Executive functions and their disorders

Rebecca Elliott
Neuroscience and Psychiatry Unit, University of Manchester, Manchester, UK

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The term executive function defines complex cognitive processing requiring the
co-ordination of several subprocesses to achieve a particular goal. Neuropsycho-
logical evidence suggests that executive processing is intimately connected with
the intact function of the frontal cortices. Executive dysfunction has been
associated with a range of disorders, and is generally attributed to structural or
functional frontal pathology. Neuroimaging, with PET and fMRI, has confirmed
the relationship; however, attempts to link specific aspects of executive
functioning to discrete prefrontal foci have been inconclusive. Instead, the
emerging view suggests that executive function is mediated by dynamic and
flexible networks, that can be characterised using functional integration and
effective connectivity analyses. This view is compatible with the clinical
presentation of executive dysfunction associated with a range of pathologies,
and also with evidence that recovery of executive function can occur after
traumatic brain injury, perhaps due to functional reorganisation within
executive networks.

The term ‘executive function’ is used as an umbrella for various complex

cognitive processes and sub-processes. Most attempts to define executive
function resort to a list of examples (such as task-switching, planning,
or that other useful umbrella term ‘working memory’), which reflects
the fact that executive function is by no means a unitary concept. The
neuropsychological literature converges on the view that successful
performance on tests of executive function is critically dependent on the
frontal cortex; indeed the terms ‘executive function’ and ‘frontal lobe
function’ are often used synonymously. However, recent theories have
suggested that this view is simplistic and subcortical regions may also be
critically involved. Neuropsychological deficits of patients with
Parkinson’s disease, for example, suggest that striatal structures play a
role in the mediation of executive processes.
Correspondence to:
Dr Rebecca Elliott, Advances in neuroimaging have provided the tools for assessing directly
Neuroscience and the neuronal basis of executive functions. Perhaps unsurprisingly, it appears
Psychiatry Unit, Room that these complex processes are subsumed by distributed circuitry rather
G907, Stopford Building,
University of Manchester,
than discrete structures. A key advantage of the neuroimaging approach is
Oxford Road, Manchester that it has allowed a degree of localisation of different executive
M13 9PT, UK components within prefrontal regions, and the simple ‘equivalence’ of

British Medical Bulletin 2003; 65: 49–59  The British Council 2003
DOI 10.1093/bmb/ldg65.049
Imaging neuroscience: clinical frontiers for diagnosis and management

frontal lobe function and executive processing has, therefore, undergone a

much more sophisticated dissection. Executive functions are compromised
in an array of clinical disorders; patients with various neurological and
psychiatric complaints, as well as those with trauma to the frontal lobes,
exhibit executive deficits. Neuroimaging provides a means for exploring
these deficits, as well as developing an understanding of recovery of
executive function frequently seen in patients suffering traumatic brain
injury or stroke. This chapter considers the nature of executive functions

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and how neuroimaging techniques have advanced our understanding of
these processes, as well as how they are compromised.

Defining ‘executive function’

Unlike other cognitive domains (such as memory or attention), there is no
intuitive lay concept that incorporates the essence of executive function;
therefore, any account of these processes must begin with definitions.
Executive functions are those involved in complex cognitions, such as
solving novel problems, modifying behaviour in the light of new
information, generating strategies or sequencing complex actions. In a
recent review, Funahashi1 summarised executive function as ‘a product of
the co-ordinated operation of various processes to accomplish a particular
goal in a flexible manner’. This flexible co-ordination of sub-processes to
achieve a specific goal is the responsibility of executive control systems.
When these systems break down, behaviour becomes poorly controlled,
disjointed and disinhibited. Co-ordination, control and goal-orientation
are, therefore, at the heart of the concept of executive function.

Executive functions and the prefrontal cortex

Patients with damage to the prefrontal cortex show impaired judgement,
organisation, planning and decision-making2, as well as behavioural
disinhibition and impaired intellectual abilities3. In a laboratory setting,
patients are impaired on tests such as set-shifting4, planning5, and
various fluency tasks6. These impairments all point to a breakdown of
co-ordination processes. Patients are relatively unimpaired on tests
focusing on a particular function, but when a number of different
functions must be co-ordinated in the laboratory or real-life, deficits are
clearly observed. These observations led to the influential conclusion
that executive functions are the province of the prefrontal cortex, and
indeed ‘executive function’ and ‘frontal lobe function’ became almost
interchangeable terms.’

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 Executive functions and their disorders

Beyond the prefrontal cortex

A seminal paper by Alexander et al7 proposed that a crucial organising
principle of the brain is corticostriatal circuitry, intimately linking regions of
the frontal cortex to striatal structures, via the thalamus and globus
pallidus. This model suggests a functional, as well as anatomical,
connectivity between frontal cortex and striatum. Divac et al8 showed that
lesions to the caudate nucleus in animals resulted in deficits that resemble

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those following prefrontal ablation. Evidence that striatal structures are also
important in human executive functions comes from neuropsychological
studies of neurological disorders. Patients with multiple systems atrophy,
progressive supranuclear palsy and Huntington’s disease9,10 show significant
deficits in executive function, but by far the most widely studied basal
ganglia disorder is Parkinson’s disease. Numerous neuropsychological
studies have shown that Parkinson’s disease is characterised by executive
impairments11,12, which are evident early in the course of the disorder when
pathology is confined to basal ganglia regions, and are seen in patients who
are unmedicated. Executive function deficits, therefore, appear to be a
genuine concomitant of basal ganglia damage. This has led to the
suggestion that executive function depends not on the prefrontal cortex in
isolation, but on the intact functioning of corticostriatal circuitry mediated
by dopaminergic neurotransmission.

Other disorders of executive function

Frontal lobe lesions and basal ganglia disorders are not the only pathologies
to be related to executive dysfunction. Patients with frontal dementia and
with Alzheimer’s disease also exhibit executive deficits, as do patients with
the AIDS-dementia complex. There is also evidence that patients with
subcortical ischaemic vascular disease13 show selective deficits on tests of
executive function. Furthermore, executive deficits are common in patients
with various psychiatric disorders, including depression14,15 and
schizophrenia16,17; both disorders are characterised by a wide range of
deficits, but there is a strong argument that executive function is particularly
compromised. In all these disorders, the executive deficits are attributed to
either frontal lobe damage or dysfunction, or to disruption in fronto-
subcortical connectivity.

Neuroimaging of executive functions

The neuropsychological literature, reviewed (very) briefly above, clearly
implicates the prefrontal cortex as a key determinant of executive function.

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However, executive function is not a unitary concept and the prefrontal

cortex is a heterogeneous neuro-anatomical region18. It, therefore, seems
intuitively plausible that different regions of the prefrontal cortex may
mediate different aspects of executive function. Other important
questions are the extent to which prefrontal regions may recruit
posterior cortical and subcortical regions during executive functioning,
and how the essential flexibility of executive control is achieved at a
neuronal level. Neither the animal nor the human neuropsychological

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literature have provided compelling evidence on these issues, (see
Roberts et al19 for discussion). Advances in functional neuroimaging
have provided the tools to assess prefrontal mediation of executive
functions in more detail.

Functional specialisation within the prefrontal cortex

The issues of whether different regions of the prefrontal cortex are specialised
for different aspects of executive function, and, more controversially, how
that specialisation may be characterised, are central to gaining a better
understanding of executive processing through neuroimaging.

Lateral frontal cortex and working memory

An influential hypothesis distinguishing different prefrontal regions in
functional terms is the theory that dorsolateral and ventrolateral
prefrontal regions fulfil different functions20,21. This is a hierarchical 2-
stage model of prefrontal contribution to working memory. The
ventrolateral prefrontal region (VLPFC) is proposed to control the
retrieval of representations from posterior cortex and, according to
some22, the on-line maintenance of these accessed representations. The
dorsolateral region (DLPFC) is then proposed to mediate the monitoring
and manipulation of the representations maintained in VLPFC. There
are numerous studies lending support to this theory. For example, Rowe
et al23 found that maintenance of spatial representations was associated
with very little activation of DLPFC, whereas selecting between different
representations produced significant DLPFC activity. Similarly, Wagner
et al24 reported that rote rehearsal in working memory preferentially
activated VLPFC, while elaborative rehearsal preferentially activated
DLPFC. Furthermore, their event-related design allowed them to
demonstrate a significant temporal difference between VLPFC and
DLPFC responses. The DLPFC response systematically lagged behind
the VLPFC response, consistent with a hierarchical model.
However, not all evidence supports the simple separation between DLPFC
and VLPFC function. Several studies have reported similar patterns of
response in DLPFC and VLPFC during maintenance rehearsal25. In a

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 Executive functions and their disorders

neuropsychological study, Petrides26 found that selective damage to

DLPFC did not disrupt maintenance at a low load (relatively few items
to be remembered), but as the load increased, impairments became
apparent. It thus appears that DLPFC may play some role in main-
tenance in working memory, at least at high loads. The debate continues,
with some authors arguing that the effects of increasing load in DLPFC
actually reflect increased monitoring when stimuli are encoded26, while
others24 are content to allow for a limited role of DLPFC in maintenance

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per se.

Clustering of frontal activations in executive function

Whether or not DLPFC and VLPFC play dissociable roles in working
memory function, it is clear that these regions are also involved in other
aspects of executive function. In a recent meta-analysis, Duncan and
Owen28 considered the pattern of activation observed in studies chosen
to reflect a wide range of different tasks. Their initial analysis considered
studies of auditory discrimination, divided visual attention, motor
initiation, task-switching, planning and semantic processing. In spite of
the diversity of task demands, there was a striking clustering of the
activations observed in these studies. Specifically, three main clusters
were distinguished; dorsal anterior cingulate, a region dubbed ‘mid-
dorsolateral’ and a ‘mid-ventrolateral’ region.
The initial analysis was followed by a more systematic assessment of
studies which had manipulated a particular cognitive demand: response
conflict, task novelty, working memory load, memory delay or
perceptual difficulty. For each of these demands, five or more studies
had assessed the effects of manipulating that demand. Once again, the
clustering was striking, with the same three areas involved in all five
types of manipulation. The authors concluded that a common network,
involving these three regions, is recruited by diverse cognitive demands.
However, they did not rule out the possibility that there may be finer
specialisations within this network. One possibility is that there is fine
specialisation within each region at a level that cannot be resolved by
functional imaging, particularly in group studies where the necessary
normalisation and smoothing of raw images reduce the anatomical
resolution. An alternative, and not mutually exclusive, possibility is that
specialisation within these regions is a matter of degree, such that
although a broad network is activated by different tasks, the relative
magnitude of activations within each region may be task-dependent.
Finally, it is possible that the three regions do subserve different
functions, but that these functions are sufficiently abstract to be
involved in many different complex cognitive tasks. The evidence
discussed above, that DLPFC and VLPFC may play differential roles in
working memory, would support this final suggestion. Evidence from

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studies using N-back (see below) and reverse span tasks20,22 also point to
a selective enhancement of DLPFC activity (but not VLPFC or dorsal
cingulate activity) when subjects must undertake re-organisation of
material in working memory. Again this supports the suggestion that
there is at least some degree of functional segregation among these three
prefrontal regions.

Specialisation for material rather than function

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A different approach to the issue of prefrontal specialisation focuses on
whether different regions are recruited depending on the nature of the
material being processed in a particular task29. Specifically, it is argued
that prefrontal cortex is organised into verbal, spatial and object-
processing regions. This theory has been addressed in detail by two
recent meta-analyses of N-back tasks. In these tasks, subjects are
presented with a series of stimuli, one at a time, and are required to
report whether the present stimulus is the same as one several stimuli
before (2 stimuli before in a 2–back task, 3 before in a 3-back, and so
on). The nature of the stimuli can be varied, as can the working memory
load (the higher ‘N’, the harder the task). These tasks are classic
executive function tests in that they require subjects to monitor stimulus
input and flexibly up-date information in working memory to generate
appropriate responses. In their meta-analysis, Smith and Jonides30
reported that increasing the demands of N-back tasks was associated
with increasing DLPFC activity, and that verbal compared to spatial N-
back tasks recruited more left-sided compared to right-sided regions.
The authors suggested that these data could be interpreted as supporting
both domain specificity and functional specificity models, with domain
specificity reflected by laterality of response and functional specificity
reflected by the VLPFC/DLPFC dissociation, as proposed by the
hierarchical Petrides/Owen theory. However, another meta-analysis of
N-back tasks by D’Esposito et al22 suggested that such distinctions may
be too simplistic. They found that any domain-specificity was more a
matter of degree than a complete dissociation. Also, they stressed that
posterior cortical areas, as well as prefrontal regions, were selectively
recruited by increasing cognitive demands. As with the functional
specialisation debate, it appears that the concept of domain specificity is
more complex than it first appeared.

Distributed networks and functional integration

The neuroimaging literature reviewed above is starting to suggest that a
new approach may be needed to understand prefrontal mediation of
executive function31. Various meta-analyses, including those discussed
here, lead to an emerging view that executive processes are mediated by
networks incorporating multiple cortical regions (posterior as well as

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 Executive functions and their disorders

prefrontal regions) with collaborative and overlapping functions29,32. A

key contribution of functional neuroimaging is the demonstration that
the component regions may be differentially engaged depending on the
cognitive load33. This view represents a major conceptual shift, and
significantly increases the challenge to functional imaging. Instead of a
relatively straightforward exercise in one-to-one mapping of structure to
function, this view necessitates an understanding of how multiple brain
regions may be flexibly combined with each other. These combinations

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may depend not only on task requirements but also on individual skills
and experience.
Many early functional imaging studies of cognition focused on the
functional segregation approach of mapping individual functions to
discrete regions. If executive function is to be better understood by a
flexible, collaborative and overlapping network model, this will involve
a paradigm shift towards a functional integration approach. Structural
equation modelling and effective connectivity analysis can be used to
assess the dynamic changes in functional interactions between regions of
a network depending on the cognitive demands34. McIntosh et al35 used
a working memory task with variable delays and showed that the
strength of the top-down connection between prefrontal cortex and
temporal and occipital areas increased as the delay, and therefore
cognitive load, increased. Top-down, condition-specific modulation of
visual processing by the prefrontal cortex has also been demonstrated36,
suggesting that flexible interactions between prefrontal and posterior
regions may influence perception as well as cognition. Other studies
have reported dynamic task-dependent changes in functional interaction
between prefrontal regions dependent on task demands37. In a recent
review, Funahashi1 presents converging evidence from single unit
recording studies in animals and functional imaging studies using the
effective connectivity approach, and suggests that understanding the
dynamic and flexible modulation of neuronal interactions is the key to
understanding how the brain exerts executive control.

Neuroimaging of executive dysfunction

As discussed above, executive dysfunction is associated with a range of

neurological and psychiatric disorders. The ubiquity of executive
impairments, often in the absence of structural damage to the prefrontal
cortex, is intuitively consistent with the network view of executive
function. A dynamic and flexible neuronal network could be
compromised in many different ways, and to different extents. It could
also, potentially, prove more robust in the face of traumatic insult than
a fixed one-to-one mapping between structure and function.

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Executive dysfunction mediated by impaired connectivity?

The executive dysfunctions associated with basal ganglia disorders
provide neuropsychological evidence that frontostriatal circuitry, rather
than discrete prefrontal regions, may be important in mediating
executive function. PET studies of patients with Parkinson’s disease38
have shown that two different tests of executive function (planning and
spatial working memory) are associated with abnormal function in the
globus pallidus. Regional cerebral blood flow in the prefrontal cortex,

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however, was not significantly different from that seen in controls. The
authors argue that striatal dysfunction affects the expression of frontal
lobe functions by disrupting transmission through frontostriatal
circuitry. More recently, a structural equation modelling approach has
been used to look directly at whether Parkinson’s disease is associated
with disrupted connectivity. Rowe et al39 found that ‘attention to
action’, where subjects had to focus on forthcoming motor responses,
was associated with enhanced effective connectivity between prefrontal
and premotor regions in normal subjects. This enhanced connectivity
was not seen in patients with Parkinson’s disease, suggesting a context-
specific functional disconnection within cortical networks.
The disorder where executive dysfunction has been most extensively
studied using functional imaging is probably schizophrenia. There have
been many studies demonstrating hypofrontality associated with
executive impairments in schizophrenia, although many of these studies
are plagued by confounds40. In the absence of a clear focal pathology,
theories of disordered connectivity in schizophrenia are particularly
appealing41,42. Analyses of functional and effective connectivity have
clearly demonstrated abnormalities in schizophrenic patients during
performance of executive tasks. Fletcher et al43 reported abnormal
anterior cingulate modulation of fronto-temporal connectivity during
list learning. Prefrontal disconnectivity has also been associated with
verbal fluency44 and working memory45. Neuroimaging evidence for
impaired connectivity has provided the insights that underpin a new
generation of neuropathological and neurodevelopmental theories of
schizophrenia46,47.

Implications for recovery

The dynamic network approach to understanding executive function
also has implications for understanding how the brain recovers from
trauma. Executive function is frequently compromised as a result of
brain injury, but, like language and motor functions, executive functions
may recover to at least some extent. Functional imaging provides an
exciting tool to study recovery. Both PET and fMRI have been used to
demonstrate that there is extensive functional re-organisation following
a head injury or stroke48,49. Neighbouring or contralateral regions may

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 Executive functions and their disorders

be recruited to subserve the original function; the extent to which this

occurs is dependent on age, neurological status and exact task
demands50. The processes of recovery and re-organisation are
conceptually more plausible in a dynamic and flexible network model.
However, these processes remain poorly understood and are an
important challenge for future functional imaging research.

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Conclusions and future directions
Executive function is, by definition, complex, and this review has only
scratched the surface of the current debates concerning the neuronal basis
of executive function and dysfunction. It is clear that although the
prefrontal cortex is a vital component of the circuitry subserving executive
function, posterior cortical regions and subcortical structures collaborate
with prefrontal cortex to mediate successful executive processing.
The advent of functional neuroimaging techniques has provided the
means to study the neuronal basis of human executive function directly.
Early imaging experiments attempted to dissociate component processes
of executive function and attribute them to discrete prefrontal foci.
Although there is some evidence for both functional and material
specificity in prefrontal cortices, it appears that this is more a matter of
degree than reflecting fixed and fundamental dissociations. It is also
clear that the same prefrontal regions mediate very different executive
functions. An increasingly influential view is, therefore, that we should
not be looking for one-to-one mappings between structure and function.
Rather, we should be using more sophisticated analysis approaches to
study flexible and dynamic changes in effective and functional
connectivity between brain regions. This has dramatic implications for
our understanding of normal and abnormal executive functions.
From a clinical perspective, a dynamic network approaches is
synchronous with the rising trend for disconnection models of
neurological and psychiatric disorders. Important challenges for the
future will be to gain a more through understanding of these models,
and to construct theoretical frameworks for understanding the
mechanisms of both disconnection and functional re-organisation.

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