Neurocognitive deficits in decision-making and planning of patients with DSM-III-R borderline personality disorder

BACKGROUND: Repeated, self-damaging behaviour occurring in the context of borderline personality disorder (BPD) may reflect impairments in decision-making and planning cognition. However, there has been no systematic neuropsychological examination of these particular cognitive functions in patients diagnosed with BPD. Such investigations may improve our understanding of the possible role of brain dysfunction in BPD and improve the characterization of the psychological difficulties associated with this disorder. METHOD: Forty-two psychiatric patients with a diagnosis of DSM-III-R BPD (41 of whom gave a history of self-harm), without a history of specified 'psychoses' or current major affective disorder, were clinically assessed before completing computerized tasks of decision-making and planning previously shown to be sensitive to frontal lobe dysfunction, and tests of spatial and pattern visual recognition memory previously shown to be sensitive to frontal lobe damage and temporal lobe damage respectively. The performance of the BPD patient group was compared with that of a non-clinical control group consisting of 42 subjects. RESULTS: The performance of the BPD patients on the decision-making task was characterized by a pattern of delayed and maladaptive choices when choosing between competing actions, and by impulsive, disinhibited responding when gambling on the outcome of their decisions. BPD patients also showed impairments on the planning task. There was no evidence of impaired visual recognition memory. Additional analyses suggested only limited effects of current medication and history of previous substance use disorder. CONCLUSIONS: These findings suggest that BPD is associated with complex impairments in dissociable cognitive processes mediated by circuitry encompassing the frontal lobes. These impairments may mediate some of the behavioural changes evident in BPD. Further work is needed to examine the specificity of these findings.     

Disinhibition of sequential actions following right frontal lobe damage

Action disorganization syndrome (ADS) is a frontal lobe neuropsychological syndrome characterized by deficits in the performance of familiar sequential tasks such as making a cup of tea. In this study, we examined the performance of familiar sequential tasks by 3 patients with right frontal brain tumours and no other areas of brain damage. When task-irrelevant objects were presented as distractors in addition to the target objects, all patients used the distractors in accordance with the target task. These patients showed few of the sequential and omission errors that had been previously reported in patients with ADS. Although normal participants could suppress the activation of task-irrelevant objects, these patients had difficulty with this process, which would normally be carried out by the right frontal lobe to determine the most suitable action behaviour. The intact left frontal lobe may receive bottom-up activation from the distractors and modify this schema to match the behavioural context. Our findings suggest that patients with only right frontal lobe damage may be characterized more by action disinhibition than by disorganization.     

A meta-analytic review of the sensitivity of the Wisconsin Card Sorting Test to frontal and lateralized frontal brain damage

The author conducted 2 meta-analyses on the Wisconsin Card Sorting Test (WCST). The 1st compared participants with frontal lobe damage to those with posterior brain damage, whereas the 2nd compared participants with left and right frontal damage. Effect sizes based on the difference between groups were calculated for WCST variables and a composite measure. Effect sizes for these variables, except nonperseverative errors, indicated significantly poorer performance for participants with frontal damage. There were no significant differences for the left versus right comparisons. Moderator analyses using the composite measure for the frontal versus nonfrontal analyses indicated that the largest effect size was for dorsolateral damage. Though this study indicates that the WCST is sensitive to frontal lobe damage, caveats are discussed.     

Editorial: From pediatrics to geriatrics

We examined the organizational skills of normal and dyslexic subjects on a battery of cognitive tasks. Twenty dyslexic and 20 normal readers were administered five language and visuospatial measures and compared on both quantitative performance scores and qualitative problem‐solving strategies. Relative to control subjects, dyslexics were impaired on verbal fluency, recalled fewer words on a verbal learning task and had difficulty solving conceptual problems and completing mazes. In addition, dyslexic subjects had difficulty generating and executing efficient problem‐solving strategies. Even when presented with a goal‐directed, organized approach, dyslexic subjects continued to employ less efficient strategies. It is suggested that the deficient strategy formulation and execution in dyslexic individuals may result from primary frontal lobe dysfunction.     

The neuroanatomical basis of understanding sarcasm and its relationship to social cognition

The authors explored the neurobiology of sarcasm and the cognitive processes underlying it by examining the performance of participants with focal lesions on tasks that required understanding of sarcasm and social cognition. Participants with prefrontal damage (n=25) showed impaired performance on the sarcasm task, whereas participants with posterior damage (n=16) and healthy controls (n=17) performed the same task without difficulty. Within the prefrontal group, right ventromedial lesions were associated with the most profound deficit in comprehending sarcasm. In addition, although the prefrontal damage was associated with deficits in theory of mind and right hemisphere damage was associated with deficits in identifying emotions, these 2 abilities were related to the ability to understand sarcasm. This suggests that the right frontal lobe mediates understanding of sarcasm by integrating affective processing with perspective taking.     

Frontal lobe functioning in conduct disordered juveniles: preliminary findings.

This investigation assessed the hypothesis that conduct disordered juveniles may suffer from a maturational lag in the development of behaviors believed associated with the frontal cortex. Twenty conduct disorder (CD) juveniles and 20 normal comparison subjects were compared on nine Lurian tasks that measure behavior attributed to frontal lobe functioning. A three-way ANOVA, with gender, race, and group as factors of interest, revealed significant differences on the verbal conflict task, verbal retroactive inhibition task, and on a measure of receptive vocabulary. Using receptive vocabulary as a covariate, an ANCOVA showed no significant differences between the groups on any of the tasks. These findings appear to support the potential impact that language dysfunction can have in the development of disinhibitory behavior. Other interpretations of the findings are presented.     

Characterising error-awareness of attentional lapses and inhibitory control failures in patients with traumatic brain injury

Awareness deficits are a significant problem following traumatic brain injury (TBI). This study examined error processing as candidate marker of awareness and compared the performance of 18 TBI participants and 18 controls using an online error-monitoring task while participants performed simple go/no-go tasks. Error-monitoring performance was compared where the no-go target was part of (a) a predictive sequence, (b) predictive sequence plus a dual-task element and (c) a random sequence. Results showed that the TBI participants, in contrast to control participants, were significantly impaired at monitoring their errors during both predictive sequence tasks but were not impaired on the random sequence task. These findings suggest that following TBI, when an error is more impulsive it may be more easily monitored, whereas when an error is characterised by attentional drift, subsequent error-processing mechanisms may fail to engage. Higher levels of online error-awareness were also associated with lower levels of anxiety, fewer symptoms of frontal dysfunction and greater competence in everyday functioning.     

Is it bigger than a breadbox? Performance of patients with prefrontal lesions on a new executive function test.

Executive deficits of problem solving and concept formation have been associated with frontal lobe dysfunction. Here we describe a new clinical test of concept formation based on the parlor game, Twenty Questions. The Twenty Questions Test requires examinees to ask the fewest number of yes/no questions possible in order to identify a target item from an array of 30 line drawings. The items belong to a number of categories and subcategories that exist in a hierarchical, semantic structure. Patients with focal prefrontal lesions asked significantly more questions than controls in their attempt to guess the target items and sometimes exhausted the 20-question limit. Qualitative analyses revealed that patients tended to use ineffective categorization strategies, for example, relying exclusively on questions that referred to single items. Taken together with previous findings, we conclude that prefrontal cortex supports the on-line organization and conceptualization of category exemplars in concept-formation tasks.     

Figural fluency: differential impairment in patients with left versus right frontal lobe lesions.

Based on an experimental study, Jones-Gotman and Milner demonstrated that patients with right frontal lobe lesions were impaired on design fluency. We sought a clinical adaptation and developed a psychometrically sound technique for design fluency. The present study explores the validity of the Ruff Figural Fluency Test (RFFT) in discriminating patients with either right frontal or nonright frontal lobe lesions. In the first of two studies, six subjects with circumscribed focal lesions were given the RFFT and the Jones-Gotman and Milner figural fluency task. In the second study, we identified a larger sample of 30 patients with focal lesions in the right frontal, left frontal, right posterior, or left posterior cortex. The results from both studies support the validity of the RFFT as a measure which is sensitive to right anterior dysfunction.     

The relationship between auditory ERP and neuropsychological assessments in schizophrenia.

To clarify the cognitive significance of event-related potential (ERP) abnormalities in schizophrenia, we examined the relationships of amplitudes and latencies of ERP components with performance on neuropsychological tests in schizophrenic patients. Twenty patients underwent the Trail Making B Test (TM-B), which is sensitive to frontal lobe dysfunction, and the logical memory, verbal paired-association, and visual reproduction subtests of the Wechsler Memory Scale (WMS), which are sensitive to temporal lobe dysfunctions, and ERP recordings during performance of an oddball auditory discrimination task. Pearson product-moment correlations indicated that an increased P200 amplitude was correlated with poor performance on the TM-B, whereas a decreased P300 amplitude was correlated with poor performance on the verbal paired-association subtest of the WMS. These findings suggest that a P200 abnormality represents the frontal lobe dysfunction, and a P300 abnormality represents the left temporal lobe dysfunction in schizophrenia.     

Dimensional weighting and task switching following frontal lobe damage: Fractionating the task switching deficit

Deficits in task switching can be found after frontal lobe damage. Here we demonstrate an impairment in task switching specifically linked to when perceptual weights have to be moved between different dimensions of the same stimulus. A patient (DS) with left frontal lobe damage showed normal performance when he responded to the meaning (a word task) or location (a location task) of a word presented to the left or right of fixation when there was no switching between the tasks. However, when the two tasks were switched every 16 trials in a block, DS showed severe difficulty in performing both tasks (Experiment 1). There were then abnormally large switch costs and effects of stimulus-response congruency. The difficulty was not simply due to switching tasks per se: There were no costs of switching when one of the tasks was modified to have different stimulus displays from the other (Experiment 2). The deficit was also not greater when the switch had to be made from a well-practised task to an unpractised task with more arbitrary stimulus-response mappings, indicating no particular problem in disengaging from a learned task or in configuring new stimulus-response links (Experiment 4). We suggest instead that DS was impaired at shifting attentional weights across different dimensions of the same stimulus, a process required with practised and unpractised tasks alike. The results link this process of shifting attention across stimulus dimensions to the left frontal lobe.     

Effects of divided attention on temporal processing in patients with lesions of the cerebellum or frontal lobe

Prefrontal cortex and cerebellum have both been implicated in temporal processing tasks although the exact contribution of each system remains unclear. To investigate this issue, control participants and patients with either prefrontal or cerebellar lesions were tested on temporal and nontemporal perceptual tasks under 2 levels of attentional load. Each trial involved a comparison between a standard tone and a subsequent comparison tone that varied in frequency, duration, or both. When participants had to make concurrent judgments on both dimensions, patients with frontal lobe lesions were significantly impaired on both tasks whereas the variability of cerebellar patients increased in the duration task only. This dissociation suggests that deficits on temporal processing tasks observed in frontal patients can be related to the attention demands of such tasks; cerebellar patients have a more specific problem related to timing.     

"No longer Gage": frontal lobe dysfunction and emotional changes.

This review presents the multiple changes in emotional response and personality that occur after damage to the frontal systems, proposes operational definitions, and analyzes the published reports according to these definitions. Neurological causes of frontal lobe damage and associations of frontal dysfunction with psychiatric disturbances are summarized. It is concluded that symptoms of frontal lobe damage that have been labeled as emotional disturbances may be classified as disorders of drive or motivation, mood (subjective emotional experience), and affect (emotional expression). It is proposed that the primary change after frontal lobe pathology is a disorder of personality, a change in the stable response patterns that define an individual as a unique self. Dysfunction of personality includes cognitive abilities, with a disorder of self-reflective awareness as a key deficit.     

An impaired attentional dwell time after parietal and frontal lesions related to impaired selective attention not unilateral neglect

The attentional blink, a measure of the temporal dynamics of visual processing, has been documented to be more pronounced following brain lesions that are associated with visual neglect. This suggests that, in addition to their spatial bias in attention, neglect patients may have a prolonged dwell time for attention. Here the attentional dwell time was examined in patients with damage focused on either posterior parietal or frontal cortices. In three experiments, we show that there is an abnormally pronounced attentional dwell time, which does not differ in patients with posterior parietal and with frontal lobe lesions, and this is associated with a measure of selective attention but not with measures of spatial bias in selection. These data occurred both when we attempted to match patients and controls for overall differences in performance and when a single set stimulus exposure was used across participants. In Experiments 1 and 2, requiring report of colour–form conjunctions, there was evidence that the patients were also impaired at temporal binding, showing errors in feature combination across stimuli and in reporting in the correct temporal order. In Experiment 3, requiring only the report of features but introducing task switching led to similar results. The data suggest that damage to a frontoparietal network can compromise temporal selection of visual stimuli; however, this is not necessarily related to a deficit in hemispatial visual attention but it is to impaired target selection. We discuss the implications for understanding visual selection.     

Dimensional weighting and task switching following frontal lobe damage: Fractionating the task switching deficit

Deficits in task switching can be found after frontal lobe damage. Here we demonstrate an impairment in task switching specifically linked to when perceptual weights have to be moved between different dimensions of the same stimulus. A patient (DS) with left frontal lobe damage showed normal performance when he responded to the meaning (a word task) or location (a location task) of a word presented to the left or right of fixation when there was no switching between the tasks. However, when the two tasks were switched every 16 trials in a block, DS showed severe difficulty in performing both tasks (Experiment 1). There were then abnormally large switch costs and effects of stimulus–response congruency. The difficulty was not simply due to switching tasks per se: There were no costs of switching when one of the tasks was modified to have different stimulus displays from the other (Experiment 2). The deficit was also not greater when the switch had to be made from a well-practised task to an unpractised task with more arbitrary stimulus–response mappings, indicating no particular problem in disengaging from a learned task or in configuring new stimulus–response links (Experiment 4). We suggest instead that DS was impaired at shifting attentional weights across different dimensions of the same stimulus, a process required with practised and unpractised tasks alike. The results link this process of shifting attention across stimulus dimensions to the left frontal lobe.     

Frontal lobe functioning in boys with attention‐deficit hyperactivity disorder

Prior attempts to relate attention‐deficit hyperactivity disorder (ADHD) to frontal lobe dysfunction have yielded mixed results. The present study attempted to minimize several methodological problems that may have contributed to these inconsistencies. A relatively large sample of rigorously defined ADHD boys (n = 66) and controls (n = 64) at two different age levels were administered a battery of neuro‐psychological tests sensitive to frontal damage in adults. ADHD boys were inferior to controls on a Vigilance task, Stroop, FAS, Rey‐Osterrieth Complex Figure, and Porteus Mazes. The groups did not differ on Trail Making or on aspects of Wisconsin Card Sorting sensitive to cognitive flexibility. ADHD boys and controls were comparable on several control tasks. Both groups showed a developmental advance in skills implicating prefrontal cortex between ages 6 to 8 and ages 9 to 11, but the relative deficit of the ADHD children appeared stable during this period. It is suggested that a longitudinal study would assist the interpretation of resemblances and differences between ADHD boys and adults with known frontal lobe impairment.     

Conceptual implicit memory impaired in amnestic mild cognitive impairment patient

Explicit memory has been well proven to be impaired in amnestic mild cognitive impairment (aMCI), and conceptual implicit memory is impaired in Alzheimer's disease. However, it is unclear whether implicit memory is affected in aMCI. In the present study, 35 patients with aMCI and 35 healthy elderly subjects were administered a neuropsychological battery of tests including conceptual and perceptual implicit memory tasks (category exemplar generation, image identification) as well as explicit memory tasks. Patients with aMCI exhibited impairment in explicit memory tasks and selective impairment in conceptual priming tasks, while the effect of perceptual priming was preserved. More importantly, category exemplar generation task priming, but not perceptual priming, was positively correlated with verbal fluency test performance in the aMCI group. The dissociation between the 2 components of implicit priming suggests that conceptual priming impairment in aMCI patients may be related to frontal lobe dysfunction.     

Localization of epileptic foci in Children with childhood absence epilepsy by magnetoencephalography combined with synthetic aperture magnetometry

This present study was aimed to investigate the localizable diagnostic value of magnetoencephalography (MEG) combined with synthetic aperture magnetometry (SAM) in childhood absence epilepsy (CAE).Thirteen CAE patients underwent MEG detection at resting state and after hyperventilation,and then the epileptic foci were located by SAM.In the thirteen CAE patients,epileptic foci were found in five cases (38.5%),and they were all located in the bilateral frontal lobe,suggesting that the frontal lobe in some CAE patients may serve as the epileptic foci.Our findings indicate that MEG combined with SAM could be of diagnostic value in localizing the epileptic foci in certain CAE patients.     

Is the right hemisphere involved in idiom comprehension? A neuropsychological study

Nonambiguous idiom comprehension was assessed in 15 right brain-damaged (RBD) and 12 left brain-damaged (LBD) aphasic patients by means of a string-to-picture matching task. Idiom comprehension was found to be severely impaired with a bias toward literal interpretation. The RBD patients, though impaired, performed significantly better than LBD patients; their performance was correlated with visuospatial abilities and was significantly affected by lesion site. The results of this study suggest that the performance of RBD patients in the comprehension of idiomatic sentences may be affected by (a) an involvement of the frontal lobe and/or (b) visuospatial deficits that may impair their performance on the picture-matching task.     

Differentiating among prefrontal substrates in psychopathy: neuropsychological test findings

Frontal lobe and consequent executive dysfunction have long been related to psychopathy. More recently, there have been suggestions that specific regions of frontal cortex, rather than all of frontal cortex, may be implicated in psychopathy. To examine this issue, the authors presented 25 individuals with psychopathy and 30 comparison individuals with measures preferentially indexing the orbitofrontal cortex (OFC; object alternation task), dorsolateral prefrontal cortex (DLPFC; spatial alternation task), and anterior cingulate cortex (ACC; number-Stroop reading and counting tasks). The individuals with psychopathy showed significant impairment on the measure preferentially sensitive to OFC functioning. In contrast, the 2 groups did not show impairment on the measures preferentially sensitive to the functioning of the DLPFC or ACC. These results are interpreted with reference to executive dysfunction accounts of the disorder.