-2 repitition.
35. RECENT MEMORY
(ORIENTATION)
• Ask the Q. in sequence.
1. PERSON
Name
Age 3. TIME
Birth date
Date
Day of the week.
Time of the day
2. PLACE Season of the year
Location Duration of time
City with the examiner.
Home address
36. • Normal people usually perform well ,
some time with less scores in ‘time
orientation’
failed items are usually date of
month and day of week .( mainly
illiterates)
• Orientation to time and place are
actually measures of recent memory,
as they test the pts ability to learn
these changing facts
37. REMOTE MEMORY
• Evaluated by pts ability to recall personal
events and historic events.
PERSONAL Normal and those
INFORMATION
with mild nonspecific
Where were you born? brain damage do
School information
Vocational history with same accuracy.
Family information
Impaired perfor-
mance is pathologic.
38. HISTORIC FACTS
Four CM s during your lifetime
Last elections
• Normal person tells with out difficulty
• If pt has no memory of these events,
this implies deficient memory.
( some Q. depend on literacy
level of pts )
39. NEW LEARNING ABILITY
• This is to assess pts ability to actively
learn new material ( to acquire new
memories)
• All stages of memory process __ are
necessary for adequate performance.
Any defect at any stage l/t loss of
this ability.
40. FOUR UNRELATED WORDS
• Tell that “I am going to tell u 4 words that u
have to remember.
In a few minutes, u have to recall these
words
• Ask him to repeat the words after they are
presented- to ensure that he understood.
• After 5 min , ask him to recall the words
41. • Ex) Fun – carrot – knee – honesty
Red – happiness – brush – grapes
• Normal pt < 60 yrs accurately recalls three
or four words after 10 min delay.
pt > 80 yrs recalls two words
normally after 5 min delay.
42. • If he cannot recall ,
1. cues – semantic (‘one word is color’)
phonemic (‘hap… for happy’)
2. ask to select from a series of words.
When 2 yeilds better than 1(recall),
the problem may be due to retrieval defect,
rather than storage. This indicates normal
implict memory.
43. VERBAL STORY FOR IMMEDIATE
RECALL
• Tell the pt “ I am going to read a short
story and I want u to remember,
and I want u to tell me what I have told ”
• Read the story slowly and correctly
without any pauses.
• Ask the pt to retell the story as accurately
as possible.
44. It was july / ramu had packed up / their four
children / and were off on vacation .
They were taking / their yearly trip / to the
beach / of vizag.
This year / they were making / a one day stop
/ at araku.
After a long day drive / they came back to
hotel / and found that / they had left / their
suit cases / in the garden.
• No. of correct memories _________
• Describe confabulations , if present.
45. • Of these 20 separate ideas, a normal
person of < 70 yrs should be expected to
produce atleast 10 items
• This is a sensitive method of assessing
short term verbal recall.
• Story recall discriminates b/w
Normal and AD pts
Brain damaged and low IQ pts
46. VISUAL MEMORY (Hidden objects)
• Tested in all pts, but mainly useful in
aphasic pts. and also for illiterates.
• Tell the pt that you are going to hide some
objects and ask him to remember where
they are.
• Hide 4 or 5 common objects like – keys,
pen, etc in various areas of pt’s sight.
• After 5 min , ask pt to find the objects.
• Ask him to name the objects that he could
not find.
47. Assess by following Q.
• Number of hidden objects found.
• Number of hidden objects named, but not
found.
• Number of hidden locations found, but
objects not named.
Normal person < 60 yrs finds 4 or 5 objects.
Impaired visual memory – finds < 3 objects.
Aphasic pt should find the objects , but may
not be able to name them.
48. PAIRED ASSOCIATE
LEARNING
• Another highly sensitive measure of new-
learning ability.
• Tell the pt that you are going to read a list
of words – two at a time .
• Pt is expected to remember the two paired
words. ( ex. High – Low )
• Read the 1st presentation list and test for
recall by saying 1st recall list .
(Give the first word of pair – ask for other)
49. • Correct the incorrect responses , if any.
• After 10 sec, give 2nd presentation and
recall lists.
1 ST PRESENTATION 2 nd PRESENTATION
LIST LIST
Weather - box House - income
High - low Book – page
House - income Weather - box
Book – page High - low
1 st RECALL LIST 2 nd RECALL LIST
House - ______ High - ____
High - ____ House - ______
Weather - _______ Book - ____
Book - ____ Weather - _______
50. • No. of easy paired associates recalled :
• No. of difficult paired associated recalled :
• Normal pt < 70yrs – recalls two easily
paired associates and atleast one hard on
1st recall
and to recall all on 2nd trail.
• Total PAL score is the best measure of
verbal learning.
51. • What is memory ?
• Types of memory
• Understanding memory – anatomical
and physiological basis
• How to evaluate memory ?
• What are its clinical implications ?
52. CLINICAL IMPLICATIONS
• Limbic structures are involved in LTS
and retrieval of recent information.
• Structures required for immediate
recall and remote memory are not yet
established.
53. IMMEDIATE RECALL
• Performed by language cortex surrounded by
sylvian fissure.
(it requires registration, short term holding and
repetition, doesn’t require LTS)
Mechanism is not known. May be due to
? Reverberating circuits
? Cortical after images
• STM is a property of cortical sensory, motor and
integrative areas.
If these basic sensory – motor areas are
damaged , STM is disrupted.
54. • Most common cause for failure of tests -
inattention.
• Inattention may be –
organic - confusional states.
- dementia.
functional – anxiety and depression
• Pt. with dementia have difficulty with
immediate memory due to –
> inattentiveness
> cortical ( sensorimotor) atrophy
> intellectual detriment.
55. Recent memory
• Limbic structures –
Medial temporal lobe
Mamillary bodies
Dorsal medial nuclei of thalamus
are essential subcortical links in storage and
retrieval of both verbal and non verbal
memories
56. • Bilateral temporal damage
Damage to phc and entorhinal cortex
Orbitofrontal lobe damage (AcA
aneurysm rupture)
-- impair recent memory.
• In damage of these structures,
# anterograde amnesia &
# retrograde amnesia occurs.
i.e pt. is fixed in time
57. ISOLATED LIMBIC SYSTEM DAMAGE –
organic
amnestic state.
Severe anterograde amnesia
Moderate to severe retrograde amnesia
Confabulation
Intact immediate memory
No change in premorbid levels of intellegence.
They don’t remember time , place , person.
Causes : bil. Hippocampal lobectomy
HSV encephalitis
bil. Hippocampal infarction.
korsakoff syndrome.
58. POST HEAD INJURY –
Some retrograde amnesia
Transient anterograde amnesia
Mech. - temporal lobes are concussed againest
bony confines of middle cranial fossa , which
causes disruption of hippocampal function.
Post traumatic amnesia is usually reversible, if
significant it is permanent.
In boxers (dementia pugilistica),gradual but
permanent memory disturbances occur.
59. In head injury, ‘shrinking retrograde
amnesia’ occurs. i.e retrograde amnestic
period shortens in days following recovery
of consiousness.
initially pt doesn’t recall yrs preceding
RTA . With in days, pt remembers all but
few minutes preceding RTA.
ALZHEIMER’S DISEASE – Defect in new
learning
61. • Deficit in retrieving the information , and
not in storage.
In cortical process memory traces
are stored without pt awareness.
Implict memory is retained which
don’t need active recall. Even then it
doesn’t help him – as he doesn’t realize
that they are stored.
(In hippocampal + temporal lobe damage,
both storage and retrieval are
defective.)
62. TRANSIENT GLOBAL AMNESIA
• Transient ischemia of both medial temporal
lobes secondary to decreased perfusion in
PCA territory.
Acute , but temporary confusional state.
Amnesia .
Disoriented to time , place.
Significant defect in new learning ability.
• Recovers in hrs-days, but left with
permenant amnesia for the episode itself.
64. REMOTE MEMORY
• Older memories stored in association
cortex and these doesn’t require limbic
system for retrival from storage.
• Seen in Alzheimer’s disease and Pick’s
disease (atrophic dementias)
• In koraskoff psychosis and bil temporal
lobectomy,
remote memory retained.
recent memory lost.
65. ALZHEIMER’S DEMENTIA
• Difficulty with STM - atrophy of basic
sensory association cortex.
• Decreased recent memory acquisition –
degeneration of hippocampus
• Defect in remote memory – widespread
cortical atrophy.
66. FUNCTIONAL MEMORY
DISTRUBANCES
• First and most common psychiatric
condition with memory disturbance is
DISSOCIATIVE STATE (now, psychogenic
amnesia) .
1.Dissociative amnesia or fugue : pts lose
their identity and travel to new location.
2.Dissociative state or localized amnesia: pt
have periods of hrs to days when thay carry
out normal routine life and become aware
that they remember nothing during this
period.
67. • During these states,
pts are not confused (as seen with TGA).
able to learn new material (unlike those
in organic amnesia).
3. Ganser’s syndrome :
syndrome of approximate answers.
Pt routinely give approx. answers as if thay
have knowledge regarding the Q.
These pts have clouded consciousness ,
hallucinations and conversion Sx.
68. • Ganser’s syndrome seen in –
Prisoners
Schizophrenia
Brain Disease.
Malingering.
4. Malingering :
pts may give approx answers ,
memory loss is inconsistent , fail all
memory tests, but remembers football
score of past week.
69. TAKE HOME MESSAGE
• Information must first get registered in basic
sensory cortical area and then processed through
limbic system for new learning to occur. Finally
memory is established in appr. association
cortex.
• Immediate recall lost – pri. sensory / motor cortex.
Learning – hippocampus / DMN of thalamus.
Old remote memories – widespread cortex .
• Careful testing is important for clinical and
anatomical diagnosis
