Unthinkable

by Helen Thomson

  You can test this idea right now. Start by clenching the corners of your mouth. Slowly pull each side up. Then a little bit more. Now open your mouth slightly. Squeeze your cheeks up toward your eyes and there you have it, you’re smiling. Stay like this for a moment. Do you feel better? You should—scientists have shown that the physical act of smiling actually makes you feel happier. According to Damasio’s theory, the brain notices the muscle movements associated with smiling, attaches all the positive values it knows are associated with this reaction and creates the feeling of happiness.

  Recent studies have suggested that the brain region responsible for integrating all the information coming from our internal sensations is the insula—a fold that lies deep in the center of the brain. One promising theory suggests that information coming from the body is collated and integrated in the back and middle areas of the insula, before being re-represented by the front, or anterior, insula, which generates the feeling that pops up into our consciousness.

  “The anterior insula is the area of the brain that forms a default setting of “‘this is me here and now,’” says Nick Medford, a consciousness expert at Brighton and Sussex Medical School. Medford spends much of his time placing people in brain scanners and showing them pictures of grotesque surgery, filthy bathrooms and cockroaches—images designed to elicit aversive reactions. When we look at these kinds of highly evocative stimuli, the insula lights up with activity. When Medford showed fourteen people with depersonalization these images, however, he found a startling lack of activity, specifically in the left anterior insula, compared with people without the disorder. The study also showed some evidence that a region called the ventrolateral prefrontal cortex might also be involved in inhibiting the insula’s response to the gruesome images. This area is known to help keep our emotions in check; in people with depersonalization disorder, it seems to be overactive, or too controlling.

  Ten of the fourteen people with depersonalization in Medford’s study had their brains scanned again, four to eight months after receiving a drug used in mood disorders. Those who showed increased activation of the insula were the same people whose symptoms had improved. Those who showed improvements also had decreased activation in their ventrolateral prefrontal cortex after taking the drugs, whereas it was still active in those whose symptoms had persisted.8

  Medford figured that if people with depersonalization had a suppressed neural response to the world, then this would also be apparent in their body’s autonomic reaction to stimuli. In this context, the word “autonomic” refers to the things that happen in the body that we cannot control (the basis for Larson’s lie-detector test). Medford focused on skin conductance—a way of measuring when the skin momentarily becomes a better conductor of electricity as we become aroused. When this occurs, sweat glands become more active and conductance increases. Skin conductance is one of neuroscientists’ favorite tools since it allows us to gain an objective insight into our emotional responses: you can’t fake a sweaty palm.

  And neither could those with depersonalization. No matter how grotesque or displeasing a picture, people with depersonalization showed few signs of their body reacting.9 Somehow their body’s automatic response to the outside world has been dialed down, and is not integrated into subjective feelings about themselves or the world around them. But why does this create the sense that they do not own their own voice, or that the world has become unreal?

  It turns out the explanation might be related to something we have already come across—the idea that the brain makes sense of the world using predictions. As we saw in Sylvia’s chapter, the brain does not process every single aspect of the sensory input it receives from the body and the outside world; instead it makes a “best guess” at what these inputs might mean. If it makes an errant prediction, then it either updates future predictions or creates a perception of the world that better suits the input it is receiving.

  This prediction model might also explain depersonalization disorder. When everything is working well, the brain makes predictions about things that are happening inside the body and these match with the actual signals it receives. This culminates in feelings that can be attributed to “you.” If there is something wrong, however—a problem generating or integrating internal signals, say—then the predictions that the brain makes about the internal state of the body and the actual signals it receives don’t match up. Perhaps, to make sense of this confusion, your brain then attributes bodily signals and the feelings they produce as coming from someplace else. The result is the sense that you are no longer attached to your body or your thoughts, and that the world around you is going on without you being fully part of it.

  And once this peculiar feeling sinks in, it appears to be hard to avoid ruminating over it. This, in turn, can lead to our earlier paradox: despite feeling numb about the world around them, people with depersonalization can still feel an overwhelming sense of internal anxiety.

  * * *

  Her month in hospital was the last time that Louise wondered whether she was going mad. During that time she was referred to Medford.

  “I went into his office and told him about what was going on. I was so upset. I just felt like I was the only person in the whole world who was feeling this way, but he turned to me and told me that it sounded like depersonalization disorder. I just thought, ‘Oh my God, I’m not insane.’ It was such a relief to hear that it was a condition, that I wasn’t psychotic, and I didn’t have a tumor. It made it all a lot easier to deal with.”

  Some people with depersonalization find certain mood stabilizers can help control their anxiety, but they are not effective in all cases. Others, like Louise, find cognitive behavioral therapy works well. This generally helps those with depersonalization to break out of the vicious cycle of obsessively dwelling on the strangeness of their internal and external worlds, which can exacerbate their symptoms.

  Louise was also shown how to separate her depersonalization symptoms from those of anxiety and depression. “Now, when it’s at its worst, I handle it in a much calmer way. I tell myself it’s all right, it’s just a process happening in my brain, don’t panic. Nothing is wrong—I’m still me, that’s the important thing. Now when it happens, the rational side of my brain is quicker at responding to it, so that I don’t get the absolute panic that was there before.”

  Louise sits back on her barstool and we listen to the rain hitting the garage door for a moment. It is strangely peaceful, despite the noise and the bright colors all around us.

  “I’m not saying that I’ll never freak out about it again,” she says, “but I feel like I’m prepared for it now, so I don’t think it’ll ever get as bad as it once was. I’ve got my weapons now.”

  Suddenly little footsteps pad down the stairs and a semi-naked toddler waddles into the room.

  “Thank God, it’s not the same with Morgan and Martha,” Louise says quickly, and emphatically. “I’ve read about people with depersonalization completely dissociating from their emotions. I do have that with the people around me, but not with my children.” She stares at Morgan. “Never with them. They actually saved my life. If it wasn’t for those two, I would never have got through this and come out the other side.”

  AFTER SAYING MY GOOD-BYES to the children, I head outside and back into the pouring rain. I sit in the car for a while, watching the water slide down the windshield. It has a calming effect on me. A feeling that occurs only because of the seamless integration of my internal and external worlds. We may think with our brains, but as Aristotle argued all those years ago, we really do feel with our hearts.

  I find it incredible that our most basic feelings of existence are underpinned by an ability to sense the internal state of our body. And that being good at it can help us in so many ways. I wondered, Was there any means of getting better at it?

  It is often stated that meditation can help increase awareness of our internal body, but there is little scientific evidence to back this up. In fact, when Sa
hib Khalsa at the University of Iowa tested a group of experienced meditators who practiced either Tibetan Buddhism or Kundalini yoga, he found they were no better at detecting their heartbeats than nonmeditating subjects.10

  Many other experimental attempts to manipulate interoception have also proved ineffective. It seemed, for a while, that our interoceptive awareness was robust and unchangeable. However, in 2013, Vivien Ainley and her colleagues at Royal Holloway, University of London, showed that the solution may have been staring us right in the face.11 Her team asked forty-five participants to count their heartbeat while staring at a photo of themselves or at six words that described themselves, such as their first name, their hometown and the name of their best friend. The participants were significantly better at this task when looking at their own photo or staring at these words than when they looked at a picture of someone else or at six random words. It’s not yet clear why this works, but the team suggests that focusing on self-referential images and text may enhance the accuracy of interoception by shifting the brain’s attention from the outside world to the inside world via the insula.

  It has clinical implications: it might help not only people with depersonalization, but also people with more common disorders such as anorexia and depression, both of which have been tentatively linked to low levels of interoceptive awareness.

  Whether this kind of training will lead to persistent levels of increased interoception is yet to be investigated. But when we’re surrounded by a growing industry of brain-training apps and smart drugs that promise to give you a competitive edge in this world, I like the idea that we might be able to make better decisions, improve our attention and become more empathetic—simply by looking in the mirror.

  Graham

  Waking Up Dead

  Turning off the main road and into a maze of one-way streets, I eventually find the entrance I am looking for. I pull up, climb out of the car and stand, watching an old man in a white baseball cap furiously squirt weedkiller onto a patio tile. He holds his back as he straightens up to take aim from another angle.

  When he turns to look at me, I quickly walk away, embarrassed to be caught staring. I’m surrounded by aisles of mobile homes propped up on bricks—their yellow, blue and brown cladding faded, a casualty of harsh British winters. Today, however, the sky is blue and I can hear the squawk of sea gulls hovering nearby. Following an unpaved path farther into the estate, I finally spot my destination in the distance. Outside a tiny brown home a man is standing, hands in pockets, clearly waiting for somebody. His face is turned away from me and I slow down, momentarily delaying our introduction.

  Suddenly, the man turns and looks in my direction. “Helen?” I smile nervously and nod my hello.

  I have no idea how to begin this particular conversation.

  Graham is fifty-seven but looks older. His face is freckled and weathered, he has several days of stubble and his hair is receding evenly toward the top of his head. He is wearing tracksuit bottoms and a thick hooded fleece pulled up tight around his neck. I can see his pride and joy, an old maroon Jaguar, parked prominently on his front lawn and know that somewhere across the estate are both his ex-wives, one of whom he still cares for deeply.

  I follow him into his tiny home. The porch smells of smoke, and odd bits of carpet line the floor. He leads me through a miniature hallway and points to a faded leather couch.

  “Make yourself at home.” He has a surprisingly soft West Country accent.

  “Right, thanks.”

  I sit down, and try to muster some sort of tact. “So,” I say, as he joins me in the living room, “you used to think you were dead.”

  * * *

  If there was ever a brain that deserves to be in these pages, it is that which makes a person believe they are dead. I first came across the condition in 2011, during an interview with Vilayanur Ramachandran, whom Time magazine had just placed on its list of one hundred most influential people in the world.

  We were both in San Diego to attend the Society for Neuroscience’s annual meeting, one of the biggest science conferences in the world, and I had been given the rare opportunity of a face-to-face interview.

  Thankful that he had remembered to turn up—he has a notoriously terrible memory—I quickly whisked him out of the press room and into a small adjoining corridor. As we walked, he turned to me. “You know, there are these patients who believe they are dead. They say they can smell rotting flesh but that there’s no point in suicide, because why bother when they’re already dead?”

  It was his idea of small talk. I looked at him in surprise.

  “Yeah,” he said, his eyes twinkling, “it’s really spooky.”

  WHILE HUMANS BEGAN IMAGINING this scenario centuries ago—corpse-like creatures were the mainstay of the Viking afterlife, and draugrs were the undead bodies of Norse mythology—Ramachandran was in fact referring to a clinical delusion of death that is known as Cotard’s syndrome, sometimes referred to as walking corpse disorder.

  The medical literature rarely mentions Cotard’s, but when it does, it always refers to the French neurologist Jules Cotard as the father of the condition, the person who first described it during the 1880s and by whose name it later became known.

  The young Cotard was said to have a “serious and reflective” personality.1 After studying at the Faculté de Médecine in Paris, he became close to the French philosopher Auguste Comte—a friendship thought to have sparked his intense interest in the mind. In 1864, Cotard became an intern at La Salpêtrière, a teaching hospital in Paris, famed for producing some of the world’s greatest neurologists. There he became “a passionate student for . . . madness in its multiple forms.”2

  After a short time performing military service during the Franco-Prussian War, Cotard returned home, where he spent several years in a psychiatric clinic, later opening a clinic of his own in Vanves, a small but densely populated suburb of Paris. Having had the opportunity to study psychiatric disorders from all corners of the country, Cotard became particularly intrigued by severe delusions. It was then that he first described patients with “délire des négations,” which he characterized as a type of melancholic belief that leaves a person feeling as if certain parts of their body or aspects of their world have died, or in its most extreme form that one does not exist at all. In 1882, he wrote a chapter for the Archives de Neurologie, which paints a vivid picture of the condition. “Patients,” he said, “have no entrails, no brain, no head, they no longer eat, no longer digest, no longer dress, and in fact, they resolutely refuse food and often retain their faecal matter.”3

  Some, he added, believe it is their intellectual faculties that have died, that they are being transformed into halfwits, are prevented from thinking, are being told nonsense, and on occasion they even consider that their intelligence has been removed. Sometimes the delusion can relate to the outside world, in which “patients imagine that they have no family, no country, that Paris has been destroyed, that the world no longer exists.”

  No more than one hundred cases of Cotard’s syndrome have since been identified. At least five of these, and probably several more, were described by Cotard himself in lectures and papers he produced throughout his career.

  One particular patient of his was the rather exotic-sounding “Mademoiselle X.” When Mademoiselle X was asked what she was called, she said that she did not have a name. When probed, she claimed she used to be called Catherine, but wished to speak no further about how she had lost her name. She said she had no age and had never had any parents. When Cotard asked Mademoiselle X, and others like her, if they suffered from headaches, stomachaches or any pain in the body whatsoever, they answered simply that they had “no head, no stomach, no body.”

  Cotard also wrote about Madame C, who claimed that her throat had been removed, that she no longer had a stomach or any blood. Monsieur C (no apparent relation) refused to wear any clothes because his whole body was no more than a large nut. Monsieur A believed that he had no penis,
no testicles, in fact “no longer had anything at all.”4

  When I started this book, I thought a lot about what Ramachandran had said. I asked several doctors whether they had heard of the condition. The few who had, said they’d only ever read about it, and that the people who suffered from it had either passed away—in the more traditional sense—or were dotted around the world in psychiatric care homes, having never fully recovered.

  Then one day, out of the blue, along came Graham. He had been a patient of Adam Zeman, a neurologist at the University of Exeter. Zeman told me that he had been treating Graham, who had suffered from Cotard’s for many years, but was now apparently in “good fettle” and entirely happy to talk to me.

  A few weeks passed while we got the go-ahead from Graham’s psychiatrist, and then, as promised, Graham’s telephone number landed in my inbox. Which is how I came to be sitting on a leather couch, miles from home, listening to a middle-aged man talk calmly about his recent death.

  * * *

  “So, you used to think you were dead.”

  “That’s right,” Graham says, lowering himself onto the couch opposite, seemingly quite at ease.

  In the 1990s, Graham lived in this same mobile home but led a very different life. He had two children and only one ex-wife. He worked for a company that provides drinking and waste water for a corner of England. He was a contractor, installing water meters. He was going through his second divorce, and over time became severely depressed. He stopped going to work, avoided his friends and rarely left home. One day, Graham ran a bath for himself, and stepped into it, holding a plugged-in hairdryer.

  “Was there something that happened that tipped you over the edge?” I ask gently.

  “I don’t think so. I was just so low, you know. I don’t know how I could have got so low. I don’t really like to think about it,” Graham replies.