Entre os fatores etiológicos da disfunção executiva (DE) contam-se causas muito diver- sas.
Traumatismos cranioencefálicos, especialmente por projétil de arma de fogo, os TCEs fechados (risco de lesão axonal difusa) e as contusões com hematoma intra-parenquima- toso. Crianças com traumatismo cerebral fechado grave contam-se entre estes doentes (Levin e Hanten, 2005; Wilde et al., 2005)
Epilepsias do lobos frontais, geralmente consequentes a um TCE (parciais complexas, generalizadas e Jacksonianas), fazem também parte das causas de DE.
Patologia Vascular, mais frequente em idosos por enfarte das artérias cerebral anterior, comunicante anterior, ramos sílvicos da cerebral média e porção anterior pericalosa e caloso marginal ou por rutura de aneurismas da artéria comunicante anterior.
Neoplasias, incluindo meningiomas (polares, bilaterais ou do rego olfativo), gliomas (glioblastomas bilaterais em “forma de borboleta”, oligodendrogliomas, etc.) e metásta- ses.
Esclerose Múltipla, pois as áreas frontais são região de grande implantação de placas de desmielinização (segunda área mais atingida do neuroeixo).
Doenças degenerativas, incluindo doença de Pick, doença de Alzheimer, doença de Parkinson (Dagher, Owen, Boecker e Brooks, 2001) e coreia de Huntinghton.
Patologia Infeciosa, como abcessos, herpes simplex, HIV e neurossiflis (rara).
Vários quadros psicopatológicos encontram-se também entre as causas importantes da DE. Os doentes com esquizofrenia têm demonstrado ter dificuldades em planear, contro- lar, ter flexibilidade cognitiva, na memória de trabalho, na inibição da resposta, organi- zação, fluência e monitorização.
Segundo Austin e Mitchell (1995), na depressão existe uma perturbação na rede funcio-
nal paralela que liga o pré-frontal a regiões subcorticais. Os défices executivos podem persistir depois da recuperação de uma perturbação do humor, sugerindo que pode estar implicados na sua etiologia (Austin et al., 2001).
O DE é também comum entre doentes com um síndrome de stress pós-traumático, per- turbação bipolar (Andersson, Barder, Hellvin, Løvdahl e Malt, 2008; Cahill, Walter e Ma- lhi, 2009), perturbação obsessivo-compulsiva (Watkins et al., 2005) e distúrbio de défice de atenção com hiperatividade (DDAH) (Geurts, Verte, Oosterlaan, Roeyers e Sergeant, 2004; Goldberg et al., 2005; Mahone et al., 2002), autismo (Geurts et al., 2004; Goldberg et al., 2005; Hill, 2004), síndrome de Tourette (Mahone et al., 2002; Watkins et al., 2005) e na na perturbação anti-social da personalidade (Morgan e Lilienfeld, 2000).
AVALIAÇÃO
Para a avaliação neuropsicológica do funcionamento executivo existem vários instrumen- tos, mas não existe consenso na forma de operacionalizar e medir as FE (Alvarez e Emory, 2006). Alguns testes avaliar funções específicas como a atenção, o planeamento (ou programação), a inibição ou controlo inibitório, a memória, a flexibilidade cogniti- va, a abstração, e a tomada de decisão.
Os testes que avaliam a atenção incluem os subtestes do Behavioural Inattention Test (BIT Star e Letter Cancellation time; Wilson et al., 1987); o teste das Trilhas (Reitan, 1958; Ashendorf et al., 2008; Sánchez-Cubillo et al., 2009); o teste de fluência verbal Fluency* (5-minute ‘s’ words; Thurstone e Thurstone, 1962); o teste Hayling (Burgess e Shallice, 1996); os subtestes da Behavioural Assessment of the Dysexecutive Syndrome battery (BADS, Wilson et al., 1996); o teste Wisconsin Card Sorting (Grant e Berg, 1948) (ver revisão de Crawford e Channon, 2002), o Teste Stroop (Castro, Cunha e Martins, 2000; Sabri, Melara e Algom, 2001), s subtestes da Bateria da Avaliação da síndrome Di- sexecutiva (Norris e Tate, 2000) o teste de Wisconsin de Classificação de Cartas (Stuss et al., 2000; Royall et al., 2002), e subteste Span de Dígitos, da Escala Wechsler de Inte- ligência para Adultos III (Wechsler, 2008).
A inibição pode medir-se através dos testes das trilhas (Sánchez-Cubillo et al., 2009), Teste de Hayling e Brixton (Burgess e Shallice, 1996), Labirintos de Porteus (Porteus e Diamond, 1962), o Stroop (Castro, Cunha e Martins, 2000; Sabri, Melara e Algom, 2001; Gyurak et al., 2009) e o subteste do Neuropsychiatric Inventory Questionnaire (Cummings et al., 1994).
* No sentido de avaliar a capacidade de emitir comportamentos verbais em sequência obedecendo a regas pré-estabelecidas.
O planeamento pode ser medido pelos testes das torres de Londres (Krikorian, Bartok, e Glay, 1994; Souza, Ignácio, Cunha, Oliveira, e Moll, 2001), e também o teste dos Labirin- tos (Papazian et al., 2006; Porteus e Diamond, 1962)), Teste do Relógio (Aprahamian, Martinelli, Neri, e Yassuda, 2009; Atalaia-Silva e Lourenço, 2008; Wong et al., 2004), e pelo Teste das Trilhas (Sánchez-Cubillo et al., 2009; Souza, Ignácio, Cunha, Oliveira, e Moll, 2001).
Para a memória, revela-se adequado o AMIPB Story Recall (Coughlan e Hollows, 1985), o PASAT que avalia a memória de trabalho, pela Figura Complexa de Rey Osterrieth (Olivei- ra, Rigoni, Andretta, e Moraes, 2004; Rey, 1988; Troyer e Wishart, 1997;); subteste Span de Dígitos da WAIS-III (Wechsler, 2008), Teste das Trilhas (Sánchez-Cubillo et al., 2009), Teste de Fluência Verbal (Banhato e Nascimento, 2007; Rodrigues, Yamashita, e Chiappetta, 2008).
Para a avaliação da flexibilidade cognitiva aplicam-se as séries de Luria, Teste de Hayling e Brixton (Burgess e Shallice, 1996); Teste das Trilhas (Moll, Oliveira-Souza, Moll, Bramati, e Andreiuolo, 2002; Oliveira-Souza, Ignácio, Cunha, Oliveira, e Moll, 2001;Sánchez-Cubillo et al., 2009) Teste de Wisconsin de Classificação de Cartas (Olivei- ra-Souza, Ignácio, Cunha, Oliveira, e Moll, 2001; Royall et al., 2002; Stuss et al., 2000). Para a avaliação do raciocínio dedutivo, podem usar-se as Matrizes progressivas de Ra- ven e as avançadas I (Raven, 1976).
Para a tomada de decisão pode aplicar-se o Teste de Wisconsin de Classificação de Car- tas (Royall et al., 2002; Stuss et al., 2000), o subteste dos cubos da WAIS-III (Wechsler, 2008), ou o Teste do Relógio (Aprahamian, Martinelli, Neri, e Yassuda, 2009).
Existem também instrumentos que avaliam várias funções, tais como a Bateria Neuropsi- cológica de Luria-Nebraska (Kashden e Franzen, 1996; Maia et al., 2005; McKinzey, Podd, Krehbiel, Mensch, e Trombka, 1997) e a Frontal Assessment Battery (FAB, Dubois, Slachevsky, Litvan, e Pillon, 2000).
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