Neuropsychologic Assessment of Frontal Lobe Dysfunction

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The nature of executive control

Traditionally, the concept of executive control was linked inextricably to the function of the frontal lobes. The groundwork for elucidating the nature of executive control was laid by Alexander Luria [1] as early as 1966. Luria proposed the existence of a system in charge of intentionality, the formulation of goals and plans of action subordinate to the goals, the identification of goal-appropriate cognitive routines, the sequential access to these routines, the temporally ordered transition

Neuropsychologic measures of executive control

To the extent that current understanding of the nature of executive control is not a unitary construct, it would be impossible to design a single test to measure it. There are, however, a number of neuropsychologic tests that provide an adequate measure of specific aspects of executive control. Among them, the family of Tower tests, the Wisconsin Card Sorting Test, and the family of Stroop tests [13] stand out.

Executive control batteries

Among the several batteries of executive control evaluation that exist, the Delis-Kaplan Executive Function System (D-KEFS) [20] and the Executive Control Battery (ECB) [21] stand out.

Actor-centered nature of executive control

In a typical neuropsychologic test, one possible response is correct and others are incorrect. The determination of what is correct and what is incorrect is inherent in the test design and does not require any knowledge of the patient making the choice. To this extent, a typical neuropsychologic test is deterministic and veridical. A rigid structure of the test minimizes its ability to identify the executive control deficit in a clinical evaluation. A new generation of tests is needed to

Working memory and its assessment

Historically there are has been a great deal of controversy regarding the role of the frontal lobes in memory. During the last few decades, the work by Patricia Goldman-Rakic [2] and Joaquin Fuster [4] helped to clarify the role of the frontal lobes in memory and introduced the concept of working memory. The construct of working memory, like many other influential concepts, has been somewhat overused. Sometimes it is used interchangeably with the construct of short-term memory. Common sense

Clinical conditions requiring the assessment of executive functions

The prefrontal cortex is afflicted in a wide range of conditions [29], [30]. Historically, it was thought that to find prefrontal dysfunction one has to look for focal frontal lesions. The findings of the last few decades make it clear that the frontal lobes are particularly vulnerable in numerous nonfocal conditions. Today, schizophrenia is regarded as substantially involving the frontal lobes [31], [32]. Traumatic brain injury often produces frontal lobe syndrome accompanied by pronounced

Summary

Given the pervasive nature of executive deficit, assessment of executive functions is of crucial importance in neuropsychiatry, child and adolescent psychiatry, geriatric psychiatry, and other related areas. A number of neuropsychologic tests of executive function commonly are used in assessing several clinical disorders, including but not limited to traumatic brain injury, schizophrenia, depression, attention deficit disorder/attention deficit hyperactivity disorder, and dementia. Because the

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  • Cited by (57)

    • E.L., a modern-day Phineas Gage: Revisiting frontal lobe injury

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      We selected tests for the most common neuropsychological functions sensitive to damage in the frontal lobe16 (Table 1; Extended Table 1). It is notable that E.L.’s decision-making impairments were not detected by gold standard tests of cognitive assessment, such as, IGT, CBT, WCST, and the ROCFT.16 From a clinical perspective, we identified deficits in E.L. across working memory, including short-term memory, and using task switching tests, an executive function that involves the ability to unconsciously shift attention between dual-tasks.

    • Frontal-subcortical behaviors during Alzheimer's disease in individuals with Down syndrome

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      Studies suggest that, in individuals with DS, typical symptoms of frontal lobe dysfunction, such as behavioral changes (disinhibition, executive dysfunction, and apathy) appear as an early manifestation before the appearance of short-term memory impairment, which is the characteristic early feature of AD (Ball et al., 2006; Deb et al., 2007; Dekker et al., 2018; Fonseca et al., 2016; Oliver et al., 2011). The frontal lobe is responsible for the interconnections between the major sensory and motor systems of the brain, integrating the components necessary for human behavior (Goldberg and Bougakov, 2005). Neuropsychological aspects related to the frontal lobe include executive functions (such as planning, inhibitory control, working memory, and abstract thinking), attention, and behavior.

    • Behavior, neuropsychology and fMRI

      2016, Progress in Neurobiology
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      The use of a standardized battery of such tests when applied to patients with neurological problems may give rise to these being correlated with certain patterns of test scores and when confirmed by peer review this becomes a construct assisting in the identification of the brain lesion. Working memory is such a construct, defined as ‘what needs to be memorized; making a decision as to the type of information that is useful at the moment and then selecting this information out of the total fund of knowledge available’ (Goldberg and Bougakov, 2005; Goldman-Rakic, 1987). Whether such a construct makes sense is unclear for we do not ‘select information’ but recall information as best we can.

    • Executive functioning and depressed mood before and after unilateral frontal lobe resection for intractable epilepsy

      2013, Neuropsychologia
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      While depressed patients had reduced mental flexibility both before and after surgery compared to non-depressed patients, it is after surgery that this differentiation was apparent for perseverative responding and conceptual reasoning. Results of the present study were considered consistent with previous studies that have found executive deficits in executive functioning in patients with frontal lobe injury using the WCST, TMTB and letter fluency (see Alvarez & Emory, 2006; Demakis, 2003; Goldberg & Bougakov, 2005; Henry & Crawford, 2004; Nyhus & Barceló, 2009; Stuss & Alexander, 2007; Stuss & Levine, 2002 for reviews). Our results do not allow for a greater explication of the question of whether there is greater executive-cognitive impairment with resection to dorsolateral prefrontal cortex versus ventral lateral or medial prefrontal cortex given that most of our patients experienced excision across multiple areas within the frontal lobe.

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    This work was supported by East-West Science and Education Foundation.

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