The Tell-Tale Brain

Clearly “someone” in there knew she was paralyzed for, if not, why would she exaggerate the arm’s ability?

5. Projection—Ascribing your own deficiencies to another person. In the clinic: “The [paralyzed] arm belongs to my mother.” In ordinary life: “He is a racist.”

6. Intellectualization—Transforming an emotionally threatening fact into an intellectual problem, thereby deflecting attention from and blunting its emotional impact. Many a person with a terminally ill spouse or family member, unable to face the potential loss, starts treating the illness as a purely intellectual challenge. This could be regarded as a combination of denial and intellectualization, though the terminology is unimportant.

7. Repression—The tendency to block the retrieval of painful memories, which if dredged up would be “painful to the ego.” Although the word has made it into pop psychology, memory researchers have long been suspicious of repression. I lean toward thinking that the phenomenon is real, for I have seen many clear instances of it in my patients, providing what mathematicians call an “existence proof.”

For example, most patients recover from anosognosia after having been in denial for a few days. I had been seeing one such patient who insisted for nine days in a row that his paralyzed arm was “working fine,” even with repeated questioning. Then on the tenth day he recovered completely from his denial.

When I questioned him about his condition, he immediately stated, “My left arm is paralyzed.”

“How long has it been paralyzed?” I asked, surprised.

He replied, “Why, for the last several days that you have been seeing me.”

“What did you tell me when I asked about your arm yesterday?”

“I told you it was paralyzed, of course.”

Clearly he was “repressing” his denials!

Anosognosia is a striking illustration of what I have repeatedly stressed in this book—that “belief” is not a single thing. It has many layers that can be peeled away one at a time until the “true” self becomes nothing more than an airy abstraction. As the philosopher Daniel Dennett once said, the self is more akin conceptually to the “center of gravity” of a complicated object, its many vectors intersecting at a single imaginary point.

Thus anosognosia, far from being just another odd syndrome, gives us fresh insights into the human mind. Each time I see a patient with this disorder, I feel like I am looking at human nature through a magnifying glass. I can’t help thinking that if Freud had known about anosognosia, he would have taken great delight in studying it. He might ask, for example, what determines which particular defense you use; why use rationalization in some cases and outright denial for others? Does it depend entirely on the particular circumstances or on the patient’s personality? Would Charlie always use rationalization and Joe use denial?

Apart from explaining Freudian psychology in evolutionary terms, my model may also be relevant to bipolar disorder (manic-depressive illness). There is an analogy between the coping styles of the left and right hemispheres—manic or delusional for the left, anxious devil’s advocate for the right—and the mood swings of bipolar illness. If so, is it possible that such mood swings may actually result from alternation between the hemispheres? As my former teachers Dr. K. C. Nambiar and Jack Pettigrew have shown, even in normal individuals there may be some spontaneous “flipping” between the hemispheres and their corresponding cognitive styles. An extreme exaggeration of this oscillation may be regarded as “dysfunctional” or “bipolar illness” by psychiatrists even though I have known some patients who are willing to tolerate the bouts of depression in order to (for example) continue their brief euphoric communions with God.

OUT OF BODY EXPERIENCE: DOCTOR, I LEFT MY BODY BEHIND

As we saw earlier, one job of the right hemispheres is to take a detached, big-picture view of yourself and your situation. This job also extends to allowing you to “see” yourself from an outsider’s point of view. For example, when you are rehearsing a lecture, you may imagine watching yourself from the audience pacing up and down the podium.

This idea can also account for out-of-body experiences. Again, we only need to invoke disruption to the inhibitory circuits that ordinarily keep mirror-neuron activity in check. Damage to the right frontoparietal regions or anesthesia using the drug ketamine (which may influence the same circuits) removes this inhibition. As a result, you start leaving your body, even to the extent of not feeling your own pain; you see your pain “objectively” as if someone else were experiencing it. Sometimes you get the feeling that you have actually left your body and are hovering over it, watching yourself from outside. Note that if these “embodying” circuits are especially vulnerable to lack of oxygen to the brain, this could also explain why such out-of-body sensations are common in near-death experiences.

Odder still than most out-of-body sensations are the symptoms experienced by a patient named Patrick, a software engineer from Utah who had been diagnosed with a malignant brain tumor in his frontoparietal region. The tumor was on the right side of his brain, which was fortunate because he was less worried about it than he would have been had it been on the left. Patrick had been told he had less than two years to live even after the tumor had been removed, but he tended to play it down. What really intrigued him was much stranger than either he or anyone else could have imagined.

He noticed that he had an invisible but vividly felt “phantom twin” attached to the left side of his body. This was different from the more common sort of out-of-body experience in which a patient feels he is looking down on his own body from above. Patrick’s twin mimicked his every action in near-perfect synchrony. Patients like him have been studied extensively by Peter Brugger of the University Hospital Zurich. They remind us that even the congruence between different aspects of your mind such as subjective “ego” and body image can be deranged in brain disease. There must be a specific brain mechanism (or dovetailing suite of mechanisms) that ordinarily preserves such congruence; if there weren’t, it could not have been affected selectively in Patrick while leaving other aspects of his mind intact—for indeed, he was emotionally normal, introspective, intelligent, and amiable.¹⁰

Out of curiosity I irrigated his left ear canal with ice water. This procedure is known to activate the vestibular system and can provide a certain jolt to the body image; it can, for example, fleetingly restore awareness of the paralysis of the body to a patient with anosognosia due to a parietal stroke. When I did this for Patrick, he was astonished to notice the twin shrinking in size, moving, and changing posture. Ah, how little we know about the brain!

Out-of-body experiences are seen often in neurology, but they blend imperceptibly into what we call dissociative states, which are usually seen by psychiatrists. The phrase refers to a condition in which the person mentally detaches herself from whatever is going on in her body during a highly traumatic experience. (Defense lawyers often use the dissociative state diagnosis: that the accused was in a such a state, and that she was