The Robber of Memories: Memory loss in Art and Medicine

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…and he recalled that the Magdelena, father of waters, one of the great rivers of the world, was only an illusion of memory’
Gabriel Garcia Marquez ‘Love in a time of cholera’

Probably the most embarrassing experience I will never remember
My first personal experience of a significant memory lapse took place when as a medical student I took part in a study of oral Midazolam. I didn’t feel any different for a few hours after taking the drug and decided that I would make my own way home. An hour later I started to feel very sleepy, and everything for a few hours after that became a blur, a black hole in my memory. I was later told that I had walked into a packed meeting 20 minutes late, sat down in the front row beside the speaker’s wife and had promptly fallen asleep for the rest of the meeting! No matter how hard I tried, I could not piece together one thing the speaker had said or indeed how I had made my way home. Even though this was a trivial event, it was strangely frustrating and my mind kept churning the events over and over for weeks to try and get it back. I felt as if I had been robbed of something precious. It made me wonder what it must be like for people who begin to lose their memory, especially the most treasured memories of their loved ones.

A memorable Film informs an improbable clinical encounter

One of the most striking descriptions of memory loss in art has to be Christopher Nolan’s Memento. In the film the main character tries to compensate for his dramatic and specific deficit in short term memory by tattooing all over his body aide-memoire notes to himself as part of an obsessive and desperate search for the truth. I have encountered many patients with general memory loss in clinical practice but I did wonder if this dramatic failure of short term memory was just a fictional construct or if it could really happen. My question was recently answered when I came across someone with exactly the same deficit, brought on by a bout of encephalitis. She had suddenly become unable to form new memories whilst her past memories remained unaffected and her higher mental function was mostly intact. She continued to work out her puzzles but she  could not retain any new information for more than a couple of minutes. She just could not understand why she couldn’t go home or why people weren’t telling her what was going on. The frustration and anger that this caused was already beginning to distort her normally placid and cheerful character. Apart from ‘locked in syndrome’, I can’t imagine too many conditions more terrible to develop. The ability to remember (and forget) is definitely something we take for granted.

Probably the most memorable book I will always struggle to remember clearly
This leads me in a roundabout way to some of the books I have read this summer. The first was the Gabriel Garcia Marquez classic ‘100 years of Solitude’ which begins with the memorable line “Many years later, as he faced the firing squad, Colonel Aureliano Buendía was to remember that distant afternoon when his father took him to discover ice.” The novel revolves around the Buendia family and the people of Macondo, who have been afflicted by a plague of insomnia whose side effect is a loss of  memory.  We read how the people in this imaginary village had to resort to labelling everyday objects and even write instructions on how to use them.  In the words of Jacob Silverman, “Garci­a Marquez, who has described himself as a professional of the memory, that awareness (i.e. of slippage of memory) must be especially piquant, both because his work is so predicated on notions of memory, history, and ancestry, and because neurological conditions run in his family.” There are many references to memory in his works, and when reading ‘100 years of Solitude’ I almost felt as if I was being transported into a world where I myself was losing my grip on reality and getting lost in an impossible jumble of characters. The thread of history gets tied into so many knots that it takes an effort to unravel it (including regular reference to the family tree, for instance). In spite of the use of magical realism, some of the insights from these books are now being reflected or confirmed by research. For instance, we now know how important sleep is in developing and shaping our memories. Garcia Marquez’ books are also strongly influenced by the author’s experiences and travels in the area of Columbia near the Magdelena river.

Probably the least likely but most memorable travel itinerary in the world

This novel was the inspiration for another book I read this summer: ‘The Robber of Memories’ by Michael Jacobs. Jacobs is another writer with a life long obsession with memory, not to mention his childhood interest in tales of the Spanish exploration of South America. In his own words “The older I got the more I appreciated the role of travel as a stimulus to memories, and the way in which journeys even to new places were somehow always awakening memories of places seen in an ever-receding past”. This book is an intensely personal travelogue/meditation but should be of interest to those of us who want to gain an insight into the experiences of patients or relatives with memory loss or dementia.  ‘Escaping’ for some respite from his role of carer for his elderly mother with dementia, Jacobs embarked on a mission fraught with danger, following in the literary footsteps of his hero Garcia Marquez. Unusually, his journey was a quest to retrace his hero’s love affair with the Magdalena river, ignoring the threat of FARC guerilla attacks to make his way to the source of the river. The story begins with a meeting with the aged author, now himself in the lonely hinterland of early dementia. Garcia Marquez himself has had to let go of so many precious memories, but images of his beloved river had remained. His 81 year-old literary agent Balcells was quoted as saying of him:  ‘Gabo carries a constant glare of nostalgia in his eyes’. That description would have fitted my patient to a tee.

Mingled through the narrative Jacobs reminisces about his parents’ loss of memory and frets with anxiety and guilt about having left his mother. A dread of what might happen to him if he was to follow his parents into the fog of dementia seems to be an undercurrent throughout. He re-reads ‘100 years of Solitude’ and finds evidence that the author may have had a premonition of what was going to happen to him. He meets Marcela, whose mother has Alzheimer’s disease. She tells him about the tales of the disappeared, about the days when two or three unidentified bodies floated down the river every day. In itself, this is a powerful metaphor for the brutal ravages of dementia, separating sufferers from their loved ones in a way that reopens old wounds and prevents them from getting closure for their grief. She said that her mother could still recall some of the trauma but she couldn’t recall where or when they had happened. Jacobs quizzes the locals about the local myth about a ‘robber of memories’ who would visit you in your sleep. It is almost as if he was challenging the robber in his own backyard!

As we are led slowly up the river Jacobs reveals his plan to visit the village of Yarumal, where so many of its inhabitants are struck down early in life with Alzheimer’s disease. The seemingly fanciful idea of a whole community being struck by a ‘plague’ of memory loss is actually based in the strange but real world of the Magdalena. He meets and talks to Fransciso Lopero, a leading researcher who has made the sudy of this unique tribe his life work. Genetic discoveries here have allowed susceptible people in this town to be identified so that in future  potential treatments or vaccines can be tested in this group before they develop clinical symptoms of Alzheimer’s disease.

Many seek for hope at the end of the rainbow: Jacobs sought hope at the source of the Magdelena. And after all, the best research is essentially an adventure into the unknown inspired by a passionate hope and anticipation of discovery. Sadly, Jacobs died from cancer earlier this year. At least he was spared a house call by the ‘robber of memories’.

Further reading
The town of Yarumal and Alzheimer’s disease: Telegraph article by Michael Jacobs
Telegraph Obituary for Michael Jacobs
BBC Article (2011) about Francisco Lopera and his research in Yarumal
Selected quotes and memories of ‘Gabo’ – Huffington Post

More about Alzheimer’s disease from the Alzheimer’s Society

Meddling with the mind and mining the memories

How do memories form and why do some memories become extraordinarily painful? We have all heard about conditions like post-traumatic stress syndrome, where traumatic memories linked with painful and distressing emotions cause real and disabling distress every time they are recalled. Have you ever been tempted to banish some of your memories into oblivion? The film ‘Eternal Sunshine of the Spotless Mind’ explored what might happen if we were able to selectively erase some of our painful memories. The consequences were not always as positive as expected.

But what about musculoskeletal pain? Does memory play a part in establishing chronicity in chronic pain? Some of the recent research on Fibromyalgia Syndrome (FMS) using fMRI seems to support the theory that painful stimuli can become ‘amplified’ in the brain and form inappropriate linkages with fear and emotion centers in the brain. These are the sort of links that would normally only be made with really severe painful stimuli such as a life threatening injury. Now, it has to be admitted that brain imaging studies in FMS are small and the findings can easily be disputed – but what if they were correct and point to a serious distortion of the interpretative neural matrix in the brain? We all have an ‘interpretative filter’ for sensory signals in the brain – the mechanisms by which the brain ‘triages’ the incoming signals into normal everyday stuff we can safely ignore and the sort of warnings that we really need to worry about.

So – what if part of the problem with FMS was that exercise has become inextricably linked with negative memories? We know that the opposite can occur: healthy people who exercise may get an ‘endorphin buzz’ that gives them a natural ‘high’ after exercise that makes them want to do it again. People who enjoy competing get a competition ‘high’ that makes them want to have another go. Are we prepared to put up with more pain if we have a strong memory of the ‘gain’? Can there be a polar opposite to ‘psychological dependence’?

Some of my patients with FMS previously enjoyed exercise and had been very fit before something happened to them. FMS patients will often recall having gone out for a walk and becoming so disabled by pain that they couldn’t get home again – this sort of negative memory seems to set up a fear of exercise and a conviction that exercise is unhelpful.

A pill to erase your memory?There are two interesting lines of research that could spell hope for patients with FMS. One was highlighted in an article by Jonah Lehrer in Wired magazine called ‘The Forgetting Pill’. Now I hasten to add that the drug in question has so far only been trialled in mice and is a very long way from being used in humans – but it highlights an interesting direction of research that may eventually have major benefits. The basic idea is that deep-seated memories are constantly being remolded in a process that involves neurons creating new linkages through protein synthesis. A Neurologist David Sactor from Columbia University has discovered a form of Protein Kinase C called PKM zeta that is crucial to this process. He and colleagues have developed a PKM zeta inhibitor ‘ZIP’ which has been shown to cause selective erasure of unpleasant memories in rats. Yes, rats. And by the way, ZIP had to be injected into the rats’ brains. So at the moment the only people likely to be planning to use ZIP will be evil dictators. But it is an intriguing idea and the concept that you only have to recall a memory to raise the possibility of changing the nature of the memory is an important one. Professor Alain Brunet from McGill University has conducted successful trials using Propranolol (an established drug for high blood pressure) to suppress painful memories in PTSD sufferers. There’s also a good article on this at the Smithsonian website.

Transcranial direct current stimulationThe second area of research – more directly relevant to patients with FMS – is the recent use of Transcranial Magnetic Brain Stimulation or Transcranial Direct Current Stimulation (tDCS). Preliminary trials have been quite positive, although we cannot be certain how these low level and painless magnetic/electric fields can alter what is going on in the brain. One of the more plausible theories is that they may alter the neuronal excitation and thereby alter the abnormal levels of ‘amplification’ of signals in FMS. Is it possible that this works in a similar way to the memory modification techniques – splitting unhealthy links between sensory areas in the brain cortex from emotion/fear areas?

Some work that suggests a possible link was recently featured in a BBC Horizon programme on memory. In the programme a musician with ‘focal dystonia’ played the piece of music that he most associated with his early memories of the ‘twitch’ that had ruined his performing career. By recalling the memory whilst applying a low voltage current using tDCS the researchers felt that they could alter the excitation state of the neurons and dampen down the effect of the old memories. Old associations could potentially be ‘over-written’ by remembering a new performance with a more positive outcome.

If this early work with tDCS or Transcranial magnetic stimulation in FMS is replicated by independent researchers it will open up a whole new field of treatment. Our best proven interventions for treating FMS currently involve re-training the mind and body using graduated exercise programs or cognitive behavioral therapy. However, this is tough and some patients just can’t break out of the vicious cycle of pain, fatigue and insomnia.