rewards, and penalties [12]. The subjects (players) are presented with 4 decks of cards, a loan of a certain amount of facsimile U.S. dollar bills and asked to play. They are also instructed to lose the least amount of money and win the most. There are 2 advantageous and 2 disadvantageous decks, the latter leading to an overall loss. Simultaneously, physiological data such as GSR are recorded. The reference study showed first that healthy controls chose advantageous decks whereas patients with prefrontal lesions did not [12]. Second, healthy controls generated anticipatory GSR (i.e., autonomic response) before being explicitly aware of a risky choice, whilst patients did not, even with knowledge of their risky choice.
GSR measures were utilized in combination with other modality tasks, for example, by Blair and Cipolotti [27]. Patient JS, who developed acquired sociopathy following a trauma that lesioned the orbitofrontal cortex bilaterally, has been assessed in much detail with a series of twelve tests embracing 3 types of processing, namely (1) reversal learning, (2) expression recognition and emotional responding, and (3) social cognition. Together with simultaneous GSR recordings, salient facial and environmental stimuli as well as visual and auditory inputs were applied during expression and emotional tasks. Moreover, different levels of social cognition were investigated. These measures included emotion attribution, theory of mind (i.e., the ability to attribute mental states to oneself and to others), moral/conventional distinction, and social situation tasks. JS performed well on the reversal learning tasks but was severely impaired on expression recognition and emotional responding tasks despite intact face processing. Autonomic responses (i.e., GSR) were preserved for auditory but not for visual stimuli. Finally, although showing no impairment on the theory of mind task, he failed almost all the social cognition tasks. JS’s results were significantly different from those of a dysexecutive patient without aberrant behavior as well as from a group of individuals with developmental psychopathy. This study therefore showed that autonomic measures can contribute, but are not sufficient to disentangle the complex processes underlying acquired sociopathy. More generally, it revealed that the more various and “composite” the measures are, the broader the resulting behavioral spectrum is.
Conclusions
We have discussed the introduction of assessment of emotions and behavior in neurological patients along with the understanding of frontal lobe functions. From observational and descriptive reports, behavioral measures have moved to auto- and hetero-evaluation questionnaires. It has then evolved to tasks where patients are more actively involved, resembling daily life situations. Not unexpectedly, as the assessment tools have expanded and become more specific, an increasing complexity of mechanisms underlying behavior has begun to emerge.
Behavioral assessment is nevertheless of importance since impairments are strongly related to poor outcome. Together with the interaction of pre-morbid factors such as personality and cognitive deficits, behavioral deficits diminish independent social behavior and increase social handicap [28]. However, measuring behavior directly faces the normality issue. In analogy to Mesulam questioning the existence of standards regarding behavior [4], this raises the necessity to consider an individual’s behavior in its entirety, which includes pre-morbid functioning, interindividual and cultural differences. Finally, as an encouraging perspective, it is worth noting that behavioral disorders can benefit from neurorehabilitation: both individual and group training programs have shown successful results [29, 30].
Acknowledgements
The authors would like to thank Ian Gatfield for language editing and proofreading.
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