EXECUTIVE FUNCTIONS
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),
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.
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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,
2 Department of Neurology,
3 Department and Clinic of
Rehabilitation,
4 Department of Neurolinguistics,
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”
CONSTANTINE G. LYKETSOS, M.D., M.H.S.
ADAM ROSENBLATT, M.D.
PETER RABINS, M.D., M.P.H.
Conclusions
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,
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
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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Neurology, Vol 35, Issue
12 1731-1741, Copyright © 1985 by
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ARTICLES |
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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[Full Text]
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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.
Abstract
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.
Abstract
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.