Annual Review of Psychology  Vol. 53: 401-433

ADULT CLINICAL NEUROPSYCHOLOGY: Lessons from Studies of the Frontal Lobes

Donald T. Stuss1 and ­Brian Levine2­

The Rotman Research Institute, Baycrest Centre for Geriatric Care, Departments of Psychology and Medicine (1,2Neurology, 1Rehabilitation Science), University of Toronto, Toronto, Ontario M6A 2E1; e-mail: dstuss@rotman-baycrest.on.ca blevine@rotman-baycrest.on.ca

            Abstract Clinical neuropsychologists have adopted numerous (and sometimes conflicting) approaches to the assessment of brain-behavior relationships. We review the historical development of these approaches and we advocate an approach to clinical neuropsychology that is informed by recent findings from cognitive neuroscience. Clinical assessment of executive and emotional processes associated with the frontal lobes of the human brain has yet to incorporate the numerous experimental neuroscience findings on this topic. We review both standard and newer techniques for assessment of frontal lobe functions, including control operations involved in language, memory, attention, emotions, self-regulation, and social functioning. Clinical and experimental research has converged to indicate the fractionation of frontal subprocesses and the initial mapping of these subprocesses to discrete frontal regions. One anatomical distinction consistent in the literature is that between dorsal and ventral functions, which can be considered cognitive and affective, respectively. The frontal lobes, in particular the frontal poles, are involved in uniquely human capacities, including self-awareness and mental time travel.


Also, Lloyd Cripe did a nice chapter in Sbordone and Long's (1896) Ecological Validity of

Neuropsychological Testing, entitled "The Ecological Validity of Executive Function Testing"

that does a nice conceptual job of integrating research and theory to propose assessment

more reliant on qualitative assessment.




Med Sci Monit, 2002; 8(1): CS1-9

Active and passive executive function disorder subsequent to closed-head injury

Maria P1 abcd, Henryk Kurzbauer2 df, Jan Talar3 acg,

Bruce Duncan MacQueen4 def

1 Department of Medical Rehabilitation, Cracow Rehabilitation Center, Cracow, Poland

2 Department of Neurology, MSWiA Hospital, Cracow, Poland

3 Department and Clinic of Rehabilitation, Medical University, Bydgoszcz, Poland

4 Department of Neurolinguistics, Medical University, Bydgoszcz, Poland

    Background: Executive dysfunction is one of the most destructive sequelae of closed head injuries (CHI), often impeding or even preventing the patient's return to normal functioning. On the basis of extensive clinical testing of patients with neurobehavioral disturbances resulting from CHI, the authors propose a new typology of executive dysfunction based on the primary behavioral distinction between active ('acting without thinking') and passive ('thinking without acting') forms of executive function disorder. Material/Methods: Two patients were selected for detailed presentation. Both present with mild to moderate motor and cognitive symptoms resulting from closed head injury. The medical histories of the two patients are similar (educated professionals, mid-40s, married with children, injuries suffered in a traffic accident, 2 months in coma) except for the location of focal injuries. Results: Despite considerable progress in rehabilitation, the extent of functional disorder is disproportionately large in comparison to the degree of objective disability measured by standard instruments. It is suggested that the reason for this disparity lies in executive dysfunction. In particular, a model for executive functioning will be presented to explain why and how selective destruction of particular anatomical/functional components leads to the behavioral consequences known as 'executive dysfunction'. Conclusions: Executive dysfunction is a distinct clinical syndrome which occurs in at least two distinguishable varieties, active and passive.



Psychosomatics 45:3, May-June 2004

Forgotten Frontal Lobe Syndrome or “Executive Dysfunction Syndrome”





Executive dysfunction syndrome is commonly encountered in psychosomatic medicine. It likely reflects dysfunction anywhere along the multiple circuits connecting the frontal lobes with subcortical matter. It is clear that these circuits are important functional units that underlie many disorders in psychiatry. Therefore, it is important that specific clinical criteria to define the syndrome be established, both for clinical and research purposes. Data are needed to determine if executive dysfunction syndrome is best construed as a single syndrome or three syndromes. Scales with good reliability are needed to quantify different aspects of this syndrome, especially the behavioral aspects. Such measures might be used to quantify severity and to assess response in targeted treatments. The pathogenetic relationship of executive dysfunction syndrome with the frontal-subcortical loops will require delineation, as this ultimately will lead to more targeted therapy. Finally, little can be said at present about treatment. There is some suggestion that executive dysfunction syndrome responds poorly in some cases to traditional psychiatric therapies, which at times lead to a worsening of the patient’s condition. Several alternative therapies might be considered in this context, including dopamine augmenters, SSRIs, and cholinesterase inhibitors.



Executive Control Function: A Review of Its Promise and Challenges

for Clinical Research

A Report From the Committee on Research of

the American Neuropsychiatric Association

Donald R. Royall, M.D.

Edward C. Lauterbach, M.D.

Jeffrey L. Cummings, M.D.

Allison Reeve, M.D.

Teresa A. Rummans, M.D.

Daniel I. Kaufer, M.D.

W. Curt La France, Jr., M.D.

C. Edward Coffey, M.D.

The Journal of Neuropsychiatry and Clinical Neurosciences 2002; 14:377–405

E-mail: royall@uthscsa.edu.

            This report reviews the state of the literature and opportunities for  research related to "control function" (ECF). ECF has recently been separated  from the specific cognitive domains (memory, language, and praxis) traditionally  Used to assess patients. ECF impairment has been associated with lesions  to the frontal cortex and its basal ganglia– connections. No single putative ECF measure can yet serve as a " standard." This and other obstacles to  assessment of ECF are reviewed. ECF impairment and related frontal  system lesions and metabolic disturbances have been detected in many  psychiatric and medical disorders and are strongly associated with functional outcomes, disability, and specific problem behaviors. The  prevalence and severity of ECF deficits in many disorders remain to be  Determined, and treatment has been attempted in only a few disorders.  Much more research in these areas is necessary.



Executive functions and their disorders

Rebecca Elliott

Neuroscience and Psychiatry Unit, University of Manchester, Manchester, UK

British Medical Bulletin 2003; 65: 49–59

            The term executive function defines complex cognitive processing requiring the co-ordination of several subprocesses to achieve a particular goal. Neuropsychological evidence suggests that executive processing is intimately connected with the intact function of the frontal cortices. Executive dysfunction has been associated with a range of disorders, and is generally attributed to structural or functional frontal pathology. Neuroimaging, with PET and fMRI, has confirmed the relationship; however, attempts to link specific aspects of executive functioning to discrete prefrontal foci have been inconclusive. Instead, the emerging view suggests that executive function is mediated by dynamic and flexible networks, that can be characterised using functional integration and effective connectivity analyses. This view is compatible with the clinical presentation of executive dysfunction associated with a range of pathologies, and also with evidence that recovery of executive function can occur after traumatic brain injury, perhaps due to functional reorganisation within executive networks.



Neurology, Vol 35, Issue 12 1731-1741, Copyright © 1985 by American Academy of Neurology

Severe disturbance of higher cognition after bilateral frontal lobe ablation: patient EVR

PJ Eslinger and AR Damasio

    After bilateral ablation of orbital and lower mesial frontal cortices, a patient had profound changes of behavior that have remained stable for 8 years. Although he could not meet personal and professional responsibilities, his "measurable" intelligence was superior, and he was therefore considered a "malingerer." Neurologic and neuropsychological examinations were otherwise intact. CT, MRI, and SPET revealed a localized lesion of the orbital and lower mesial frontal cortices. All other cerebral areas had normal structure and radioactivity patterns. Such impairments of motivation and complex social behavior were not seen in control cases with superior mesial or dorsolateral frontal lesions.





Neurology, Vol 35, Issue 12 1731-1741, Copyright © 1985 by American Academy of Neurology




Severe disturbance of higher cognition after bilateral frontal lobe ablation: patient EVR

PJ Eslinger and AR Damasio

After bilateral ablation of orbital and lower mesial frontal cortices, a patient had profound changes of behavior that have remained stable for 8 years. Although he could not meet personal and professional responsibilities, his "measurable" intelligence was superior, and he was therefore considered a "malingerer." Neurologic and neuropsychological examinations were otherwise intact. CT, MRI, and SPET revealed a localized lesion of the orbital and lower mesial frontal cortices. All other cerebral areas had normal structure and radioactivity patterns. Such impairments of motivation and complex social behavior were not seen in control cases with superior mesial or dorsolateral frontal lesions.

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Varney, Nils R. Menefee, Lynette. Psychosocial and executive deficits following closed head injury: Implications for orbital frontal cortex. Journal of Head Trauma Rehabilitation. Vol 8(1) Mar 1993, 32-44.

Discusses potentially catastrophic neurobehavioral symptoms that often occur following major or minor head trauma.
Two areas of cognitive impairment are emphasized. The first concerns posttraumatic psychosocial deficits that are not readily amenable to detection with traditional psychological testing. The second concerns an evolving area of neuropsychological testing related to assessment of executive functions. Arguments are presented that among the head injured, some deficits in both areas may reflect damage to orbital frontal cortex. Patients with traumatic brain injury, particularly when mild, may appear normal, claim to be normal, and test well. Nevertheless, they may suffer a potentially devastating syndrome involving a constellation of disabilities. Collateral informants must be interviewed and vocational histories be obtained from sources other than the patient.

Martzke, Jeffrey S. Swan, Cynthia S. Varney, Nils R.  Posttraumatic anosmia and orbital frontal damage: Neuropsychological and neuropsychiatric correlates. Neuropsychology. Vol 5(3) Jul 1991, 213-225.
20 head-injury patients (aged 24-66 yrs) with marked posttraumatic anosmia (loss of smell and taste), presumably indicating damage to the orbital frontal cortex, were administered a standard neuropsychological battery, a series of tests sensitive to frontal lobe pathology, and a collateral interview with a close friend or relative designed to assess the presence of psychosocial symptoms characteristically attributed to damage to the frontal lobes. Ss had major psychosocial deficits or higher order cognitive impairments as well as significant problems with activities of daily living. Poor empathy, poor judgment, and absentmindedness seemed to be particularly important in the symptom complex of the Ss, but many additional symptoms were present and referred to regularly in the observational reports of Ss' relatives. Without collateral interviews, at least half of the manifestly disabled Ss might have been misdiagnosed as neuropsychologically normal.