A chef who loses his memory for six hours, a swimmer who can’t stop hiccupping, a mum who refuses to accept her disability may be psychosomatic, these just are some of the intriguing case histories in a new book by consultant neurologist.
NATHAN was a Canadian chef, living in Dublin with his wife of 25 years, Janet.
They had been settled in Ireland for many years and ran a small restaurant together. It was a good life and he had few cares in the world.
He was a creature of habit. His daily routine was to have breakfast with Janet, then a quick shower before setting off for a walk.
On this cold February morning, Nathan followed his usual routine and nothing seemed amiss until he got home.
‘What time is it?’ he asked Janet.
‘Oh, about half past ten,’ she replied.
After a minute, he asked again. ‘What time is it?’
‘It’s about half ten,’ she replied again, assuming he had not heard her the first time.
‘But what time is it now?’
‘Are you getting deafer or just ignoring me?’ she asked.
She looked closely at his expressionless face for a moment until he spoke.
‘What time is it?’ There was no inflection in the question.
‘What time is it?’ he said again.
By the time I saw Nathan in Casualty it was three hours since he had had his scrambled eggs and toast with his wife that morning.
He seemed completely oblivious to what was happening.
‘Where am I?’ He asked the same question over and over again, only occasionally looping back to ‘What time is it?’
It was close to two o’clock that same afternoon when the fog began to lift. The questions continued but the range expanded.
‘Where’s my car?’ ‘Where am I?’ ‘Where’s my wife?’ ‘What time is it?’ Nathan’s neurological examination was normal — apart, obviously, from his ability to take in any new information.
He could see. He could hear. He could drink the cup of coffee given to him. He could speak.
The tone, power and coordination of his limbs were as they should be.
His reflexes were all present and his big toes turned downwards (as they should) when I scratched the soles of his feet. Yet he could not process his circumstances.
He was not unlike a small child briefly separated from a parent in a supermarket.
About an hour later, Nathan suddenly piped up: ‘What the hell is going on?’ He sounded totally different.
Gone was the robotic repetition. The blank-faced automaton was replaced by a playful, smiling, Santa Claus-like figure who reached out his hand to comfort his anxious-looking wife.
‘I’m fine, Janet,’ he laughed. ‘Why all the fuss and what on earth am I doing in St Vincent’s?’
Nathan’s scans and blood tests were all fine. His recovery appeared complete but he would never regain the lost time despite his best attempts.
I have seen hundreds of similar cases over the years, and the existential angst on the faces of people who have had an episode of transient global amnesia (TGA) is always striking.
The exact cause of such bouts of temporary amnesia remains unknown. It has variously been thought to be due to either a stroke, a seizure or a migraine, but definitive proof of what causes it remains elusive.
The unfortunate individual loses their short-term memory and the ability to lay down new memories for up to twenty- four hours.
It can be provoked by immersion in water (hot or cold) or extremes of exertion and excitement. Sometimes MRI brain scans can show a lack of blood flow in the memory centres of the brain but this is variable in my experience. The precise cause remains mysterious.
Something as mundane as a hiccup, which we all experience, can be a case of food going down the wrong way or it can herald a cataclysmic brain injury.
So while most normal people will wait for an episode of hiccups to blow over, or hold their breath to stop them, a hiccupping neurologist will worry about the brainstem. No wonder we seem weird to many people.
I was called to Casualty to see Joseph, a 38- year- old Scot who was having difficulty swallowing.
Earlier that day he had been doing the front crawl in the swimming pool and after getting out of the water he complained of some pain in his neck. He did not put too much store by it.
He had been a rower and had had a fair few neck injuries in his time.
But at home an hour or so later he started choking on his evening meal.
He could not swallow the roast potatoes, however small he cut them.
Then he started to hiccup, and did not stop.
Joseph’s hiccupping was the first sound I heard when I approached his trolley in a pretty chaotic Casualty. He and his wife both looked exhausted and troubled.
I explained that I had been asked to have a look see if there was a neurological cause for his swallowing problems and persistent hiccupping.
His speech was very slurred and I found it hard to understand him, so I proceeded with the examination.
The combination of the neck pain, the sudden onset of his symptoms and the slurred speech suggested the hiccups could be due to a vertebral artery dissection — that he had torn a small blood vessel in his neck.
He was probably predisposed to a tear like that by his previous injuries and this vulnerability was possibly increased by his vigorous front crawl.
As a result of this tear he had had a small stroke in the lower part of his brainstem controlling his swallow and some of his speech mechanisms.
The hiccups were also due to this. These certainly seemed to be the most distressing symptom for him.
We arranged an urgent brain scan and identified the damaged blood vessel.
The hiccups disappeared after two days and, with the aid of blood thinners to avoid further injury, Joseph was eating and talking properly again within a week.
I met [Debbie] in London in the late nineties.
Her left hand had started to take on a life of its own one January. She then started to have trouble walking as well and arrived at the clinic on crutches.
She had a husband and two young children but came alone to her appointment. She had great family support, she assured me, and told me her family life was a very happy one.
Incredibly friendly and apparently open and sincere, Debbie was instantly likeable. I was taken aback, however, when, with much encouragement to get her to move her arms and legs, I could not find a clear-cut neurological problem. I was pleasantly surprised for her, as my initial — wrong — impression when she struggled in the door was that this was not going to turn out well.
I told her the good news, adding that in case I was wrong once more, I would look for the usual neurological suspects that can sometimes fool us.
But I reassured her that I did not expect to find anything serious.
Her mood turned instantly and her sunny demeanour was replaced by a glare.
‘How dare you say there is nothing wrong with me; what do you know anyway?’ she said.
I was gobsmacked by this rapid change and tried to explain again that I was only glad for her that I had found nothing on my examination that might point to conditions like MS or MND but that I would be making doubly certain with the tests I had planned.
Throughout this very uncomfortable exchange Debbie’s left hand had stopped rising in the air and it dawned on me (rather slowly, I admit) that this was what we describe as a functional neurological disorder.
It was ‘real’ in that Debbie was displaying the symptoms she was presenting with, and that they originated in her brain, but there was nothing structurally wrong with her brain or nervous system.
In times past we might have labelled Debbie’s symptoms as ‘psychosomatic’.
Giving Debbie vague explanations for her symptoms was not going to satisfy her or indeed facilitate her recovery.
So I tried a different approach and spoke optimistically about how a problem like this was treatable and how, in due course, and with physical and perhaps some cognitive behavioural therapy, she could expect a return to normality, including going back to work.
‘If you think I’ll ever be well enough to go back to work then you haven’t a clue what you’re doing,’ she shouted.
She was only 28 years of age and had not worked for five years because of her disability. She was living on benefits.
Surely, I said, she’d feel much better by regaining her self-confidence and becoming an active member of society again? I was wrong for the third time in quick succession.
‘You can go fuck yourself, you prick!’ she said and stormed out of the room.
I paused for a minute and took a few deep breaths to regain my composure. I stood to call the next patient and asked the clinic nurse to chase after Debbie as she had forgotten her crutches.