: Phantoms in the Brain

CHAPTER 7 The Sound of One Hand Clapping

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CHAPTER 7

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 Im 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 ones left arm or leg is paralyzed was termed anosognosia (unaware of illness) by the French neurologist Joseph Fran?ois 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.

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 Im touching your nose.

Can you actually see yourself touching my nose?

Yes, I can see it. Its 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, Im clapping, she replied.

I didnt 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 masters eternal koan or riddle what is the sound of one hand clapping?

One doesnt 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 shes paralyzed? After all, shes 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. Dodds confabulation is on the extreme end of the scale. Denial patients more commonly concoct inane excuses or rationalizations why their left arms do not move when asked to demonstrate the use of that arm. Most dont 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, theyve been prodding and poking at me all day. Im sick of it. I dont want to move my arm.

Another patient, Esmerelda, took a different strategy.

Esmerelda, how are you doing?

Im fine.

Can you walk?

Yes.

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 cant move my arm now.

On other occasions she employed other excuses: Well, Ive never been very ambidextrous, doctor.

Watching these patients is like observing human nature through a magnifying lens; Im 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, doesnt belong to him! Theres an unbridled willingness to accept absurd ideas.

Not long ago, at the Rivermead Rehabilitation Center in Oxford, England, I gripped a womans 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, Whats that arm doing in my bed?

Well, whose arm is it?

Thats my brothers 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 ones own body parts which is occasionally seen in conjunction with anosognosia. Needless to say, both conditions are quite rare.

Why do you think its your brothers arm?

Because its big and hairy, doctor, and I dont 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 doesnt 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 doesnt 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 wouldnt 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 doesnt 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 bodys left side. When people suffer damage to the left brain hemisphere, with paralysis on the bodys 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 brains 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 doesnt 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 patients 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 its not obeying his command, he may adamantly continue to deny that its 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 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 anosognosia. 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, Id 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, doesnt 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 dominant hemisphere because it, like a chauvinist, does all the talking (and maybe much of the internal thinking as well), claiming to be the repository of humanitys highest attribute, language. Unfortunately, the mute right hemisphere can do nothing to protest.

Other obvious specializations involve vision and emotion. The right hemisphere is concerned with holistic aspects of vision such as seeing the forest for the trees, reading facial expressions and responding with the appropriate emotion to evocative situations. Consequently, after right hemisphere strokes, patients tend to be blissfully unconcerned about their predicament, even mildly euphoric, because without the emotional right hemisphere they simply dont comprehend the magnitude of their loss. (This is true even of those patients who are aware of their paralysis.) In addition to these obvious divisions of labor, I want to suggest an even more fundamental difference between the cognitive styles of the two hemispheres,4 one that not only helps explain the amplified defense mechanisms of anosognosia but may also help account for the more mundane forms of denial that people use in daily life such as when an alcoholic refuses to acknowledge his drinking problem or when you deny your forbidden attraction to a married colleague.

At any given moment in our waking lives, our brains are flooded with a bewildering array of sensory inputs, all of which must be incorporated into a coherent perspective thats based on what stored memories already tell us is true about ourselves and the world. In order to generate coherent actions, the brain must have some way of sifting through this superabundance of detail and of ordering it into a stable and internally consistent belief system a story that makes sense of the available evidence. Each time a new item of information comes in we fold it seamlessly into our preexisting worldview. I suggest that this is mainly done by the left hemisphere.

But now suppose something comes along that does not quite fit the plot. What do you do? One option is to tear up the entire script and start from scratch: completely revise your story to create a new model about the world and about yourself. The problem is that if you did this for every little piece of threatening information, your behavior would soon become chaotic and unstable; you would go mad.

What your left hemisphere does instead is either ignore the anomaly completely or distort it to squeeze it into your preexisting framework, to preserve stability. And this, I suggest, is the essential rationale behind all the so-called Freudian defenses the denials, repressions, confabulations and other forms of self-delusion that govern our daily lives. Far from being maladaptive, such everyday defense mechanisms prevent the brain from being hounded into directionless indecision by the combinatorial explosion of possible stories that might be written from the material available to the senses. The penalty, of course, is that you are lying to yourself, but its a small price to pay for the coherence and stability conferred on the system as a whole.

Imagine, for example, a military general about to wage war on the enemy. It is late at night and he is in the war room planning strategies for the next day. Scouts keep coming into the room to give him information about the lay of the land, terrain, light level and so forth. They also tell him that the enemy has five hundred tanks and that he has six hundred tanks, a fact that prompts the general to decide to wage war. He positions all of his troops in strategic locations and decides to launch battle exactly at 6:00 a.m. with sunrise.

Imagine further that at 5:55 A.M. one little scout comes running into the war room and says, General! I have bad news. With minutes to go until battle, the general asks, What is that? and the scout replies, I just looked through binoculars and saw that the enemy has seven hundred tanks, not five hundred!

What does the general the left hemisphere do? Time is of the essence and he simply cant afford the luxury of revising all his battle plans. So he orders the scout to shut up and tell no one about what he saw. Denial!

Indeed, he may even shoot the scout and hide the report in a drawer labeled top secret (repression). In doing so, he relies on the high probability that the majority opinion the previous information by all the scouts was correct and that this single new item of information coming from one source is probably wrong.

So the general sticks to his original position. Not only that, but for fear of mutiny, he might order the scout actually to lie to the other generals and tell them that he only saw five hundred tanks (confabulation). The purpose of all of this is to impose stability on behavior and to prevent vacillation because indecisiveness doesnt serve any purpose. Any decision, so long as it is probably correct, is better than no decision at all. A perpetually fickle general will never win a war!

In this analogy, the general is the left hemisphere5 (Freuds ego, perhaps?), and his behavior is analogous to the kinds of denials and repressions you see in both healthy people and patients with anosognosia. But why are these defense mechanisms so grossly exaggerated in the patients? Enter the right hemisphere, which I like to call the Devils Advocate. To see how this works, we need to push the analogy a step further. Supposing the single scout comes running in, and instead of saying the enemy has more tanks, he declares, General, I just looked through my telescope and the enemy has nuclear weapons. The general would be very foolish indeed to adhere to his original plan. He must quickly formulate a new one, for if the scout were correct, the consequences would be devastating.

Thus the coping strategies of the two hemispheres are fundamentally different. The left hemispheres job is to create a belief system or model and to fold new experiences into that belief system. If confronted with some new information that doesnt fit the model, it relies on Freudian defense mechanisms to deny, repress or confabulate anything to preserve the status quo. The right hemispheres strategy, on the other hand, is to play Devils Advocate, to question the status quo and look for global inconsistencies. When the anomalous information reaches a certain threshold, the right hemisphere decides that it is time to force a complete revision of the entire model and start from scratch. The right hemisphere thus forces a Kuhnian paradigm shift in response to anomalies, whereas the left hemisphere always tries to cling tenaciously to the way things were.

Now consider what happens if the right hemisphere is damaged.6 The left hemisphere is then given free rein to pursue its denials, confabulations and other strategies, as it normally does. It says, I am Mrs. Dodds, a person with two normal arms that I have commanded to move. But her brain is insensitive to the contrary visual feedback that would ordinarily tell her that her arm is paralyzed and that shes in a wheelchair. Thus Mrs.

Dodds is caught in a delusional cul-de-sac. She cannot revise her model of reality because her right hemisphere, with its mechanisms for detecting discrepancies, is out of order. And in the absence of the counterbalance or reality check provided by the right hemisphere, there is literally no limit to how far she will wander along the delusional path. Patients will say, Yes, Im touching your nose, Dr. Ramachandran, or All of the medical students have been prodding me and thats why I dont want to move my arm. Or even, What is my brothers hand doing in my bed, doctor?

The idea that the right hemisphere is a left-wing revolutionary that generates paradigm shifts, whereas the left hemisphere is a die-hard conservative that clings to the status quo, is almost certainly a gross oversimplification, but, even if it turns out to be wrong, it does suggest new ways of doing experiments and goads us into asking novel questions about the denial syndrome. How deep is the denial? Does the patient really believe hes not paralyzed? What if you were to confront patients directly: Could you then force them to admit the paralysis? Would they deny only their paralysis, or would they deny other aspects of their illness as well? Given that people often think of their car as part of their extended body image (especially here in California), what would happen if the front left fender of their car were damaged? Would they deny that?

Anosognosia has been known for almost a century, yet there have been very few attempts to answer these questions. Any light we could shed on this strange syndrome would be clinically important, of course, because the patients indifference to their predicament not only is an impediment to rehabilitation of the weak arm or leg, but often leads them to unrealistic future goals. (For example, when I asked one man whether he could go back to his old occupation of repairing telephone lines a job that requires two hands for climbing poles and splicing wires he said, Oh, yes, I dont see a problem there.) What I didnt realize, though, when I began these experiments, was that they would take me right into the heart of human nature. For denial is something we do all our lives, whether we are temporarily ignoring the bills accumulating in our to do tray or defiantly denying the finality and humiliation of death.

Talking to denial patients can be an uncanny experience. They bring us face to face with some of the most fundamental questions one can ask as a conscious human being: What is the self? What brings about the unity of my conscious experience? What does it mean to will an action? Neuroscientists tend to shy away from such questions, but anosognosia patients afford a unique opportunity for experimentally approaching these seemingly intractable philosophical riddles.

Relatives are often bewildered by their loved ones behavior. Does Mom really believe shes not paralyzed? asked one young man. Surely, there must be some recess of her mind that knows whats happened. Or has she gone totally bonkers?

Our first and most obvious question, therefore, is, How deeply does the patient believe his own denials or confabulations? Could it be some sort of surface facade or even an attempt at malingering? To answer this question, I devised a simple experiment. Instead of directly confronting the patient by asking him to respond verbally (can you touch my nose with your left hand?), what if I were to trick him by asking him to perform a spontaneous motor task that requires two hands before he has had a chance to think about it. How would he respond?

To find out, I placed a large cocktail tray supporting six plastic glasses half filled with water in front of patients with denial syndrome. Now if I asked you to reach out and grab such a tray, you would place one hand under either side of the tray and proceed to raise it. But if you had one hand tied behind your back, you would naturally go for the middle of the tray its center of gravity and lift from there. When I tested stroke patients who were paralyzed on one side of their body but did not suffer from denial, their nonparalyzed hand went straight for the middle of the tray, as expected.

When I tried the same experiment on denial patients, their right hands went straight to the right side of the tray while the left side of the tray remained unsupported. Naturally, when the right hand lifted only the right side of the tray, the glasses toppled, but the patients often attributed this to momentary clumsiness rather than a failure to lift the left side of the tray (Ooops! How silly of me!). One woman even denied that she had failed to lift the tray. When I asked her whether she had lifted the tray successfully, she was surprised. Yes, of course, she replied, her lap all soggy.

The logic of a second experiment was somewhat different. What if one were actually to reward the patient for honesty? To investigate this, I gave our patients a choice between a simple task that can be done with one hand and an equally simple task that requires the use of two hands. Specifically, patients were told that they could earn five dollars if they threaded a light bulb into a bare socket on a heavy table lamp or ten dollars if they could tie a pair of shoelaces. You or I would naturally go for the shoelaces, but most paralyzed stroke patients who do not suffer from denial choose the light bulb, knowing their limitations. Obviously five dollars is better than nothing. Remarkably, when we tested four stroke patients who had denial, they opted for the shoelace task every time and spent minutes fiddling with the laces without showing any signs of frustration. Even when the patients were given the same choice ten minutes later they unhesitatingly went for the bimanual task. One woman repeated this bumbling behavior five times in a row, as though she had no memory of her previous failed attempts. A Freudian repression perhaps?

On one occasion, Mrs. Dodds kept on fumbling with the shoelaces using one hand, oblivious to her predicament, until finally I had to pull the shoe away. The next day my student asked her, Do you remember Dr. Ramachandran?

She was very pleasant. Oh, yes, I remember. Hes that Indian doctor.

What did he do?

He gave me a childs shoe with blue dots on it and asked me to tie the shoelaces.

Did you do it?

Oh, yes, I tied it successfully with both my hands, she replied.

Something odd was afoot. What normal person would say, I tied the shoelace with both my hands? It was almost as though inside Mrs. Dodds there lurked another human being a phantom within who knows perfectly well that shes paralyzed, and her strange remark was an attempt to mask this knowledge. Another intriguing example was a patient who volunteered, while I was examining him, I cant wait to get back to two-fisted beer drinking. These peculiar remarks are striking examples of what Freud called a reaction formation a subconscious attempt to disguise something that is threatening to your self-esteem by asserting the opposite. The classic illustration of a reaction formation, of course, comes from Hamlet, Methinks the lady doth protest too much. Is not the very vehemence of her protest itself a betrayal of guilt?

Let us return now to the most widely accepted neurological explanation of denial the idea that it has something to do with neglect, the general indifference that patients often display toward events and objects on the left side of the world. Perhaps when asked to perform an action with her left hand, Mrs. Dodds sends motor commands to the paralyzed arm and copies of these commands are simultaneously sent to her body image centers (in the parietal lobes), where they are monitored and experienced as felt movements. The parietal lobes are thus tipped off about what the intended actions are, but since shes ignoring events on the left side of her body, she also fails to notice that the arm did not obey her command. Although, as I argued earlier, this account is implausible, we did two simple experiments to test the neglect theory of denial directly.7

In the first experiment, I tested the idea that the patient is simply monitoring motor signals that are being sent to the arm. Larry Cooper is an intelligent fifty-six-year-old denial patient who had suffered a stroke one week before I went to visit him in the hospital. He lay under a blue and purple quilt his wife had brought to the room, with his arms flopped outside the covers one paralyzed, one normal. We chatted for ten minutes and then I left the room, only to return five minutes later. Mr. Cooper! I exclaimed, approaching his bed.

Why did you just now move your left arm? Both arms were dead still, in the same position as when I had left the room. Ive tried this on normal people and the usual response is utter bewilderment. What do you mean? I wasnt doing anything with my left arm or I dont understand; did I move my left arm? Mr. Cooper looked at me calmly and said, I was gesticulating to make a point! When I repeated the experiment the next day, he said, It hurts, so I moved it to relieve the pain.

Since there is no possibility that Mr. Cooper could have sent a motor command to his left arm at the exact moment I questioned him, the result suggests that denial stems not merely from a sensory motor deficit. On the contrary, his whole system of beliefs about himself is so profoundly deranged that theres apparently no limit to what he will do to protect these beliefs. Instead of acting befuddled, as a normal person might, he happily goes along with my deception because it makes perfect sense to him, given his worldview.

The second experiment was almost diabolical. What would happen, I wondered, if one were temporarily to paralyze the right arm of a denial patient whose left arm, of course, really is paralyzed. Would the denial now encompass his right arm as well? The neglect theory makes a very specific prediction because he only neglects the left side of his body and not the right side, he should notice that the right arm isnt moving and say, Thats very odd, doctor; my arm isnt moving. (My theory, on the other hand, makes the opposite prediction: He should be insensitive to this anomaly since the discrepancy detector in his right hemisphere is damaged.)

To paralyze a denial patients right arm, I devised a new version of the virtual reality box we had used in our phantom limb experiments. Again, it was a simple cardboard box with holes and mirrors, but they were positioned very differently. Our first subject was Betty Ward, a seventy-one-year-old retired schoolteacher who was mentally alert and happy to cooperate in the experiment. When Betty was comfortably seated, I asked her to put a long gray glove on her right hand (her good one) and insert it through a hole in front of the box. I then asked her to lean forward and peek into the box through a hole in the top to look at her gloved hand.

Next, I started a metronome and asked Betty to move her hand up and down in time with the ticking sounds.

Can you see your hand moving, Betty?

Yes, sure, she said. Its got the right rhythm.

Then I asked Betty to close her eyes. Without her knowledge, a mirror in the box flipped into position and an undergraduate stooge, who was hiding under the table, slipped his gray gloved hand into the box from a hole in the back. I asked Betty to open her eyes and look back into the box. She thought she was looking at her own right hand again, but, because of the mirror, she actually saw the students hand. Previously I had told the stooge to keep his hand absolutely still.

Okay, Betty. Keep looking. Im going to start the metronome again and I want you to move your hand in time with it.

Tick, tock, tick, tock. Betty moved her hand but what she saw in the box was a perfectly still hand, a paralyzed hand. Now when you do this experiment with normal people, they jump out of their seat: Hey, whats going on here? Never in their wildest dreams would they imagine that an undergraduate was hiding under the table.

Betty, what do you see?

Why, I see my right hand moving up and down, just like before, she replied.8

This suggests to me that Bettys denial crossed over to the right side of her body the normal side with no neglect for why else would she say that she could see a motionless hand in motion? This simple experiment demolishes the neglect theory of anosognosia and also gives us a clue for understanding what really causes the syndrome. What is damaged in these patients is the manner in which the brain deals with a discrepancy in sensory inputs concerning the body image; its not critical whether the discrepancy arises from the left or right side of the body.

What we observed in Betty and in the other patients weve discussed so far supports the idea that the left hemisphere is a conformist, largely indifferent to discrepancies, whereas the right hemisphere is the opposite: highly sensitive to perturbation. But our experiments only provide circumstantial evidence for this theory. We needed direct proof.

Even a decade ago, an idea of this kind would have been impossible to test, but the advent of modern imaging techniques such as functional magnetic resonance (fMR) and positron emission tomography (PET) has tremendously accelerated the pace of research by allowing us to watch the living brain in action. Very recently, Ray Dolan, Chris Frith and their colleagues at the Queen Square Neurological Hospital for Neurological Diseases in London performed a beautiful experiment using the virtual reality box that we had used on our phantom limb patients. (Recall this is simply a vertical mirror propped in a box, perpendicular to the persons chest.) Each person inserted his left arm into the box and looked into the left side of the mirror at the reflection of his left arm so that it was optically superimposed on the felt location of his right arm. He was then asked to move both hands synchronously up and down, so that there was no discrepancy between the visual appearance of his moving right hand (actually the reflection of his left) and the kinesthetic movement sensations from joints and muscles emerging from his right hand. But if he now moved the two hands out of sync as when doing the dog paddle then there was a profound discrepancy between what the right hand appeared to be doing visually and what it felt it was doing. By doing a PET scan during this procedure, Dr. Frith was able to locate the center in the brain that monitors discrepancies; it is a small region of the right hemisphere that receives information from the right parietal lobe. Dr. Frith then did a second PET scan with the subject looking into the right side of the mirror at the reflection of his right hand (and moving his left hand out of sync) so the discrepancy in his body image now appeared to come from his left side rather than the right. Imagine my delight when I heard from Dr. Frith that once again the right hemisphere lit up in the scanner. It didnt seem to matter which side of the body the discrepancy arose from right or left it always activated the right hemisphere. This is welcome proof that my speculative ideas on hemispheric specialization are on the right track.

When I conduct clinical Grand Rounds presenting a denial patient to medical students one of the most common questions I am asked is Do the patients only deny paralysis of body parts or do they deny other disabilities as well? If the patient stubbed her toe, would she deny the pain and swelling in that toe? Do they deny that they are seriously ill? If they suddenly had a migraine attack would they deny it? Many neurologists have explored this in their patients, and the usual answer is that they dont deny other problems like my patient Grace who, when I offered her candy if she could tie shoelaces, shot back at me, You know Im diabetic, doctor. I cant eat candy!9

Almost all the patients I have tested are well aware of the fact that theyve had a stroke and none of them suffers from what you might call global denial. Yet there are gradations in their belief systems and accompanying denials that correlate with the location of their brain lesions. When the injury is confined to the right parietal lobe, confabulations and denials tend to be confined to body image. But when the damage occurs closer to the front of the right hemisphere (a part called the ventromedial frontal lobe), the denial is broader, more varied and oddly self-protective. I remember an especially striking example of this a patient named Bill who came to see me six months after he had been diagnosed with a malignant brain tumor. The tumor had been growing rapidly and compressing his right frontal lobe, until it was eventually excised by the neurosurgeon.

Unfortunately, by then it had already spread and Bill was told that he probably had less than a year to live.

Now, Bill was a highly educated man and ought to have grasped the gravity of his situation, yet he seemed nonchalant about it and kept drawing my attention to a little blister on his cheek instead. He bitterly complained that the other doctors hadnt done anything about the blister and asked whether I could help him get rid of it. When I would return to the topic of the brain tumor, he avoided talking about it, saying things like Well, you know how these doctors sometimes incorrectly diagnose things. So here was an intelligent person flatly contradicting the evidence provided by his physicians and glibly playing down the fact that he had terminal brain cancer. To avoid being hounded by a free-floating anxiety, he adopted the convenient strategy of attributing it to something tangible and the blister was the most convenient target. Indeed, his obsession with the blister is what Freud would call a displacement mechanism a disguised attempt to deflect his own attention from his impending death. Curiously, it is sometimes easier to deflect than to deny.10

The most extreme delusion Ive ever heard of is one described by Oliver Sacks, about a man who kept falling out of bed at night. Each time he crashed to the floor, the ward staff would hoist him back up, only to hear a resounding thud a few moments later. After this happened several times, Dr. Sacks asked the man why he kept toppling out of bed. He looked frightened. Doctor, he said, these medical students have been putting a cadavers arm in my bed and Ive been trying to get rid of it all night! Not admitting ownership of his paralyzed limb, the man was dragged to the floor each time he tried to push it away.

The experiments we discussed earlier suggest that a denial patient is not just trying to save face; the denial is anchored deep in her psyche.11 But does this imply that the information about her paralysis is locked away somewhere repressed? Or does it imply that the information doesnt exist anywhere in her brain? The latter view seems unlikely. If the knowledge doesnt exist, why does the patient say things like I tied my shoelaces with both my hands or I cant wait to get back to two-fisted beer drinking? And why evasive remarks like Im not ambidextrous? Comments like these imply that somebody in there knows she is paralyzed, but that the information is not available to the conscious mind. If so, is there some way to access that forbidden knowledge?

To find out, we took advantage of an ingenious experiment performed in 1987 by an Italian neurologist, Eduardo Bisiach, on a patient with neglect and denial. Bisiach took a syringe filled with ice-cold water and irrigated the patients left ear canal a procedure that tests vestibular nerve function. Within a few seconds the patients eyes started to move vigorously in a process called nystagmus. The cold water sets up a convection current in the ear canals, thereby fooling the brain into thinking the head is moving and into making involuntary correctional eye movements that we call nystagmus. When Bisiach then asked the denial patient whether she could use her arms, she calmly replied that she had no use of her left arm! Amazingly, the cold water irrigation of the left ear had brought about a complete (though temporary) remission from the anosognosia.

When I read about this experiment, I jumped out of my seat. Here was a neurological syndrome produced by a right parietal lesion that had been reversed by the simple act of squirting water into the ear. Why hadnt this amazing experiment made headlines in The New York Times? Indeed, I discovered that most of my professional colleagues had not even heard of the experiment. I therefore decided to try the same procedure on the next patient I saw with anosognosia.

This turned out to be Mrs. Macken, an elderly woman who three weeks earlier had suffered a right parietal stroke that resulted in left side paralysis. My purpose was not only to confirm Bisiachs observation but also to ask questions specifically to test her memory something that hadnt been done systematically. If the patient suddenly started admitting that she was paralyzed, what would she say about her earlier denials? Would she deny her denials? If she admitted them, how would she account for them? Could she possibly tell us why she had been denying them, or is that an absurd question?

I had been seeing Mrs. Macken every three or four days for two weeks, and each time we had gone through the same rigmarole.

Mrs. Macken, can you walk?

Yes, I can walk.

Can you use both arms?

Yes.

Are they equally strong?

Yes.

Can you move your left hand?

Yes.

Can you move your right hand?

Yes.

Are they equally strong?

Yes.

After going through the questions, I filled a syringe with ice-cold water and squirted it into her ear canal. As expected, her eyes started moving in the characteristic way. After about a minute, I began to question her.

How are you feeling, Mrs. Macken?

Well, my ear hurts. Its cold.

Anything else? What about your arms? Can you move your arms?

Sure, she said.

Can you walk?

Yes, I can walk.

Can you use both your arms? Are they equally strong?

Yes, they are equally strong.

I wondered what these Italian scientists were talking about. But as I was driving home, I realized that I had squirted the water into the wrong ear! (Cold water in the left ear or warm water in the right ear causes the eyes to drift repetitively to the left and jump to the right. And the opposite is true. Its one of those things that many physicians get confused about, or at least I do. So I had inadvertently done the control experiment first!) The next day we repeated the experiment on the other ear.

Mrs. Macken, how are you doing?

Fine.

Can you walk?

Sure.

Can you use your right hand?

Yes.

Can you use your left hand?

Yes.

Are they equally strong?

Yes.

After the nystagmus, I asked again, How are you feeling?

My ears cold.

What about your arms? Can you use your arms?

No, she replied, my left arm is paralyzed.

That was the first time she had used that word in the three weeks since her stroke.

Mrs. Macken, how long have you been paralyzed?

She said, Oh, continuously, all these days.

This was an extraordinary remark, for it implies that even though she had been denying her paralysis each time I had seen her over these last few weeks, the memories of her failed attempts had been registering somewhere in her brain, yet access to them had been blocked. The cold water acted as a truth serum that brought her repressed memories about her paralysis to the surface.

Half an hour later I went back to her and asked, Can you use your arms?

No, my left arm is paralyzed. Even though the nystagmus had long since ceased, she still admitted she was paralyzed.

Twelve hours later, a student of mine visited her and asked, Do you remember Dr. Ramachandran?

Oh, yes, he was that Indian doctor.

And what did he do?

He took some ice-cold water and he put it into my left ear and it hurt.

Anything else?

Well, he was wearing that tie with a brain scan on it. True, I was wearing a tie with a PET scan on it. Her memory for details was fine.

What did he ask you?

He asked me if I could use both my arms.

And what did you tell him?

I told him I was fine.

So now she was denying her earlier admission of paralysis, as though she were completely rewriting her script. Indeed, it was almost as if we had created two separate conscious human beings who were mutually amnesic: the cold water Mrs. Macken, who is intellectually honest, who acknowledges her paralysis, and the Mrs. Macken without the cold water, who has the denial syndrome and adamantly denies her paralysis!

Watching the two Mrs. Mackens reminded me of the controversial clinical syndrome known as multiple personalities immortalized in fiction as Dr. Jekyll and Mr. Hyde. I say controversial because most of my more hard-nosed colleagues refuse to believe that the syndrome even exists and would probably argue that it is simply an elaborate form of playacting. What we have seen in Mrs. Macken, however, implies that such partial insulation of one personality from the other can indeed occur, even though they occupy a single body.

To understand what is going on here, let us return to our general in the war room. I used this analogy to illustrate that there is a sort of coherence-producing mechanism in the left hemisphere the general that prohibits anomalies, allows the emergence of a unified belief system and is largely responsible for the integrity and stability of self. But what if a person were confronted by several anomalies that were not consistent with his original belief system but were nonetheless consistent with each other? Like soap bubbles, they might coalesce into a new belief system insulated from the previous story line, creating multiple personalities. Perhaps balkanization is better than civil war. I find the reluctance of cognitive psychologists to accept the reality of this phenomenon somewhat puzzling, given that even normal individuals have such experiences from time to time. I am reminded of a dream I once had in which someone had just been telling me a very funny joke that made me laugh heartily implying that there must have been at least two mutually amnesic personalities inside me during the dream. To my mind, this is an existence proof for the plausibility of multiple personalities.12

The question remains: How did the cold water produce such apparently miraculous effects on Mrs. Macken?

One possibility is that it arouses the right hemisphere. There are connections from the vestibular nerve projecting to the vestibular cortex in the right parietal lobe as well as to other parts of the right hemisphere.

Activation of these circuits in the right hemisphere makes the patient pay attention to the left side and notice that her left arm is lying lifeless. She then recognizes, for the first time, that she is paralyzed.

This interpretation is probably at least partially correct, but I would like to consider a more speculative alternative hypothesis: the idea that this phenomenon is somehow related to rapid eye movement (REM) or dream sleep. People spend a third of their lives sleeping, and 25 percent of that time their eyes are moving as they experience vivid, emotional dreams. During these dreams we are often confronted with unpleasant, disturbing facts about ourselves. Thus in both the cold-water state and REM sleep there are noticeable eye movements and unpleasant, forbidden memories come to the surface, and this may not be a coincidence.

Freud believed that in dreams we dredge up material that is ordinarily censored, and one wonders whether the same sort of thing may be happening during ice water in the ear stimulation. At the risk of pushing the analogy too far, lets refer to our general, who is now sitting in his bedroom late the next night, sipping a glass of cognac. He now has time to engage in a leisurely inspection of the report given to him by that one scout at 5:55 a.m. and perhaps this mulling over and interpretation correspond to what we call dreaming. If the material makes sense, he may decide to incorporate it into his battle plan for the next day. If it doesnt make sense or if it is too disturbing for him, he will put it into his desk drawer and try to forget about it; that is probably why we cannot remember most of our dreams. I suggest that the vestibular stimulation caused by the cold water partially activates the same circuitry that generates REM sleep. This allows the patient to uncover unpleasant, disturbing facts about herself including her paralysis that are usually repressed when she is awake.

This is obviously a highly speculative conjecture, and I would give it only a 10 percent chance of being correct. (My colleagues would probably give it 1 percent!) But it does lead to a simple, testable prediction.

Patients with denial should dream that they are paralyzed. Indeed, if they are awakened during a REM episode, they may continue to admit their paralysis for several minutes before reverting to denial again. Recall that the effects of calorically induced nystagmus Mrs. Mackens confession of paralysis lasted for at least thirty minutes after the nystagmus had ceased.13

Canst thou not minister to a mind diseased,Pluck from the memory a rooted sorrow,Raze out the written troubles of the brain,And with some sweet oblivious antidoteCleanse the stuffed bosom of that perilous stuffWhich weighs upon the heart?William Shakespeare

Memory has legitimately been called the Holy Grail of neuroscience. Although many a weighty tome has been written on this topic, in truth we know little about it. Most of the work carried out in recent decades has fallen into two categories. One is the formation of the memory trace itself, sought in the nature of physical changes between synapses and in chemical cascades within nerve cells. The second is based on the study of patients like H.M. (briefly described in Chapter 1), whose hippocampus was removed surgically for epilepsy and who was no longer able to make new memories after the surgery, though he can remember most things that happened before surgery.

Experiments on cells and on patients like H.M. have given us some insights about how new memory traces are formed, but they completely fail to explore equally important narrative or constructive aspects of memory.

How is each new item edited and censored (when necessary) before being pigeonholed according to when and where it occurred? How are these memories progressively assimilated into our autobiographic self, becoming part of who we are? These subtle aspects of memory are notoriously difficult to study in normal people, but I realized that one could explore them in patients like Mrs. Macken who repress what happened just a few minutes earlier.

You dont even need ice water to chart this new territory. I found that I could gently prod some patients into eventually admitting that the left arm is not working or weak or sometimes even paralyzed (although they seemed unperturbed by this admission). If I managed to elicit such a statement, left the room and returned ten minutes later, the patient would have no recollection of the confession, having a sort of selective amnesia for matters concerning his left arm. One woman, who cried for a full ten minutes when she realized that she was paralyzed (a catastrophic reaction), couldnt remember this event a few hours later, even though it must have been an emotionally charged and salient experience. This is about as close as one can get to a Freudian repression.

The natural course of the denial syndrome provides us with another means of exploring memory functions.

For reasons not understood, most patients tend to recover completely from the denial syndrome after two or three weeks, though their limbs are almost always still paralyzed or extremely weak. (Wouldnt it be wonderful if alcoholics or anorexics who reject the awful truth about their drinking or their body image were able to recover from denial so quickly? I wonder whether ice water in the left ear canal will do the trick! ) What if I were to go to a patient after he is over the denial of his paralysis and ask, When I saw you last week and asked you about your left arm, what did you tell me? Would he admit that he had been in denial?

The first patient whom I asked about this was Mumtaz Shah, who had been denying her paralysis for almost a month after her stroke and then recovered completely from the denial (although not from the paralysis). I began with the obvious question: Mrs. Shah, do you remember me?

Yes, you came to see me at Mercy Hospital. You were always showing up with those two student nurses, Becky and Susan. (All this was true; so far she was right on target.)

Do you remember I asked you about your arms? What did you say?

I told you my left arm was paralyzed.

Do you remember I saw you several times? What did you say each time?

Several times, several times yes, I said the same thing, that I was paralyzed.

(Actually she had told me each time that her arm was fine.)

Mumtaz. Think clearly. Do you remember telling me that your left arm was fine, that it wasnt paralyzed?

Well, doctor, if I said that, then it implies that I was lying. And I am not a liar.

Mumtaz had apparently repressed the dozens of episodes of denial that she had engaged in during my numerous visits to the hospital.

The same thing happened with another patient, Jean, whom I visited at the San Diego Rehabilitation Center.

We went through the usual questions.

Can you use your right arm?

Oh, yes.

Can you use your left arm?

Yes.

But when I came to the question Are they equally strong? Jean said, No, my left arm is stronger.

Trying to hide my surprise, I pointed to a mahogany table at the end of the hall and asked her whether she could lift that with her right hand.

I guess I could, she said.

How high could you lift it?

She assessed the table, which must have weighed eighty pounds, pursed her lips and said, Oh, I suppose I could lift it about an inch.

Can you lift a table with your left hand?

Oh, sure, Jean replied. I could lift it an inch and a half!

She held up her right hand and showed me with her thumb and index finger how high she could hoist a table with her lifeless left hand. Again, this is a reaction formation.

But the next day, after she had recovered from her denial, Jean repudiated these same words.

Jean, do you remember I asked you a question yesterday?

Yes, she said, removing her eyeglasses with her right hand. You asked me if I could lift a table with my right hand and I said I could lift it about an inch.

What did you say about your left hand?

I said I couldnt use my left hand. She gave me a puzzled look.14

The model of denial that we considered earlier provides a partial explanation for both the subtle forms of denial that we all engage in, as well as the vehement protests of denial patients. It rests on the notion that the left hemisphere attempts to preserve a coherent worldview at all costs, and, to do that well, it has to sometimes shut out information that is potentially threatening to the stability of self.

But what if we could somehow make this unpleasant fact more acceptable more nonthreatening to a patients belief system? Would he then be willing to accept that his left arm is paralyzed? In other words, can you cure his denial by simply tampering with the structure of his beliefs?

I began by conducting an informal neurological workup on the patient, in this instance, a woman named Nancy. I then showed her a syringe full of saline solution and said, As part of your neurological exam, I would like to inject your left arm with this anesthetic, and as soon as I do it, your left arm will be temporarily paralyzed for a few minutes. After making sure that Nancy understood this, I proceeded to inject her arm with the salt water. My question was, Would she suddenly admit that she was paralyzed, now that it had been made more acceptable to her, or would she say, Your injection doesnt work; I can move my left arm just fine? This is a lovely example of an experiment on a persons belief system, a field of inquiry I have christened experimental epistemology, just to annoy philosophers.

Nancy sat quietly for a few moments waiting for the injection to take effect while her eyes darted around looking at various antique microscopes in my office. I then asked her, Well, can you move your left arm?

No, she replied, it doesnt seem to want to do anything. Its not moving. Apparently my mock injection had worked, for she was now able to accept the fact that her left arm was indeed paralyzed.

But how could I be sure that this was not simply the result of my persuasive charm? Maybe I was just hypnotizing Nancy into accepting that her arm was paralyzed. So I did the obvious control: I repeated the same procedure with her right arm. After ten minutes, I went back into the room and, after chatting briefly about various topics, said, As part of the neurological exam, Im going to inject your right arm with this local anesthetic, and after I give you the shot, your right arm will be paralyzed for a few minutes. I then gave her the injection, with the same syringe containing saline solution, waited a bit and asked, Can you move your right arm? Nancy looked down, lifted her right hand to her chin and said, Yes, its moving.

See for yourself. I feigned surprise. How could that be possible? I just injected you with the same anesthetic that we used on your left arm! She shook her head with disbelief and replied, Well, I dont know, doctor. I guess its mind over matter. I have always believed that.15

What we call rational grounds for our beliefs are often extremely irrational attempts to justify our instincts.

Thomas Henry Huxley

When I began this research about five years ago, I had no interest whatsoever in Sigmund Freud. (He might have said I was in denial.) And like most of my colleagues I was very skeptical of his ideas. The entire neuroscience community is deeply suspicious of him because he touted elusive aspects of human nature that ring true but that cannot be empirically tested. But after I had worked with these patients, it soon became clear to me that even though Freud wrote a great deal of nonsense, there is no denying that he was a genius, especially when you consider the social and intellectual climate of Vienna at the turn of the century. Freud was one of the first people to emphasize that human nature could be subjected to systematic scientific scrutiny, that one could actually look for laws of mental life in much the same way that a cardiologist might study the heart or an astronomer study planetary motion. We take all this for granted now, but at that time it was a revolutionary insight. No wonder his name became a household word.

Freuds most valuable contribution was his discovery that your conscious mind is simply a facade and that you are completely unaware of 90 percent of what really goes on in your brain. (A striking example is the zombie in Chapter 4.) And with regard to psychological defenses, Freud was right on the mark. Can anyone doubt the reality of the nervous laugh or rationalizations? Remarkably, although you are engaging in these mental tricks all the time, you are completely unaware of doing so and youd probably deny it if it were pointed out to you. Yet when you watch someone else doing it, it is comically conspicuous often embarrassingly so. Of course, all this is quite well known to any good playwright or novelist (try reading Shakespeare or Jane Austen), but Freud surely deserves credit for pointing out the pivotal role of psychological defenses in helping us organize our mental life. Unfortunately, the theoretical schemes he constructed to explain them were nebulous and untestable. He relied all too often on an obscure terminology and on an obsession with sex to explain the human condition. Furthermore, he never did any experiments to validate his theories.

But in denial patients you can witness these mechanisms evolving before your very eyes, caught in flagrante delicto. One can make a list of the many kinds of self-deception that Sigmund and Anna Freud described and see clear-cut, amplified examples of each of them in our patients. It was seeing this list that convinced me for the first time of the reality of psychological defenses and the central role that they play in human nature.

Denial: The most obvious one, of course, is outright denial. My arm is working fine. I can move my left arm its not paralyzed.

Repression: As we have seen, the patient will sometimes admit with repeated questioning that she is in fact paralyzed, only to revert soon afterward to denial apparently repressing the memory of the confession she made just a few minutes earlier. Many cognitive psychologists argue that repressed memories, such as sudden recollections of child abuse, are inherently bogus the harvest of psychological seeds implanted by the therapist and brought to flower by the patient. But here we have proof that something like repression is going on, albeit on a smaller time scale, with no possibility that the patients behavior was unduly influenced by the experimenter.

Reaction formation: This is the propensity to assert the exact opposite of what one suspects to be true of oneself. For example, a latent homosexual may drink his beer, strut around in cowboy boots and engage in macho behavior, in an unconscious attempt to assert his presumed masculinity. There is even a recent study showing that, when viewing X-rated film clips of male pornography, men who are overt gay bashers paradoxically get bigger erections than men who are not prejudiced. (If youre wondering how the erections were measured, the researchers used a device called a penile Plethysmograph.) I am reminded of Jean the woman who said she could lift a large table an inch off the ground with her right hand and then added, when questioned, that her paralyzed left hand was actually stronger than the right; that she could use it to lift the table an inch and a half. Also recall Mrs. Dodds, who when asked whether she tied her shoelaces, replied, Yes, I did it with both my hands. These are striking examples of reaction formation.

Rationalization: We have seen many examples of this in this chapter. Oh, doctor, I didnt move my arm because I have arthritis in my shoulder and it hurts. Or this from another patient: Oh, the medical students have been prodding me all day and I dont really feel like moving my arm just now.

When asked to raise both hands, one man raised his right hand high into the air and said, when he detected my gaze locked onto his motionless left hand, Urn, as you can see, Im steadying myself with my left hand in order to raise my right.

More rarely, we see frank confabulation:

I am touching your nose with my left hand.

Yes, of course Im clapping.

Humor: Even humor can come to the rescue not just in these patients but in all of us as Freud well knew. Just think of the so-called nervous laugh or of all those times when youve used humor to deflate a tense situation. Can it be a coincidence, moreover, that so many jokes deal with potentially threatening topics like death or sex? Indeed, after seeing these patients, I am convinced that the most effective antidote to the absurdity of the human condition may be humor rather than art.

I remember asking a patient who was a professor of English literature to move his paralyzed left arm. Mr. Sinclair, can you touch my nose with your left hand?

Yes.

Okay, show me. Please go ahead and touch it.

Im not accustomed to taking orders, doctor.

Taken aback, I asked him whether he was being humorous or sarcastic.

No, Im perfectly serious. Im not being humorous. Why do you ask?

So it would seem that although the patients remarks are often tinged with a perverse sense of humor, they themselves are unaware that theyre being funny.

Another example: Mrs. Franco, can you touch my nose with your left hand?

Yes, but watch out. I might poke your eye out.

Projection: This is a tactic used when, wanting to avoid confronting a malady or disability, we conveniently attribute it to someone else. This paralyzed arm belongs to my brother, for I know perfectly well that my own arm is fine. I leave it for psychoanalysts to decide whether this is a true case of projection. But as far as Im concerned, its close enough.

So here we have patients engaging in precisely the same types of Freudian defense mechanisms denial, rationalization, confabulation, repression, reaction formation and so forth that all of us use every day of our lives. Ive come to realize that they present us with a fantastic opportunity to test Freudian theories scientifically for the first time. The patients are a microcosm of you and me but better, in that their defense mechanisms occur on a compressed time scale and are amplified tenfold. Thus we can carry out experiments that Freudian analysts have only dreamed of. For example, what determines which particular defense you use in a given situation? Why would you use an outright denial in one case and a rationalization or reaction formation in another? Is it your (or the patients) personality type that determines which defense mechanisms you use? Or does the social context determine which one you muster? Do you use one strategy with a superior and another with social inferiors? In other words, what are the laws of psychological defense mechanisms?

We still have a long way to go before we can address these questions,16 but, for me, its exciting to contemplate that we scientists can begin encroaching on territory that until now was reserved for novelists and philosophers.

Meanwhile, is it possible that some of these discoveries may have practical implications in the clinic? Using cold water to correct someones delusion about body image is fascinating to watch, but could it also be useful to the patients? Would repeated irrigation permanently cure Mrs. Macken of denial and make her willing to participate in rehabilitation? I also started wondering about anorexia nervosa. These patients have disturbances in appetite but are also delusional about their body image claiming actually to see that they are fat when looking in a mirror, even though they are grotesquely thin. Is the disorder of appetite (linked to feeding and satiety centers in the hypothalamus) primary, or does the body image distortion cause the appetite problem? We saw in the last chapter that some neglect patients actually start believing that the object in the mirror is real their sensory disturbances actually cause changes in their belief system. And in denial or anosognosia patients, you often notice a similar warping of their beliefs to accommodate their distorted body image. Could some such mechanisms be involved in anorexia? We know that certain parts of the limbic system such as the insular cortex are connected to the hypothalamic appetite centers and also to parts of the parietal lobes concerned with body image. Is it conceivable that how much you eat over a long period of time, your intellectual beliefs about whether you are too fat or thin, your perception of your body image and your appetite are all more closely linked in your brain than you realize so that a distortion of one of these systems can lead to a pervasive disturbance in the others as well? This idea can be tested directly by doing the cold-water irrigation on a patient with anorexia (to see whether it would temporarily correct her delusion about her body image). This is a far-fetched possibility but its still worth trying, given the ease of the procedure and the lack of an effective treatment for anorexia. Indeed, the disorder is fatal in about 10 percent of cases.

Freud bashing is a popular intellectual pastime these days (although he still has his fans in New York and London). But, as we have seen in this chapter, he did have some valuable insights into the human condition, and, when talking about psychological defenses, he was right on target, although he had no idea why they evolved or what neural mechanisms might mediate them. A less well known, but equally interesting idea put forward by Freud was his claim that he had discerned the single common denominator of all great scientific revolutions: Rather surprisingly, all of them humiliate or dethrone man as the central figure in the cosmos.

The first of these, he said, was the Copernican revolution, in which a geocentric or earth-centered view of the universe was replaced with the idea that earth is just a speck of dust in the cosmos.

The second was the Darwinian revolution, which holds that we are puny, hairless neotenous apes that accidentally evolved certain characteristics that have made us successful, at least temporarily.

The third great scientific revolution, he claimed (modestly), was his own discovery of the unconscious and the corollary notion that the human sense of being in charge is illusory. He claimed that everything we do in life is governed by a cauldron of unconscious emotions, drives and motives and that what we call consciousness is just the tip of the iceberg, an elaborate post hoc rationalization of all our actions.

I believe Freud correctly identified the common denominator of great scientific revolutions. But he doesnt explain why this is so why would human beings actually enjoy being humiliated or dethroned? What do they get in return for accepting the new worldview that belittles humankind?

Here we can turn things around and provide a Freudian interpretation of why cosmology, evolution and brain science are so appealing, not just to specialists but to everyone. Unlike other animals, humans are acutely aware of their own mortality and are terrified of death. But the study of cosmology gives us a sense of timelessness, of being part of something much larger. The fact that your own personal life is finite is less frightening when you know you are part of an evolving universe an ever-unfolding drama. This is probably the closest a scientist can come to having a religious experience.

The same goes for the study of evolution, for it gives you a sense of time and place, allowing you to see yourself as part of a great journey. And likewise for the brain sciences. In this revolution, we have given up the idea that there is a soul separate from our minds and bodies. Far from being terrifying, this idea is very liberating. If you think youre something special in this world, engaging in a lofty inspection of the cosmos from a unique vantage point, your annihilation becomes unacceptable. But if youre really part of the great cosmic dance of Shiva, rather than a mere spectator, then your inevitable death should be seen as a joyous reunion with nature rather than as a tragedy.

Brahman is all. From Brahman come appearances, sensations, desires, deeds. But all these are merely name and form. To know Brahman one must experience the identity between him and the Self, or Brahman dwelling within the lotus of the heart. Only by so doing can man escape from sorrow and death and become one with the subtle essence beyond all knowledge.

Upanishads, 500 b.c.
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