Unthinkable

by Helen Thomson

  “What did?” I ask, taken aback.

  “My hair. I used to have nice hairy legs.”

  “What, and now you don’t?” I say, staring at his naked ankles.

  “Nothing! They all fell out. Just like a plucked chicken.”

  There is a moment’s pause.

  “I should probably become a diver,” he says, his face breaking into the first smile I have seen that morning.

  “What did the doctors say?”

  “They couldn’t explain it. They couldn’t explain any of it. I kept on telling them that I’d fried my brain in the bath. But they just wouldn’t listen.”

  And just like that I believe in him.

  Zeman, on the other hand, had been convinced of the legitimacy of Graham’s claims the moment he met him. “I believed him, yes, absolutely,” he told me when I later admitted that I’d briefly had my doubts.

  Laureys had needed more convincing. “He’s saying his brain is dead. It’s very strange when you interact with him, you think it’s impossible that he believes this. Of course you think twice; you think, is he tricking me?”

  Both researchers, however, were sure of one thing: they needed another look inside Graham’s brain. Something had altered Graham’s sense of self, and they wanted to find out what.

  INSIDE THE CYCLOTRON RESEARCH CENTER at the University of Liège, Graham was placed into a machine that resembled a giant white doughnut. There his brain was analyzed using positron emission tomography, more commonly known as a PET scan. This type of scan monitors all the metabolic activity in the brain—that’s all the different cellular processes that are going on at any one time. You’d expect to see quite a lot of activity in someone who is awake.

  “What we saw was shocking,” said Laureys.

  Metabolic activity across large areas of Graham’s brain was so low that it resembled someone who was asleep or in a coma.14

  “I’ve never seen anyone who was on his feet, who was interacting with people, with activity that low,” Laureys said. “And I’ve been doing this a very long time. Seeing this pattern in someone who is awake is quite unique to my knowledge.”

  With what’s known about echoes and the amount of activity that should be taking place around the brain of someone who’s conscious, it just didn’t add up. When Zeman and Laureys wrote a paper about Graham, they entitled it “Brain Dead Yet Mind Alive.”

  While there was nothing wrong with the structure of Graham’s brain, his PET scan had shown something very different. First, his frontoparietal network was low in activity. But there were two other regions of the brain that were also problematic.

  The first was what’s called the default mode network: a collection of neurons that form part of the frontoparietal network but also include some regions of the temporal lobe. Our default mode network is switched on when we’re not concentrating on anything. It’s associated with mind-wandering, daydreaming and self-referential thoughts. It allows us to think about ourselves, to recollect our past and plan for our future. This ability to think about the things that are happening to us helps us make sense of the world. For instance, right now I can smell bread because I put my bread maker on a few hours ago. I can hear a strange clicking behind my head because my neighbors are doing DIY. My back is aching because my posture is bad and I’ve been hunched over my computer for too long. My world is making perfect sense. I have my default mode network to thank for that. Graham’s default mode network, however, was barely functioning—which might explain why he had such a reduced sense of self. But why did he come to the conclusion that he was dead?

  You might think that believing in your own death, despite the presence of overwhelming evidence to the contrary, would require exceptional effort. But perhaps not. The brain hates to be confused. Just as we have seen many times in the book already, when the brain is faced with conflicting information, it tries very hard to make sense of the new scenario, and generally lands upon the simplest narrative to explain an abnormal experience. It’s just like the rubber-hand illusion that we saw in Matar’s chapter: when we see a brush stroking a rubber hand and feel that same brush stroke on our own hand, our brain comes to the conclusion that the rubber hand must belong to us.

  We can demonstrate just how easily the brain can fool itself in people who have a split brain, which happens when their corpus callosum—the region of tissue that connects the two hemispheres of the brain—is severed. This is usually because it has been surgically removed to treat epileptic seizures. Unfortunately some of our abilities are located in just one side of our brain. As we’ve seen earlier in this book, our basic language skills are normally controlled by an area in the left hemisphere. Because split-brain patients don’t have any nerves connecting the two hemispheres, they cannot pass information back and forth between the two. So if you show them something only in their left visual field—which is processed in the right side of the brain—they won’t be able to describe it because the information won’t be passed from the right side of the brain to the language centers in the left. Let’s say you show their left eye a picture of a snowy field and their right eye a chicken. Then get them to pick two corresponding images. In this classic experiment, the split-brain patient usually picks something like a snow shovel and a chicken’s claw. But ask them to describe why they picked each picture and their answer is unusual—they would say something like “I picked the shovel because I could use it to clean out the chicken coop.” The language area of the brain has access only to what the right eye has seen—the chicken—and has made up a story for why they have picked a picture of a shovel. Here, then, you can see just how easily one’s own brain can tell tales, albeit ones it believes are perfectly true.

  Simply put, Graham’s conclusion that he was dead was likely the most straightforward narrative to explain his bizarre new experience of the world. Once he had come to this conclusion, though, why did he not dismiss this ludicrous idea out of hand? In order to do so, Graham would have to use the brain systems that allow us to evaluate our beliefs. Various pieces of evidence suggest that these brain systems exist in the right dorsolateral prefrontal cortex—the second area of Graham’s brain that was particularly low in activity. As Zeman explained it to me: “How can you rationalize with someone if the part of their brain responsible for rationalizing has become irrational?”

  I ASK GRAHAM what he thought of his brain scans when he saw them.

  “I didn’t think anything,” he says. “I’d never seen one before, I didn’t know what it showed, just that it showed I had this thing they called Cotard’s.”

  Whether this label gave him any solace is unclear. While it told him that the doctors understood he had a disorder, it didn’t give him any self-awareness or new tools to cope with the problem.

  “It didn’t change the fact that I thought I was dead,” he says. “It was just a word that they used to describe my weird brain.”

  In the year that followed, Graham spent most of his time either at his mother’s house, or sitting staring at the wall in his tiny mobile home. There was only one other place he would visit—the local graveyard. Sometimes, he tells me, he would spend the whole day there.

  “I just felt it was where I ought to be, you know?” he says.

  He would walk around the graves, trying his best to understand his overwhelming urge to be buried.

  “It was the nearest thing to death that I could get. I thought, ‘I’m brain-dead anyway so I’m not going to lose out on anything, I might as well stay up here.’ I felt like I was at home there.”

  On more than one occasion Graham would go missing and his worried family would call the police. Each time they found him in the middle of the cemetery, happy to spend the rest of his days in a place dedicated to the dead.

  * * *

  At that very moment, on the other side of Europe, there was someone who could sympathize with Graham’s condition. She was a middle-aged lady, let’s call her Mary, who had just been rushed into Karolinska University Hospital i
n Stockholm, screaming.

  The doctors and nurses were unable to calm her and she refused to tell them what was wrong. Mary’s medical notes showed a history of kidney failure and that she’d recently been treated for shingles with an injection of acyclovir. Her doctors decided it was best to put her on dialysis, which would wash out any toxins that may have built up in her blood and that might be causing her pain. An hour later, Mary had found her voice. She said the reason she was so upset was that she was sure she was dead. The doctors tried to reassure her and continued her dialysis. Two hours later, she said, “I’m not quite sure whether I’m dead anymore but I’m still feeling very strange.” After another two hours, the woman told the staff, “I’m pretty sure I’m not dead anymore . . . but my left arm is definitely not mine.” Within twenty-four hours, her nihilistic delusions had all but disappeared.15

  The Swedish pharmacologist Anders Helldén and his colleague Thomas Lindén were intrigued by Mary’s experience. Helldén said he had started to notice other cases of transient Cotard’s, appearing and then disappearing in several patients with kidney failure. He scoured Swedish medical records and discovered eight people who had been in an identical situation over the past three years. They all had a similar story—some kind of kidney failure and treatment with a drug called acyclovir injected directly into their blood supply. You might recognize the name: acyclovir is a common drug used to treat cold sores.

  When the pair re-analyzed samples of blood taken from all of the patients, they discovered high levels of CMMG, a molecule produced when the body breaks down acyclovir. Most patients had also developed very high blood pressure.

  I asked Helldén what he made of it all. “We have a feeling that CMMG is causing some kind of constriction of the arteries in the brain,” he said. Somehow, the parts of the brain affected by this constriction arouse in patients a transient belief that they are dead.

  I ASKED ZEMAN whether we could say for sure that Graham’s condition occurred as a result of his electrocution. Although it seemed far too coincidental to be much else, I know that such correlations don’t sit well with scientists.

  Zeman said that it’s impossible to say for sure: “Without stronger evidence—a before-and-after brain scan, for instance—we should be hesitant to say that Graham’s suicide attempt caused his delusions.”

  I wondered whether you might expect to see such strange activity in the brain of others with severe depression. Could Graham’s brain be an extreme example of this more common condition? The symptoms of depression are similar in many ways to Graham’s—hopelessness, loss of interest in life, lack of movement and a detachment from the rest of the world.

  The causes of depression are complex, and are yet to be fully understood, but the most recent evidence suggests that the condition may be a result of a lack of serotonin, which is involved in stabilizing mood, and a lack of glutamate, which causes the finger-like tips of neurons to become shriveled so they can no longer pass messages around the brain. I asked Zeman if he thought Graham could have been on the extreme end of this diagnosis, but he said he wouldn’t expect to see Graham’s brain changes in depression, even if severe. The pattern of low metabolic activity was much more acute and widespread than classically reported in major depressive disorders.

  “Of course, with a single case study, one can never be sure,” he said, “but Graham’s brain changes were exceptional.”

  There may not be causal evidence to prove that Graham’s electrocution triggered his disorder, but we do know that it’s not the first time a jolt to the head has led to Cotard’s. In the late eighteenth century, Charles Bonnet, whom we met in Sylvia’s chapter, wrote a brief report on one of his patients. He described her as an “honourable old lady of almost 70 years.” This woman was in her kitchen preparing a meal when a draft came through the door and hit her on the neck, causing her to experience sudden paralysis on one side of her body, “as if hit by a stroke.” For four days she was unable to move or speak. When her speech returned she demanded that her friends should dress her in a shroud and place her in a coffin since she had died. She became agitated when her daughter and her friends tried to persuade her otherwise and scolded them for not offering her this last service. Eventually, they did as she requested and laid her out in a shroud. She tried to make herself look as neat as possible, inspecting the seams and expressing dissatisfaction with the color of the linen. According to Bonnet, this woman slowly recovered, although her delusions returned several times a year.16

  It was with little fanfare that Graham’s delusions also eventually lifted. He can’t pinpoint the moment he first became aware that he felt better. Whether it was the right concoction of antidepressants, or just a matter of time, his delusions drifted away three years after they began.

  “At some point I just came to thinking this is bloody ridiculous, I’ve got to have a brain,” he tells me. Graham’s doctors put his recovery down to a combination of drugs and general brain repair. Graham was taking lithium, imipramine and amisulpride, which all modulate chemicals, including serotonin and dopamine, that are vital for controlling the passage of activity around the brain and in doing so can improve mood and help to treat psychotic behavior.

  “Gradually I just felt a bit more like myself,” Graham says. “Only sometimes I felt a bit dead—but most of the time it was just me again.”

  He pauses and takes a sip from a mug, which informs me that he is the “Best Grandad in the World.” He points to a picture on top of a side table and smiles. “Lovely my grandchildren are, good as gold.”

  “Do you see them often?” I ask.

  He seems surprised at the question. His simple, fairly emotionless answers to my questions so far had given the impression of him as being a bit of a loner.

  “All the time. I see them every week, go round for lunch on a Sunday and see them all.”

  “What about other people, do you go out much now?” I ask.

  “Not on holiday, I’m a bit old for that, but I go down to the club every week, see my mates.”

  “Do you still see your ex-wife too?” I say.

  “Yeah . . . every week.” He quickly adds, “The first one, not the second one.” His tone turns wistful. “I’m not sure what went wrong there to be honest. I should never have let her go.”

  Although I have been in his house all morning, talking about a subject that seems, to me, to be rife for self-examination, I am struggling to understand exactly how Graham feels about his strange experiences. He seems to find it difficult to express his feelings, and is somewhat disengaged from his past. At one point he tells me that he hopes his tale will help other people who find themselves in a similar situation—it’s a sweet sentiment, but he doesn’t seem to realize quite how unusual his experience was.

  “I suppose,” he says, when I point this out to him.

  I wonder whether this was just Graham. A man of few words. Or whether the lack of engagement is linked to his condition.

  “Do you feel any different now?” I ask him. “Did the Cotard’s change you in any way?”

  “Sometimes I wonder, am I different from who I used to be? I don’t know. Some of my mates sometimes say, ‘You ain’t your normal self today,’ and I think, ‘Am I not? Who am I? What’s different?’”

  He pauses again to consider the past, and I’m struck by what seems to be a moment of discomfort, the strongest emotion I’d seen so far over the memories of his condition. “It was just bizarre, you know, how could I have felt so odd?” he says. “Just sounds funny now I talk about it.”

  I wonder, not for the first time that day, whether Graham would ever truly understand the extent to which his Cotard’s had changed his life. The only thing he was sure of was his appetite. It never returned.

  “It’s the only thing that is left over from the Cotard’s,” he says. “I used to eat regular meals, now I could take it or leave it. I never feel hungry.”

  I ask him if that was it—an empty stomach, all that remained of the dis
order. He hesitates for a moment before answering.

  “You know, sometimes I still get funny thoughts now and then. I’m sitting there sometimes and I’ll suddenly feel a little bit dead. Just every now and then it happens, and then it goes away.”

  OUT OF THE WINDOW, I catch sight of Martin, arriving for his daily rendezvous with his brother and I gather up my stuff to leave. As I make my way back to the car, I spot the old man in the cap. He is back outside, squirting at another hardy weed that had popped up between a crack in the pavement. I wave at him and smile.

  I leave the estate and drive home deep in thought. Graham epitomizes everything that is so mysterious about consciousness and our sense of self. Here we have a man who can walk, talk and breathe—things that should capture the essence of being conscious—yet for some time, those basic aspects of life were not enough to create a full sense of existence. It is desperately frustrating that the one thing we are unable to comprehend is our ability to comprehend anything in the first place. Perhaps it is because, as the late philosopher Gilbert Ryle put it, “in searching for the self, one cannot simultaneously be the hunter and the hunted.”17 We will always find it hard to examine our own mind when it is the thing that is doing the examining.

  We might never solve this mystery. But I take solace in the fact that disorders like Cotard’s offer a little glimmer of hope that this may not be the case. For instance, as a result of Helldén’s acyclovir studies, there is now (in theory) a way to turn Cotard’s on and off at will. Alone, it won’t reveal the wizard behind the curtain, or give us all the answers we seek, but it might just propel us another step forward in the endless voyage toward understanding the most complex mystery of the human brain.

  Joel

  Feeling Other People’s Pain

  Joel Salinas was minding his own business in a lecture theater when he felt someone’s hand around his throat. The sensation took him by surprise. It lasted for just a second, before he noticed the lecturer standing at the front of the theater. He had his hand around his throat, and was rubbing it softly. It’s times like that, says Joel, when this weird trait can really catch you off guard.