Memory and Thought

How does Memory Work in everyday life?

In its simplest form, memory refers to the continued process of information retention over time. It is an integral part of human cognition, since it allows individuals to recall and draw upon past events to frame their understanding of and behavior within the present. Memory also gives individuals a framework through which to make sense of the present and future.

We had an epiphany a few days ago and now have a much better idea of why people can become “strange”  overnight. It involves sudden acute loss of autobiographical memory, a form of retrograde memory, accompanied by cognitive impairment in what looks like major or bipolar depression. And it is impossible to describe if it happens to you. And it is impossible to imagine this happening to anyone, mostly because it is very hard to imagine losing the ability to imagine. This is what happened to Paula all those years ago.

One morning, Paula woke up in a fright, to find that she’d lost her ability to think normally. She woke up cognitively impaired, and lost her autobiographical memory and did not know it, but she noticed that she had become weirdly incompetent and incapacitated. Oh, she was also short of breath, but did’t know it, just felt it when she tried to speak.

Paula  ” I woke up one night in a panic, with a sensation of  anguish and distress which lasted over a year. I drove to work, said hi to my friends and colleagues and then was shocked to realize that I had no idea what else to say [unusual for me] and then I went to teach my class and realized to my horror,  that I’d lost all memory of the content. I did not know what to do. The students got frustrated with me and started jeering, they weren’t kind. No one was kind.  I had been a very popular and very entertaining teacher. I had difficulty doing anything that I could do easily only yesterday. I did not remember how I usually interacted with my husband or with my children. Overnight, something happened to me to erase my personal knowledge of me. I did not understand it then.I do not really understand it now. I do not think anyone does. It was a nightmare, and it lasted over a year before lifting. Even after it lifted, I did not understand what had happened.”

No one understood that she had suddenly lost her autobiographical memory.

We are not scientists or doctors or even writers. This investigation was thrust on us by what happened to Paula. We have kept records of our findings and our speculations in this blog .

Paula and I decided that the goal of any therapy or medications would be to restore her normal memory and cognitive ability. We figured that the sensation of anguish and impaired intellect would resolve together because we assumed that the two were linked. [We were correct].

Interestingly, no one realized that Paula had lost her memory for self. This is because Paula knew who she was, where she was, and knew who the people around her were. She knew how to drive and drove herself to work. She knew where she worked and where her office was. Paula did not know that parts of her memory were impaired. . She knew that she was a teacher but when she began teaching a class , she did not know that she no longer remembered anything about her subject and in desperation, had to read haltingly from her notes. It was so embarrassing and so so startling. She did not realize that she did not know her own address or phone number, [she found this out while trying to organize an event at her home]. This too was startling. And every time she tried to do anything, she did not realize that she might no longer have the knowledge. She was startled every time she tried to do something and failed due to lack of memory. Which was all day long.

What was also strange, was her memory loss for conversation. She had no memory of how she used to interact with anyone, colleagues she saw every day, friends, close family, etc…She mostly said nothing when people tried to strike up a friendly conversation and had no thoughts in her head at all. She mostly looked at the person in near silence and wanted to escape because nothing came to mind to say or comment or respond. She was so confused about what was happening to her.

Others immediately noticed that she was “not herself” but they never imagined that she was amnesic. Paula did not know that she was amnesic. She just knew that her mind was mostly empty of thought. The only thoughts remaining to her were linked to her own observations of her faulty performance in conversation or while teaching or doing something else she no longer knew how to do.

After witnessing herself not being able to converse or to teach, she had fleeting thoughts about what she saw taking place; thoughts like...”why don’t I know why to say? what do I usually say? what is wrong with me? what is happening to me. this is very serious, i need to see a doctor, oh no they will not understand, I don’t understand. oh no, I am so screwed….no one will know what to do ….oh no……and so on…..“.

Then Paula forgot that anything was wrong with her memory until the next time she tried to do her job or spoke to someone…..again and again and again….It was very upsetting….all day long.

Paula did not know how to explain or what to say so she remained mostly silent…..She stayed silent also because she was short of breath, but she did not know that either.

She knew enough to realize that no one [except Dr Emile Kraepelin ] understood that that she might remain in this incapacitated state for a long time yet it might be possible to restore her mental status and. her normal function. And Dr Kraepelin died in 1926, after a successful career.

She knew what happened to people who lost their autobiographical memories, in effect losing their mind. She thought that her life as it used to be, was finished.

Her silence and confusion was taken by others to be the result of a major depression, instead of a dementia or delirium. No medical diagnosis was investigated or seriously considered.

Paula was given psychotherapy and a number of different medications to try to treat her depression. The doctor’s goal was to return her mood to normal. He had no idea [even after she tried to tell him] that she was amnesic, cognitively impaired- to the extent she was, and that was why she was frightened. She’d lost her frame of reference. She’s lost her memory for everyday things. She was operating as if she was in a foreign land without any usual guideposts. And no one seemed to notice except to think that she was upset. She was upset! Wouldn’t you be upset?

Oddly enough, it was near impossible for her to initiate spontaneous thoughts or actions.. All her thoughts were in response to her actions, or lack there-of. Otherwise her mind was blank.

She had immense difficulty with spontaneous motor actions. [except for sitting still, and staring blankly or pacing mindlessly]. She relied on watching others in order to “jump start” her actions- the ones she wished to do. Seeing someone else getting up, helped her to get up. Someone driving to work, helped her remember to go to work and to start moving. She could copy actions as a way to start an action, since she could not start on her own, spontaneously.

So strange….she had no sensations of hunger or needing to go to the bathroom or to sleep. …and she ate very little as a result, did not go to the bathroom much, and did not sleep much either. She felt a huge and continual sensation of anguish which seemed to block out anything else. She lost weight and began to look poorly. She was unaware the decline in her physical condition.

She was silent because of her lack of spontaneous thought and speech and shortness of breath.

She needed someone else to quiz her and present her with cues in order to help her memory so that she could communicate.

Are you depressed ? No

Are you having trouble with your memory? Yes

But no one asked. No one knew she lacked spontaneous thinking or speech. How could they?

This is why we are telling you now.

Because what happened to Paula could happen to you.

We are supposing that Paula would have been able to answer yes when asked about memory loss but since no one did, we are not really sure. She may have been too confused to answer yes and might have only been able to respond with an ” I don’t know”. which to us is a yes.

The next step would be to give her a fast test of executive function and memory. The Trail Making Test B is a perfect test for this.

Trail making tests have been extensively used in neuropsychological assessment (e.g., Butler, Retzlaff & Vanderploeg, 1991Rabin, Barr & Burton, 2005Sellers & Nadler, 1992). Most variants of this test, which was apparently introduced in 1938 by Partington (Partington & Leiter, 1949), have at least two conditions. In condition A the participant is to draw lines to connect circled numbers in a numerical sequence (i.e., 1-2-3, etc.) as rapidly in possible. In condition B the participant is to draw lines to connect circled numbers and letters in an alternating numeric and alphabetic sequence (i.e., 1-A-2-B, etc.) as rapidly as possible.

Although trail making tests are very simple, they have been hypothesized to reflect a wide variety of cognitive processes including attention, visual search and scanning, sequencing and shifting, psychomotor speed, abstraction, flexibility, ability to execute and modify a plan of action, and ability to maintain two trains of thought simultaneously (for citations see Lezak, Howieson & Loring, 2004Salthouse & Fristoe, 1995, and Strauss, Sherman & Spreen, 2006). What cognitive abilities are involved in trail-making performance? Timothy A. Salthouse Intelligence. 2011 July-August; 39(4): 222–232. doi: 10.1016/j.intell.2011.03.001

Once I understood the extent of her loss of memory I gave her the Trail Making B test and had her tell me how she was doing. She was able to respond “in the moment” that she could not remember the first number long enough to connect to the correct answer [1-A, 2-B, etc…] at any speed. Wow! That was really bad.

We used the Trail Maker B and her memory [or lack there-of] of her address and phone number in order to discover which medication would begin to bring back her intelligence. [intelligence in this case referring to her autobiographical memory and normal baseline mental status, before she got sick].

We think that in the absence of clear evidence of permanent damage to the brain, that the goal of treatment of anything that impairs mental status and self memory should be to restore the person to their baseline as much as possible, no matter how long it takes.

This was our goal, we monitored her daily for this, we chose to continue any medication that seemed to help-even minimally, at first- and we succeeded!

We tried to stop the medication several times once Paula’s mental status was restored and she was fine for months and then became as sick as she had been at the start.

We finally understood that she needed this medication for life.

We don’t know how it works. We don’t ‘know much about amnesia or autobiographical memory and how thats works. We know very little, nothing really.….only that after the first year on this medication she began to improve and that it took 10 years to obtain stable return of her intelligence and memory.

We had help from Dr Emile Kraepelin who had studied thousands of cases very similar to Paula and we knew that these attacks were remitting / relapsing without medication and we know that patients did not suffer permanent dementia. And we knew that to the outside world, these attacks looked like bipolar depression and occasionally turned into mania [also sometimes overnight].

Dr Kraepelin hypothesized that this was a metabolic syndrome, due to the pattern of abnormal vital signs [including rate of breathing] he saw during attacks of depression with psychomotor slowing and during attacks of mania with psychomotor excitement in the same patient. He studied thousands of unmedicated patients. He was able to describe the natural history of this syndrome. And he did these studies up to 1926…… Only for his work and hypothesis to be forgotten completely.

Except by us.

Dr Kraepelin described what was happening to his patients, he talked to them [although much of what they said was incomprehensible] and he was interested in what was wrong with them physiologically , not just their brain.

We owe Paula’s recovery , in part , to him. Thanks to him, we understood that Paula’s thoughts and actions were “inhibited” during depressive attacks and “excited” or “uninhibited” during manic ones. We knew that these attacks were reversible, no matter how long they lasted and that they recovered spontaneously [but slowly enough to have wasted lives].

Thanks to his work we knew what the goal of Paula’s treatment was; the goal was to be 100% recovery of native baseline intelligence and memory.

And with that she returned to her normal self.



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