Unthinkable

by Helen Thomson

  It’s not clear what happened next. Graham remembers ringing his brother Martin in a panic; Martin phoned for an ambulance. Graham stayed in the hospital for weeks, cared for by doctors who initially diagnosed him with severe depression. But, unbeknown to them, his depression had morphed into something entirely different.

  “What happened while you were there?” I ask.

  “I just felt like I didn’t have anything in my head,” Graham says. “I was convinced that I didn’t have a brain, that I’d done something to it in the bath. It was blank. Just a blank mind.”

  “And that’s what you told the doctors?”

  “I told them that I didn’t have a brain no more.”

  These feelings persisted, while doctors tried to work out what was wrong. Often, they would attempt to rationalize. “Graham, how can you walk, how can you sit here talking to me, if you don’t have a brain?” they’d say. This dilemma puzzled Graham as much as his doctors.

  “It’s difficult to describe,” he says. “It was like my brain was a sponge that couldn’t hold any water.”

  He lists the side effects of death with surprisingly little feeling. “I didn’t really have any thoughts—no emotions. I didn’t feel anything. I couldn’t smell anything either. I lost my sense of taste. Even my favorite cigarettes didn’t give me any hit and I’d been smoking those since I was twelve. I gave them up just like that—normally I’d have been climbing the walls. Nothing gave me any pleasure anymore. I didn’t even remember what pleasure felt like. I just had this blank mind and I knew—I couldn’t say why—I just knew that I didn’t have a brain no more.”

  “And at no point did you think, ‘Okay, I know I must have a brain because I am sitting here breathing?’”

  “No. I didn’t know what to make of it. I didn’t know how I could breathe or talk when my brain was dead. I just knew it was.”

  This was the challenge that faced Graham’s doctors. He could speak, breathe and walk, but was unable to incorporate those abilities into a sense of feeling alive. How, then, do you convince a person that they are alive when they claim overwhelming evidence to the contrary? Graham’s doctors tried all sorts of pharmacological solutions, prescribing him antipsychotics and antidepressants, but nothing worked. A scan showed no problem with the anatomical structures in his brain, and no amount of psychotherapy made any difference.

  “It just reinforced what I already knew,” says Graham. “I told the doctors that my brain was dead—they may as well have been giving me Smarties.”

  They had reached an impasse: Graham wasn’t going to convince his doctors of his death, nor could he be convinced that he was alive. So they all agreed that he could return home under the watchful eye of a community nurse and his brother.

  Graham points to the couch. “I sat right there, just like you are now,” he says. “All day. For months. I didn’t have anything to think about, didn’t want to do anything, say anything, see anyone. Just stared at that wall. Like a vegetable. Somehow my body hadn’t realized my brain was dead. But I knew it was. Horrible really, thinking about it now. But that was that.”

  That was that. I close my eyes and think about this unpleasant possibility for a moment. “How did you cope?” I ask.

  “What could I do?” says Graham. “I was dead. I just accepted it.”

  * * *

  Although Cotard wrote extensively about patients like Graham, the medical community may have made a mistake in naming the disorder after him. In his book Mental Disorder in Earlier Britain,5 Basil Clarke touches upon the work of Levinus Lemnius, a Dutch physician. He describes some of Lemnius’s patients—one of whom sounded very similar to Graham. Was it actually Lemnius who was the first to describe the disorder, centuries earlier?

  To find out, I paid a visit to Cambridge University’s rare books room. It’s a large and almost completely silent room, save for the scratching of the occasional pencil across paper—pens are strictly forbidden here. My book was ready and waiting when I arrived: a tiny leather-bound thing, printed in 1581, entitled The Touchstone of Complexions by Levinus Lemnius.6

  Carefully, I carried the old book to the back of the room and placed it on a plush velvet stand as instructed. I was hoping to find mention of Graham’s disorder somewhere within its crinkled old pages.

  Lemnius was, by all accounts, a popular writer, having published work on astrology, length of life and occult mysteries. The Touchstone of Complexions was a sort of early pop-science account of different diseases and why they occur, and claimed to contain “most easy rules . . . whereby everyone may perfectly try and thoroughly know the exact state, habit, disposition and constitution of his body outwardly: as also the inclinations, affections, motions, and desires of his mind inwardly.”7

  Had Lemnius known that Cotard’s existed, he would no doubt have blamed it on an imbalance of the humoral system—such was the accepted medical understanding of his time. Indeed, the four humors—black bile, yellow bile, blood and phlegm—and an exposition on their importance in keeping the human organism in balance are the main subject matter of this tiny leather-clad book.

  In the final chapter, I eventually found what I was looking for. By this point, Lemnius had reached the brain and was spending some time on the different types of melancholy, paying special attention to patients who suffer from what he called “a depression of the spirits.” He picked out a particularly interesting case study. “A certain gentleman fell into such an agony, and fool’s paradise,” he wrote, “that he thought himself dead, and was in himself persuaded to be departed out of this life.”

  The friends and acquaintances of this gentleman tried flattering and scolding him in an attempt to restore him to his former strength, but nothing worked. He rebutted everything they had to say and turned away any food they offered, affirming himself to be dead, “and that a man in his state needed no sustenance or nourishment.”

  That sounded familiar. Doctors had tried to get Graham to eat and drink, but he’d told them he had no need. He wouldn’t have bothered with food at all if he hadn’t been forced to consume something each day by his family.

  When the gentleman in Lemnius’s anecdote refused any help, he ended up at the real death’s door, so to speak. At this point, his friends came up with an ingenious plan. They dressed themselves in shrouds—cloth normally wrapped around corpses—and sat at a table in his parlor, spread with several platters of food. Upon seeing his friends, the man demanded to know who they were and what they were doing. They answered that they were all dead.

  “What? Do dead men eat and drink?”

  “Yes,” they replied, “and that shall thou prove true, if you will come and sit with us.”8

  Apparently this peculiar brand of logic persuaded the man to feed himself rather well. Disappointingly, Lemnius makes no mention of whether he eventually recovered.

  Back in Graham’s mobile home, I tell him of Lemnius’s story. It seems to make him sad. He tells me that he owes a lot to his family, particularly his brother Martin.

  “He made sure I ate during the day,” he says. “He still comes to see me every day to make sure I’m okay. It must have been awful for him to see me like that.” (I later asked to speak with Martin, to hear his recollection of Graham’s illness, but he declined.)

  I ask Graham whether any of his friends knew anything about his condition.

  “No, I didn’t tell anybody. It’s kind of a weird thing to say to someone—‘I ain’t got a brain.’ My mates would have just said, ‘We’ve known that for years!’ I didn’t understand it myself, I couldn’t go around telling everyone I was dead. They’d think I was mad.”

  On the odd occasion that a case study of Cotard’s appears in medical texts, it is often accompanied by disturbing descriptions of the patient’s experiences. In one, a lady who believed she was in purgatory, having died but not yet moved on, poured acid all over herself, believing that to be the only way to rid herself of her body. This leads me to ask Graham, why, as the weeks turned i
nto months and then years, he didn’t try to commit suicide again.

  “I remember trying to work all that out,” he says. “I did consider it. It was awful really, but the thing was, I believed if I tried to commit suicide again, put myself under a train or put my head on the line . . . well, it’s like I told the nurse, I told her, ‘I’m sure my head would still be there, I’d still be able to speak because I’m already dead, so the train can’t really kill me.’”

  Luckily for Graham, medicine has progressed enormously since the days of the four humors. A few months after his Cotard’s began, Graham was referred to Adam Zeman, the neurologist who had orchestrated our initial introduction. Zeman consulted another neurologist called Steven Laureys at the University of Liège in Belgium, because, as he once told me with a smile, “I knew he liked weird things.”

  “How could I forget,” said Laureys, when I asked him about it. “It’s the one and only time my secretary has ever said, ‘You have to come and speak to this man because he’s telling me he’s dead.’”

  * * *

  If there are two people you want on your side when you think you’re dead, it’s these two. Over the course of his career, Laureys has performed some of the most fascinating experiments on the human mind—with somewhat startling results. His lab does all it can to understand, diagnose and treat people who suffer from disorders of consciousness. Occasionally that means discovering that people previously thought to be in a vegetative state with no awareness are in fact locked in—completely aware of their surroundings but with no way of letting anyone know.

  In 2006, Laureys and his colleague Adrian Owen developed a test to check whether someone in an apparent vegetative state could in fact follow orders, by inviting them to think about moving around their house or playing tennis. These two thoughts produce very different patterns of activity in the brain, which the team could identify using brain scans. Their first patient—a twenty-three-year-old woman who had fulfilled all the criteria for vegetative state after a road traffic accident—was able to produce the two patterns of brain activity on request. Later they discovered she was very much aware of her surroundings, despite not being able to move, because she was able to answer their questions by attributing the two different thoughts (thinking about moving around her house or playing tennis) to the words “yes” and “no.”9

  Zeman, on the other hand, has concentrated his career on understanding the more bizarre disorders of consciousness, such as permanent déjà vu, that can occur as a result of epilepsy, or more recently, insomnia-induced transient amnesia, whereby people who are severely sleep deprived—doctors, for example—perform complex activities like resuscitation, then completely forget they have done it. Together, the two neurologists have seen more kinds of consciousness than you might imagine could exist.

  It might sound strange to talk about different kinds of consciousness when most people think about either being conscious or not. But as we’ve seen in the previous two chapters, many aspects of our consciousness can take their leave. Tackling the subject of consciousness is not for the faint-hearted. It is a subject that the world’s most brilliant thinkers—psychologists, neuroscientists and philosophers alike—have spent many centuries struggling to explain. Most scientists believe that our consciousness, or sense of self, arises from the behavior of a vast assembly of brain cells that act in concert with the body. We can, in theory, map all this neural activity in complete detail and in doing so explain all our behavior entirely in terms of brain states. We can say, for instance, how the brain functions to produce memory and attention and colors. This is what scientists call the Easy Problem. But even if we understand the brain activity underneath all our behaviors, it still does not solve the Hard Problem—why this brain activity results in our rich experience of colors and sounds, or the way pain feels, or the experience of lust. Our conscious sense of self has stubbornly resisted all attempts to understand and describe its existence.

  The neuroscientist Anil Seth says that if we want to understand consciousness, we should aim our sights somewhere in between the Easy and the Hard Problem and investigate how certain properties of consciousness arise using measurable biological mechanisms.

  For instance, we can start by trying to pinpoint exactly what distinguishes a conscious brain from an unconscious one. Seth says it doesn’t seem to have anything to do with how many neurons are active. We know this because the cerebellum at the back of the brain contains far more brain cells than the cortex but can be completely missing without affecting consciousness at all. In 2014, a twenty-four-year-old woman was admitted to the Chinese PLA General Hospital of Jinan Military Area Command in Shandong Province complaining of dizziness and nausea. She told doctors she’d had problems walking steadily for most of her life, and her mother reported that her speech only became intelligible at the age of six. Doctors scanned her brain and immediately identified the source of the problem—her entire cerebellum was missing.10

  So if it’s not to do with the number of neurons, what else might distinguish the conscious from the unconscious brain? A landmark experiment by Adenauer Casali, at the University of Milan, and his colleagues recently tackled this question by stimulating the brain using short pulses of magnetic stimulation. When they did this to people under anesthetic or who were asleep but not dreaming, it created a wave of activity that flowed a short distance from the point of stimulation. However, when they did the same thing in people who were conscious, the wave traveled much farther over the surface of the cortex. Anil Seth later described this technique as being like banging on the brain and listening to it echo.11 Casali and his team have begun to use this echo to create what they have fondly termed a consciousness meter—a way of working out whether a human, or indeed any kind of animal, is conscious or not.12

  We can also pinpoint key brain regions responsible for consciousness. For example, there appears to be a group of regions toward the front and top of the brain, called the frontoparietal network, that are vital for consciousness to arise. This network can be further divided into two. Activity in areas along the outside of the frontal and parietal lobes seems to be correlated with our awareness of things in our external world—the smells, tastes and sounds around us. Activity in the second network, distributed among the inner parts of the two lobes, is correlated with our awareness of our inner self—the perception of our body and our mental imagery, for example. When we are concentrating on our external environment, we see the associated network increase in activity as the other decreases. The opposite holds true when we consider our internal self.

  In recent years, scientists have also questioned whether our consciousness needs something akin to an orchestra conductor—something that directs proceedings. One proponent of this idea was Francis Crick, a pioneering neuroscientist who early in his career identified the structure of DNA. Just days before he died in the summer of 2004, Crick was working on a paper with his colleague Christof Koch, at the Allen Institute for Brain Science in Seattle, in which he hypothesised that this conductor would need to integrate information rapidly across distinct regions of the brain and bind together information arriving at different times to make sense of the world. For example, information about the smell and color of a flower, its name and a memory of the date can be bound into one conscious experience of being handed a rose on Valentine’s Day.

  The pair suggested that the claustrum—a thin, sheet-like structure that connects to several other diverse regions—is perfectly suited to this job. The claustrum, deeply embedded toward the center of the brain, is rarely exposed to scientific investi-gation. However, in 2014, Mohamad Koubeissi at George Washington University in Washington, DC, and his colleagues were using electrodes to record brain activity in a woman with epilepsy when they realized that one of their electrodes was placed upon the claustrum.

  When the team zapped the area with high-frequency electrical impulses, the woman lost consciousness. She stopped reading the text she had been given and stared blankly into space
—she was awake but not aware; she didn’t respond to auditory or visual commands and her breathing slowed. As soon as the stimulation stopped, she immediately regained consciousness with no memory of the event. The same thing happened every time the area was stimulated during two days of experiments.13

  It’s difficult to say that one area of the brain is more important than another in triggering our conscious experiences. I like to think about it as a car: there are many parts of a car that are needed to make it run. Some are more vital than others—you definitely need petrol and an engine and a key or fob, for instance. Perhaps these parts of the car are like neurons, the frontoparietal network and the claustrum. Without one or the other you don’t have any consciousness. But there are several other aspects of a car that make it run properly—windshield wipers, a steering wheel, brakes—which I liken to the bits of the brain that help us have agency over our body, that integrate our internal and external worlds, that help us experience color and sound. When one of these aspects of the car goes wrong we can still drive, but something doesn’t feel right.

  * * *

  A waft of stale smoke inside Graham’s house reminds me of something he’d said to me in passing. Despite having told me that he’d given up smoking, he’d admitted that he would still occasionally smoke the odd cigarette, regardless of the fact that he didn’t get a hit from them.

  “Just for something to do, like,” he’d said.

  Something in Graham’s manner, in his recollection of this habit, puzzles me. Why, if you truly think you’re dead—you don’t eat, you don’t drink—would you bother having a cigarette? Unless, of course, you still had some kind of craving. It crosses my mind, probably as it had some of his doctors’, that I should be taking everything he was saying with a bigger pinch of salt. Just as this thought occurs to me, Graham reaches down to the bottom of his trousers, rolls up the hems and shows me his legs.

  “They all fell out you know,” he says.