The Man Who Wasn't There: Investigations into the Strange New Science of the Self (3 page)

Many of the patients Laureys sees are in a bad way. Some are comatose, some in a state of unresponsive wakefulness (previously called vegetative), others are minimally conscious, and yet others are people suffering from locked-in syndrome (those who are conscious but completely paralyzed, and are sometimes able to move only their eyes).

After more than a decade of work with such patients as well as
healthy subjects, Laureys’s team has identified a network of key brain regions in the frontal lobe (the part of the cortex beneath the forehead) and the parietal lobe (which is behind the frontal lobe). He considers activity in this network to be the signature of conscious awareness. This awareness can be analyzed in two dimensions, he told me. One is awareness of the external world: everything you perceive through your senses, whether it’s vision, touch, smell, sound, or taste. The other dimension is internal awareness, something more closely related to the self, which includes the internal perception of one’s body, thoughts that are triggered regardless of external stimuli, mental imagery and daydreaming, much of which is self-referential. “It’s an oversimplification to reduce this very rich complexity we call consciousness, but I think it’s meaningful to take those two dimensions,” he emphasized.

And indeed, Laureys’s team has shown that
the frontoparietal network associated with conscious awareness is actually two different networks. Activity in one correlates with awareness of the external: a network of lateral frontoparietal brain areas—the regions on the outer side of the frontal and parietal lobes. The other correlates with awareness of the internal and is potentially related to aspects of the self: a network of areas along the brain’s midline—the inner parts of the frontal and parietal lobes, near the cleft that separates the two hemispheres of the brain.

Studies in healthy patients showed that these two dimensions of awareness are inversely correlated: if you are paying attention to the external world, then activity in the network associated with external awareness goes up while the regions associated with internal awareness dampen down. And vice versa.

Besides this frontoparietal network, there’s another key region of the brain that’s involved in conscious awareness: the thalamus.
There are long-distance two-way connections between the thalamus and the frontoparietal network, and Laureys’s work suggests that it’s the dynamics of information exchange and processing in these regions that takes us from being merely aroused to being consciously aware.

However, throughout our discussion, Laureys repeatedly insisted, “We should not be neo-phrenologists.” He was referring to
the dubious field of phrenology pioneered by German doctor Franz Joseph Gall (1758–1828), who argued that each and every mental faculty was the product of a specific brain region, and that these regions created characteristic bumps on the skull. So you could, in theory, run your fingers over someone’s skull and figure out the relative strength of these “organs” inside their brain.

The self, said Laureys, is not something that can be localized to one brain area.

When Laureys met Graham, he too found Graham a very depressed man. Laureys noticed Graham’s blackened teeth; he had stopped brushing. Graham repeated the same story that he told Adam Zeman—that he was brain dead. “He was not faking anything,” Laureys told me. “So we scanned him.”

Did he object to being scanned? I asked.

“He said ‘I don’t care,’” said Laureys.

Despite his condition, Graham was still using the first-person pronoun, “I,” to refer to himself.

Laureys’s team produced both magnetic resonance imaging (MRI) and positron emission tomography (PET) scans of Graham’s brain. The MRI scans showed no structural brain damage. But the PET
images revealed something very interesting: the frontoparietal network associated with external and internal conscious awareness had very low metabolic activity. Part of the internal awareness network is the so-called default mode network (DMN), which has been shown to be active during self-referential activity. A key hub in this network is a brain region called the precuneus—one of the most connected regions in the brain. In Graham’s case, the default mode network and the precuneus were far too quiet—almost down to levels Laureys had seen in patients in a state of unresponsive wakefulness. It’s true that Graham was on medication, but Laureys thinks that medication alone could not explain
the extent of the lowered metabolism.

The lowered metabolism had also spread to the lateral surface of the frontal lobes—specifically
some regions that are known to be involved in rational thought.

Though both Laureys and Zeman cautioned against making too much out of one case, the results are suggestive. It’s likely that the impaired metabolic activity in the midline regions had caused Graham to have an altered self-experience—maybe a greatly reduced sense of self. But because that lowered metabolic activity had spread to other regions of the frontal lobes, he was unable to talk himself out of that altered experience, as he otherwise might have. He became convinced he was brain dead.

A more recent case study, published in November 2014, also supports this hypothesis. Two Indian doctors were treating
a sixty-five-year-old woman with dementia, when she began to show signs of classic Cotard’s. “Our patient presented to us with beliefs like ‘I think I am dead and what I am is not me,’ ‘I do not exist,’ ‘there is nothing in my brain, just vacuum,’ and ‘it is infectious and I’m infecting my close relatives and I am responsible for all their suffering,’” Sayantanava
Mitra of the Sarojini Naidu Medical College, Agra, India, wrote to me in an email.

Mitra’s team scanned her and the MRI scan revealed that the frontotemporal brain regions had atrophied. They noted, in particular, that a deep-brain region called the insula was heavily damaged in both hemispheres. There’s growing evidence that the insula is responsible for the subjective perception of our body states, a crucial aspect of our conscious experience of selfhood. So, a damaged insula was likely hampering the woman’s sense of her own body, and her dementia made it difficult for her to correct false perceptions, leading to claims of being dead.

The doctors started her on mild doses of antipsychotic and antidepressant medications. She recovered enough to take part in psychotherapy, with the therapist using her MRI scans as “evidence against her belief that her head was rotten,” Mitra said. The therapist was able to shake her out of her false beliefs. She was eventually discharged, and continues to get better on her medication.

Graham, too, eventually recovered. Cotard’s syndrome is, thankfully, transient in most people, even though the treatment at times might involve electroconvulsive therapy.

“I think Cotard’s delusion is a victory of metaphor over simile,” Zeman told me. “There are mornings when most of us get up and feel as if we are half-dead. So alterations of your experience which you might express using that kind of simile are not so uncommon. But the bizarre thing about Cotard’s is that people begin to treat this simile as if it were literally true. And for that to happen, there surely has to be some disturbance of reason.”

The paucity of patients with Cotard’s syndrome means that the neural underpinnings of their delusions are yet to be fully understood, but it’s clear that Cotard’s syndrome is giving us a glimpse into the nature of the self.

Take, for instance, something philosopher Shaun Gallagher calls
the immunity principle, an idea that goes back to Austrian philosopher Ludwig Wittgenstein. It refers to the fact that when we make a statement like “I think the Earth is flat,” we can be wrong about Earth’s flatness, but we cannot be wrong about the “I,” the subjective self that is making the assertion. When we use the pronoun “I,” the word refers to the one who is the subject of an experience, not someone else. I cannot be wrong about that. Or can I?

Cotard’s delusion certainly gets philosophers thinking (if they need any further enticement), as do various other conditions, such as schizophrenia. In Cotard’s delusion, the firm belief that “I don’t exist” seemingly challenges the immunity principle. But even though the delusional person is wrong about the nature of his existence (which is analogous to Earth’s flatness), the immunity principle holds because there is still an “I” making the claim, and that “I” cannot refer to anyone else but the person experiencing nonexistence.

What or who is that “I”? The question permeates this book. Whoever or whatever the “I,” it manifests itself as a subject of experiences.

But how does the brain, with its physical, material processes, give rise to a seemingly immaterial, private mental life (at the core of which seems to be the “I,” the subjectivity)? This is the so-called hard problem of consciousness. Neuroscience doesn’t have an answer so far. Philosophers disagree vehemently on whether science can ever solve this problem, or whether this problem is illusory, one that might disappear as we understand the brain in more and more detail. This book
does not offer neuroscientific solutions to the hard problem of consciousness—there are none, yet.

But this book does address the nature of the self. One way to think of the self is to consider its many facets. We are not just one thing to others or even to ourselves; we present many faces. The great American psychologist William James identified
at least three such facets: the material self, which includes everything I consider as me or mine; the social self, which depends on my interactions with others (“
a man has as many social selves as there are individuals who recognize him and carry an image of him in their mind”); and the spiritual self (“
a man’s inner or subjective being, his psychic faculties or dispositions”).

The search for the self is also well served by thinking of it in terms of two categories: the “self-as-object” and the “self-as-subject.” It turns out that some aspects of the self are objects to itself. For instance, if you were to say, “I am happy”—the feeling of happiness, which is part of your sense of self at that moment, belongs to the self-as-object category. You are aware of it as a state of your being. But the “I” that feels happy—the one that is aware of its own happiness—that’s the more slippery, elusive self-as-subject. The same “I” could also be depressed, ecstatic, and anything in between.

With this distinction in mind, if you take Laureys’s studies, which show that in healthy subjects the frontoparietal network activity constantly switches back and forth from internal to external awareness, what seems to be changing is the content of one’s consciousness: from awareness of external stimuli to awareness of aspects of one’s self. When you are self-aware, in that you are conscious of your own body, your memories, and your life story, aspects of the self become the contents of consciousness. These comprise the self-as-object.

It’s possible that parts of this self-as-object are not being
experienced vividly in Cotard’s syndrome. Whatever it is that tags objects in our consciousness as mine or not-mine, self or not-self, may be malfunctioning (we’ll see in coming chapters some mechanisms that could be behind such tagging). In Graham’s case,
the
mineness
or vividness that is usually attributed to, say, one’s body and/or emotions was maybe lacking. And the resulting untenable belief that he was brain dead entered his conscious awareness unchallenged, given his underactive, low-functioning lateral frontal lobes.

But regardless of what one is aware of, isn’t there someone who is always the subject of the experience? Even if you are completely absorbed in something external, say, a melancholic violin solo—and the contents of your consciousness are devoid any self-related information, whether of your body or worries about your job—does the feeling that
you
are having that experience ever go away?

To help us get closer to some answers, we can turn to insights of people suffering from various perturbations of the self, which serve as windows to the self. Each such neuropsychological disorder illuminates some sliver of the self, one that has been disturbed by the disorder, resulting at times in a devastating illness.

These words from Lara Jefferson’s
These Are My Sisters: A Journal from the Inside of Insanity
leave us in no doubt of the damage wrought to the self in a schizophrenic person: “
Something has happened to me—I do not know what. All that was my former self has crumbled and fallen together and a creature has emerged of whom I know nothing. She is a stranger to me. . . . She is not real—she is not I . . . she is I—and because I still have myself on my hands, even if I am a maniac, I must deal with me somehow.”