Technology has evolved considerably since my first years in the Medical Center and, as we all know, the speed of that evolution is itself increasing. Today any reasonable 10-year-old can remember a time before the first iPhone. I can myself recall an even worse epoch when there were no cell phones at all, not even flip phones. In those days, I knew the location of every single telephone booth there was along the corridor between my house and the hospital—and along both sides of the road–because when my beeper went off, I had to find a pay phone in a big hurry to call in. This made for skittish driving when I was on call. And not just me: I know of accidents–one of them grimly fatal–that occurred when a colleague’s beeper went off on the drive home, or on the drive into work, and good road safety was challenged by the programmed, urgent need to find a telephone. Continue reading “Handguns”
Most of us in our post-industrial world spend a remarkable fraction of our mental powers just trying to stay organized. I wake up in the morning, and before I throw the covers off I’m already starting to reconstruct my schedule. Who am I supposed to see today? What am I doing for lunch? Where did I put my beeper? What are my afternoon meetings? Do I have time to get gas in the car? What is the name of the security guard who buzzes me onto the in-patient unit? What is my password to the ATM? What was I supposed to tell the Volvo mechanic about that leak? What’s my password to my work computer? Wait, do I have change for the tolls? What’s my iTunes password? What’s my email password? None of this stuff is particularly fun to remember–just required learning that has to be exercised a hundred times a day to allow access to what we actually do for work.
That sort of instrumental retrieval is different than those unpredicted events of recall–like when the name abruptly pops into my mind of that song I woke up hearing in my head this morning: “A Good Woman’s Love.” I haven’t thought of that song in two decades until this morning, and who knows why I thought of it then. I can randomly pull other things out of my memory–for instance, where we buried our dog Amos in the back yard. I recall breakfast with my father, who always ate two runny poached eggs, with black pepper, and two pieces of toast that my mother made for him. I can still smell that pepper. He would be wearing his khaki Marine uniform, and a brown tie with a Windsor knot. At the dinner table, once in a while, something would prompt him, and he would start reciting the first 100 lines or so from the Prologue to the Canterbury Tales–in Middle English–because that was the sort of thing he was asked in high school to learn. That was his memory task in his day, which–given who my father was–provided him with about as much intrinsic satisfaction as I am provided by recalling my computer passwords: just stuff he put into his head that stayed there.
I also remember how he enjoyed watching John Wayne westerns–‘Oat Operas’–, which later was another thing that popped into my head that morning as I strolled into a nursing home I consulted to. I was there to evaluate the mental status of an elderly man–let’s name him Paul– who had fallen down his basement stairs. His wife had found him unconscious at the bottom of the steps, called Emergency Services, and he was taken to the Medical Center to be evaluated for fractures and bleeds. Once he was cleared, and determined to be medically stable, he was then discharged to a sub-acute setting to provide some supervision and careful medical attention before he was sent home again. I was part of that careful medical attention. We wanted to be sure that the confusion he displayed upon regaining consciousness did indeed resolve as anticipated before we let him go.
In real life Paul had been a high school teacher, and I was anticipating a relatively benign interview with an educated, articulate adult who had spent his professional life trying to instill in others a respect, if not a regard, for the intellectual qualities of mental life. My kind of guy. As I stepped into his room, where I expected to find him, several things happened at once. I was startled to see that he was in fact not laying in his bed at all, but was crouching down behind it, sandwiched between the bed and the wall. This was unique in my experience. I have had people try to elope from hospital rooms, and even a few who have fought with whoever tried to come in, but I had not ever–either then or later–walked in and found someone who was trying to hide. And then I heard him start hissing at me, “Get down! Get down!”
Well, I’m no fool, there was space enough beside him behind the bed, so I bent down and scurried over to join him. He was still in his pajamas, and was sporting a huge bruise that engulfed his right eye and cheekbone, and extended to his forehead and toward his temple. I could see why he had been evaluated for a skull fracture: he had evidently hit his head really hard. When he saw me coming, he made room for me, so I squeezed down beside him, the two of us peering cautiously over the bedspread, and back out into the room. This could have been awfully silly, if anyone happened to see us. But he was so obviously terrified. You have to respect that sort of terror.
Or at least I do. I spent the next few heartbeats getting comfortable–I mean, I didn’t know how long we were going to be hiding behind the bed–, and also trying to get oriented to my new friend. I had elected instinctively to join him in his universe: I did not take him to be assaultive, or in any way dangerous. He was organized in his behavior, and inhabiting a legible, consensual world–even if I could not yet identify it. After all, he invited me into his place, and fully expected me to grasp what was at stake. He was also openly concerned for my safety–which prompted all that frantic hissing when I entered the room. He wanted to convey a sense of urgency without giving his position away. But I still didn’t know what was going on his mind. Was he psychotic? I didn’t really think so, but I also didn’t know what could have instilled such fear in this peaceful nursing home, full of old people in wheel chairs.
The bed was meant to protect us from someone or something that was roaming just outside our line of sight. So I quietly asked, “Where did they go?” Seemed like a logic thing to want to know.
He thought so too. “Indians,” he told me as he scanned the horizon with his one good eye. They woke him up, he told me, and had been shooting at him.
I have to admit that I was surprised by his answer–non-plussed, in fact, and almost speechless. I think partly because I’d joined him in his place of terror, I was just naturally expecting something closer to the sources of my own nightmares than Indians–like some creature out of Predator or Alien, some hideous being that would tear my arms off at the shoulder, and then start eating them in front of me. But I mean, Indians are just people, like all the rest of us. I can deal with people.
But his answer also meant that I had a glimmer of where he was, not only what planet he was hiding on, but which landscape on that planet. I was settling in.
“Where are the arrows?” I asked, pretending to look around us. My aim was to see if Paul could be redirected to his literal surroundings, enticed by the observable things around him into a physical environment other than, and in competition with, the mental place he was hiding in. As he glanced around to find them, his expression changed from fear to a puzzled, suspended look as he noticed the dresser, the tray table with the pills and magazines on it, and so on. As he saw these things, he also recognized that they were incongruous with the landscape he thought he was inhabiting. It began to feel like that scene in The Matrix, when Neo is given the red pill, and is then sucked out of the world he truly thought was real, into a world he definitely did not expect to exist. I was sitting right beside this guy, watching as he was swept from a Southwestern desert landscape in the 19th Century, and into a 21st Century New England nursing home.
As he sat there, holding his breath and trying to figure out what was going on, a nurse walked down the hallway outside the room, clearly visible from where we were behind the bed.
Should we warn the nurses? I asked–but by that time I was aware he had come with me all the way back into the material world of the nursing home, and that he, too, was aware of the remarkable discrepancy between what had been so persuasively real–all those arrows whistling by his head, the burning Conestoga wagons, the horses and the sounds of war–and the here-and-now noises of the nursing home with the chair alarms going off as an ancient person tried to stand up, who wasn’t supposed to because of the risk of falling.
My task at that point was, first, to cushion his panic, because he wasn’t all that sure he belonged in a nursing home any more than he belonged in a wagon train somewhere. And then, as he assimilated his surroundings with what he was beginning to remember about his accident and his several days in the hospital, his fear changed into a grave anxiety regarding what was happening to him. It was no longer a matter of one outer world morphing into a different one, but rather a question of his own interior sanity. Because he was aware that his mind was playing tricks on him.
The nature of those tricks was precisely what I was there to determine, in which he was as invested as I was. He began telling me how he came to hit his head: he had been going into the basement to start the laundry, and slipped on his wife’s bra, which had been tossed down the stairs to be washed, but had landed on one of the steps. He hadn’t seen it, and his feet went out from under him. He recalled some of his time in the hospital, though many of the details remained discontinuous. He couldn’t account for all the days intervening between when he fell, and when he started to clear in his mind. He remembered the trip in the ambulance from the hospital to the nursing home, which was embarrassing, because he had been so self-conscious as the attendants strapped him onto the wheeled gurney, maneuvered him through the public hallways of the hospital, out of the double doors of the Emergency Room with everyone watching, and into the waiting ambulance–and then performed a similar task in reverse to get him into his present room. Everybody remembers that trip, if they have ever had to take it.
What he could not figure out, however, was why he thought he had been participating in the Indian Wars in the American Southwest. And he was terribly afraid he would have further instances of these intrusive experiences. So was I, for that matter, because I could not determine from the way the evaluation was proceeding why he should have had that experience. His intellect was sound: cogent and reasonable. He was fluent in his verbal production, and he readily devised strategies to organize novel information, both verbal and visual. His attention span was variable, but that was to be expected given the head injury
And then we tested his memory, which was remarkable in its presentation. The volume itself of what he could recall was a little bit low for his age, but still within normative limits. However, he was experiencing a startling number of intrusions. He could not tell the difference between what he was formally asked to learn, and these extraneous details that would insert themselves in his memory, so that he thought he was recalling information that in fact he was making up without knowing it.
Here’s the way it works. Read a list of words to a person: sixteen words selected from four categories, four words to each category. There are fruits, items of clothing, vehicles and tools. But you do not mention to the person that there are any categories–just read the words in a random order. During the third of five trials, Paul recognized that the words could be grouped into categories; he perceived conceptual relationships, in other words, that would allow him to group similar words, and exclude those that were dissimilar. He was appropriately using his intellect.
However, after a delay, I read him a recognition list of words–about 50 of them. All of the words on the original list were included, but so were other unrelated words (birds, household appliances), as well as words that could be in one of those four original categories, but in fact were not on that list. There simply were other fruits and tools—none of which could he have learned since they in fact were never presented to him. His task now was to say whether any given word on this second list was also one of the words he had learned on that first list of 16 words. If it wasn’t on that first list, he was to say so.
The trouble was that Paul ‘remembered’ everything. Anytime he encountered a word that was within a category on that first list, he believed that he remembered it being present. That is, even though I never mentioned the word ‘apple’, he thought he remembered me saying that word simply because I did say ‘watermelon.’ Both are fruits. This is a major problem. He wasn’t mixing up categories, but he could not keep straight the different sources of the information that he was newly learning: when I happened to say one thing, and when I said something different. This meant that any given detail of information in his mind could be combined with any other bit of mental information to make a new experience–entirely new, a completely made-up story of events that he had no idea he was fabricating, but which he absolutely believed to be accurate. He was jumbling together information that he knew, regardless of the source from which he learned about it.
Just think about the implications here. If I cannot identify the source of my memory of velociraptors, then I’m going to be terrified to venture outside my house, because I do not want to be seen by roaming dinosaurs that will treat me as a slow-moving prey animal. I will know that I am in my own house, but also remember those velociraptors sprinting around outside, and so will keep indoors, and play it safe. In this way I change my behavior according to information that I have cobbled together from different sources of knowledge: my lived experience in my house, and my memories of dinosaurs that I have extracted from their fictional source (Jurassic Park), and inserted into a category of experiential information to which they do not belong.
In Paul’s case, just before he went to bed he had been shown a 1950’s movie about the Wild West, and when he woke the next morning, the events of the movie were mixed in among the compendium of his mental details, all assimilated into the particulars of his experience at large. He had vivid memories of the battle, the excited noises, people shooting and being shot, some of whom he now thought he knew. He remembered everything he saw–except the part about the source of what he was seeing: it was a movie, and not his lived experience.
The formal term for this sort of memory impairment is ‘confabulation,’ which at times can be very difficult to distinguish from psychosis. The most common problem with it, however, is to distinguish it at all. The person who is struggling with a confabulated memory does not know that he has a problem: he ‘feels’ his recall is clear and reliable, he relates his experience with notable confidence–indeed, with exactly the same confidence that your or I might tell about our time at work today, or who we met over lunch, and what we said. There is no intrinsic difference in the details of the memory; the difference lies in the various sources from which those details were extracted.
Paul recognized that he had a problem because the memories he had upon waking were so out of keeping with his room in the nursing home. And in this instance was he lucky. If he had been shown a different movie–say, a spy movie to keep him entertained that night–, then the presence of his fabrications would have been far less obvious, and perhaps impossible to trace. Who would ever know whether he had in fact worked under cover during World War II to aid escaping Jews? How would you test that out? You probably would want to interview family members, but that is not necessarily a reliable source. I know, for instance, that my own father was an officer in the European theater during WWII, but I don’t know much about what his actual duties were, or whether he also had unwritten orders he carried out under cover. He never told me his military secrets, and so I would be of no help to an inquisitive doctor asking me about the truth value of my father’s memories, if my father ever wound up in a nursing home with a head injury, which he never did.
In Paul’s instance, however, his memory complaints were evident, and so were the improvements he demonstrated over time, although truth requires me to admit he remained vulnerable to confusing combinations of memories for as long as I knew him. And indeed there were times when he again lapsed into his life in the great southwest, and regaled his grandchildren with tales of adventure. They spiced everyone’s life up, which isn’t always, you know, a bad thing.