by Bor, Daniel
THE DIFFICULTY OF REPAIRING HUMPTY DUMPTY
Accurately finding ways of judging whether a vegetative patient is conscious is always only half of what’s on the mind of the patient’s loved ones. The family members also want to know if the patient will recover, and whether there are any treatments that will aid the healing process. Here, the news is not so encouraging, although there are a range of potential treatments.
For instance, Nicholas Schiff and colleagues carried out a procedure known as deep brain stimulation on one thirty-eight-year-old patient who had previously been in a minimally conscious state for six years. This technique involves an operation to insert electrodes deep into the brain, and in this case using those wires to continuously stimulate the thalamus for 12 hours each day. In this way, not only was the thalamus reactivated, but so were its many connected regions, including the prefrontal cortex.
Before the surgery, there were only the barest signs of awareness, with the patient occasionally able to follow verbal instructions, but unable to utter a single word himself. Almost immediately after the electrodes were turned on, the patient seemed to wake up far more effectively; he could now keep his eyes open and turn his head toward a spoken voice. This was dramatic in itself, but the patient continued steadily to improve. By the end of the study six months later, he was not only uttering single words for the first time and naming objects, but sometimes even saying short sentences. Whereas before he’d had little motor control and wasn’t even able to chew food, now he could hold a cup to his lips and feed himself three meals a day. These are all remarkable improvements, but it’s important to emphasize that, despite such dramatic progress, the patient was by the end still very ill, a shadow of his former self. It’s also unclear whether this procedure would work at all on PVS patients, who, unlike this man before his operation, show no obvious signs of consciousness.
A different and controversial approach, this time deliberately directed instead to PVS patients, simply involves dosing these patients with medication. Ralf Claus and colleagues have provided provisional evidence that, for some vegetative patients, a common sleeping drug, zolpidem, can paradoxically allow them to wake up for about 4 hours at a time. It’s almost as if their ability to sleep and wake has gone totally askew and this drug may temporarily reset and recalibrate the system. From showing no signs of consciousness beforehand, one PVS patient a few hours after zolpidem was administered could verbally answer questions appropriately and even perform simple calculations. Although other research groups have also shown that zolpidem can indeed improve conscious levels in such patients, it seems that only a small minority, about one in fifteen participants, will have any kind of benefit from the drug.
Occasionally, patients with few signs of consciousness can spontaneously recover on their own, even after years. In one famous case, a man named Terry Wallis suffered from massive brain damage and a coma after being thrown from his pickup truck. A few weeks after the accident, he was judged to be in a minimally conscious state. He remained in this state for nineteen years, until one day, out of the blue, he appeared almost normally conscious. Three days after this, he was already able to speak almost normally. This sounds, on the surface, miraculous, but when you start examining the details, you find that the situation isn’t nearly as encouraging as it at first appeared. Wallis had severe amnesia, poor working memory, an inability to plan or strategize, impulsive behavior, and a changed character, now far less mature than his nineteen-year-old self at the time of the accident. In line with this, his brain scans revealed severe brain shrinkage, even though there was some promising evidence that new pathways were growing, which might have explained why he woke up in the first place.
With all these patients, a good prognosis critically depends on how much brain damage has already occurred and what caused the patient to be in this state in the first place. Returning to the case of Terri Schiavo, despite the hopes and prayers of her parents, her brain shrinkage was so severe that there was, sadly, very little brain left (see Figure 9), and certainly no hope that any pill or stimulator would fix her.
For the vast majority of these PVS patients, or indeed anyone who suffers from some form of serious brain damage, probably the best future hope for effective treatment is via some form of stem cell therapy. Theoretically, stem cells injected into the brain could turn into new neurons to reverse the extensive brain damage. At present, though, there are both real dangers to the treatment, with stem cells tending to form tumors, and great difficulties in rebuilding large sections of cortex. And even if, in the decades to come, stem cell therapy did mature and become a viable treatment, it might well be that patients would emerge with most of their old memories, skills, and personalities wiped out from the initial brain damage. They would be disturbingly reborn, with a new consciousness and character to grow, piece by piece. It’s hard to imagine what extra challenges such a patient would face, when even in normal development and in our daily lives we so frequently struggle to find a mentally healthy path through our experiences.
8
Consciousness Squeezed, Stretched, and Shrunk
Mental Illness as Abnormal Awareness
SHARP FRACTURES IN AWARENESS
My wife and I have been together for thirteen years. In some ways, because of her fierce emotional warmth, her busy intellect, and the fact that we think alike on many topics, it has been very easy to be with her. In other ways, through absolutely no fault of hers, it has been, on occasion, a struggle. My wife suffers from one of the various forms of bipolar disorder and, like many people plagued by this illness, she endured many exasperating years as the psychiatrists toyed with a sequence of alternative diagnoses before landing on the current label. They then prescribed an even longer sequence of largely ineffective medications, and we reacted to each new drug with the increasingly tired cycle of hope, frustration, and despair.
When my wife is ill, she is usually “down”: She will sleep much of the day, profess to be perpetually lethargic, and be globally, profoundly lacking in motivation—sometimes to such an extent that she can hardly move her body. She can’t make decisions, can’t recall normally vivid memories, and will fail to understand topics that in normal circumstances she’d grasp with ease. She will feel either numb or terribly distraught. Her thoughts and feelings will bend heart-wrenchingly away from rationality. They will converge on the view that she is the most ugly person alive (when in fact she is very good looking), that she is incredibly fat (she has a BMI of about 21), that she is utterly stupid (she holds a PhD in genetics, along with a clutch of other degrees, from both Oxford and Cambridge Universities), and that she is the most unkind, unpopular person in the world (she in fact has a large set of friends, and is very giving toward them).
Far less frequently, she will be “up”: She will sleep little—perhaps skipping bed for a night or two. She will feel high, disinhibited, excited, and easily excitable, almost as if she were drunk. She will have lots of energy and start various new projects, some of which, under normal circumstances, she would think were a complete waste of time. She will make lots of connections between ideas, rather like forming new, insightful chunks, but at their extreme form, the connections will make no sense, and the ideas may be somewhat absurd and, in hindsight, embarrassing.
Of course, illnesses like bipolar disorder are tremendously complex. But I’ve been struck at times by the extent that her symptoms could be explained by a warping of her consciousness. When she’s within a depressive episode, it’s as if there isn’t enough consciousness to go round; she’s perpetually tired, and she lacks the awareness to realize the extreme irrationality of her beliefs about herself. When she’s in a manic episode, it almost seems as if there’s too much consciousness for her brain to cope with; she never gets sleepy, her melting pot of ideas is boiling too hot and bubbling over the rim, and her “innovation machine” of a conscious mind repeatedly spews out spurious insights.
She was prescribed many of the standard drugs for depressi
on and bipolar disorder—for instance, selective serotonin reuptake inhibitors (SSRIs), to raise her mood (by raising her serotonin levels), and mood stabilizers, like lithium (whose effect no one really understands), to keep her on an even keel. Although some of these drugs made her physically very ill, and one or two made her mental health plummet frighteningly, none helped her bipolar symptoms (a somewhat common experience in patients like her). Eventually, we were lucky enough to chance upon a particular stimulant medication. This drug, within a day, removed the bulk of her depressive symptoms. It’s not perfect, and may not be suitable for many other bipolar patients, but it is orders of magnitude better than the more conventional medications she tried and allows her to lead a far more functional life than before.
But why should a drug that promotes wakefulness have such a profound effect on one’s feelings of worthlessness? And what other mental illnesses might benefit from being perceived as more closely connected with consciousness than previously thought?
The World Health Organization (WHO) estimates that up to a quarter of all people around the globe are affected by mental illness at some point in their lives—with anxiety and depression the most common conditions. Suicide now ranks as one of the leading causes of death in young adults. Unlike other major illnesses, such as cancer and heart disease, which tend to occur later in life, mental illness is most likely to emerge in adolescence or early adulthood. This means both that the pain to the patient can be more long lasting and debilitating and that its economic burden to the state is larger.
Although it’s difficult to estimate the loss to the economy due to mental illness, the World Economic Forum recently made an attempt at this. Taking all the relevant factors into account, such as direct costs to treat the illness, work-hours lost to disability, and so on, it calculated that in 2010 the global cost of mental illness was around $2.5 trillion—a staggering amount, but likely to increase dramatically over the next twenty years. Mental illness will thus soon account for the majority of the world’s economic burden for all noncommunicable diseases (which also include conditions such as cardiovascular disease, chronic respiratory disease, cancer, and diabetes). The entire global health budget is only about double the current mental illness global economic burden, though a tiny proportion of this is spent on mental health. In fact, mental illness must surely be the most underfunded sector of health care by far, when the true costs of mental illness are considered. Therefore, one of the most sensible policy changes that could be undertaken to positively affect economic growth figures would be to focus on improving mental health in the populace.
Perhaps part of the reason for the political neglect of mental illness is the legacy view that these aren’t real illnesses, as well as the assumption that psychiatric conditions are too complicated to treat effectively. While the first assumption is inaccurate and damaging, there is some truth to the second position. As my wife and I know all too well, the decades of research have hardly scratched the surface in our understanding of mental illness. This is probably because many of these conditions are caused by a large set of genes that interact with environmental events in extremely complex ways. But that doesn’t preclude new perspectives from shedding light on these profound sources of suffering. And even minor progress in treating mental illness, a disturbingly common condition, could lead to a dramatic improvement for society, both from its soothing reduction of individual torments and from the potential to make the economy more productive and efficient.
In this chapter I consider the idea that almost all mental illnesses can be rewritten as disorders of consciousness. This is a strategy that may engender useful, novel perspectives on these conditions, as well as exciting new routes for treatment. I’ll also suggest in the epilogue to follow that insights from our emerging knowledge of the nature and purpose of consciousness can help explain and alleviate the emotional struggles we all face on a day-to-day basis.
AUTISM AND OVER-CONSCIOUSNESS
From the perspective of consciousness and psychiatry, autism stands out as a special, fascinating syndrome. Although historically seen as a disorder defined by social impairments, it is rapidly being rewritten as a condition caused by an overabundance of awareness.
A developmental disorder that is apparent from early childhood, autism symptoms include a lack of understanding of the thoughts and emotions of others, poor language skills, and obsessive, repetitive behaviors. The majority of autistic children are classed as mentally retarded and have the condition for life.
As with most psychiatric conditions, autism is probably best viewed more as a cluster of symptoms than a single syndrome, and there is much variability in level and type of disability among autistics. For this reason, most people talk of autism spectrum disorders, rather than simply “autism.” And this continuum includes people with Asperger’s syndrome, who have some symptoms of autism, such as poor social skills, but who generally function well in life, and may have a high IQ.
The traditional view is that all autistic symptoms stem from an inborn, specific deficit in grasping anything remotely social—this is why autistics can’t understand other people, and in pronounced cases don’t learn the social activity of communication. Most theories along these lines, though, struggle to explain the full range of symptoms common in autism, such as repetitive behaviors, which seem to have nothing to do with a lack of social skills. And this traditional view seems out of sync with emerging evidence that many severely autistic children can show marked improvements in social and verbal skills if they participate in an intensive behavioral intervention program centering around gentle social encouragement through play, such as the Early Start Denver Model or the Son Rise Program. This raises the strong possibility that these social and communication problems, far from being the central cause of autism, are a reversible side effect of a deeper difference between autistics and others.
One emerging suite of theories on autism suggests that this disorder is centrally defined not at all by a poverty of mental skills, but instead by the excessive richness of information these people experience. In other words, in some sense autistics have an overabundance of awareness, and all their symptoms are merely their way of dealing with this supercharged consciousness.
But how does this fit with the view that autistics are so poor at processing information that they are regularly classed as mentally retarded? The simple answer is that it doesn’t fit, because most autistics aren’t really mentally retarded at all. For a start, the Asperger’s subbranch of the autistic spectrum involves individuals with a normal, or, more usually, a raised IQ, sometimes markedly so, such that many physicists, mathematicians, and engineers probably have some autistic traits. Simon Baron-Cohen, a world expert on autism, and Iain James have speculated that certain prominent figures, including Albert Einstein and Isaac Newton, suffered from Asperger’s syndrome. Einstein, for instance, was very developmentally challenged in learning to talk, was a loner as a child, and would obsessively repeat sentences until about the age of seven.
Some autistics really are severely mentally disabled—for instance, they might be unable to go to the toilet by themselves—but I don’t believe this is necessarily because they lack the mental resources to perform such a task. Trying to assess a child who has poor language skills and an aversion to novel activities is remarkably challenging, but increasingly scientists are critical of this mentally retarded label for autistics, and this may well be another case of researchers jumping to the conclusion that poor performance on a test must mean inability to carry out a related everyday function.
There are two popular, but very different, ways of measuring IQ: the Wechsler Intelligence Scales, which use a shotgun approach, giving subjects a large range of different tests, including various language tasks; and the Raven’s Progressive Matrices, a single nonlinguistic test that involves finding the logically correct option to complete the hole in a patterned grid. Unsurprisingly, many autistic children are rated as severely mentally retarded on the more conv
entional Wechsler IQ scale, with its heavy language component. But if you give autistics the Raven’s matrices test instead, suddenly their IQ jumps. Their scores are, on average, 30–70 points higher than they were on the Wechsler test, and as a group they appear at least as intelligent as normal children.
Thus, autistics generally aren’t mentally retarded, and their social and communication problems can be dramatically improved with the right behavioral therapy. But what evidence is there that they are actually more conscious than normal people? Actually, there is a wealth of data from a wide range of sources.
A small subset of autistic people will exhibit isolated islands of incredible ability. For instance, there’s Stephen Wiltshire, who can draw a landscape with stunning accuracy after just a single viewing. Or there’s Derek Paravicini, who may not know how to hold up three fingers, but despite his blindness is a highly accomplished pianist who has filled concert halls and can play a tune perfectly after hearing it just once. And there’s also Daniel Tammet, already mentioned in this book (Chapter 5), an autistic man who can perform fiendish calculations and memorize gargantuan streams of numbers.
Until recently, it was thought that only 10 percent or so of autistic individuals had some form of superior skill. But increasingly, it’s becoming clear that most have superior abilities in a range of perceptual and analytical areas.
From a biological perspective, in many ways autism is the opposite of schizophrenia. The two conditions share many of the same gene abnormalities, but while schizophrenics will have one variant of a given gene—say, involving a deletion of a section of DNA—autistics will have the opposite variant—for instance, with a duplication of the same section. And while schizophrenics show a slowed brain growth in childhood, autistics have an accelerated brain growth compared to normal children.
