Elsevier

Neuropsychologia

Volume 48, Issue 12, October 2010, Pages 3377-3391
Neuropsychologia

Reviews and perspectives
Neuropsychological assessment of the orbital and ventromedial prefrontal cortex

https://doi.org/10.1016/j.neuropsychologia.2010.08.012Get rights and content

Abstract

Assessment of the functions of the orbitofrontal cortex and ventromedial prefrontal cortex has proven to be a unique challenge for neuropsychologists. Orbitomedial damage occurs in a range of disorders including traumatic brain injury, ruptured aneurysms, surgical resection, and frontotemporal dementia. We review the effects of orbitomedial damage on a range of neuropsychological tasks, including tasks measuring object alternation and reversal learning, decision-making (gambling), facial emotion recognition, theory of mind, olfactory recognition, autobiographical memory and behavioral rating measures. At present, there is no singular gold standard measure of orbitomedial dysfunction, and assessment requires an integrative approach that reflects the heterogeneity of the region. The heterogeneous neuropsychological deficits arising from orbitomedial damage are difficult to ascribe to a unitary function or process, but appear to reflect a set of processes necessary for monitoring and adapting to changing reinforcement contingencies.

Research highlights

▶ Traditional clinical batteries are insufficient for assessing orbitomedial functions. ▶ Several experimental tasks are sensitive to orbital and ventromedial damage. ▶ The range of deficits have critical implications for models of orbitomedial function.

Introduction

Identifying and assessing the functions of the orbitofrontal cortex (OFC) and ventromedial prefrontal cortex (VMPFC) has proven to be a unique challenge for neuropsychologists. At a superficial level, individuals with dysfunction in these regions often appear cognitively intact, even demonstrating normal performance on standard neuropsychological batteries. Yet, the deficits associated with ventral frontal damage can cause disastrous consequences, not infrequently leading to major interpersonal, occupational and legal problems. In the present paper we review the neuropsychological literature on the effects of ventral frontal damage in humans. In doing so, we aim to both evaluate the diagnostic utility of existing measures purported to tap the functions of the OFC and VMPFC, and to highlight the implications of these findings for further elucidating the specific functions of the region.

Section snippets

Anatomy of the OFC and VMPFC

The OFC comprises the ventral surface of the prefrontal cortex (PFC). Although several specific gyri and sulci are identifiable in the OFC (see Fig. 1), most of the neuropsychological literature in humans, generically labels damage to any of these gyri as OFC damage, or makes use of broad labels such as poster, anterior, medial or lateral OFC.

The VMPFC is centered along the inferior portion of the medial wall of the frontal lobe. The exact boundaries of this region are not always defined, but

Sources of OMPFC damage

Several types of neuropathology produce damage to the OMPFC in humans. These range from closed head injuries and penetrating head wounds, to cerebrovascular accidents, tumors, neurosurgical excisions, and neurodegenerative disorders. Because such conditions vary widely in terms of their pattern of impact within the OMPFC and the degree to which they impact neighboring brain regions, it is useful to briefly consider the general features of damage caused by these conditions.

Patients with OMPFC

Toward a neuropsychology of the OMPFC

The functions of the OMPFC have at times been described as enigmatic. While some of this enigma arose because of a lack of specific tasks tapping the region in the early development of neuropsychology, we suspect that the divergent nature of tasks that are sensitive to OMPFC damage has also contributed to the continued difficulty conceptualizing the functions of the region. At least five themes arise in the types of neuropsychological tasks that are sensitive to OMPFC damage: (1) an ability to

Learning and adapting to changing reinforcement contingencies

The broadest group of cognitive tasks showing sensitivity to OFC lesions involve tasks in which the individual must learn a reward contingency that diverges from expectation or that is changing over time. In his seminal 1964 chapter on the OFC, Mishkin (1964) put forth the hypothesis that animals with OFC lesions have a “perseveration of central sets” in which they are unable to overcome or inhibit prepotent responses. Both object alternation (OA) and object reversal learning (ORL) tasks

Decision-making (gambling) tasks

In recent years, intense interest has developed on the potential use of gambling tasks as probes for VMPFC dysfunction. This line of inquiry stems from the repeated anecdotal observation of poor, and often risky, decision-making in patients with OMPFC lesions (Eslinger and Damasio, 1985, Harlow, 1868). Unlike the experimental tasks described already, gambling tasks have emerged strictly within the context of studies of human patients. The Iowa Gambling Task (IGT) is the most widely used of

Social processing and theory of mind

Facial expressions are a critical aspect of human nonverbal communication of emotion. A number of neuroimaging studies involving explicit judgments about faces implicate the OFC in aspects of facial judgments (Dougherty, Shin, & Rauch, 2006). However, the importance of the OFC to emotional recognition of facial expressions is unresolved. Large lesions that include the OFC have been observed to cause deficits in facial emotion recognition (Blair and Cipolotti, 2000, Heberlein et al., 2008,

Olfactory testing

The OFC receives substantial input from the olfactory system, and is often described as secondary olfactory cortex (Carmichael, Clugnet, & Price, 1994). The strongest olfactory projections are located in the posterior OFC, but neuroimaging data demonstrates that multiple areas of the OFC are responsive to odorants (Gottfried & Zald, 2005). Although olfactory functioning has often been overlooked as a major focus of clinical neuropsychology, the existing data suggest that it is among the most

Interview and questionnaire data

Although cognitive and olfactory measures are sensitive to OMPFC dysfunction, they do not capture the range of real world abnormalities exhibited by patients with ventral frontal lesions. Because symptoms can occur in the absence of gross deficits on traditional neuropsychological measures, interview and questionnaire data provide essential information in assessing behavior that is not captured in the lab environment. Indeed, interview data characterizing changes in personality, disinhibition,

Functional implications

The above review of lesion effects on neuropsychological measures and behavioral rating scales indicates that a heterogeneous group of behaviors are affected by OMPFC lesions. This poses a significant challenge to attempts to define the OMPFC in terms of a singular theoretical or conceptual framework. Based on the different phylogenetic trends involving the OFC and medial frontal wall (Barbas, 1988), and the different connectional patterns of the ventral medial wall and OFC (Barbas and Pandya,

Conclusions

In summary, we propose that research and clinical characterization of the OMPFC requires an integrative approach in which standard testing batteries are augmented with neuropsychiatric and frontal-specific rating scales in order to capture the full range of behavioral, cognitive and personality disturbance arising from OMPFC damage. While individual “OMPFC” measures are increasingly utilized to assess the functioning of the OFC or VMPFC in psychiatric and neurological disorders, testing is

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