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Impairment of Social Perception Associated with Lesions of the Prefrontal Cortex

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Impairment of Social Perception Associated with Lesions of the Prefrontal Cortex Article Impairment of Social Perception Associated With Lesions of the Prefrontal Cortex Linda Mah, M.D. Objective: Behavioral and social im- Results: Relative to the comparison sub- pairments have been frequently reported jects, patients whose lesions involved the Miriam C. Arnold, M.A. after damage to the prefrontal cortex in orbitofrontal cortex demonstrated im- humans. This study evaluated social per- paired social perception. Contrary to pre- Jordan Grafman, Ph.D. ception in patients with prefrontal cortex dictions, patients with lesions in the dor- lesions and compared their performance solateral prefrontal cortex also showed on a social perception task with that of deficits in using social cues to make inter- healthy volunteers. personal judgments. All patients, particu- larly those with lesions in the dorsolateral Method: Thirty-three patients with pre- prefrontal cortex, showed poorer insight frontal cortex lesions and 31 healthy into their deficits, relative to healthy volunteers were tested with the Interper- volunteers. sonal Perception Task. In this task, sub- Conclusions: These findings of deficits in jects viewed videotaped social interac- social perception after damage to the or- tions and relied primarily on nonverbal bitofrontal cortex extend previous clinical cues to make interpersonal judgments, and experimental evidence of damage- such as determining the degree of inti- related impairment in other aspects of so- macy between two persons depicted in cial cognition, such as the ability to accu- the videotaped scene. Patients with pre- rately evaluate emotional facial expres- frontal cortex lesions were classified ac- sions. In addition, the results suggest that cording to lesion involvement of specific the dorsolateral prefrontal cortex is re- regions, including the orbitofrontal cor- cruited when inferences about social in- tex, dorsolateral prefrontal cortex, and teractions are made on the basis of non- anterior cingulate cortex. verbal information. (Am J Psychiatry 2004; 161:1247–1255) Behavioral changes and disturbances in social inter- mind” (9, 10), and impaired ability to gain access to social action occur frequently after lesions of the prefrontal cor- knowledge (11–13). In the current study, we investigated tex, particularly those that involve the ventromedial pre- whether patients with orbitofrontal cortex lesions show frontal cortex or orbitofrontal sectors. Case reports of deficits in social perception, or the ability to use verbal patients with orbitofrontal cortex lesions, such as those of and nonverbal cues to interpret social interactions. Defi- Phineas Gage (1, 2) and E.V.R. (3), described striking be- cits in perception of social cues have been demonstrated havioral changes leading to social dysfunction. These dys- in other neuropsychiatric disorders that involve prefrontal functions include inappropriate affect, disinhibition and cortex abnormalities, such as schizophrenia (for a recent lack of restraint, impaired insight and self-monitoring, so- review, see reference 14). cial withdrawal, and failure to perceive and respond to in- In this study, we used a standardized task of social cog- terpersonal cues. Patients who exhibit impaired social be- nition, the Interpersonal Perception Task (15), to compare havior may have preserved intellectual functions, such as the performance of patients with prefrontal cortex lesions language, memory, and perception, and may perform with limited or no deficits on standard neuropsychological with that of healthy volunteers. The Interpersonal Percep- tests that are believed to be sensitive to frontal lobe dys- tion Task consists of 30 different videotaped social interac- function (3, 4). tions for which subjects are required to make judgments Various mechanisms have been proposed to explain the regarding different aspects of the relationships of the per- aberrant social behavior observed after orbitofrontal cor- sons depicted, such as level of intimacy and social status. tex lesions. These explanations have focused on deficits in This task is unique in that the scenes in the Interpersonal decision making because of lack of a “somatic marker” (5, Perception Task show unrehearsed, spontaneous behavior 6), inability to alter behavior appropriately in response to of nonactor individuals. Thus, the Interpersonal Percep- a change in reinforcement contingencies (7, 8), difficulties tion Task is more representative of real-life social situa- in representing the mental states of others or in “theory of tions, compared with other social cognitive tasks such as Am J Psychiatry 161:7, July 2004 http://ajp.psychiatryonline.org 1247 PREFRONTAL CORTEX DAMAGE AND SOCIAL PERCEPTION FIGURE 1. Composite Images of Damaged Brain Regions in Four Groups of Patients With Lesions in the Prefrontal Cortex Who Participated in a Study of Social Perceptiona Patients With Lesions in the Patients With Lesions in the Orbitofrontal Cortex (N=12) Dorsolateral Prefrontal Cortex (N=4) Patients With Lesions in the Patients With Lesions in the Orbitofrontal/ Orbitofrontal/Anterior Cingulate Cortex (N=5) Dorsolateral Prefrontal/Anterior Cingulate Cortex (N=5) a Lighter colors denote areas of greatest overlap of lesions among patients. evaluating depictions of emotions in static pictures of standard neuropsychological measures and scores on the faces. Neurobehavioral Rating Scale (32), an observer-rated mea- Studies of patients with lesions confined to the frontal sure of neuropsychiatric symptoms. We were specifically lobes demonstrate involvement of the ventromedial/orbito- interested in the relationship between Interpersonal Per- frontal prefrontal sectors in socially relevant behaviors (5, ception Task performance and measures of executive func- 6, 8, 9, 12, 13, 16–29). Inability to monitor behavior and de- tion and working memory, because some studies have creased insight have also been reported after prefrontal demonstrated an association between executive function cortex damage (e.g., reference 30), but there is little empir- and performance on social cognitive tasks (22, 26). We hy- ical support for these clinical observations (but see refer- pothesized that the ability to shift attention from one indi- ences 30, 31). We hypothesized that, relative to healthy vol- vidual to another or from one conceptualization of a situa- unteers, patients with lesions involving the orbitofrontal tion to another on the basis of new information would cortex would demonstrate deficits in social perception on facilitate accurate interpersonal perception. the Interpersonal Perception Task. No differences in per- formance were expected between the healthy volunteers Method and patients with prefrontal cortex lesions that did not in- volve the orbitofrontal cortex. We also hypothesized that Subjects patients with lesions in the prefrontal cortex would have Thirty-three consecutive outpatients (30 male patients, three decreased awareness of their social cognitive ability, rela- female patients) with nonprogressive prefrontal cortex lesions and 31 healthy comparison subjects (23 male subjects, eight fe- tive to healthy comparison subjects. To better understand male subjects) matched for age and educational level were in- any observed deficits in social cognition, we compared cluded in the study. The patients had a mean age of 52.5 years performance on the Interpersonal Perception Task with (SD=7.5) and 14.1 years of education (SD=2.5), and the compari- 1248 http://ajp.psychiatryonline.org Am J Psychiatry 161:7, July 2004 MAH, ARNOLD, AND GRAFMAN TABLE 1. Sample Scenarios and Questions From Subscales of the Interpersonal Perception Task Interpersonal Perception Task Subscale Sample Scenario Sample Question Reply Choices Kinship A group consisting of an adult man, Who is the child of the two adults? Only the little boy. an adult woman, a boy child, and a girl Only the little girl. child is depicted. Neither the boy nor the girl. Deception A man presents two consecutive and differ- Which is the lie, and which is the The first is a lie; the second is the truth. ent accounts of an event to the viewer. truth? The first is the truth; the second is a lie. Competition The conclusion of a racquetball game Who won the racquetball game? The man on the left. in which two men are competing The man on the right. is depicted. Social status A man and a woman engaged Who is the higher status person? The man. in conversation are depicted. The woman. Intimacy Two women and a man conversing with one Which woman is engaged to be The woman on the left. another are depicted. married to the man? The woman on the right. Neither woman. son subjects had a mean age of 54.5 years (SD=9.8) and 14.9 years lesion volume. Twelve patients formed the orbitofrontal cortex le- of education (SD=2.0). The patients and the comparison subjects sion group, and four patients were included in the dorsolateral did not differ in age (t=0.91, df=62, p=0.37) or number of years of prefrontal cortex lesion group. Two other groups were formed. education (t=1.40, df=62, p=0.17). One included patients whose lesions involved primarily orbito- frontal cortex and anterior cingulate cortex regions (N=5). The re- Lesion Analysis maining patients (N=5) included those with lesions involving all All patients had cerebral lesions restricted to the frontal lobes. three areas in roughly equal proportions and one patient with Most of the patient group had acquired prefrontal cortex lesions both dorsolateral prefrontal cortex and anterior cingulate cortex secondary to
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