The case of Paula, similarities, differences with the case of H.M.

H.M. was a very very famous patient, who received experimental surgery to correct his severe seizures. And, it worked. The seizures abated, but afterwards Henry Molaison was left with permanent amnesia. ” He could remember some things — scenes from his childhood, some facts about his parents, and historical events that occurred before his surgery — but he was unable to form new memories. If he met someone who then left the room, within minutes he had no recollection of the person or their meeting.…..He experienced every aspect of his daily life — eating a meal, taking a walk — as a first. Yet his intellect, personality, and perception were intact,Brain Primer The Curious Case of Patient H.M. BrainFacts.org https://www.brainfacts.org/in-the-lab/tools-and-techniques/2018/the-curious-case-of-patient-hm-082818

Paula’s amnesia was more selective; she remembered her surroundings and the people in them. Her intellect, though, was significantly dulled and she had difficulty remembering how to do things that she had done many times before. She also had great difficulty doing familiar things that required a lot of steps, like cooking or paying bills or keep appointments. She compensated by writing things down but there was no guarantee that she would look at what she’d written, even if it was right in front of her. Her personality changed in that she was no longer able to be social and she was mostly quiet around others, including people closest to her. She did not know how to behave around people anymore. She did not remember her own opinions, she couldn’t make even simple decisions because she had no references from the past and no longer knew what she liked or disliked or how she usually spent her days at work, at home and around people. And she could not remember the words or concepts that would communicate to others what had suddenly happened to her memory and skills. She understood enough, though, that she was disappointing others and that she was failing at every task and that she had not always been this way. She felt a lot of guilt for not being able to function normally as before. It was an awful experience to live through every day for over a year.

Separate from her amnesia was the chronic sensation of anguish . Difficulties with breathing for any reason can cause a sensation of anguish with visible or barely visible signs of shortness of breath. Guyton and Hall Textbook of Medical Physiology [check to see which edition I have…] Paula had significant shortness of breath during this episode but she was not aware of it [beyond the anguish] and she compensated in ways that were not easily observable unless one looked and listened very carefully and knowledgeably. For example her use of accessory muscles reflected her need to use force to exhale [which is an indicator of difficulty breathing] and she was unable to speak more than a few words at a time [an indicator of difficulty breathing] and her voiced speech pattern changed significantly- became quiet and hesitant and slow. [again, easily a result of her – not easy to see -shortness of breath]. It is difficult to observe difficulty breathing and shortness of breath when breathing is so depressed and slow. Normal shortness of breath usually means breathing that is too fast and shallow, not breathing that is too slow and very deep, but cannot keep up with the needs of the body, or of the circulation , and /or of the brain.

Paula was unaware that her breathing was abnormal and so no one knew. No one understood the nature of the problem that was causing dyspnea [anguish] and high blood pressure and fast heart rate, at times with abnormal patterns and mild hypothermia. She could not report these physical signs and symptoms either. These are physiologic signs which are taken care of by the autonomic nervous system and are largely involuntary and invisible seamless [unless mindfully measured]. And I suspect no one is aware that hypercapnia can cause this pattern of physical signs and that hypercapnia may not necessarily progress to the point of coma or death, as long as the body is able to keep it in check , at least enough to avoid death, if not enough to avoid mental confusion.

The only way to test for hypercapnia is to draw blood from the arteries, something which most doctors are reluctant to do because it is an invasive and painful procedure. The only way to get a doctor to do an “arterial blood gas” test or ABG is the suspicion of hypercapnia. Hypercapnia is difficult to detect [being an endogenous and invisible gas, produced by the body.] Hypercapnia is an invisible syndrome with visible patterns of effects, such as sudden mental dullness and onset of attacks of quiet delirium/melancholic depression/reversible dementia.

This is most likely, we think, what happened to Paula. The only was anyone would have checked out this hypothesis would be if Paula had told a doctor she thought that she had dementia from depressed breathing and active , effortful exhaling, with mental confusion and significant autobiographical memory loss. And obviously, she could not even tell them that once she recovered. The only way we even figured out that this might be a possible cause for her long attack, was by reading Kraepelin’s work on “The Bodily Signs of Manic and Depressive and Mixed attacks, Chapter 3, Manic Depressive Insanity” and noting Kraepelin’s mention of depressed and/or other abnormal patterns of breathing and abnormal blood pressure, heart rate, body temperature and patterns of mental confusion matching the locomotor patterns of attacks of delirium. Because Kraepelin thought to measure these physiologic signs. Because he thought about what the abnormal patterns meant. And his conclusion was that these abnormal physical signs pointed to metabolic dysfunction of the body, affecting the metabolic function of the brain.

Memory for recent events  or for personal information [autobiographical memory] is also affected by metabolic substrates necessary for normal cell metabolism [in addition to strokes, physical injury to brain tissue and other better known causes]. Too much or too little of these various metabolites., for example- co-enzymes  such as * B1 or   the levels of * endogenous carbon dioxide -an important physiological gas [PC02] in the cell, tissue and blood, in addition to anatomical surgical lesions such as H.M.’s. ,can cause partial amnesia for self that might be reversible or might be permanent. * B1/Thiamine and selected thiamine antivitamins — biological activity and methods of synthesis Adam Tylicki,1Zenon Łotowski,2Magdalena Siemieniuk,1 and  Artur Ratkiewicz3 Biosci Rep. 2018 Feb 28; 38(1): BSR20171148. Published online 2018 Jan 10.  doi: 10.1042/BSR20171148PMCID: PMC6435462, * Hypercapnic Encephalopathy Roger F Butterworth. Basic Neurochemistry: Molecular, Cellular and Medical Aspects. 6th edition. Siegel GJ, Agranoff BW, Albers RW, et al., editors. Philadelphia: Lippincott-Raven; 1999.

What is Autobiographical Memory?

Abstract

Autobiographical memory refers to memory for personal information. The compromise of autobiographical memory in Alzheimer’s disease (AD) results in a loss of knowledge about events and facts that defined the patients’ life, and consequently, degradation of their self-knowledge and sense of identity.  Geriatr Psychol Neuropsychiatr Vieil 2017 Dec 1;15(4):443-451. doi: 10.1684/pnv.2017.0704. Autobiographical memory compromise in Alzheimer’s disease: a cognitive and clinical overview.

This is why Alzheimer’s Disease is a Dementia, because of the loss of self and memories of self. It seems to be a permanent and progressive syndrome but no one has really looked at the may peripheral causes that might be messing with brain and neuromuscular metabolism, all are fixated only on the brain. Yet it is well known that brain dysfunction can be due to local or peripheral mechanisms anywhere in the body, affecting any organ function. So why are we not looking at physiologic vital signs in these patients? Is breathing rate, heart rate, blood pressure and body temperature normal in these patients? I do not think anyone knows. Do they have organ failure [also a slowly progressive syndrome which affects metabolism of the body and the brain] ? Depressed breathing that begins to affect mental function is a form of respiratory failure [hyercapnia] , we know that different levels of liver failure, kidney failure and heart failure will also affect the metabolism of the brain causing brain failure or dementia. Is the dementia curable if one supports the peripheral failing organs? Again, no one knows. No one is studying this yet. Why? We do not know, these things are certainly taught in all medical schools.

I think that this loss of autobiographical memory is the very essence of madness, insanity, delirium and dementia. This is why people act so strangely, without their autobiographical they do not remember how they usually act or think, yet they know that they used to be fine before they became “strange” to themselves as well as to other who know them well.

Dementia is a much more serious decline in mental function. Memory loss, particularly for recently acquired information, is often the first symptom, and it becomes worse with time. People who have dementia may forget entire events, not just the details. They may do the following:

  • Have difficulty remembering how to do things they have done many times before and how to get to places they have often been to
  • No longer do things that require many steps, such as following a recipe
  • Forget to pay bills or keep appointments
  • Forget to turn off a stove, lock the house when they leave, or take care of a child left in their care

In the early stages of dementia, people may be aware of their memory loss. But as dementia progresses, they, unlike people with age-related changes in memory, become unaware of their memory loss and often deny that they have such loss.

Finding the right word, naming objects, understanding language, and doing, planning, and organizing daily activities become more and more difficult. People with dementia eventually become disoriented, not knowing what time or even what year it is or where they are. Their personality may change. They may become more irritable, anxious, paranoid, inflexible, or disruptive.

There are many forms of dementia. Alzheimer disease is the most common. Most forms of dementia progressively worsen until the person’s death.

Some conditions that increase the risk of heart and blood vessel disorders (such as high blood pressure, high levels of cholesterol, and diabetes) seem to increase the risk of dementia”. Memory Loss By Michael C. Levin , MD, College of Medicine, University of Saskatchewan Last full review/revision Aug 2021| Content last modified Aug 2021 https://www.merckmanuals.com/en-ca/professional/neurologic-disorders/symptoms-of-neurologic-disorders/memory-loss

This is what happened to Paula during her so called depressive attacks. She suffered a serious yet reversible decline in her mental function. And she felt awful- physically. She had loss of appetite, involuntary weight loss, lethargy, looked dehydrated, and could no longer function normally. These should have been obvious physical signs but they were overshadowed by people’s assumptions that everything was psychological. Paula lost her autobiographical memory for many tasks she used to do easily, such as doing her job, conversing with people, cooking, taking care of small children, decisions – any decisions- about anything, facts she had learnt, the list was endless and she was endlessly puzzled and disturbed about how that could be the case.

It happened overnight. With a snap of the finger Paula was mostly gone. No one knows but me, even now, how impaired Paula was. We did not really identify what happened as an episode of dementia at first. Instead we kept describing what she could no longer do. One cannot really self analyze their own dementia. Doctors do not test autobiographical memory, they do not think of this at all…especially when it happens so abruptly and especially when the person is young and looks depressed.

What is fascinating is how much of a person’s behavior is sort of the same as their usual, even after loosing their autobiographical memory. And they are not able to say so because they are so disoriented when it happens. They stay disoriented and confused until they get better, IF they get better. If you follow that person around and watch them trying to perform their usual tasks, you will quickly become aware when they have lost memory for what to do. Asking them is not useful. Watching them perform a task is much more informative than asking them any questions about what is wrong. They simply do not know what is wrong..They must show you not tell you.

Luckily we got Paula back! [Unlike many others] .

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s