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Case Study banner
Wednesday 11:00-11:30,
7 May - 28 May 2008
Claudia Hammond presents a series on case studies that have made a significant contribution to psychological research.
11 - 11.30am
21 May 2008
Listen to this programme in full
Diagram of Phieas Gage's injury
Phineas Gage was a railway worker in 19th century Vermont who survived a bizarre accident: A metre-long iron rod shot through his head, changing him and the study of neuroscience forever.
In the third programme Claudia visits Harvard Medical School Museum in Boston to see for herself what remains of The Man With The Hole In His Head. At the Oliver Zangwill Centre for Neuropsychological Rehabilitation in Ely, Cambridgeshire she meets clients with brain injuries similar to those suffered by Phineas Gage and discovers how far we've come in understanding and treatment since Gage suffered his appalling trauma on 13 September 1848.

A moment's distraction was Phineas' downfall. As foreman of the gang clearing rocks for the laying of the railway line near Cavendish, Vermont, he was responsible for setting the charge, drilling a hole in the rock and using an iron rod to tamp the explosive down before lighting the fuse. But this time the tamping iron struck the side of the hole, setting a spark which ignited the powder and sent the iron - over a metre long and 3 centimetres in diameter - up through his skull above the eye and out through the top of his head, landing 30 metres away. Unconscious for a few seconds, Gage then got up, rode an oxcart into town and lived for a further 12 years.

But he was no longer the hardworking, dependable and well-liked foreman. Now Gage swore and was shiftless, behaving inappropriately. For the first time here was evidence that the brain affects the way we behave; the scene was set for the mapping of the brain.

Futher information

An Odd Kind Of Fame: Stories of Phineas Gage, by Malcolm Macmillan
Publisher: MIT Press; New Ed edition (2 Sep 2002), ISBN-10: 0262632594 ISBN-13: 978-0262632591

Descartes' Error: Emotion, Reason and the Human Brain, by Antonio Damasio
Publisher: Vintage (6 Jul 2006) ISBN-10: 0099501643 ISBN-13: 978-0099501640

The Feeling of What Happens: Body, Emotion and the Making of Consciousness, by Antonio Damasio
Publisher: Vintage; New Ed edition (5 Oct 2000) ISBN-10: 0099288761 ISBN-13: 978-0099288763


Phineas Gage information website, maintained by Malcolm Macmillan

The Warren Anatomical Museum, Harvard Medical School

The Oliver Zangwill Centre

John Aggleton 

Antonio Damasio 


The Ballad of Phineas Gage by Dan Lindner
from Mystery and Memories, Banjo Dan’s Songs of Vermont Vol III – VSB 106

Difficulties with decision making after acquired brain injury

Dr Andrew Bateman, Clinical Manager

Oliver Zangwill Centre for Neuropsychological Rehabilitation, Ely UK
Prof Jonathan Evans, Professor of Applied Neuropsychology, University of Glasgow, UK

Having difficulty with making decisions is a common problem after head injury, stroke, encephalitis, tumours, anoxia (lack of oxygen to the brain) and in many other neurological conditions including progressive conditions such as dementia. It is one element of a broader set of mental skills that have been called ‘executive functions’ – these are the skills needed to enable us to deal with problems that arise in everyday life and to cope with new situations. Everyday life is full of situations in which we have to make decisions, some minor (which toothpaste will I buy? what will I have for dinner tonight?), some major (will I stay in this relationship? will I change my job?).

Decision making involves many different cognitive functions working together – long-term memory (how have I dealt with similar situations in the past? what choices have I made previously?), working memory (holding information in mind, thinking things through) and emotion (how important is this decision to me? how will the possible outcomes make me feel?) are all involved.

Because decision making involves a lot of different processes, this means that if any one of these processes is affected by brain injury or neurological illness, then decision making may be impaired. People are affected in different ways – some find it hard to make a decision at all, finding that even what seem like simple decisions such as what toothpaste to buy become almost impossible. Some people become impulsive, making hasty decisions, apparently acting without thinking things through. Poor judgement in relationships, with money or in business can have devastating consequences for the individual and their family. All of us, with or without brain injury, have difficulty making decisions from time to time, but brain injury or neurological illness can make this much more frequent.

Decision making and following through with plans of action
For some people, a decision about a plan of action might be made, but it is difficult for the individual to follow through with the plan. It is as if a person’s intention, or goal, becomes neglected. This can sometimes be because the person becomes distracted by other tasks or activities. The person ‘forgets’ to do things, not because what has to be done has been completely forgotten, but rather that it is difficult to keep the thing to be done in mind (e.g. take medication, go to appointments, give someone a message, carry out daily tasks, watch a favourite TV programme). This type of remembering is often called ‘prospective remembering’. It requires alertness to the plans for the day. Psychologists use the concept of a ‘mental blackboard’ to describe how we keep things we intend to do in mind (written on a mental blackboard), but the difficulty can be that for a person after brain injury, things are easily rubbed off a mental blackboard, and so are temporarily ‘forgotten’, though the person may remember their intention when reminded.

The cognitive problems that cause difficulties with decision making or prospective remembering may also make it difficult for an individual to be aware of their problems. This can be difficult for the person and his or her family and friends and cause conflict. The brain injured person is showing bad judgement or not doing important things, but is unaware of the difficulties. So, one of the first challenges to overcome is related to the need for the individuals to achieve a degree of self-awareness and understanding of the problems they are experiencing. This may require sensitive feedback from family, friends or professionals and for the individual to want to learn about possible solutions.

Emotions and mood
It is hard to make decisions when an individual feels worried, anxious or depressed. It may be a cycle that is compounded where difficulty with decision making contributes to emotional problems. It is important to recognise that rarely are decisions made without some reference to how the individual feels about the decision. There are many approaches to managing these kinds of emotional difficulties, beyond the scope of this briefing sheet. However this is an important issue to recognise and treat where appropriate.

Working out how to improve the ability to make decisions, to be better at solving problems, planning, following through with plans, and remembering to do things can be challenging and may be best done with the help of a professional such as an occupational therapist or clinical psychologist. The first step in rehabilitation is understanding the problem, but with something as complex as decision making or problem solving difficulties this may not be straightforward which is why the help of a professional may be important.

For some people learning to manage impulsivity is important –developing a habit of often stopping and thinking, even if just briefly, about what you are doing and what you have to do can help to interrupt a tendency to act without thinking. The idea is that people become better at using ‘self-talk’, regulating your own actions or behaviour.

In Goal Management Training, people learn to be better at being clear what it is they are trying to achieve (specifying the goal in a situation), at working out and keeping in mind (or keeping things on the ‘mental blackboard’) the steps needed to achieve the goal, and then regularly checking their mental blackboard to make sure that important tasks are kept in mind. A recent study by researchers in Cambridge and Glasgow showed that goal management training combined with SMS text message reminders to check the mental blackboard helped people with brain injury to remember to carry out a task (making a phone call to a voicemail service) that had to be done four times a day at specific times.

Goal management is also discussed in Trevor Powell’s helpful guide to Head Injury. He suggests individuals should “Try to create structure out of unstructured situations. Set yourself goals and break these down into specific tasks so that you know what you have to do. Use Checklists (p86)”. There is some more information available in Trevor’s book that can be ordered via the Headway web-site.

Although written primarily with the education environment in mind, there is also a very helpful web-site resource prepared by a leading practitioner in the US, Dr Mark Ylvisaker:

One extract from this includes the following general ‘script’ that an individual can learn to ask themselves….
GOAL: What’s the goal? What are you trying to achieve? What do you want to have happen? What’s it going to look like when you’re done?
OBSTACLE: What is standing or could stand in the way of you achieving the goal? What is the problem?
PLAN: So what’s the plan? What do you need to do? Can you write out a checklist? Do you need help to list the steps? Do you need help for any one of the steps? Do you want to do it as a team? Do you think that plan will work??
PREDICTION: So how well do you think you will do? How many can you get done? On a scale of 1 to 10, how well will you do?
DO: [Perhaps solving problems along the way or revising the plan]
REVIEW: So how’d it work out? What worked? Anything that didn’t work? Why or why not? What are you going to try next time?

It is important to edit the script to suit the individual, the language they prefer to use and their needs.

Another reminding system that has been shown to be useful for remembering to do things is NeuroPage.

NeuroPage uses a simple pager worn by the person with the memory/planning impairment to provide reminders of things to do and other information. The impaired person or a relative/carer provides a list of reminders that are entered on to computer (at the Oliver Zangwill Centre in Ely) and then this computer automatically sends out the message to the person’s pager at the correct time. The pager beeps or vibrates and the person receives their message. This simple system has been shown through extensive research to be effective in helping people with executive and memory problems arising from a wide range of conditions. In conjunction with a checklist, there is good evidence that using a device such as NeuroPage can enable individuals to complete a wide range of complex and personally meaningful tasks.

In the most research paper to investigate the benefits of NeuroPage the researchers concluded that paging “can cue a process of goal monitoring that bridges the gap between intention and action” (Fish Manly and Wilson, 2008).

A list of academic research publications is available on request or on the Neuropage website.

Further help
Sometimes an individual needs training to be able to overcome the difficulties described in this information sheet. In these circumstances it is appropriate to seek advice of an Occupational Therapist, Clinical Psychologist or Clinical Neuropsychologist. Talk to your GP about how to access further support in your area.

Further information

Useful books for further information:
Memory problems after brain injury. Booklet available from Headway (see below)

Head Injury: A practical Guide, by Trevor Powell, available from Headway.

Coping with Memory Problems: A Practical Guide for People with Memory Impairments, their Relatives, Friends and Carers, by Linda Clare and Barbara Wilson available from Harcourt publishers

Other useful organisations to contact:
Headway – The Brain Injury Association
4 King Edward Court
Tel: 0808 800 2244

Encephalitis Society
7B Saville Street,
Malton North
YO17 7LL
Tel 01653 699 599

The Stroke Association
Stroke House,
240 City Road,
Tel: 020 7566 0300
Helpline Number: 0845 30 33 100

Alzheimer’s Society
Gordon House
10 Greencoat Place
Tel: 020 7306 0606

If you would like further information about NeuroPage please contact:

The NeuroPage Service
Oliver Zangwill Centre
Princess of Wales Hospital
Lynn Road
Ely CB6 1DN
Tel: 01353 652176

For more information about the Oliver Zangwill Centre, please see

Donations to the Oliver Zangwill Centre Charitable Trust are gratefully received.

Research literature from the Oliver Zangwill Centre and the MRC Cognition and Brain Sciences Unit, Cambridge

Evans, J.J., Wilson, B.A, (2003) Who makes good use of memory aids? Results of a survey of people with acquired brain injury Journal of the International Neuropsychological Society, 9, 925–935

Evans, J.J., Emslie, H.C. Wilson, B.A. (1998) External cueing systems in the rehabilitation of executive impairments of action. Journal of the International Neuropsychological Society,4, 399-408

Fish,J., Manly,T, Emslie, H.C., Evans, J.J., and Wilson, B.A. (2007) Compensatory strategies for acquired disorders of memory and planning: Differential effects of a paging system for patients with brain injury of traumatic versus cerebrovascular aetiology. J. Neurol. Neurosurg. Psychiatry, Nov 2007; doi:10.1136/jnnp.2007.125203

Fish,J., Manly,T and Wilson, B.A. (2008) Long-term compensatory treatment of organizational deficits in a patient with bilateral frontal lobe damage. Journal of the International Neuropsychological Society, Volume 14, Issue 01, January 2008, pp 154-163

Wilson, B.A., Scott, H, Evans, J.J., Emslie H. (2003) Preliminary report of a NeuroPage service within a health care system. NeuroRehabilitation, 18(1):3-8

Wilson, B.A., Emslie, H.C., Quirk, K and Evans, J.J. (2001) Reducing everyday memory and planning problems by means of a paging system: a randomised control crossover study Journal of Neurology, Neurosurgery and Psychiatry; 70: 477 - 482.

Wilson, B.A., Emslie, H.C., Quirk, K. and Evans, J.J. (1999) George: Learning to Live Independently With NeuroPage. Rehabilitation Psychology Vol44, No.3 284-296

Wilson, B.A., Evans, J.J., Emslie, H.C. and Malinek, V (1997) Evaluation of NeuroPage: a new memory aid. Journal of Neurology, Neurosurgery and Psychiatry, 63:113-115

Wilson, B.A., Emslie, H., Quirk, K., Evans, J., & Watson, P. (2005). A randomised control trial to evaluate a paging system for people with traumatic brain injury. Brain Injury 19, 891-894.

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