Errol Morris on photography.
(This is the fourth part of a five-part series.)
4.
BELIEF IS NOT A MONOLITHIC THING
V.S. Ramachandran has written about anosognosia in a number of journal articles and in his extraordinary book with Sandra Blakeslee, “Phantoms in the Brain.” Ramachandran rarely settles for the status quo. If there is something unexplained, he pursues it, trying to provide an answer, if not the answer. He has made a number of spectacular discoveries, most famous among them his innovative use of mirror-boxes to treat phantom limb syndrome. Rather than devise complex experiments, he prefers simple intuitive questions and answers. His work on anosognosia is a perfect example.
Ramachandran was taken in by a question that haunts Babinski’s original work on anosognosia — the question of whether the anosognosic knows (on some level) about the paralysis. What is going on in
an anosognosic brain? (Babinski’s original question: Is it real?) Almost any deficit can be explained as volitional. How do you know that an anosognosic patient is really in denial, or oblivious, or
indifferent to his/her paralysis? How do you know that the patient is not feigning illness? This was a critical question during World War I, when neurologists had to deal with a flood of injured soldiers and
had to discriminate between the truly damaged and those just malingering.
ERROL MORRIS: As I understand it, from the earliest descriptions of anosognosia, there were two things that people had fixed in their heads: one was, of course, the organic illness, the hemiplegia,
the other was the lack of awareness.
V.S. RAMACHANDRAN: Hemiplegia itself is not a part of anosognosia, as you know, but the lack of awareness — the whole spectrum ranging from active denial to just indifference or just playing it down, all of those are called “anosognosia.” I’ve written about that quite extensively in my book “Phantoms in the Brain.”
ERROL MORRIS: In that book, you suggest that anosognosia is not an underlying neurological condition; it’s about our lack of knowledge of something caused by an underlying neurological condition. About our not-knowing things that we should know — not knowing that we are not making any sense, not knowing that we are paralyzed, not knowing we are missing limbs.
V.S. RAMACHANDRAN: Well, you can have anosognosia for Wernicke’s aphasia [a neurological disorder that prevents comprehension or production of speech] or you can have it for amnesia. Patients that are amnesic don’t know they are amnesic. So, it has a much wider, broader usage. Although it was originally discovered in the context of hemiplegia by Babinski and is most frequently used in that context, the word has a broader meaning. Wernicke’s aphasiacs are completely lacking in language comprehension and seem oblivious to it because [although] they smile, or they nod to whatever you say, they don’t understand a word of what you’re saying. They have anosognosia for their lack of comprehension of language. It’s really spooky to see them. Here’s somebody producing gibberish, and they don’t know they’re producing gibberish.
ERROL MORRIS: But Babinski only used it in the context of hemiplegia.
V.S. RAMACHANDRAN: That is correct.
ERROL MORRIS: So when did that change?
V.S. RAMACHANDRAN: Offhand, I can’t tell you when they started using the term “anosognosia” for other types of denial. I’ll tell you one thing that may be of interest to you. I saw a lady, not long ago, in India, and she had complete paralysis on her left side, a very intelligent woman, but had both anosognosia and somatoparaphrenia — you know what that is, right?
ERROL MORRIS: Not really.
V.S. RAMACHANDRAN: Denial that a body part, in this instance, an arm, belongs to her. It’s part of the same spectrum of disorders. So the wonderful thing about her is that she has a great sense of humor and was really articulate and intelligent. So I asked her, “Can you move your right arm?” and the usual list of questions, and she said “Yes, of course.” I said, “Can you move your left arm?” She said, “Yes.” “Can you touch my nose?” “Yes, I can touch your nose, sir.” “Can you see it?” “Yes, it’s almost there.” The usual thing, O.K.? So far, nothing new. Her left arm is lying limp in her lap; it’s not moving at all; it’s on her lap, on her left side, O.K.? I left the room, waited for a few minutes, then I went back to the room and said, “Can you use your right arm?” She said, “Yes.” Then I grabbed her left arm and raised it towards her nose and I said, “Whose arm is this?” She said, “That’s my mother’s arm.” Again, typical, right? And I said, “Well, if that’s your mother’s arm, where’s your mother?” And she looks around, completely perplexed, and she said, “Well, she’s hiding under the table.” So this sort of confabulatory thing is very common, but it’s just a very striking manifestation of it. No normal person would dream of making up a story like that. But here is the best part. I said, “Please touch your nose with your left hand.” She immediately takes her right hand, goes and reaches for the left hand, raising it, passively raising it, right? Using it as a tool to touch my nose or touch her nose. What does this imply? She claims her left arm is not paralyzed, right? Why does she spontaneously reach for it and grab her left arm with her right hand and take her left hand to her nose? That means she knows it is paralyzed at some level. Is that clear? [53]
ERROL MORRIS: Yes. Presumably, if she didn’t know it was paralyzed, she wouldn’t try to lift it with her right hand.
V.S. RAMACHANDRAN: And it gets even better, she’s just now told me that it’s not her left arm, it is her mother’s arm, so why is she pulling up her mother’s arm and pointing it at my nose? What we call belief is not a monolithic thing; it has many layers.
ERROL MORRIS: Like a deck of cards. But it again raises the question of whether this phenomenon is real? Isn’t that Babinski’s question? This is true of your work on anosognosia — the idea of trying to devise a set of experiments to determine whether someone is pretending to not-know something. Are they feigning a lack of awareness? Are they truly oblivious? Or is that knowledge buried somewhere in the brain? Do we live in a cloud of belief that is separate from the reality of our circumstances?
V.S. RAMACHANDRAN: Absolutely, and overall, fortunately, it’s a positive cloud in most of us. If we knew about the real facts and statistics of mortality, we’d be terrified.
ERROL MORRIS: Indeed.
V.S. RAMACHANDRAN: It may well be our brains are wired up to be slightly more optimistic than they should be.
Ramachandran has used the notion of layered belief — the idea that some part of the brain can believe something and some other part of the brain can believe the opposite (or deny that belief) — to help explain anosognosia. In a 1996 paper [54], he speculated that the left and right hemispheres react differently when they are confronted with unexpected information. The left brain seeks to maintain continuity of belief, using denial, rationalization, confabulation and other tricks to keep one’s mental model of the world intact; the right brain, the “anomaly detector” or “devil’s advocate,” picks up on inconsistencies and challenges the left brain’s model in turn. When the right brain’s ability to detect anomalies and challenge the left is somehow damaged or lost (e.g., from a stroke), anosognosia results.
In Ramachandran’s account, then, we are treated to the spectacle of different parts of the brain — perhaps even different selves — arguing with one another.
We are overshadowed by a nimbus of ideas. There is our physical reality and then there is our conception of ourselves, our conception of self — one that is as powerful as, perhaps even more powerful than, the physical reality we inhabit. A version of self that can survive even the greatest bodily tragedies. We are creatures of our beliefs. This is at the heart of Ramachandran’s ideas about anosognosia — that the preservation of our fantasy selves demands that we often must deny our physical reality. Self-deception is not enough. Something stronger is needed. Confabulation triumphs over organic disease. The hemiplegiac’s anosognosia is a stark example, but we all engage in the same basic process. But what are we to make of this? Is the glass half-full or half-empty? For Dunning, anosognosia masks our incompetence; for Ramachandran, it makes existence palatable, perhaps even possible.
[53] Oliver Sacks provides (also from “A Leg to Stand On”) a particularly dramatic example of a patient trying to throw his arm out of bed. “. . . the patient at Mount Carmel who ‘discovered’ his long-lost brother in his bed. ‘He’s still attached to me!’ he said indignantly. ‘The cheek of it! Here’s his arm!’ holding up, with his right hand, his own left arm.”
[54] See V.S. Ramachandran, The evolutionary biology of self-deception, laughter, dreaming and depression: some clues from anosognosia, Medical Hypotheses, November 1996, 47(5):347-62. This idea of the right brain as the “devil’s advocate” is further discussed in Ramachandran’s Phantoms in the Brain. I hope to return to these fascinating ideas in a forthcoming essay.
Continue to Part 5.