Affect Regulation and Loss of Initiative in a Case of Orbitofrontal Injury

Personality change after injury to the orbitofrontal cortex has frequently been described in the literature. However, there are only a few specific and reliable methods available for the assessment of personality change after brain injury. Here we present a patient, LP, whose personality has changed due to a ruptured aneurysm of the anterior communicating artery that resulted in bilateral ventromesial prefrontal lesions. Although his performance on extensive conventional neuropsychological tests was within normal range, he exhibited severe behavioral problems characterized by lack of initiative, inappropriate social timing, and blunt affect. The patient's behavioral problems were measured with extensive assessment of personality characteristics and traits using methods from psychodynamic and psychometric traditions. Although no general signs of psychopathology were found, there were some indications that he was suffering from personal problems that fluctuated, as cognitive functions sometimes do after frontal-lobe injury. Intensive psychoanalytic psychotherapy allows us to hypothesize about some of the dynamics behind his acquired “loss of initiative,” although the very nature of his problems appears to be an obstacle to this kind of psychotherapy. This case study, like similar ones presented in the literature, reminds us to be cautious of accepting negative findings concerning standardized test performance as evidence of the absence of real-life problems after frontal-lobe injury.