Switched On

by John Elder Robison

Speech

  ONCE THE FIRST TMS study was complete, I learned that the frontal lobe regions Shirley and Lindsay had stimulated were associated with Broca’s area, a region neuroscientists believe to be the seat of language in humans. The before and after exercises we did measured aspects of speech, and they picked up some changes. My voice became more expressive, with more tonal range and more change in rhythm or prosody. Several other people in the study saw similar benefits. But the big effects from those stimulations—to me—had very little to do with talking. For me, the impact was all about sensing and feeling emotion. That leads me to wonder if the function of Broca’s area is not as well defined as neurologists believe. Some scientists are asking the same question after observing near-normal language in people with major damage to their speech centres.

  Alvaro and his researchers also thought Broca’s area controlled more than just speech. They had chosen to stimulate there because of Broca’s relationship to mirror neurons. Broca is one of the key parts of the brain’s mirror neuron system, which is tied in turn to social interaction. According to Lindsay, that’s probably why I had such strong emotional responses to its stimulation.

  Broca’s area is a region in the left frontal lobe named for Pierre-Paul Broca, a French physician of the mid-nineteenth century. Dr. Broca examined the brains of patients who died with language impairment from stroke, disease, or injury, and he discovered a strong correlation between lesions or damage to the part of the brain that now bears his name—whose function was previously unknown—and the ability to speak. This marked a major milestone in our understanding of brain organization.

  Damage in that region seemed to produce deficits in language, which is now diagnosed as Broca’s aphasia, or expressive aphasia. The researchers in the TMS lab had devised some novel theories about how the regions around Broca’s area might be interconnected, and specifically how they might be differently connected in autistic people.

  A burst of high-frequency TMS pulses applied over Broca’s area on the left side would shut down the ability to speak, Shirley told me. This wasn’t what they were doing in the autism study—what they proposed was a much subtler tweaking. But I was intrigued by her comment and didn’t let it go. “Did you actually try it yourself?” I asked her. It turned out that she had—in fact, quite a few of the researchers, as part of their training to work in the lab, had experienced the speech-suppression TMS. They offered to show me what it felt like.

  In an earlier conversation Alvaro had said he believed every scientist or doctor who administered TMS should know how it felt so she could relate to her patients. On a visit to the lab that summer, I got to experience that myself. The speech centre stimulation made for a safe yet very powerful demonstration. “It’s only temporary,” was the last thing I heard before the machine fired a burst of electromagnetic energy into the left side of my brain. With no more than a slight pop, language was gone. The vanishing was so complete, I didn’t even know what I’d lost because the entire concept of words and the ability to string thoughts together simply disappeared. One moment there was a dialogue playing in my head, a little voice saying, I wonder what’s going to happen when they do this. The next moment, the voice was gone. All that remained was feeling. The comfort of the chair, and a sense of familiarity with the people beside me.

  I was incapable of a realization like “I can’t talk!” since it consists of words. Without words I had ceased to be a creature of coherent logical thought. Instead, I lived in the moment with sound, sight, smell, and feeling. Some say that’s how a dog experiences the world, although dogs are much more reliant on their sense of smell, which is far better than ours. And of course they are capable of barking.

  Did I truly become like a dog in the blink of an eye? I couldn’t have told you in the moment, because all vocalization—speaking or barking—was suppressed. But as I remember it, my ability to understand spatial relations—and complex things—remained intact. I know that because I looked around the lab at drawers and doors and felt a familiarity with their function while my mind remained mute. Opening a door was still a familiar idea to me, even if I lacked the words to describe it. For the brief time my speech was suppressed, I still recognized the physical world around me, and my mind still worked as before, just without language. To me, that shows that you don’t have to know the word “camera” to pick one up and take a picture. That said, I would be mighty impressed if Oigy, our Imperial War Pug dog, started using my camera, no matter what kind of stimulation we gave her.

  But were we so different, my pug and I? If I’d been without words all my life, like Oigy, how could I have grasped the concept of a puzzle or a camera? Though words aren’t necessary to do things like open doors or use complex tools, how could I have learned those skills in the first place if I lacked the words to understand my teachers? That brief insight into life without language gave me a lot to think about.

  I’ve always felt I learn best by doing. And learning by doing could probably take me reasonably far with no words at all. I surely could have learned to use a saw, hammer, and nails and done basic carpentry without language. But I can’t imagine how I’d ever learn something as complex as electronic circuit analysis without words to put the technology into perspective.

  So there I sat, fully aware but wordless. In my newly altered state I felt many things in rapid succession, but fear was not among them. There was a curiosity that something had happened, though exactly what that was eluded me. As the effect of the TMS wore off, language returned, and with it a sense of wonder that such a profound change could be wrought so easily and so completely.

  “What if language had never returned?” I asked, once I could speak again. I thought I’d been silenced for a matter of minutes, but Lindsay assured me it was only around thirty seconds. And I wouldn’t have stayed mute, she explained, because the paths of language are very deeply ingrained in my brain. We may disrupt them for a moment, but it would take far more than a brief stimulation to remove them for good.

  Later on we would learn that autistic people experience more profound and more lasting change from TMS than non-autistics do. Lindsay researched that issue in several studies that I took part in, the most recent of which ended in 2014. She believes autistic people have more brain plasticity, which causes us to change more, and to stay changed longer, in response to life events. That may also explain why a stimulation that had a brief and minor effect on her might have a much different impact on me, and why I felt it lasted a lot longer.

  It was strange that under the influence of that stimulation, it had never crossed my mind to be scared. I’d even felt a sense of peace. Was “scared” just my speech centre talking, expressing its own primal fear that the little man in my head might finally be silenced? Would the rest of my mind care?

  Loss of language, as I experienced it, was immediately replaced by the expansion of something that was always there—a holistic understanding of the natural world through sight, smell, and sound. That background is there for all of us, but it’s usually overpowered by the words flowing through the thing we call consciousness. Some might say the state I was in was akin to one of meditative bliss. I felt one with the world around me, freed from the strictures of logic and spoken language. Yet meditative bliss is a state that’s pursued and attained voluntarily. Loss of language is no one’s goal.

  Try to imagine living your whole life that way. You can’t, really. Because living without language would mean living without the thoughts required to form those words.

  Still, after pondering the experience and the questions it raised, I ended up with more questions: Does being without speech bring us closer to a natural world or a spiritual one? Might such a revelation—if that is the word for it—become visible after a time of not talking? Is this the reason monks and other spiritual devotees take vows of silence or spend time in silent retreat?

  As Lindsay pointed out, all of my philosophical musings were based on one brief experience during which I gave up speech
voluntarily. She didn’t think there was any comparison between that experiment and being born with major language impairment.

  “Where would you be today if you’d never developed the ability to speak or understand language?” I had to concede she was right—and that was a scary prospect to think about. Most everything I’ve done to achieve and maintain independence has been founded on reading or hearing instructions and taking the words to heart. Without language, I’d have been left with observation and imitation, and I don’t think that would have taken me anywhere near as far in comparison.

  That was perhaps why she saw her own experience with speech-suppression TMS in such a different light. Whereas I accepted whatever happened, she resisted it. As soon as her speech was suppressed, she tried to speak. She thought she was talking, but no words came out, and she didn’t like that realization one bit. “I can’t believe you thought it was tranquil,” she told me. “I thought it was incredibly powerful and scary.”

  It was fascinating to consider how differently we had experienced the very same stimulation. The brain is a mysterious thing.

  A More Subtle Result

  EVEN THOUGH THE study ended, I continued visiting the lab, to talk and learn more. When I look back on that time, it’s amazing to observe how the effects of a dozen half-hour TMS sessions had come to dominate my thinking. Before we began I’d believed my intelligence and my senses were largely immutable and unchangeable. The experiments had shown me how shortsighted that view was. After experiencing TMS it was hard not to think that anything was possible, if only the doctors knew where to aim the coil. The researchers were already planning follow-up studies, and I was proud to be able to offer some thoughts about them. I wanted to know if I could recapture the greater insight I had experienced briefly. Alvaro, Lindsay, and I talked a lot about that through the summer of 2008.

  I’d been a passive participant in the original research, letting the scientists stimulate whatever area was next on their agenda. Now I took the lead, or tried to, by asking them to “hit that area that made me see emotion again.” At first they were reluctant, saying I’d completed that part of the study and they could not do it again. As a research subject, you are expected to accept that. But Alvaro and I discussed the fact that the tests they had devised in the first study had totally failed to capture the greatest effects TMS had had on me. Though research scientists generally can’t deviate from the original study protocol that they present to the hospital’s ethics board, Alvaro was also a medical doctor who treated patients. That gave him more latitude.

  As it happened, the crew in the TMS lab were already contemplating a follow-up study to try to measure some of the effects the first study had missed. Alvaro agreed to speed that up a bit and try it out on me. When doctors use a tool like TMS in ways that are not FDA approved it’s called “off-label.” That’s what my next session would be—the hospital’s first off-label use of TMS to treat autism, one whose findings would guide a larger study.

  I was excited and hopeful but also a little bit afraid as I returned to the lab on August 12, the day before I turned fifty-one. The possibility of pain or medical catastrophe didn’t scare me anymore, but I was still preoccupied with the “zero-sum game” idea, the thought that enhancing my emotional sensitivity could somehow dull my mechanical awareness. In the absence of any proof one way or the other, in the months that had passed that idea had taken firm root in my mind. My new emotional insight seemed like just such a trade-off, given the emotional fragility I’d also had to contend with. I’d quickly learned that it takes practice to handle the strong emotions. In the three and a half months since the study had ended, I was starting to realize that the old maxim “Ignorance is bliss” might well apply to my former autistic blindness, with respect to reading emotions in certain people.

  Then there was the question of what would happen when we stimulated an area that we’d targeted already. Every other TMS session had stimulated fresh territory in my brain. We’d never tried hitting one spot repeatedly, though in their depression treatment they’d found that repeated stimulation of an area made the effect last longer.

  With that in mind, Lindsay and Shirley planned to reenergize the part of my brain that had precipitated the hallucinations and insight into others. This latest stimulation would be essentially the same as the one before, but there would be an important difference. The first time, my brain may have been primed by the TMS session that had preceded it. Now, it had cooled off for several months and the effects of this experiment would be from the single treatment alone.

  When I got to the lab, they immediately set me to work at the computer screen with a battery of tests I’d never seen before. I looked at stick figures, and at photos of whole people and faces on the computer monitor. They asked me to “pick the identical expressions,” “recognize the sad face,” or “press a button to indicate what this person is feeling.” After three months of imagining myself to have more insight into people, their testing put me in my place. Seeing the images flash by on the screen and having no idea what they meant was a big disappointment.

  This time, though, I questioned the tests and not myself. You are different, my inner voice assured me. I recalled the number of people who had seen me and said, “You’ve changed! What’s up?” Those were people I knew casually; they had no idea I’d done the TMS but they saw a difference in how I related to them. Something must have changed to make those people comment. And it was a good difference—I could sense that myself.

  Yet I knew I was failing the tests Shirley and Lindsay had devised for me. What were the differences between real-life social interactions and the experiments in the lab? I asked myself. The lab environment was totally artificial. They’d set me before a computer that flashed faces with exaggerated expressions and then expected me to choose a word for what I saw: angry, sad, scared, disgusted, happy, or neutral. We started with a face flashing for 100 milliseconds—a tenth of a second—but that was too fast. It didn’t make any sense. “Why one hundred milliseconds?” I asked.

  Lindsay conceded it was a somewhat arbitrary choice. “We want to see you choose on instinct, not logic,” she said, “so we used a shorter time.” Meanwhile, I was unsure if I should blame their timing or myself for my inability to pick the right expressions. I thought to myself, Maybe after another TMS session I’ll get these. . . . Maybe it’s just too fast because I’m slow. . . .

  She adjusted the program to leave the faces up a bit longer and I did the tests again with a new set of faces. I still felt I couldn’t do it, and it upset me a lot. But was my newfound ability really lost? Had the comments on how I had changed been tapering off these past few months? First I had questioned their test; now I was questioning myself. I’d arrived at the lab excited but now I was scared, and anxious.

  Shirley and Lindsay tried to reassure me—“There is no failure on a test like this”—but I’d heard that line before and I knew there were right answers and wrong ones. There’s no such thing as a test where the answers don’t mean anything.

  For a long nasty moment it was as if I were back in high school and the people on the screen were other students making faces and ridiculing me. The one genuine emotion I’d recognized looking at those computer faces was disgust.

  In a few cases, I saw a fairly neutral face, and I picked “neutral,” but I thought they were brooding and a bit angry too, and most of the others seemed so exaggerated as to feel fake.

  Then I thought back to the earlier facial recognition tests I’d done in the lab. Back then when I’d looked at faces on a computer screen, I’d had no idea what I was seeing. This time I was recognizing a single emotion—disgust. And I was recognizing other expressions as “not disgust,” even if I wasn’t sure what they meant. Maybe I hadn’t lost everything I’d gained. One of my therapist friends told me that we often imagine catastrophe when we anticipate what’s ahead, and I knew he was right.

  We moved on to the TMS room, and I settled myself in the chair. Lindsa
y positioned the coil on my head and pressed the button. We were once again stimulating my frontal lobe, an area in front of my right ear.

  I gazed at the wall—at nothing in particular—as the pulses tapped away at my cranium. The familiar trance-like feelings of TMS returned, and I sat placidly through the stimulation. As soon as the session was done, I turned to the researchers. They had changed places during the session, so Shirley stood behind me, holding the TMS coil. At that moment, Lindsay was seated at the desk, working with the computer. Looking in Lindsay’s eyes I said, “Do I look any different?”

  “Maybe,” she answered. “You’re looking at me very intently.” Hearing her, I looked away, not wanting to seem rude or intrusive. I realized I’d been gazing into her eyes, and I’d sensed concern and curiosity. Was that what she was feeling? I was embarrassed to ask, as if I’d been peeking into a private space and I had no business remarking on it.

  I looked briefly at Shirley, and the feeling was the same. Was this what had happened before? So much had changed, it was impossible for me to tell. I turned to the desk, where their computer test was waiting. As in the original study I would do a series of tests, then receive TMS and do a similar set of tests right after.

  As I sat at the computer, looking at faces, I realized something was now different. I no longer felt a personal connection to what I saw. When I’d looked at the faces before TMS I felt that the emotions I saw—principally disgust—were directed at me personally. Now when I saw expressions of disgust and dislike, I felt as if I were seeing a stranger on the street looking at where a dog had just thrown up. They might have looked disgusted, but it didn’t mean anything to me.

  I also didn’t feel the undercurrent of disgust in as many of the expressions. Somehow, the test had troubled me before TMS but it didn’t bother me at all afterward. The TMS seemed to change how I perceived the expressions.

  Then they handed me another test—recognizing expressions from photocopies of eyes, some of which were deliberately grainy. On that test, I felt a definite improvement after TMS. Shirley said, “Look closely. Take your time,” yet I felt whatever reaction I had to the eyes almost instantly. Concentrating didn’t change my responses.