On Identifying the Factors Responsible for Frontal Lobe Dysfunction of the Human Brain: An Application of Multi-Event Survival Analysis to Wisconsin Card Sorting Data

Anirban  Dutta; Jonali  Gogoi; Dibyojyoti  Bhattacharjee

Authors

Anirban Dutta Department of Statistics, Centre for Distance and Online Education, Assam down town University, Assam, India
Jonali Gogoi Department of Statistics, School of Physical Sciences, Assam University, Silchar, Assam, India
Dibyojyoti Bhattacharjee Department of Statistics, School of Physical Sciences, Assam University, Silchar, Assam, India

Keywords:

Survival analysis, multi-event analysis, psychology, short term memory, human brain

Abstract

The frontal lobe, located in the anterior region of the brain, plays a crucial role in facilitating cognitive functions. Its vulnerability to injuries due to its location can lead to impaired decision-making, increased risk-taking behaviour, and diminished working memory performance. The extent of frontal lobe dysfunction is often difficult to detect with advanced imaging techniques; thus, researchers rely on low-tech neuropsychological evaluations to assess cognitive deficits and functional impairments. One such tool is the Wisconsin Card Sorting Test (WCST), where participants encounter many errors throughout the test’s evaluation process. An individual’s performance in WCST can be considered a case of a multi-event survival process, given that the participant may experience numerous failures during the test. The study investigated the influence of various socio-demographic and lifestyle factors on the frequency of errors and, consequently, the degree of front lobe dysfunction. The Andersen-Gill (AG) model is implemented, and it revealed that alcohol abstinence and self-confidence in one’s working memory significantly affect the frequency of errors observed in the WCST. Future research should focus on exploring additional factors to enhance the models' ability to capture significant patterns in error risks and shed light on various dimensions of assessing individuals’ cognitive flexibility.

References

Abernathy K, Chandler LJ, Woodward JJ. Alcohol and the prefrontal cortex. Int Rev Neurobiol. 2010; 91: 289-320.

Al-Khalidi HR, Hong Y, Fleming TR, Therneau TM. Insights on the robust variance estimator under recurrent-events model. Biometrics. 2011; 67(4): 1564-1572.

Amorim LD, Cai J. Modelling recurrent events: a tutorial for analysis in epidemiology. Int J Epidemiol. 2015; 44(1): 324-333.

Andersen PK, Gill RD. Cox's regression model for counting processes: a large sample study. Ann Stat. 1982; 10(4): 1100-1120.

Anderson SW, Damasio H, Jones RD, Tranel D. Wisconsin card sorting test performance as a measure of frontal lobe damage. J Clin Exp Neuropsychol. 1991; 13(6): 909-922.

Balan TA, Putter H. A tutorial on frailty models. Stat Methods Med Res. 2020;29(11): 3424-354.

Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav. 1983; 24(4): 385-396.

Demakis GJ. A meta-analytic review of the sensitivity of the Wisconsin Card Sorting Test to frontal and lateralized frontal brain damage. Neuropsychology. 2003; 17(2): 255-264.

Dispenza J. You are the placebo: making your mind matter. Carlsbad (CA): Hay House; 2014.

Donaldson MG, Sobolev B, Kuramoto L, Cook WL, Khan KM, Janssen PA. Utility of the mean cumulative function in the analysis of fall events. J Gerontol A Biol Sci Med Sci. 2007; 62(4): 415-419.

Elahi C, Rocha TAH, Sakita F, Ndebea AS, Fuller A, Haglund MM, et al. An evaluation of traumatic brain injury patient outcomes at a referral hospital in Tanzania: evidence from a survival analysis. Neurosurg Focus. 2019; 47(5): E6. https://doi.org/10.3171/2019.8.FOCUS19515

Feldstein SN, Keller FR, Portman RE, Durham RL, Klebe KJ, Davis HP. A comparison of computerized and standard versions of the Wisconsin Card Sorting Test. Clin Neuropsychol. 1999; 13(3): 303-313.

Fortuny LA, Heaton RK. Standard versus computerized administration of the Wisconsin Card Sorting Test. Clin Neuropsychol. 1996; 10(4): 419-424.

Franz DJ. “Are psychological attributes quantitative?” is not an empirical question: conceptual confusions in the measurement debate. Theory Psychol. 2022; 32(1): 131-150.

Grant DA, Berg EA. A behavioral analysis of degree of reinforcement and ease of shifting to new responses in a Weigl-type card-sorting problem. J Exp Psychol. 1948; 38(4):404-411.

Greve KW, Bianchini KJ, Hartley SM, Adams D. The Wisconsin Card Sorting Test in stroke rehabilitation: factor structure and relationship to outcome. Arch Clin Neuropsychol. 1999; 14(6): 497-509.

Grimaldi P, Lau H, Basso MA. There are things that we know that we know, and there are things that we do not know we do not know: confidence in decision-making. Neurosci Biobehav Rev. 2015; 55: 88-97.

Heaton RK, PAR Staff. Wisconsin Card Sorting Test: computer version 4. Lutz (FL): Psychological Assessment Resources; 2003.

Heaton RK, Chelune GJ, Talley JL, Kay GG, Curtiss G. Wisconsin Card Sorting Test manual: revised and expanded. Odessa (FL): Psychological Assessment Resources; 1993.

Howard M, Gregertsen EC, Hindocha C, Serpell L. Impulsivity and compulsivity in anorexia and bulimia nervosa: a systematic review. Psychiatry Res. 2020; 293: 113354. https://doi.org/10.1016/

j.psychres.2020.113354

Kleinbaum DG, Klein M. Survival analysis: a self-learning text. 3rd ed. New York: Springer; 2012.

Kohli A, Kaur M. Wisconsin Card Sorting Test: normative data and experience. Indian J Psychiatry. 2006; 48(3): 181-184.

Kolakowsky-Hayner SA. Wisconsin Card Sorting Test. In: Kreutzer JS, DeLuca J, Caplan B, editors. Encyclopedia of clinical neuropsychology. New York: Springer; 2011.

Kongs SK, Thompson LL, Iverson GL, Heaton RK. Wisconsin Card Sorting Test-64 card version: professional manual. Odessa (FL): Psychological Assessment Resources; 2000.

Kopp B, Lange F, Steinke A. The reliability of the Wisconsin card sorting test in clinical practice. Assessment. 2021; 28(1): 248-263.

Landau S. Using survival analysis in psychology. Underst Stat. 2002; 1(4): 233-270.

Landry O, Mitchell P. An examination of perseverative errors and cognitive flexibility in autism. PLoS One. 2021; 16(1): e0223160. https://doi.org/10.1371/journal.pone.0223160

Lange F, Brückner C, Knebel A, Seer C, Kopp B. Executive dysfunction in Parkinson’s disease: a meta-analysis on the Wisconsin Card Sorting Test literature. Neurosci Biobehav Rev. 2018; 93: 38-56.

Lawless JF, Nadeau C. Some simple robust methods for the analysis of recurrent events. Technometrics. 1995; 37(2): 158-168.

Li QH, Lagakos SW. Use of the Wei-Lin-Weissfeld method for the analysis of a recurring and a terminating event. Stat Med. 1997; 16(8): 925-940.

Loo J. Self-esteem [Internet]. The Decision Lab; 2021 [cited 2024 Sep 27]. Available from: https://thedecisionlab.com/reference-guide/philosophy/self-esteem

Lougheed JP, Benson L, Cole PM, Ram N. Multilevel survival analysis: studying the timing of children's recurring behaviors. Dev Psychol. 2019; 55(1): 53-65.

Maier H, Smith J. Psychological predictors of mortality in old age. J Gerontol B Psychol Sci Soc Sci. 1999; 54(1): P44-54.

Meng R, Li J, Wang Z, Zhang D, Liu B, Luo Y, et al. The Chinese version of the Perceived Stress Questionnaire: development and validation amongst medical students and workers. Health Qual Life Outcomes. 2020; 18(1): 70. https://doi.org/10.1186/s12955-020-01307-1

Nelson W. Graphical analysis of system repair data. J Qual Technol. 1988; 20(1): 24-35.

Ninomiya Y, Iwata T, Terai H, Miwa K. Effect of cognitive load and working memory capacity on the efficiency of discovering better alternatives: a survival analysis. Mem Cognit. 2024; 52(1): 115-131.

Oscar-Berman M, Marinkovic K. Alcoholism and the brain: an overview. Alcohol Res Health. 2003; 27(2): 125-33.

Ozga AK, Kieser M, Rauch G. A systematic comparison of recurrent event models for application to composite endpoints. BMC Med Res Methodol. 2018;18(1): 2. https://doi.org/10.1186/s12874-017-0462-x

Page MC. Survival analysis in psychology: effects of censoring and proportionality [dissertation]. Tempe (AZ): Arizona State University; 1998.

Pirau L, Lui F. Frontal lobe syndrome. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 [cited 2026 Sep 20]. Available from: https://www.ncbi.nlm.nih.gov/

books/NBK532981

Prinja S, Gupta N, Verma R. Censoring in clinical trials: review of survival analysis techniques. Indian J Community Med. 2010; 35(2): 217-221.

PsyToolkit. Wisconsin Card Sorting Test (WCST) [Internet]. 2021 [cited 2024 Aug 28]. Available from: https://www.psytoolkit.org/experiment-library/wcst.html

Queensland Health. Brain map: frontal lobes [Internet]. Brisbane: Queensland Government; 2022 [cited 2026 Sep 20]. Available from: https://www.health.qld.gov.au/abios/asp/bfrontal

Rouault M, Fleming SM. Formation of global self-beliefs in the human brain. Proc Natl Acad Sci U S A. 2020; 117(44): 27268-27276.

Schwarzer R, Jerusalem M. Generalized self-efficacy scale. In: Weinman J, Wright S, Johnston M, editors. Measures in health psychology: a user’s portfolio. Causal and control beliefs. Windsor (UK): NFER-Nelson; 1995. p. 35-37.

Sendic G. Frontal lobe [Internet]. Kenhub; 2023 [cited 2026 Sep 20]. Available from: https://www.kenhub.com/en/library/anatomy/frontal-lobe

Somsen RJM, Van der Molen MW, Jennings JR, van Beek B. Wisconsin Card Sorting in adolescents: analysis of performance, response times and heart rate. Acta Psychol (Amst). 2000; 104(2): 227-257.

Steinke A, Kopp B, Lange F. The Wisconsin Card Sorting Test: split-half reliability estimates for a self-administered computerized variant. Brain Sci. 2021;11(5): 529. https://doi.org/10.3390/

brainsci11050529

Stoet G. PsyToolkit: a software package for programming psychological experiments using Linux. Behav Res Methods. 2010; 42(4): 1096-1104.

Stoet G. PsyToolkit: a novel web-based method for running online questionnaires and reaction-time experiments. Teach Psychol. 2017; 44(1): 24-31.

Stuss DT, Levine B. Adult clinical neuropsychology: lessons from studies of the frontal lobes. Annu Rev Psychol. 2002; 53: 401-433.

Stuss DT, Levine B, Alexander MP, Hong J, Palumbo C, Hamer L, et al. Wisconsin Card Sorting Test performance in patients with focal frontal and posterior brain damage: effects of lesion location and test structure on separable cognitive processes. Neuropsychologia. 2000; 38(4): 388-402.

Teubner-Rhodes S, Vaden KI Jr, Dubno JR, Eckert MA. Cognitive persistence: development and validation of a novel measure from the Wisconsin Card Sorting Test. Neuropsychologia. 2017; 102: 95-108.

Therneau TM, Grambsch PM. Modeling survival data: extending the Cox model. New York: Springer; 2000.

van Houwelingen HC, Putter H. Dynamic prediction in clinical survival analysis. Boca Raton (FL): CRC Press; 2012.

Wu W, Little TD. Quantitative research methods. In: Levesque RJR, editor. Encyclopedia of adolescence. New York: Springer; 2011.

Yin Y, Chou C. Multi-event survival analysis through dynamic multi-modal learning for ICU mortality prediction. Comput Methods Programs Biomed. 2023; 235: 107545. https://doi.org/10.1016/

j.cmpb.2023.107545