Phantoms in the Brain: Probing the Mysteries of the Human Mind (23 page)

The Sound of One Hand Clapping

Man is made by his belief. As he believes, so he is.
—Bhagavad Gita,
500 b.c.

The social scientists have a long way to go to catch up, but they may be up to the most important scientific
business of all, if and when they finally get to the right questions. Our behavior toward each other is the
strangest, most unpredictable, and almost entirely unaccountable of the phenomena with which we are
obliged to live.

—
Lewis Thomas

Mrs. Dodds was beginning to lose patience. Why was everyone around her—doctors, therapists, even her son—insisting that her left arm was paralyzed when she knew perfectly well it was working fine? Why, just ten minutes ago she had used it to wash her face.

She knew, of course, that she had had a stroke two weeks ago and that was why she was here, at the University of California Medical Center in Hillcrest. Except for a small headache, she was feeling better now and wished she could go home to clip her rose bushes and resume her daily morning walks along the beach near Point Loma, where she lived. She had seen her granddaughter Becky just yesterday and was thinking how nice it would be to show off to her the garden now that it was in full bloom.

Mrs. Dodds was in fact completely paralyzed on the left side of her body after a stroke that damaged the right hemisphere of her brain. I

see many such patients every month. Usually they have many questions about their paralysis. When will I walk again, doctor? Will I be able to wiggle my fingers again? When I yawned this morning, my left arm started to move a little—does that mean I'm starting to recover?

But there is a small subset of patients with right hemisphere damage who, like Mrs. Dodds, seem blissfully indifferent to their predicament— apparently unaware of the fact that the entire left side of their body is paralyzed—even though they are quite mentally lucid in all other respects. This curious disorder—the tendency to ignore or sometimes even to deny the fact that one's left arm or leg is paralyzed—was termed anosognosia ("unaware of illness") by the French neurologist Joseph François Babinski who first observed it clinically in 1908.

"Mrs. Dodds, how are you feeling today?"

"Well, doctor, I have a headache. You know they brought me to the hospital."

"Why did you come to the hospital, Mrs. Dodds?"

"Oh, well," she said, "I had a stroke."

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"How do you know?"

"I fell down in the bathroom two weeks ago and my daughter brought me here. They did some brain scans and took X rays and told me I had a stroke." Obviously Mrs. Dodds knew what had occurred and was aware of her surroundings.

"Okay," I said. "And how are you feeling now?"

"Fine."

"Can you walk?"

"Sure I can walk." Mrs. Dodds had been lying in her bed or sitting propped up in a wheelchair for the past two weeks. She had not taken a single step since her fall in the bathroom.

"What about your hands? Hold out your hands. Can you move them?"

Mrs. Dodds seemed mildly annoyed by my questions. "Of course I can use my hands," she said.

"Can you use your right hand?"

"Yes."

"Can you use your left hand?"

"Yes, I can use my left hand."

"Are both hands equally strong?"

"Yes, they are both equally strong."

Now this raises an interesting question: How far can you push this line of questioning in these patients?

Physicians are generally reluctant to

keep on prodding for fear of precipitating what the neurologist Kurt Goldstein called a "catastrophic reaction,"

which is simply medical jargon for "the patient starts sobbing" because her defenses crumble. But I thought, if I took her gently, one step at a time, before actually confronting her with her paralysis, perhaps I could prevent such a reaction.1

"Mrs. Dodds, can you touch my nose with your right hand?"

She did so with no trouble.

"Can you touch my nose with your left hand?"

Her hand lay paralyzed in front of her.

"Mrs. Dodds, are you touching my nose?"

"Yes, of course I'm touching your nose."

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"Can you actually see yourself touching my nose?"

"Yes, I can see it. It's less than an inch from your face."

At this point Mrs. Dodds produced a frank confabulation, almost a hallucination, that her finger was nearly touching my nose. Her vision was fine. She could see her arm perfectly clearly, yet she was insisting that she could see the arm move.

I decided to ask just one more question. "Mrs. Dodds, can you clap?"

With resigned patience she said, "Of course I can clap."

"Will you clap for me?"

Mrs. Dodds glanced up at me and proceeded to make clapping movements with her right hand, as if clapping with an imaginary hand near the midline.

"Are you clapping?"

"Yes, I'm clapping," she replied.

I didn't have the heart to ask her whether she actually heard herself clapping, but, had I done so, we might have found the answer to the Zen master's eternal koan or riddle—what is the sound of one hand clapping?

One doesn't need to invoke Zen koans, however, to realize that Mrs. Dodds presents us with a puzzle every bit as enigmatic as the struggle to understand the nondual nature of reality. Why does this woman, who is apparently sane, intelligent and articulate, deny that she's paralyzed? After all, she's been confined to a wheelchair for nearly two weeks. There must have been scores of occasions when she tried to grab something or just reach out with her left hand, yet all the while it lay lifeless in her lap. How can she possibly insist that she "sees" herself touching my nose?

Actually, Mrs. Dodd's confabulation is on the extreme end of the scale. Denial patients more commonly concoct inane excuses or ration−

alizations why their left arms do not move when asked to demonstrate the use of that arm. Most don't claim that they can actually see the limp arm moving.

For example, when I asked a woman named Cecilia why she was not touching my nose, she replied with a hint of exasperation, "Well, doctor, I mean these medical students, they've been prodding and poking at me all day. I'm sick of it. I don't want to move my arm."

Another patient, Esmerelda, took a different strategy.

"Esmerelda, how are you doing?"

"I'm fine."

"Can you walk?"

"Yes."

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"Can you use your arms?"

"Yes."

"Can you use your right arm?"

"Yes."

"Can you use your left arm?"

"Yes, I can use my left arm."

"Can you point to me with your right hand?"

She pointed straight at me with her good right hand.

"Can you point to me with your left?"

Her left hand lay motionless in front of her.

"Esmerelda, are you pointing?"

"I have severe arthritis in my shoulder; you know that, doctor. It hurts. I can't move my arm now."

On other occasions she employed other excuses: "Well, I've never been very ambidextrous, doctor."

Watching these patients is like observing human nature through a magnifying lens; I'm reminded of all aspects of human folly and of how prone to self−deception we all are. For here, embodied in one elderly woman in a wheelchair, is a comically exaggerated version of all those psychological defense mechanisms that Sigmund and Anna Freud talked about at the beginning of the twentieth century—mechanisms used by you, me and everyone else when we are confronted with disturbing facts about ourselves. Freud claimed that our minds use these various psychological tricks to "defend the ego." His ideas have such intuitive appeal that many of the words he used have infiltrated popular parlance, although no one thinks of them as science because he never did any experiments. (We shall return to Freud later in this chapter to see how anosognosia may give us an experimental handle on these elusive aspects of the mind.) In the most extreme cases, a patient will not only deny that the arm (or leg) is paralyzed, but assert that the arm lying in the bed next to him, his own paralyzed arm, doesn't belong to him! There's an unbridled willingness to accept absurd ideas.

Not long ago, at the Rivermead Rehabilitation Center in Oxford, England, I gripped a woman's lifeless left hand and, raising it, held it in front of her eyes. "Whose arm is this?"

She looked me in the eye and huffed, "What's that arm doing in my bed?"

"Well, whose arm is it?"

"That's my brother's arm," she said flatly. But her brother was nowhere in the hospital. He lives somewhere in Texas. The woman displayed what we call somatoparaphrenia—the denial of ownership of one's own body parts—which is occasionally seen in conjunction with anosognosia. Needless to say, both conditions are quite 94

rare.

"Why do you think it's your brother's arm?"

"Because it's big and hairy, doctor, and I don't have hairy arms."

Anosognosia is an extraordinary syndrome about which almost nothing is known. The patient is obviously sane in most respects yet claims to see her lifeless limb springing into action—clapping or touching my nose—and fails to realize the absurdity of it all. What causes this curious disorder? Not surprisingly, there have been dozens of theories2 to explain anosognosia. Most can be classified into two main categories. One is a Freudian view, that the patient simply doesn't want to confront the unpleasantness of his or her paralysis.

The second is a neurological view, that denial is a direct consequence of the neglect syndrome, discussed in the previous chapter—the general indifference to everything on the left side of the world. Both categories of explanation have many problems, but they also contain nuggets of insight that we can use to build a new theory of denial.

One problem with the Freudian view is that it doesn't explain the difference in magnitude of psychological defense mechanisms between patients with anosognosia and what is seen in normal people—why they are generally subtle in you and me and wildly exaggerated in denial patients. For example, if I were to fracture my left arm and damage certain

nerves and you asked me whether I could beat you in a game of tennis, I might tend to play down my injury a little, asserting, "Oh, yes, I can beat you. My arm is getting much better now, you know." But I certainly wouldn't take a bet that I could arm wrestle you. Or if my arm were completely paralyzed, hanging limp at my side, I would not say, "Oh, I can see it touching your nose" or "It belongs to my brother."

The second problem with the Freudian view is that it doesn't explain the asymmetry of this syndrome. The kind of denial seen in Mrs. Dodds and others is almost always associated with damage to the right hemisphere of the brain, resulting in paralysis of the body's left side. When people suffer damage to the left brain hemisphere, with paralysis on the body's right side, they almost never experience denial. Why not? They are as disabled and frustrated as people with right hemisphere damage, and presumably there is just as much

"need" for psychological defense, but in fact they are not only aware of the paralysis, but constantly talk about it. Such asymmetry implies that we must look not to psychology but to neurology for an answer, particularly in the details of how the brain's two hemispheres are specialized for different tasks. Indeed, the syndrome seems to straddle the border between the two disciplines, one reason it is so fascinating.

Neurological theories of denial reject the Freudian view completely. They argue instead that denial is a direct consequence of neglect, which also occurs after right hemisphere damage and leaves patients profoundly indifferent to everything that goes on within the left side of the world, including the left side of their own bodies. Perhaps the patient with anosognosia simply doesn't notice that her left arm is not moving in response to her commands, and hence the delusion.

I find two main problems with this approach. One is that neglect and denial can occur independently—some patients with neglect do not experience denial and vice versa. Second, neglect does not account for why denial usually persists even when the patient's attention is drawn to the paralysis. For instance, if I were to force a patient to turn his head and focus on his left arm, to demonstrate to him that it's not obeying his command, he may adamantly continue to deny that it's paralyzed—or even that it belongs to him. It is this vehemence of the denial—not a mere indifference to paralysis—that cries out for an explanation. Indeed, the reason anosognosia is so puzzling is that we have come to regard the "intellect" as primarily propositional in character—that is, certain conclusions follow incontrovertibly from certain premises—and one ordinarily expects propositional logic to be internally consistent. To listen to

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a patient deny ownership of her arm and yet, in the same breath, admit that it is attached to her shoulder is one of the most perplexing phenomena that one can encounter as a neurologist.

So neither the Freudian view nor the neglect theory provides an adequate explanation for the spectrum of deficits that one sees in anosog−nosia. The correct way to approach the problem, I realized, is to ask two questions: First, why do normal people engage in all these psychological defense mechanisms? Second, why are the same mechanisms so exaggerated in these patients? Psychological defenses in normal people are especially puzzling because at first glance they seem detrimental to survival.3 Why would it enhance my survival to cling tenaciously to false beliefs about myself and the world? If I were a puny weakling who believed that I was as strong as Hercules, I'd soon get into serious trouble with the "alpha male" in my social group—my chairman, the president of my company or even my next−door neighbor. But, as Charles Darwin pointed out, if one sees something apparently maladaptive in biology, then look more deeply, because there is often a hidden agenda.

The key to the whole puzzle, I suggest, lies in the division of labor between our two cerebral hemispheres and in our need to create a sense of coherence and continuity in our lives. Most people are familiar with the fact that the human brain consists of two mirror image halves—like the two halves of a walnut—with each half, or cerebral hemisphere, controlling movements on the opposite side of the body. A century of clinical neurology has shown clearly that the two hemispheres are specialized for different mental capacities and that the most striking asymmetry involves language. The left hemisphere is specialized not only for the actual production of speech sounds but also for the imposition of syntactic structure on speech and for much of what is called semantics—comprehension of meaning. The right hemisphere, on the other hand, doesn't govern spoken words but seems to be concerned with more subtle aspects of language such as nuances of metaphor, allegory and ambiguity—skills that are inadequately emphasized in our elementary schools but that are vital for the advance of civilizations through poetry, myth and drama. We tend to call the left hemisphere the major or