From Jonathan to Joni

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.”