An example of neuro-psychoanalytic research: korsakoff's syndrome
di Mark Solms
Transcription of the Annual Research Lecture held at The School of Oriental and African Studies on Wednesday, 7th March 2001.
The following is a very informal account of the research activities in which I am involved, illustrated by just one example. My main interest is the relationship between psychoanalysis and neuroscience. I am conducting various types of research at this interface. Rather than give an overview of the entire field, which would be very schematic and, I think, very boring, I shall focus on just one aspect, for reasons that I hope will become clear. This is possibly the most pertinent aspect of my research. I also hope by this example to convey an idea of the scope of the opportunities that exist for psychoanalysis today in this area.
My starting point is the belief that psychoanalysts and neuroscientists - or at least what are nowadays known as cognitive neuroscientists (neuropsychologists and behavioural neurologists) are studying fundamentally the same thing. We in psychoanalysis are interested, just as they are, in the human mind: how it works and what the laws are that govern its functioning. If it is self-evidently true that we are both studying and trying to understand the same thing, the same piece of nature, albeit it from different viewpoints and using different methods, then it is absurd that we have so little to do with each other. Surely we should be collaborating, comparing notes and sharing our findings with each other. It is from this starting point that I have become involved in my field of research, an example of which I shall report. Psychoanalysts will find much of what I say self-evident, analytically-speaking. It is neuroscientists particularly whom I wish to address.
What we do in psychoanalysis is attempt to understand the functioning of the human mind from the vantage point of being a human mind, that is, from the vantage point of inner experience. Our perspective on the mind is the internal surface of consciousness, as Freud would have called it. We look inwards. We try to study our patients by encouraging them to look inwards, and from their free-associations, which are their attempts to describe as honestly and accurately as they can what it is that they are experiencing during the minutes that they are lying on the couch. We make inferences, firstly, about those individual patients and what is going on inside their minds at that particular moment. From that, we make inferences about that person in general - what the structure of their personality is, and the underlying structure of the difficulties for which they have come to analysis in the first place. From there, we make abstractions about how the human mind in general works. The 'functional architecture' of the mind - as cognitive neuroscientists would describe it - is ultimately what we are trying to learn about.
Neuroscientists start from the advantage of external perception, of looking outwards, observing the mind as it is realised as a physical organ, a thing, an external object. They try by various methods and approaches to discern the functional architecture of the mind is. Thus, when neuroscientists describe a model of how memory works (and memory is central to the example I am going to be discussing), they are talking about exactly the same thing that we psychoanalysts are interested in, to the extent that we have a theory of memory and how it works.
Psychoanalysis rests largely on a single method of investigation: the clinical method. The methods of neuroscience are more various. Yet there is a method which, historically, had the same significance for cognitive neuroscience as our clinical method in psychoanalysis. This is the method of clinico-anatomical correlation. It was formally introduced into neuroscience in 1861 by Broca and it was championed by Charcot. Charcot of course had a great influence on Freud. The method involves making clinical observations about mental changes in a neurological patient, which follow from disease or damage to a particular part of the brain. The clinical observations as to how the patient's mind has changed are then correlated with anatomic observations, that is, with the sight of the lesion (the damaged part of the brain). This correlation teaches us something about what the mental functions were of the part of the brain now damaged. This method of study is, as I said, not the only method in cognitive neuroscience. It has since been supplemented by numerous other methods. Yet, as I will show, this method is the obvious place for psychoanalysts to link up with the neurosciences, if we are going to construct bridges across our two fields.
Starting in 1861 with this approach of trying to understand how the mind is altered by damage to different parts of the brain, neuroscientists have been able to develop this highly elaborated picture of the functional architecture of the mind, of how the mind works. These attempts to infer normal function from clinical observations and the anatomical location of lesions that produced them have traditionally, and of necessity, been theory-driven. One does not make clinical observations about the mind without a theory with which to organise those observations and guide one, whether as a neuroscientist or psychoanalyst. Broca began in 1861 with the theories of faculty psychology, which were fashionable at the time. These theories were rapidly replaced in behavioural neuroscience by the theories of association psychology. The theories of association psychology are not that far removed from those which guide the clinical anatomical correlation approach to mental science today, i.e., cognitive psychology. Behavioural neuroscientists today use a cognitive model to guide their exploration of the functional architecture of the mind. That model has served them well in their attempts to understand cognition, but, not surprisingly, it began to falter as neuroscience began to mature beyond the merely cognitive.
Neuropsychology has begun in very recent years to grapple with something that it previously excluded: the problems of personality, complex emotions and motivation - the truly interesting aspects of psychology. This provides a unique opportunity for psychoanalysis to build a bridge to neuroscience because psychoanalysis has a highly elaborated theory about these very aspects of mental life, which neuroscience is now starting to grapple with. Fortunately I am not alone in believing that psychoanalytic theories might be of particular help to neuroscientists who are beginning to tackle these complex problems of human subjectivity. I can align myself in this respect with the most recent winner of the Nobel Prize in Medicine Eric Kandel, who stated in an article entitled 'A new intellectual framework for Psychiatry' (American Journal of Psychiatry, 1998, vol. 155, pp. 467-69; 1999, vol. 156, pp. 505-24) that this is the future of cognitive neuroscience. In order to grapple with this aspect of mental life, they need to make a bridge to psychoanalysis, which still offers, in Kandel's words, "the most coherent and intellectually satisfying view" of personality, motivation and complex emotion (p. 105). Therefore, a window of opportunity exists here, and I for one am keen to climb through that window and make use of the opportunity. There are enormous advantages not only for neuroscience, but for psychoanalysis too. If we can find links between our psychoanalytically-derived concepts on how the mind works and the concepts of neuroscience, then we can open our theory to an entirely new range of methodological possibilities, a new range of methods for testing hypotheses that we had previously been content only to generate. The psychoanalytic method is very useful for generating hypotheses about how the mind works and for making inferences, but psychoanalysts have historically not been very good at testing their hypotheses. There is a limit beyond which the psychoanalytical method cannot go, and this applies especially to deciding between competing hypotheses in a reliable, scientific way. By making links to the neurosciences, we create the possibility of testing some of our hypotheses in ways that might make it possible to move forward in what Freud called our metapsychology, our general theory of how the mind works. That is one of the obvious advantages for psychoanalysis of making these links. There is much more I could say about these general points but I want to get to the main focus of my paper.
My wife, Karen Kaplan-Solms, is my primary collaborator in using the method that I am going to describe, but, happily, we are being joined increasingly by more than a handful of colleagues. I should also state at the outset that we are very much aware that these are the very first steps. We are drawing very broad-brushstrokes: the ABC's of trying to make anatomical or physiological descriptions of our basic psychoanalytical concepts. There is a great deal more that needs to be done beyond this first step, but the method that we use in trying to make these links is in fact not radically different from the clinico-anatomical method that I described a moment ago. We study patients with damage to circumscribed parts of their brains, just as Broca did and cognitive neuroscientists have done ever since. We try to understand how their minds are altered by the changes in their brains. However the method that we use to make our clinical observations and the theory that we use to organise those observations are psychoanalytical. We study these patients psychoanalytically in order to be able to understand psychoanalytically how their personalities and their emotional and motivational life have been altered by the brain lesion. This gives us an initial rough sketch of how these aspects of mental life, as we understand them in psychoanalysis, might be represented in the tissues of the brain. So, it is basically the clinico-anatomical method that we use - the good old-fashioned, 'meat and veg' clinical method of behavioural neuroscience. The only difference is the nature of the clinical observations. Cognitive neuropsychologists use psychometric testing to elucidate the cognitive changes. This method is really not adequate for capturing the subjective aspects of mental life. In contrast, we try to capture the changes in these patients' minds by studying them and describing them psychoanalytically. We have used this method with a wide range of different lesions and this is necessarily how one has to proceed. We study patients with damage to various parts of the brain, trying to group them together by anatomical region. For example, we researched a group of patients with damage to the right hemisphere convexity. We studied the anasognosia-neglect syndrome, which emerges with damage to that part of the brain, and which results in some very interesting personality changes. I believe that, by looking at these patients psychoanalytically, we did in fact learn some interesting things (I reported on our findings with this group of patients at one of the Society's Research Seminar's last year [Bulletin 1999, issue 1, pp. 9-29]).
I am now going to illustrate the same method but by looking at a different region of the brain. The syndrome that I am going to discuss psychoanalytically by way of an illustrative example is Korsakoff's Syndrome. This is a very bizarre, very disturbing alteration of personality that occurs when there are lesions in a particular area. The part of the brain that I am referring to is just in front of the third ventricle. There is some controversy about precisely what nuclei have to be involved in order to produce this syndrome. The dorsal medial thalamus seems to be an important focus in the production of this clinical syndrome. Lower down, the hypothalamus and the mamillary bodies are also important anatomical structures involved. The basal forebrain nuclei in the frontal lobe - and at least some tissue of the frontal cortex itself - are also increasingly believed to be implicated. The relevant areas are thus the dorsal medial thalamus, hypothalamus, basal forebrain nuclei and frontal cortex.
One needs to bear in mind that the clinical picture I am going to describe is not what 'brain damage' (in general) looks like; this is what brain damage looks like only when the damage is in this particular part of the brain. Obviously, if the damage is in a different part of the brain, a radically different personality change would result. Moreover, Korsakoff's Syndrome is not to be confused with Korsakoff's Disease. That is a disease entity, which was described in Korsakoff's original description of this syndrome in 1887. A second paper on the disorder appeared in 1889. The earlier paper elucidated a particular disease process - essentially a vitamin deficiency - a result of chronic alcoholism, which affects this part of the brain. It was however subsequently realised that any disease process that affects this part of the brain produces the same syndrome.
The patient I am going to describe did not have Korsakoff's disease, he had a different disease, but it caused him to suffer from Korsakoff's syndrome. He is one of a group of patients described in more detail in a book, written by my wife and myself (Kaplan-Solms & Solms, 2000). What I am about to discuss is the clinical syndrome, Korsakoff's Syndrome, which occurs with damage to this part of the brain regardless of what the cause of the damage was or what the pathological process was. One of the other patients described in this book (Case G, p. 215) had an anterior communicating artery aneurysm which is a kind of hemorrhage in that area. Another (Case H, p. 207) had a self-inflicted bullet wound in that area. I am going to focus on a patient (not reported in our book) whom I saw three weeks ago in London. He had a tumor, a meningiomia, in the in the aforementioned area of the brain, which was surgically removed. After the surgery, he woke up with this syndrome.
Korsakoff's Syndrome has two main features. The first is amnesia. These patients have a profound loss of memory. According to the classical descriptions, they cannot lay down new memories. Thus, they might meet you at one o'clock today; you might walk out of the room and come back in at five-past-one and they won't know you. They will believe that they have never met you. What I am describing is not some esoteric rarity; it is quite common. This is the core feature of the syndrome. These patients are literally unable to lay down new memories. They live from minute to minute without having any recollection of what happened in the moment that has just past. This amnesia affects primarily the most recent events, especially those that occur after the onset of the disease. It does however also affect the older memories, but progressively less so, so that we have a temporal gradient: the further back one goes in time, the more secure the memories are. The more recent the memories are, the more unreliable (or non-existent) they are.
The second core feature of the syndrome, which distinguishes it from other amnesic syndromes, is that of confabulation. Rather than simply forgetting memories, rather than simply saying, "I don't remember" if, for example, one puts a direct question to them in relation to a memory test, these patients invent memories. They make up stories. They have false beliefs. They fabricate events. The technical term for all of these distortions is 'confabulation'. So these cases have, not only a loss of memory, but also a replacement of the gaps in their memory, as it were, by these florid inventions, which create the impression of a psychosis. Prima facie these confabulations are a psychosis. This is why the syndrome is also sometimes described as Korsakoff's psychosis.
What theories do we have in neuropsychology to explain this syndrome? Obviously, there are controversies and all sorts of diverse opinions. To cut to heart of the matter, most theorists agree that there seem to be two or perhaps three deficits - three parts of the functional architecture of the mind that are, as it were, missing or broken to account for this syndrome. The first is that there must be some disorder of the memory systems. What they specifically say is that these patients have great difficulty in searching their memory stores. Thus there is a deficit of memory search, of finding the correct memory. The second deficit is that the memories that they do actually manage to retrieve with this defective search method, inaccurate though they may be, are not appropriately monitored. This means that there is not an adequate questioning of whether a particular memory is correct or not. The third deficit, which some think is also necessary, is a more general executive abnormality. In other words, they have a more general difficulty in monitoring and organising their mental processes altogether, in gaining insight and reflecting on the adequacy of their performances. This, very simply stated, is the generic theory that exists in cognitive neuroscience today.
Now what happens when one studies such a patient psychoanalytically, when one takes a patient like this into a psychoanalytical treatment? It must, incidentally, be a psychoanalytical treatment that you take such patients into - not only this group of patients but all the patients that we are studying in this way. If one is going to gain access to the inner life of a human being one needs to try to help them. One needs to win their trust and involvement in the task because without their involvement the process is greatly handicapped. Thus, we are trying always to help these patients. Whether we actually do help them is of course a moot point. It remains to be seen with future research the extent to which we might be able to help these patients with the really devastating changes in their emotional lives that occur with these lesions. When one gets to know these patients as people, in this way, as opposed to giving them a behavioral checklist or a questionnaire to answer or scoring them against some sort of objective criteria, then something emerges - something which to any psychoanalyst sitting with one of these patients would be absolutely self-evident but which nevertheless is something which is missing from the neuropsychological literature on them. What exactly is missing I shall describe as I proceed. However, what emerges is the fact that these confabulations, random associations, bizarre thoughts and inventions, are, in fact, far from random and far from meaningless. There is an obvious underlying structure and coherence to the train of thoughts that these patients uncontrollably spew out when one listens to them in a psychoanalytical consulting room.
I saw this particular patient with a tumor every day for the past two weeks (six sessions a week). For the first time I tape-recorded the sessions, thinking that it might be useful to capture an objective record. What we were beginning to learn was so interesting, I wanted to be able to demonstrate it. I have, however, been surprised at how disappointing the result of tape-recording is. Reading through the transcript of his extended ramblings, I realised that it really does not convey anything close to what I experienced with the patient. What follows is an excerpt of the transcript of my tenth session with him. I have edited it slightly - cut out some of the 'ums' and 'aahs' and the stammerings that never went anywhere. This is necessary if it is not to be completely incoherent. It did not feel so incoherent at the time.
I had been seeing him for nine days, Monday to Saturday. What I am reporting is the Thursday session of the second week. Each day, he fails to recognise me. He does not know who I am; he has never met me before, as far as he knows. I have nothing to do with brains or minds. I am one thing or another. One day I was a University mate of his, we were in a rowing team together. Another day I was a soccer mate of his; yet another day, a drinking partner. Frequently, I was something to do with his business activity (electronic engineering). I was a client, I was a colleague, I was a business partner and on this particular Thursday he thinks of me as a doctor. This, I believe, represents progress. The minute that I come down to the consulting room to fetch him, his hand goes up to his head, where he has a scar from the craniotomy, and he says, "Hi Doc". I was really taken by that. So I go upstairs with him to my consulting room and sit down.
As I sit down I say to him, "You pointed to your head when we met in the consulting room", wanting to try to retain this new development. He says, "I think the problem is a cartridge is missing. We must...we just need the specs" - by which he means specifications - "We just need the specs. What was it? A C49? Should we order it?" I say, "What does a C49 cartridge do?" He says, "Memory. It's a memory cartridge, a memory implant."
The implant refers to the previous session where I was a dentist in his mind. In reality, he had implants and other dental work done a few years ago. So this immediately comes to my mind. He says, "But I never really understood it. In fact, I haven't used it for a good five or six months now" - his surgery, by the way, was about ten months ago - "It seems we don't really need it. It was all chopped away by a doctor, what's his name, a Dr. Solms, I think."
Now that is also very interesting because clearly he did not know me from a bar of soap prior to his consulting me after his surgery and after the onset of this amnesia. So there is this name "Dr. Solms" somewhere in his head, and it got in there since the onset of his amnesia. "What's his name? Dr. Solms I think. But it seems I don't really need it. The implants work fine." So I say to him, "You're aware that something's wrong with your memory but-" and he interrupts me and says, "Yes, it's not working one hundred percent, but we don't really need it." Again, I think it is really an enormous step forward for him to recognize that his memory isn't working, let alone knowing that we are talking about memory at all. "Yes, it's not working one hundred percent, but we don't really need it - it was just missing a few beats. The analysis showed that there was some C or C09 missing. Denise brought me here to see a doctor."
Denise, incidentally, is his first wife. He is now remarried and his new wife, who has a different name, is who actually brought him.
He says, "Denise brought me here to see a doctor, what's his name again, Dr Solms or something, and he did one of those heart transplant things and now it's working fine again, never misses a beat." Now he is referring to heart transplants. He did in fact have angioplasty many years before. So he has had some minor heart surgery but obviously not a heart transplant.
I say to him, "You're aware that's something's amiss. Some memories are missing and, of course, that's worrying. You hope I can fix it just like those other doctors fixed the problems with your teeth and your heart. But you want that so much that you're having difficulty accepting that it's not fixed already.
He says, "Oh I see, yes, it's not working a hundred percent", and he touches his head again. "I got knocked on the head, went off the field for a few minutes but it's fine now. I suppose I shouldn't come back on, but you know me, I don't like going down. So I asked Tim Noakes" - a sports medicine specialist - "so I asked Tim Noakes because I've got the insurance, you know, so why not use it, why not go to the best and he said, fine, play on."
Obviously he is talking about his memory. Although he is talking in fact about all sorts of other things, underneath there is something guiding him, an awareness of his memory loss, which was a new development. I keep trying to point this out to him, that this is what is really worrying him, this is what is really on his mind. Eventually he starts to become a little bit agitated and starts to talk about explosives and says, "Well, in this factory" - now we're in a factory - "there are a lot of detonators lying around and it can be very dangerous and it's, you know, it's not good for youngsters to not follow the correct procedures - there can be an explosion".
I interpret this as his pointing out to me that this is getting dangerous, he is starting to feel very unsettled by what I'm talking about; some emotion is starting to get involved here, it is not just an intellectual matter. I get through to him again, I think, so that again he is focusing. Awareness again dawns on him that he has got a memory disorder and he doesn't know whether he is coming or going. He is really lost. It is extremely distressing. Then he stands up and starts searching in his pockets for a piece of paper which he says he has lost, but there was no piece of paper in his pockets and I say to him that perhaps he had left it elsewhere; I didn't see him bringing any piece of paper in here. He is searching in his pockets and takes off his trousers and shakes the trouser legs looking for the piece of paper, now in a really agitated state - the sort of state that you get into when you've lost something important, something that really matters to you, and you're looking for it. Then he takes the chair and looks under the chair, picks the chair up, looks under the chair, and I started to feel a little bit concerned, a little bit anxious for my safety with this big guy with this chair in his hands.
I'll break off the description of the session there. He was showing me how agitated he was feeling about what he had lost, about the loss of his memory.
The experience I have of this patient is that it is like trying to find a radio station or a television channel: you turn the knob and you're just off the station, then you're on the station and it's all in focus and then it goes off again and then there's all this fuzzy sort of noise and then you're just about on the station and you can see the picture flickering and then you know that's the one that you want and you try to tune it back in again, and then you're on it, and then you think thank heavens I'm there, and then it all goes again. That is what his associations are like; that is how it feels to listen to him. He - or at least part of him - is trying to find the real station, the actual memory or the awareness of what is actually happening in his world right now. As he goes on to that station, he cannot stay there, and he goes away again. But he does not go away just anywhere; he goes more or less within that waveband. He is just about on the spot that he is looking for. Thus what he throws up are all these images, thoughts and memories which are in some more or less obvious way connected with the thing that he is looking for.
In sum, he is trying to find a certain thing, but what he finds instead is a whole lot of things around it that are symbolically connected, one might say, in the broadest sense, to the topic that he is actually looking for. It is like being in a dream, quite literally, as we understand dreams in psychoanalysis, where the images are not random. Underneath or behind these images are other thoughts which connect them in a coherent way. It is exactly like this with this type of patient, as if they are speaking symbolically or metaphorically, and all one has to do is make these very simple - I almost hesitate to call them 'interpretations' - and then you get them back on track again and then they go off again.
That is the first thing one can see by looking at the content of this patient's associations. This is a cognitive account, although we are more interested in the content or meaning than perhaps a cognitive neuroscientist would be. Yet it is more than that. It is not just that the patient's thoughts go off focus. There is clearly something else at work here, which is an emotional factor. This is the second thing we notice. There are certain 'wavebands' that he cannot tolerate. He has a reduced tolerance of reality, so that when he becomes aware of the very troubled, disturbing state in which he literally does not know where he is, he cannot retain the focus. This patient does not know what happened a minute ago or who this guy is sitting in front of him. He cannot bear that awareness of the reality that he is in. Another process takes over - a sort of delusional psychotic process - in which he replaces what he observes (if he does manage to observe it) with something that is more bearable and more tolerable to him. Thus, it is not simply a cognitive defect. There is an emotionally-based factor too which accounts for the symptoms that we see in Korsakoff's Syndrome. This, I am afraid, is the only discovery (if one can call it that) that we can offer cognitive neuroscience about this syndrome. What one is seeing is not simply a deficit of the machinery of memory. There is something that rises up to fill the gap left by that deficit. In short, there is a dynamic interplay. The reality-monitoring part of the mind is weakened, and some other force, which is usually held at bay, rises up, commensurate with the weakening of that reality-monitoring force. This positive symptomatology is what I now want briefly to describe.
The type of thinking that rise up in these cases to replace their sense of reality can be summarised under four headings. I shall use some of the patients in the book I mentioned earlier as examples of these more general points.
1. Replacement of external by psychical reality
Firstly, there is a replacement of external by internal reality. These patients give a disproportionate weight to internal or psychical reality at the expense of material, external, objective reality. An example of this is the patient just described. The objective reality is 'brain'. That is what we are talking about: brain and memory disorder. Internally to him, however, these are connected to other images, which have to do with teeth and hearts, and these take precedence over the objective reality. These internal thought processes, connected to the objective topic, are treated as if they too are objectively relevant. I repeat that there is an emotional or wishful factor here too. His teeth and heart were cured. His memory problem is in all likelihood incurable. Thus, in replacing the external reality with an internal one, there is also a shift of a tendentious kind.
Another patient described in Karen's and my book (Case G, p. 218) was a man who experienced his psychotherapy as if it were a conference. To him, all of these psychotherapy sessions were conference sessions. He saw me (he believed) as part of a course. Moreover, when he was moved from one ward to another in the hospital, he experienced this as being dropped from the football team. This is the memory that it evoked for him: "I'm dropped from a football team." Thus, the internal associations take precedence over the external facts.
Many of these patients described the most amazing things that they did the previous night. These descriptions are an over-valuation of dream experiences, which are then treated as if they too were real experiences.
One patient (Case H, p. 211) was always talking about pyramids and the shifting sands outside the hospital and so on, as if we were in a desert and in Egypt. We subsequently learnt from one of the nurses that he was busy reading a book about the pyramids at Giza. Whereas you and I would read a book and fantasise about being in Egypt, to this man, he was actually in Egypt; his fantasies were just as valid as his actual experience of being in the ward. He also believed that he was in a hotel in the Caribbean while he was in our ward, and that he was on holiday on a barge (Case H, p. 208). Here the theme seems to be confined space, with strangers. Rather than it's being a hospital, it is a holiday, the Caribbean, a barge.
2. Exemption from mutual contradiction
Secondly, there is an excessive tolerance of mutual contradiction. These patients hold two or more things to be true which cannot in fact all be true at the same time. For example, one of the patients (Case F, p. 203), a woman, believed that the man in the bed next to hers was her husband, and she treated him as her husband. Although he bore no physical resemblance to her husband, she told everyone that he was her husband and she treated him literally like her husband in every way. She also recognised that her husband came and visited her daily, and when her other 'husband' was there, they were both her husband and this was quite acceptable to her. She could tolerate the idea of her real husband and this man next door both being her husband at the same time.
One patient had an even more striking tolerance of mutual contradiction (Case H, p. 209). He came excitedly to his therapist, my wife Karen, and said that he had just met in the hospital an old friend of his who died some years ago in Kenya. He was really pleased to have seen him. Once again, in a strange place, the patient recognises a familiar face. Karen asked him, "But how can you have met him here in the hospital if he died twenty years ago in Kenya?" He stopped for a moment and replied, "Yes, that must present interesting legal problems, being dead in one country and alive in another!" It is notable, and also of theoretical interest, that there is something funny about much of what these patients do. (We have a theory about humor in psychoanalysis, which I think is pertinent in these cases). Commonly these patients report that relatives of theirs are dead, but at the same time they assert that these relatives are alive. Relatives are simultaneously dead and alive. That is tolerance of mutual contradiction. We even had one patient (Case G, p. 216) who believed that he himself was dead (a contradiction if there ever was one): telling others about the experience of being dead and still being there to describe it. (One is reminded of the fact that there is no such thing as death in the unconscious).
The third feature of these cases is timelessness. For them, time is not an objective fact but rather a theoretical construct that one can use at will. In fact one patient (Case H, p. 209) even said, when contradicted on a certain point about time: "Well, there are many different types of time. There's your time, there's my time, there's adjusted time, there's municipal time, there's hospital time"; and this is exactly how it is with them. Time can be used in various ways depending on your needs. That same patient always believed it was 5 p.m., no matter what time of the morning or afternoon or night it was; it was five p.m. If he had just had breakfast, it was five p.m. If he is busy having breakfast, it is five p.m. 5:00 p.m. happened to be the time that his wife visited him every day. Thus, the wishful or emotional element is apparent again. As this particular patient was leaving the consulting room, he said to my wife, "Oh, five p.m. You know Buffy's going to be here" - I think his wife's name was something like Buffy. Karen replied: "No it's not five p.m.; it's eleven a.m." He then saw a NO SMOKING sign on the wall with a red diagonal line through a circle, which he took to be a clock-face, and said, "Look, it is five p.m." - pointing to the sign. Once again, wishful inner reality overwhelms external facts.
In fact achronogenesis, a failure to sequence events in time, is a well-described aspect of this syndrome, even in the cognitive neuroscience literature. What is also seen is a condensation of time. This is not only a failure to order events, but events happening on top of each other, as in the female patient (Case F, p. 203) mentioned before. She had had a hysterectomy, a previous hospital admission, and a deep vein thrombosis in her leg. She described all of these conditions and all three of these hospitals as what was happening to her now: she was here for a hysterectomy, she was here for a brain operation, she was here for a deep vein thrombosis; she was in this hospital, that hospital and the other hospital, all at the same time. Again one sees the dream-like quality of these patients' thoughts.
4. Primary process (mobility of cathexis)
The last of the four positive features of these cases is a primary process type of mentation: one object replaces another at will. Depending on the patient's need, a strange man can be your husband if you need him to be your husband; this thing in your head can be a dental procedure if you need it to be a dental procedure. Additionally, there is a concrete visual concretisation and objectification of abstract thoughts. The main patient, described initially, was aware that there was something wrong with his memory. He turns it into: "I've lost a piece of paper which contains specifications that was in my pocket." All of the displacements, condensations, visual representations and concretisations evident in these patients are recognisable from dreaming thought. The wishful thread is readily apparent all the way through. I will now take a step backwards and attempt to pull all this together.
What do these observations tell us about the functional architecture of the mind? What is it that this part of the brain does that psychoanalytical study of these patients elucidates, and that wasn't otherwise readily apparent? Alternatively, how can we represent our model, our understanding of the functional architecture of the mind, in this syndrome? What, psychoanalytically speaking, has gone wrong with these patients? I am going to describe in the most rudimentary theoretical terms different psychoanalytical perspectives on this. What I think we see in these patients is the four principal characteristics described above, which are what Freud described as the four 'principal characteristics of the system unconscious'. His paper on 'The Unconscious' holds that these four things, (1) replacement of external reality by psychical reality, (2) exemption from mutual contradiction, (3) timelessness and (4) primary process (mobility of cathexis), are the principal functional features of the unconscious. All four characteristics are apparent in these patients. One does not need to infer them; they are there; the unconscious is on the surface, as it were. What theoretical sense can we make of this? It seems that whatever it is that normally suppresses this type of mentation is weakened by a lesion to this part of the brain. Remember: this happens only with damage here. Other brain damaged patients are different. Something essential to what Freud called the system pre-conscious or the secondary process - the reality-oriented part of the mind or something essential to it - is missing in these patients. The reality principle breaks down with damage to this part of the brain.
We cannot localise the whole system preconscious in this part of the brain. Yet we know that some function performed by that part of the brain is essential for that entire functional system, which we call the system preconscious, or the secondary process, or the reality principle. With that function removed, what comes through or what replaces it is what Freud called the system unconscious, the primitive, wishful, reality-ignoring aspect of the mind.
This leads to the question posed earlier: What does psychoanalysis add to cognitive neuroscience's description of the cognitive deficits in these cases? We add the realisation that their positive symptoms, these more primitive tendencies in the mind which are released, account for much of what is actually seen in the symptom complex of Korsakoff's Syndrome. It is not simply a matter of deficit.
By way of this very simple example, it is possible, using the method of clinico-anatomical correlation, to find a foothold in functional anatomy, in order to link our basic psychoanalytical concepts with the functional anatomy of the brain. I have described just one syndrome and used this one theoretical concept to make sense of it. Of course, when one studies all the different syndromes that arise with damage to all different parts of the brain, one gets a much richer picture, a much more fully elaborated theoretical understanding, of what exactly is occurring in each of these syndromes. For example, a release of primary-process types of thinking does not only occur if there are lesions in this area. In different ways, other elements of primary process thinking occurs with other syndromes. By studying all these syndromes together, we get a picture of what the different aspects are of this broader complex phenomenon that we call secondary process thought. In the process of doing that, we not only manage to make links between our psychoanalytical theories and physical tissues, with all the scientific advantages that this opens up, we also have the opportunity of understanding in more detail what a global thing like 'secondary process' might be in smaller bits. We develop a deeper understanding of what that broad brushstroke concept is all about. As has happened with all the previous psychological theories that have driven this kind of research, in attempting to correlate our theoretical concepts with functional anatomy, one also finds the flaws and the shortcomings of one's theory. In this way, one can build a better theory of how the mind works. Ultimately that is the aim of both neuroscientists and psychoanalysts: to build a better theory of how the mind works.
A final point is that what is needed is, not simply doing this kind of research, but also communicating our findings with neuroscientists, with people on the other side of the divide, working on the same problem. Sadly, in the real world, it is not always the case that they are interested in our work. Historically neuroscientists have not been interested in psychoanalysis. This kind of research project in which we are involved also entails grappling with how science really works. We have gone to enormous lengths to try to create dialogues between psychoanalysts and neuroscientists, mainly by starting an inter-disciplinary journal, Neuro-Psychoanalysis, with an equal number of leading analysts and neuroscientists on its editorial board. We publish research on topics such as this one and we hold dialogues in the pages of the journal about our findings and publish psychoanalytical observations on topics of neuroscientific interest. This has been an introduction to a very broad field in which I hope I have managed to interest some of you.
Kandel, E. (1998, 1999). A new intellectual framework for psychiatry. Amer. J. of Psychiatry, 155: 467-69. (Also 156: 505-24).
Kaplan-Solms, K. and Solms, M. (2000). Clinical Studies in Neuro-Psychoanalysis. London: Karnac Books.
Solms, M. (1999). The deep psychological functions of the right cerebral hemisphere. Bulletin of British Psycho-Analytic Society, Vol. 35, No. 1, pp. 9-29.