My colleague Joni began her presentation by
describing a patient named “Elliot”, a businessman who had a tumor in his
frontal lobe. The surgeons had successfully removed the tumor, but now Elliot
“wasn’t Elliot anymore.” His life had started to fall apart. He lost his job,
where he had been a successful executive. He divorced his wife, and then married
a prostitute (which also ended badly).
Elliot had gone to see Antonio Damasio, the eminent
neuroscientist. Damasio noticed that Elliot did fine in all the usual tests,
exhibiting intact memory and excellent intelligence. But when asked to look at
pictures of emotionally charged events, like an auto accident, or people in
distress, Elliot did not register the usual signs of being affected by what he
was seeing. The damage to Elliot’s brain had caused him to be unable to access
his emotional memory to assign value to things that he sensed or actions that
he might do.
Without access to this emotional context, options could only
be evaluated based on “cold-blooded logic”, Damasio noted. And when all you
have is logic, options appeared of the same value in the landscape of
decisions, and decision-making became quite difficult.
So Elliot might take hours trying to decide between various
options for dinner. Food, after all, is something that can be viewed logically
as having some caloric value, and some health benefits, but for a normal person
the choice of what to eat is often based on memories of how it felt when you
ate that food. Without access to memory of pleasure associated with eating the food (which is
derived largely from the emotional context in which the food was eaten), the
caloric content of food becomes a sterile dimension to base decisions.
Joni used this example to motivate her own research, which
focused on the activity of neurons in the orbitofrontal cortex of animals. She
showed that the neurons increased their activity when the option promised
greater reward, and lowered their activity when the option required the animal
to exert greater effort (through lever presses). She showed that the neurons of
the orbitofrontal cortex were encoding value of the option, taking into account
a measure of the reward that it promised, minus the effort that it required.
And so perhaps when there was damage to these neurons, and
their connections to the brainstem regions that were important for registering
emotional context of events, people lost the ability to make choices based on
the subjective value of that option, that is, how they felt about that choice.
But damage to the frontal lobe, particularly the regions
that so dramatically altered the ability to make choices, also changed the way
people reacted toward the patient. Joni brought this up later as she sat in my
office, describing that a major problem that patients faced following these
forms of surgery was in their ability to continue their relationships with
people whom they had known all their lives. These friends and family members
had a hard time adjusting to a person who looked exactly the same as before,
but now suddenly had changed internally. That is, Elliot wasn’t Elliot anymore.
As Joni explained this problem, a tear formed in her eyes.
I suddenly understood that in some ways, a similar problem
was faced by people who changed their gender. For them, on the inside they were
exactly the same person as before, but now on the outside, they looked
something else entirely. That outwardly change made it hard for lifelong
friends, children, family, to maintain the relationships that they had built
together. Just when they needed it most, the critical bonds were being
strained.
You see, about a year ago, Joni was Jonathan, married and father
to children. Now, she was an elegantly dressed woman with eye shadow and
curves.
“I’m still the same person I always was. I’m just being more
authentic now.”
