Cooking a bowl of spaghetti after work might sound like a simple and effortless enough task, but for a person with executive dysfunction, it can be a minefield. There are the decisions, ('what am I using to cook the pasta?') the organisation ('did I buy the correct ingredients'; 'how long does this stay on the hob for?') and the multi-tasking (ensuring the water doesn't boil over at the same time as slicing onions and garlic).
What is executive dysfunction?
This cocktail of actions and forward planning – which might be seamless, if your executive function is not impaired – can quickly become overwhelming. There are myriad root reasons for why this occurs in some people.
'Executive Dysfunction, or executive function disorder, refers to a range of cognitive behavioural and emotional difficulties that usually occurs as a result of another disorder,' explains Dr Aaron Surtees, a leading psychologist, clinical hypnotherapist and director of City Hypnosis.
'When someone [has] this condition they struggle to multi-task, organise, plan, pay attention or remember information. The simplest way to describe executive dysfunction is a weakness in the brain’s self-management system.'
Executive dysfunction is not a diagnosis in and of itself. Rather, it is a symptom of a diagnosis. Conditions with executive dysfunction as a symptom include attention deficit hyperactivity disorder (ADHD), obsessive compulsive disorder (OCD), depression, brain trauma, including brain tumours and brain injuries, and types of dementia.
Dr Mo Qadri, Psychiatrist & Medical Psychotherapist at Cast Care Clinic, puts it this way: 'Our behaviour, memory, ability to communicate, plan, interact, multitask, problem solve, interpret, express and recognise emotions depends on several complex brain functions working together almost instantly and appearing seamless.
This effective cooperation of different parts of the brain is described as executive functioning. In some people this high functioning thinking is impaired – this is what we mean by executive dysfunction.'
What is executive function?
Another way of thinking about executive dysfunction is, naturally, as a lack of executive function. This latter term which is used to describe the suite of skills that help life to flow easily, such as planning and organisation, flexible thinking, monitoring performance, concentrating and taking in information, multitasking and memory. This all takes place in your brain's prefrontal cortex, which is located at the front of your frontal lobe.
Your frontal lobes are connected to a host of other regions in your brain, and co-ordinate what goes on, in these other regions: you might like to think of it as the conductor of the orchestra that is your brain.
This is why brain injury can result in the issue – the area is physically damaged, and no longer fires with the precision it used to – as well as why it holds hands with ADHD (it's normal for the prefrontal cortex to develop more slowly in people with this condition than in neurotypical people, and for the circuits in this part of the brain to have a different structure.)
How do you know if you have executive dysfunction?
Dr Quadri explains that most severe forms of executive dysfunction are picked up early in childhood, he says. Where this differs, it is usually attributed to the onset of an illness. At this point, it is usually assessed by doctors who undertake routine bedside testing by asking specific questions or getting you to complete tasks and observing your approach, sequencing, and ability to complete a given objective.
One of the tests used by doctors frequently is verbal fluency. This is measured by making you list as many words starting with the letter P in 60 seconds.
There is also imaging of the brain that may be offered with a view to detect causes in specific cases like those where vascular dementia is suspected.
Is executive dysfunction a symptom of ADHD?
As mentioned, yes – many of the problems people with ADHD experience are problems with executive functioning.
'ADHD is clinically a developmental impairment of executive functions,' Dr Surtees says. 'In both children and adults, [with ADHD] executive dysfunction is the underlying cause.'
ADHD, or attention deficit hyperactivity disorder, is a condition that includes symptoms such as inattentiveness, hyperactivity and impulsiveness. People with ADHD may struggle to concentrate, stay on task, make careless mistakes and find tasks which others may find easy, difficult and complex.
The difference between ADHD and executive dysfunction, however, is that the former is an official diagnosis, the latter is not: ADHD is a developmental impairment of executive function.
Is executive dysfunction a symptom of autism?
According to the Autism Awareness Centre, sources suggest that up to 80% of those with autism suffer from executive function disorder.
Jess Birchall, Head of London Autism Service, tells Women’s Health: 'Autistic people and those with learning disabilities struggle with executive dysfunction skills. Autism is a neurodevelopmental condition, and one of the common symptoms described are extreme challenges with executive functioning skills.'
What treatments exist for executive dysfunction?
Dr Quadri explains that, because there are many reasons for executive dysfunction, treatment is likely to differ from person to person. Some people, who deal with executive dysfunction due to the onset of an illness, such as an infection, psychosis, or depression, should be able to reverse the issue, by treating that illness. In some cases, however, the damage inflicted by the underlying cause may lead to permanent changes.
Where the causes are irreversible, such as those caused by dementia, the use of occupational therapy through adaptive approaches with cues and visual aids prompts may help with everyday functioning.
In the instance of ADHD, he says that there is good evidence to show that stimulant medication can help, and, in mental health causes like depression and psychosis, antidepressant and antipsychotic medication can also be beneficial. Therapies such as cognitive behavioural therapy (CBT) might also be helpful for managing.
Does executive dysfunction ever go away?
In short, it depends. Dr Surtees says that therapies are a very effective way of treating executive dysfunction and that depending on the root cause, in most instances, mental skills can be learned over time. It is, he says, a 'highly treatable condition.'
Dr Quadri takes a more hesitant approach. He says it depends on the dysfunction: 'Some are reversible whereas others are resistant to interventions, but developing better awareness will help ameliorate the stigma and encourage those affected to access support and treatment early.'
Speed of treatment, he notes, matters the overall outcome. 'The evidence demonstrates that earlier interventions can lead in some cases to better overall outcomes.'
How it feels to live with executive dysfunction: ‘Inside I knew I wasn’t coping’
Tendai White, a 38-year-old Executive Director from Loughborough, has always had problems with her memory and clumsiness – but it wouldn’t be until 28 that her problems reached crisis point.
'Throughout my life, I would oscillate between being disorganised and or super organised, depending on how I felt that day. Then, about ten years ago, I suffered from postnatal depression after the birth of my son. Three years later, I burnt out. Eventually, I was diagnosed with long-term depression, anxiety and chronic fatigue syndrome.
'From the age of 28, I had been running an international membership organisation. Everything was going well, but, inside I knew I wasn’t coping. I was forgetful, my scheduling were suffering and I was riding an emotional roller-coaster as all my energy went into my job and my son.
'To decompress, I started drinking more than is healthy and partying hard whenever I got the chance. I started not trusting my decisions and my impulsive spending had gone through the roof. This is when I realised something wasn’t right and started seeing a therapist.
'A few months in he suggested that I might have ADHD and got assessed by a psychiatrist and was formally diagnosed with ADHD two years ago and put on Xaggatin XL [ a medication which boosts the activity of certain parts of the brain which are under-active.].
'It turns out that ADHD impairs executive function in similar ways as head trauma. The medication helps me focus, I have a good support team at work and after my diagnosis, I was able to share my needs and rearrange our roles.
' For example, I now have an operations manager who is responsible for day-to-day operations and scheduling, leaving me free for more blue-sky thinking, strategy setting and so on. I realised that I am an ideas person but suck at organising resources and monitoring progress so these are covered by my team.
'I still struggle with depression, and this can aggravate my executive function as well, but generally, I’m much better.'
If you think you may have executive dysfunction:
Because executive dysfunction is not a diagnosis, the key to getting treatment is understanding what condition – such as ADHD or brain injury – is behind it. Speak to your GP or medical professional if you suspect that your executive function is impaired, and they can assess what is going on.
From there you might get help with medication or therapies (or both) to help you to manage.
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