Complex decision making after orbitofrontal damage: Neuropsychological and strategic management simulation assessment

Neuropsychological tests have considerable value in identifying deficits following brain injury, but may not adequately measure certain residual problems which limit adaptive functioning after recovery. This paper reports the case of a 48-year-old woman who suffered right orbitofrontal damage after traumatic brain injury and experienced marked difficulties handling real-world (e.g. work-related) challenges despite very good recovery. Neuropsychological measurement indicated mild difficulties in select measures of executive functions, but no severe deficiencies were encountered. Therefore, further study was undertaken with a validated, computer-scored Strategic Management Simulation technique to assess how multiple, interactive aspects of executive competency might have been affected. Results revealed significantly impaired scores on several decision-making parameters, including initiative, information utilization, breadth of strategy, opportunistic actions and aspects of emergency handling which we attributed to the effects of orbitofrontal damage. Contextual or single-task problems were handled considerably better. The data suggest that the Strategic Management Simulation may provide a particularly valuable paradigm for assessing executive function deficits as a complement to neuropsychological measurement, although further studies are needed to establish its reliability and validity in relationship to neuropsychological impairments. Refined analysis of altered decision-making competencies after orbitofrontal damage may suggest new avenues for rehabilitative intervention.