What Is Executive Dysfunction?

Overview

Executive dysfunction defines problems relating to ‘cognitive abilities that drive goal-oriented behaviour’.¹ Although treatment for executive dysfunction varies by individual cases, some individuals have shown promise in regaining and improving skills through repetitive training in video game-type platforms.

Executive function consists of four components, which is helpful from a clinical perspective as patients can be affected by each category to a different extent. The four components are Information updating and monitoring (working memory), Inhibition of prepotent responses, Mental set shifting and Fluency.

Executive dysfunction can present in patients in different ways, including symptoms of memory problems, a struggle to focus their attention, socially inappropriate behaviour, and difficulties with problem-solving. Executive dysfunction can be seen in patients with ADHD, mental health problems, and other neurological and neurodegenerative problems.² In these groups of patients, the specific symptoms of executive dysfunction are recognised to correspond to areas of the brain considered atypical or neurodiverse or areas that have been affected by injury or degeneration. 

Working memory

Common examples of working memory include remembering a phone number or a number temporarily by reciting it out loud. Those who struggle with their working memory struggle with decision-making and planning as they struggle to retain the information needed to make decisions.

Inhibition of prepotent responses

Prepotent responses refer to learned ‘automatic’ behaviour, such as those done without any active thought. Depending on the situation or the social context, these responses can be inappropriate, and in most people, these responses will be inhibited in these situations.¹ Patients who struggle with disinhibition of prepotent responses struggle to avoid responding to irrelevant or inappropriate stimuli.¹ They may often appear distracted and impulsive. 

Patients with advanced cases may exhibit behaviour that includes picking up objects with no purpose (utilisation behaviour), repeating things that are said to them (echolalia), and imitating actions involuntarily (echopraxia).¹ Diagnostic tests include the Stroop test, where patients are given several words for colours and have to read out the colour of the word rather than the word itself. 

Mental set shifting 

Mental set-shifting, which also requires the use of working memory, reflects the ability of a patient to alter their behaviour and attention in response to changing circumstances and requirements. There are many tests which can identify problems with this, which include asking the patient to perform several different hand movements (e.g. asking them to hold their fingers parallel to the ground, then to form a fist, and then to hold their fingers perpendicular to the ground).¹ By asking a patient to perform these tasks, it is possible to assess their adaptability to different requirements. This is known as the Luria manual sequencing task. 

Fluency

Fluency refers to the amount of verbal or visual information a patient can produce in a given time without repetition. This can be tested by asking a person to provide as many words as they can from a category, for example, names of different animals or varieties of fruit. To test phonemic fluency, a patient can be asked to provide as many words as possible that all begin with a specific letter. To test visual production, a patient can be asked to draw a number of visual designs that all incorporate a specific image, e.g. a square.¹ 

Symptoms associated with executive dysfunction have also been linked to mood disorders.¹ For example, memory problems, including those concerning working memory, can present in patients with depression. When the patient is treated for depression, these symptoms can resolve themselves.

Example of executive dysfunction

The following is a case study of a 54-year-old patient who had been experiencing cognitive decline for nearly two years.¹ The patient had lost their job as a high-level executive after being unable to comprehend complex information and struggling to perform planning tasks. She had also made several ‘impulsive’ decisions within her line of work, which led to poor outcomes. The patient had been unable to land a new job. After neuropsychological evaluation, she tested for moderative impairment across all aspects of executive dysfunction.1 In memory testing, she struggled with information retrieval but not with recognition. A consequent FDG-PET scan and Cerebral spinal fluid (CSF) biomarker analysis showed a low-level build-up of Amyloid-Beta 42 alongside phosphorylated tau levels, which are common indicators of Alzheimer’s disease. Consequently, the patient was diagnosed with probable dementia and prescribed anticholinesterase medication.¹

Signs and symptoms of executive dysfunction

Signs and symptoms of executive dysfunction include:

• Problems with motivation and initiation
• Problems with organisation
• Problems with flexible thinking
• Difficulties with problem-solving
• Impulsivity
• Difficulties with planning

Executive dysfunction and ADHD

ADHD is commonly mistaken as a condition that is solely associated with hyperactive children who are unable to focus. However, ADHD affects an estimated 2.5 million people in the UK and detrimentally affects a range of executive functions.³ Individuals with ADHD are estimated to be 30-40% behind their peers when it comes to transitioning from one executive function to the next during the development of cognition.¹ Although individuals with ADHD experience a variety of forms of executive dysfunctions, this varies by the individual. For example, some people with ADHD will struggle more with certain executive dysfunctions, such as planning, and less with others, such as behavioural inhibition. Some ADHD support resources recommend learning about the origins of executive functions that they struggle with the most, as being able to relate the executive function to the brain pathway can help individuals navigate and understand the symptoms that they experience. 

Management and treatment for executive dysfunction

Treatment of executive dysfunction considers patients on a case-by-case basis. For example, patients with Alzheimer’s disease, who also exhibit problems with executive dysfunction, can often benefit from taking cholinesterase inhibitors. Likewise, patients with Parkinson’s disease generally benefit from dopamine replacement therapy to manage their symptoms. However, all patients with executive dysfunction suffer from a neurodegenerative disorder or other medical problem that can be directly treated. 

Executive dysfunction rarely presents itself as the primary problem. There are, however, ways that patients can manage symptoms of executive dysfunction regardless of the cause. These include repetitive training to improve a skill using computer-based activities that resemble video games.¹ In this training, participants are required to recall places or change their behaviour according to new requirements.² Some scientists argue that it is much more beneficial for this training to be done in childhood, as executive function is still developing.² 

Additionally, some research suggests that for individuals who experience executive dysfunction as a result of ADHD or depression, there are some mindfulness-based techniques which can improve particular aspects of executive dysfunction.⁴ These techniques aim to generate awareness of thoughts and actions alongside relaxation of the body and result in improved cognitive control and attention. This type of intervention is called integrative body-mind training (IBMT).⁴

Diagnosis

Diagnosis of executive function is reliant on the assessor’s familiarity with the clinical components of the condition, as well as the relationship between behaviours and the involved sections of the brain. As a result, many individuals who present with symptoms of executive function do not always receive this as the ultimate diagnosis. Before an executive dysfunction diagnosis can be made, other conditions must be ruled out, such as neurodegenerative conditions (e.g. Alzheimer’s or Parkinson’s diseases), psychiatric conditions (e.g. depression), and other primary medical conditions.¹

The most common complaint from patients prior to a diagnosis of executive dysfunction is memory loss. Other key symptoms to enquire about include difficulties with planning and organisation, a short attention span, impulsiveness and cognitive inflexibility/mental rigidity. 

Diagnosis should begin with a neurologic examination and then neuropsychiatric tests to evaluate the performance of each component of executive dysfunction. There are a handful of different assessments to test for executive dysfunction; of these, the Montreal Cognitive Assessment (MOCA) is the most sensitive. The Executive Abilities: Measures and Instruments for Neurobehavioural Evaluation and Research (EXAMINER) tests for a spectrum of behaviours and symptoms associated with the different aspects of executive dysfunction. The test can be used in patients across a wide spectrum of ages and disorders.¹ To accurately diagnose executive dysfunction, it is necessary for the clinician to assess test results and symptoms alongside other neurological conditions and medication usage.¹

Summary

Executive dysfunction is a condition that typically presents in individuals with neurological disorders, mental health conditions, ADHD or who are otherwise neurodiverse. Executive dysfunction detrimentally affects decision-making and planning, and the ability to coordinate behaviour appropriate for the right situation. Whilst symptoms can be difficult to manage, there are medications and exercises that can greatly improve executive function.

FAQs

How can I prevent executive dysfunction?

As executive dysfunction is associated with other neurological problems and neurodegenerative diseases such as Dementia, prevention should also include prevention of these diseases. Steps can be taken to prevent the onset of Dementia, including the active treatment of hypertension in middle-aged and older adults.⁴ Other variables to manage include the treatment of depression, obesity, and maintenance of social engagement. Stopping smoking is also important for reducing the risk of developing Dementia. As the likelihood of experiencing a neurological disorder increases after trauma to the brain, prevention can also include basic safety regimes such as wearing a helmet when riding a bike.

In many cases, however, as with numerous health conditions, the development of executive dysfunction is not preventable. For example, in cases involving ADHD, forms of Dementia, or in those who are predisposed to experience depression.

How common is executive dysfunction?

There is a range of people who experience executive dysfunction, from those with neurological and neurodegenerative diseases to those with ADHD and those with mental health disorders, including depression. This makes it difficult to accurately assess how prevalent executive dysfunction is in society as it is often a symptom of another condition and not diagnosed directly. Additionally, many of those with executive dysfunction experience a combination of other debilitating conditions associated with their disorder, of which executive dysfunction is the least disruptive.

Who is at risk of developing executive dysfunction?

People who have neurological and psychiatric problems and those with mental health disorders, including depression, are at higher risk of developing executive dysfunction. 

When should I see a doctor?

Most patients who visit a doctor and have symptoms of executive dysfunction do so out of concern for memory loss. However, if you experience any symptoms of executive dysfunction, it is advisable to visit your GP, particularly if there are any concerns over memory loss.

If you suffer from executive dysfunction and have a neurological condition, the following is a helpful NHS article that provides guidance and help with decision-making and planning: https://php.cumbria.nhs.uk/patients/resources/neuropsychology/executive-dysfunction