1. FRONTAL LOBE
Functions & Assessment
Unit 1 , 20 Jul 2013
By: Shahnaz Syeda
MPhil M&SP II YEAR TRAINEE
LGBRIMH TEZPUR

2. • Commonly described as anatomic seat of human selfawareness,
• Most evolutionarily advanced components of the human
brain

3. Functional Frontal Lobe Anatomy: A Recap
• The frontal lobes have several functional areas
–
–
–
–
–
–
Primary motor cortex
Supplementary motor cortex
Pre motor cortex
Frontal eye field
Motor speech area Broca
Prefrontal cortex (4 parts)
 Dorsolateral prefrontal cortex
Orbito frontal cortex
Anterior cingulate cortex.
Ventro medial prefrontal cortex

4. Functional Frontal Lobe Anatomy:
Premotor area
Primary motor area
B4
B6
Central sulcus
Supplementary
motor area
(medially)
Frontal eye field
B8
Prefrontal area
B 9, 10, 11, 12
Lateral sulcus/Sylvian fissure
Motor speech
area of Broca B 44, 45

5. The primary motor cortex:
• It is concerned with muscle contraction, mainly on the
opposite side of the body and is responsible for the execution
of movement and the maintenance of simple movement.
• In short execution of motor movement
• In the primary motor area, most of the body is mapped. (Barr
and Kiernan, 1983, Gercharind, 1983)

6. Functional Frontal Lobe Anatomy: A recap

7. Primary motor cortex
– Function: executes design into
movement
– Lesions:/ tone;  power; 
fine motor function on contra
lateral side

8. • Premotor cortex
( area 6) lies immediately anterior to lateral portions of
primary motor cortex extends inferiorly to sylvian fissure
superiorly about 2/3 of way to the longitudinal fissure

9. • It occupy area anterior to primary motor
• Lesion# difficulty in skilled moment
• Premotor cortex contributed to motor functioning by
influencing the primary motor cortex develop programmes
for the motor functions such as routine, necessary skills, and
voluntary actions. Thus it is important for motor sequencing.
This contribution occurs both when new programmes are
formed and when previously established programme are
altered.
• Premotor area, thus programme skilled motor activities and
its execution (Barr and Kiernan, 1983).
• In short planning & programming of motor movements and
sequencing and organization of movements.

10. Supplementary motor cortex:
• Supplementary motor area lies superior to premotor area
lying mainly in longitudinal fissure .
• According to Stuss and Benson (1986), this area of the frontal
lobes seems to provide the drive for the initiation of
movement, rather than being involved in the execution of
movement.
• It is thought to mediate internal needs with external
demands in order to initiate motor programme. This
coordination refers to both new and previously established
programmes including motor speech.

11. • Supplementary motor area
– Function: intentional preparation for movement; procedural
memory
– Lesions: mutism, akinesis; speech returns but it is nonspontaneous

12. Frontal eye field
• It is located anterior to the premotor area
• Concerned with voluntary eye movement on the opposite
side of the stimulus
– Selects target and commands movement (saccades)

13. Assessment of frontal eyefield function
• Ask the patient to follow the movement of a
finger from left to right and up and down. Ask
the patient to look from left to right, up and
down (with no finger to follow). Note inability
to move or jerky movement.

14. Broca’s motor
speech area:
• Located in left hemisphere(dominant
hemisphere) in most right handed
persons
• Responsible for expressive speech.i.e.it
brings formation of words and stimulate
larynx, tongue & soft palate
lesion# causes broca’s /expressive/motor
aphasia-patients can think the words they
wish to say but can’t produce speech ,but
can write it down.

15. Pre-frontal cortex
• Part rest of frontal area excluding motor & premotor
area is prefrontal area
• Concerned with individual personality.
• Also concerned judgment, depth of emotions, social,
moral, concentration, abstract ideation&
foresightedness.
• The prefrontal cortex is concerned with memory, emotions and
intellectual functioning (Daubey and Sandok, 1978).

16. The prefrontal cortex
• It monitors and contains behaviour through higher order mental
functioning i.e. judgement and foresight (Barr and Kiernan, 1989)
• According to Luria (1973, 1980), the prefrontal cortex is important
in the maintenance and control of cortical tone. It integrates
information, both from the individual and the outside
environment and subsequently regulates the behaviour of
organism, according to the outcome of its action.
• The prefrontal areas also select appropriate responses among
available possibilities. Thus, this area regulates higher forms of
organized conscious activities, be in voluntary movements,
memory and cognition.
• Lesions lead to inflexibility and stereotypy

17. Attention
Concentration
Emotion
Executive Function
Fatigue
Guilt
Impulses
Motor
Negative Symptoms
Obsessions & Compulsions
Pain
Ruminations
Suicidality
Worry
(S M S)

18. Recap contd….
PREFRONTAL CORTEX
• Dorsolateral prefrontal cortex
[DLPFC] Executive, Problem Solving
and Analyzing
• Ventomedial prefrontal cortex
[VMPFC] Role in emotional processing
• Orbitofrontal cortex [OFC]
Regulate impulses, compulsions
and drives
• Anterior cingulate cortex [ACC ]
Selective Attention (dorsal)
Emotions depression and
anxiety (ventral)

19. • Dorsolateral pre-frontal lobes together with limbic
system is involved in working memory executive
functioning abilities, including response inhibition,
fluency and retrieval from long term memory.
DORSOLATERAL PREFRONTAL CORTEX SYNDROME
• Executive dysfunction.
• Memory problems:
• Defective working memory.
• Defective retrieval.
• Impaired attention.
• Lack of initiative & spontaneity.
• Impaired abstract thinking
• Impaired problem solving, creativity
• Impaired language & verbal fluency.

20. Neuropsychological evaluation
ATTENTION
Serial subtraction
Trail Making A test
Digit Symbol of WAIS-R
Digit cancellation
MEMORY
Wechsler Memory Scale –III
Digit span
Days and months backward
PROBLEM SOLVING
Block design test, Porteus maze test, Tower of London
test
Test of abstraction to test abstract thinking ability

21. ORBITOFRONTAL
• The orbitofrontal circuit mediates the modulation of social
behavior :Emotional life and personality structure, Arousal,
motivation, affect.
•
•
•
•
•
•
•
•
•
Anatomically synonymous with VMPFC
Personality and social changes
Silliness
Explosive, aggressive bursts
Emotional lability
Irritability
Sexual changes
Also known as the “ centre of pleasure”
Associated with the feelings of pleasure derived from eating
and sex
• Dysfunction of this area may result in anhedonia

22. • VENTROMEDIAL PREFRONTAL CORTEX
SYNDROME
Regulation of emotion: markedly reduced social emotions
such as compassion, shame and guilt, poorly regulated
anger and frustration tolerance (Michael Koenigs et al.)
Decision making: severe impairments in personal and
social decision-making Bechara A, Tranel D, Damasio H 2000

23. ANTERIOR CINGULATE SYNDROME
Akinetic mutism - patients tending neither to move
(akinesia) nor speak (mutism) Disorder of diminished
motivation (DDM).
Abulia - a lack of will or initiative
Apathy - Less extreme (An apathetic individual has an
absence of interest in or concern about emotional, social,
spiritual, philosophical and/or physical life)
Poverty of speech
Poor response inhibition

24. Frontal lobe syndrome - Overview
A personality and behavior change caused by lesion,
stroke, infection, neoplasm or degenerative disorders
in the area of frontal lobe are known as frontal lobe
syndrome leading to
 motor abnormalities
 speech and language disorders
 impairment of cognitive functions
 mood , behavioral as well as personality changes

25. The Case of Phineas Gage (Harlow 1868)
Tamping iron blown through
skull: L frontal brain injury
 Excellent physical recovery
 Dramatic personality change
‘no longer Gage’: stubborn,
lacked in consideration for
others, had profane speech,
failed to execute his plans


26. Frontal lobe syndrome: clinical
features
• Confabulation: the tendency of the patient to
produce erroneous material on being
questioned about the past, either recent or
remote.
• Utilization behaviour: Giving an instrumentally
appropriate but exaggerated response to
objects that were introduced to them.
• Abstract thinking: Impairment of abstraction
was maximum with lesions of the frontal lobe
(Goldstein,1936)

27. Error utilization difficulty: apparent lack of full
awareness of deficits. Luria has referred to this as
a lack of ‘self-criticism’ or ‘lack of critical attitude
towards one’s own action’
Disinhibition and Impulsiveness: Patient may be
disinhibited and influenced by immediacy of
situations. Uncontrolled laughter and disinhibited
sexuality are found.
Apathy and depression: Patients may appear
severely apathetic, indifferent, and lethargic, and
they may develop Bradykinesia, inertia and
mutism

28. • Motor Perseveration:2 types
compulsive repetition of a movement and inertia
of the programme itself
Verbal Behaviour:
• Broca’s aphasia
• Perseveration or in severe cases echolalia in case
of left frontal damage
• Impoverishment of spontaneous speech and a
reduction in the patient's conversational replies
which often shrink to passive responses to
questions in case of left frontal lobe damage

29. Neuropsychological Assessment
• Neuropsychology is the study of (and the assessment,
understanding, and modification of) brain-behavior
relationships.
• Screening neuropsychological examination is indicated
when:
1. Medical or injury condition is suspected to have
impacted brain health (for example, compromised
circulation, chronically poor nutrition, or drug toxicity);
2. Any relatively sudden, unexpected, and unaccounted
for changes appear in mental or cognitive performance
that impacts work or daily functioning;
3. Gradual or sudden onset of unusual physical, sensory,
or motor changes (an examination by a physician is
always indicated in these instances, as well);

30. • Full Neuropsychological examination is indicated when:
1. Screening examination is positive for likelihood of
brain disorder;
2. Brain injury or disease is already known and
comprehensive understanding of functional impact is
desired;
3. Brain injury or disease is highly suspect and
comprehensive neurofunctional characteristics are
desired to complement neurological examination and
diagnostic understanding;
4. Comprehensive diagnostic and functional nature of
brain injury or disease is necessary for rehabilitation
and life-long planning;
5. Comprehensive diagnostic, functional, and causative
nature of brain injury or disease is necessary for
forensic application;

31. What Do Neuropsychological Tests
Measure?
•
•
•
•
•
•
•
•
•
•
•
•
•
Attention and Processing Speed –
Motor Performance –
Sensory Acuity –
Working Memory –
Learning and Memory
Intelligence
Language
Calculation
Visuospatial Analysis
Problem Solving and Judgment
Abstract Thinking
Mood and Temperament
Executive Functions

32. Steps
• Clinical Diagnostic review of history of present
illness
• Onset, course and degree of cognitive &
personality changes
• Premorbid functioning
• Test of handedness
• Choice of neuropsychological test.

33. Frontal Assessment Battery
•
•
•
1. Similarities (conceptualization)
“In what way are they alike?”
A banana and an orange
•
•
2. Lexical fluency (mental flexibility)
“Say as many words as you can beginning with the letter ‘S,’ any words except
surnames or proper nouns.”
•
•
•
•
•
•
•
•
•
If the patient gives no response during the first 5 seconds, say: “for instance,
snake.” If the patient pauses 10 seconds, stimulate him by saying: “any word
beginning with the letter ‘S.’ The time allowed is 60 seconds.
3. Motor series “Luria” test (programming)
“Look carefully at what I’m doing.”
The examiner, seated in front of the patient, performs alone three times with his
left hand the series of “fist–edge–palm.”
“Now, with your right hand do the same series, first with me, then alone.”
The examiner performs the series three times with the patient, then says to
him/her:
“Now, do it on your own.”

34. 4. Conflicting instructions (sensitivity to interference)
“Tap twice when I tap once.”
To ensure that the patient has understood the instruction, a series of 3 trials
is run: 1-1-1.
“Tap once when I tap twice.”
To ensure that the patient has understood the instruction, a series of 3 trials
is run: 2-2-2.
The examiner then performs the following series: 1-1-2-1-2-2-2-1-1-2.
5. Go–No Go (inhibitory control)
“Tap once when I tap once.”
To ensure that the patient has understood the instruction, a series of 3 trials
is run: 1-1-1.
“Do not tap when I tap twice.”
To ensure that the patient has understood the instruction, a series of 3 trials
is run: 2-2-2.
The examiner then performs the following series: 1-1-2-1-2-2-2-1-1-2.

35. Test of Speed
1. Finger tapping test: This procedure measures
motor speed. By examining performance on
both sides of the body, inferences may be drawn
regarding possible lateral brain damage. [Demo]
Please rest your right/left hand comfortably here.
Spread out your palm and place your index
finger on the tapping key. As soon as I say start
tap as fast as you can with your index finger till I
say stop. Do not remove your hands, finger or
whole body.

36. Test of speed
2. Digit Symbol Substitution test.
it is a test of visuo motor co ordination, motor
persistence, sustained attention and response
speed. Rapid information processing is
required in order to substitute the symbols
accurately and quickly.

38. Test of Attention
It is a precursor to all other neurological/cognitive functions
Defined as sustained focus of cognitive resources on
information while filtering or ignoring extraneous
information
1. Color Trial Test: Developed by WHO
Focused Attention:
Free from the influence of language.
Part 1: Attention, perceptual tracking and simple sequencing.
Part 2: Requires metal flexibility in addition to the above.
It is considered as a measure of focused attention as in both
parts of the test the subject has to ignore irrelevant
numbers while scanning for the number which is next in
sequence.

40. Trail Making Test
5
A
B
4
6
1
C
2
3
D
7
Various levels of difficulty:
1. “Please connect the letters in alphabetical order as fast as you can.”
2. “Repeat, as in „1‟ but alternate with numbers in increasing order”

41. Test of Attention
• 2. Digit Vigilance Test:
The same level of mental effort or attention
deployment is reqiured over a period of time.
Inability to sustain and focus attention leads to
both increased time to complete the test as
well as errors.
- 9 and 6
- Time 15 min

43. Test of Executive Functions
• EF mediates goal directed behaviour.
• Executive functions consist of components such as
anticipation, goal selection, planning and monitoring
• Ability to
- Maintain an appropriate problem solving set
- For attainment of future goals.
- Inhibit a response or to defer it to a later appropriate time
- Prepare plan of action
- A mental representation of the task, including
- the relevant stimulus information encoded into memory
and the desired future goal state

44. Executive Functions
1.
2.
3.
4.
5.
6.
7.
8.
9.
Fluency
Working memory
Set shifting Ability
Set maintenance
Planning
Response Inhibition
Error detection
Abstraction
Organization

45. • 1. Fluency : [ capacity to generate alternatives in a
regulated manner]
• Verbal fluency – prefrontal cortex in language
dominant hemisphere.
• Design fluency – bilateral prefrontal areas
1. Phonemic Fluency- Controlled Oral Word Association
Test (COWA)
• Saying words starting with Letter F – A – S
• 3 trials approx 5 min
2. Category Fluency – as many animal names as possible
in 1 min exclude names of fish birds and snakes

46. 3. Design Fluency:
Visual Fluency is the capacity to generate new
visual forms.
Free condition: draws novel design
Fixed condition: novel design using only four
straight or curved lines.
- No geometric forms, similar/elaboration of
previous design, not meaningful or named.
- Found to be sensitive to right frontal-lobe
damage
- Time 12 min

47. • Example: healthy performance
• Novelty Score = 15
Example: right frontal performance
R = rule breaking (nameable--triangle)
P= perseverative (too similar to others)
Novelty Score = 6

49. Working Memory
• Put Forth by Baddeley (1986)
• Capacity to hold and manipulate information for
on going processes.
• Mental Sketch pad
• Verbal working memory using N back tasks
activate Broca’s area and the left supplementary
motor and premotor area
• 1 back consecutively
• 2 back after intervining consonant
• Time 12 min

51. •
•
•
•
Visual working Memory
1 Back and 2 Back
36 cards black dots
1 back – locations of the dots was
consecutively repeated
• 2 back – location of dot was repeated after
one intervening card.

52. • Planning: has been defined as the
identification and organization of the steps
and elements needed to carry out an
intention or achieve a goal.
• left frontal lesions associated with deficits of
planning (Shallice 1982)
• Components – speed of processing, mental
flexibility, working memory, regulation of
thought, error correction ability [SMWRE]
• Dorsolateral prefrontal cortex is associated
with components of generating, selecting,
remembering mental moves.

53. Tower of London
• Test evaluates the subjects ability to plan and
anticipate the results of their actions to
achieve a predetermined goal.
• Activates wide network consisting of the
dorsal prefrontal cortex, premotor cortex,
pareital cortex and cerebellum.

55. Set shifting
• Ability to change a mental set in response to
environmental contingencies.
• Ability to adapt responses to a changing
environment.
• Mental set is formed when the environment does
not change, precursor to habit, response to a
standard stimulus becomes easy.
• Lesions in Dorsolateral prefrontal cortex impair SF
ability and increase perseverated response.
• Frontal lobe leisons have been ass. with increased
errors.

56. Wisconsin Card Sorting Test
“Please sort the 60 cards under the 4 samples.
I won‟t tell you the rule, but I will announce every
mistake.
The rule will change after 10 correct placements.”
Network of
regions activated
by this test as
seen on PET
include bilateral
dorsolateral
prefrontal cortex,
inferior parietal
lobule, visual
association ,
cerebellum in
additon to the
prefrontal cortex.

57. WCST examines –
concept formation,
abstract reasoning,
ability to shift cognitive
strategies in response to
changing environment.
-128 cards
-Card 1 : 1 Red triangle (left Hand )
-Card 2 : 2 Green Stars
-Card 3 : 3 Yellow Cross
-Card 4 : 4 Blue Circles

58. Response Inhibition [E F]: refers to the
suppression of actions that are inappropriate
in a given context and that interfere with goaldriven behaviour.
Stroop Test : Bilateral superior medial prefrontal
regions impair performance on Stroop test.

59. RED BLUE ORANGE YELLOW
GREEN RED PURPLE RED
GREEN YELLOW BLUE RED
YELLOW ORANGE RED GREEN
BLUE GREEN PURPLE RED
1. Read the words column wise as fast as you can
2. You can correct yourself.
3. Name the color in which the word is printed.
4.
Time 20 min
Stroop effect Score: Time taken to name – Time taken to read the
words.

60. Verbal Comprehension
•
Ability to understanmd spoken language Token Test (De Renzi & Vignolo 1962)

62. Learning and Memory
• Rey’s Auditory Verbal Learning Test (AVLT)
• List A – Immediate
• List B – After 5 Trials of Immediate recall[interference]
List A
Trial 1
Trial 2
Trial 3
Trial 4
Trial 5
List B
IRecall A
DR A
Recognition
1 Arm
Shoes
Mirror
2 Cat
Monkey
Axe
3 Axe
Bowl
Hammer
4 Bed
Cow
Candle
5 Plane
Finger
Bed
6 Ear
Dress
Leg
7 Dog
Spider
Arm

63. VISUO CONSTRUCTIVE ACTIVITIES
Complex figure of REY.
constructional apraxia occurs due to parietal
lesions where the difficulties arise because
of the loss of spatial organization of
elements.
In frontal lobe patients difficulties arise
because of disruption of one or more of the
steps like intention, programming regulation
or verification.
The performance of frontal patients may be
facilitated if the patients were given a
structured sequence of the figure to copy.
Immediate Recall - 3 min
Delayed Recall – 30 min

64. Logical Memory
• Immediate and delayed recall of a meaningful
passage.

65. Luria Nebraska and Frontal Lobe
Motor functions (C1)
Simple and smooth coordinated movements of hand and oral motor area,
kinesthetic basis of movement, optic-spatial organization, praxis, selectivity
of motor acts, and verbal regulation of motor acts.
Visual functions (C4)
Visual perception of objects and pictures, visual-spatial orientation and
operations in space.
Expressive speech (C6)
Reflective speech, articulation of speech sounds, repetitive speech,
nominative and narrative speech.
Memory (C10)
New learning, immediate sensory traces, memory with interference, memory
for text and logical memory.
Left Hemisphere (S2)
Left-hand sensory and motor performance
Right Hemisphere (S3)
Right-hand sensory and motor performance
Impairment (S5)
Symbolic reasoning, working memory and spatially mediated performance.

66. REFERENCES
Reference:
1. Frontal Lobe - LADA A. KEMENOFF, BRUCE L. MILLER, and
JOEL H. KRAMER, University of California, San Francisco
2. Neuropsychology of prefrontal cortex, S V Siddiqui et al IJP
3. Neuropsychological Assessment of Frontal Lobe Dysfunction,
Goldberg, Bougakov.
4. HUMAN PREFRONTAL CORTEX: PROCESSING AND
REPRESENTATIONAL PERSPECTIVES
Jacqueline N.Wood and Jordan Grafman
5. Stahl’s Essential Psychopharmacology
6. Walsh(1999),Neuropsychology: A clinical approach (4th
edition),Churchil Livingstone