It all started on Twitter. It’s been years, Saul Martinez-Horta (Barcelona, 1981), clinical neuropsychologist at the Hospital of Santa Creu and Sant Pau (Barcelona), began posting on this social network on clinical cases What caught your attention the most. One editor, Kailas, raised the possibility of writing a book with them and now just posted “Brainbroken”, imitating “The man who confused his wife with a hat”, the classic written in 1985 by the famous British neurologist Oliver Sacks. Martínez-Horta is also director of the Center for Neurocognitive Diagnosis and Intervention Neuropsychology Unit (CDINC) of Barcelona.
What is a broken brain? It’s a metaphor. Brains don’t break, but for various reasons stop working as they should. The curious part when this happens is how the behavior or cognition of the human being is expressed.
What does memory loss mean? We are our memories. Reality makes sense because we have a memory. If I look at the world without knowing how to attribute meaning to what I observe, to myself, to my environment, to objects, it doesn’t make sense. There is a very immediate memory that gives life to my consciousness and another, more distant in time, that gives meaning to my whole existence. Memory can be wasted entirely or just in pieces. And the way it breaks down can profoundly transform a person’s reality. One of the first things you see when memory becomes fragmented is how the individual loses their essence.
How normal is memory loss? Cognitive deterioration has been trivialized and normalized as an unequivocal consequence of aging. Many people assume that as we age, it is normal to deteriorate significantly. And it is obvious that as we get older, we are slower, more clumsy, our memory is no longer the same… But within certain parameters. Everything that affects a person’s life and that catches the cognitive eye – whether in memory, language, behavior – of his family is not attributable to age. And it is worth a specialist to explore, but never normalize this change, because aging does not imply this. Aging carries a greater risk of things happening that can mess up a brain, but not that.
A brain can forget everything except memories of an emotional nature
And among young people? When the memory does not work well, it is very common that what is behind it is not a brain disease or a degenerative disease, but stress, fatigue, poor sleep, mood disorders.. All this causes memory malfunction. And this is a reason for consultation among many people.
In one chapter, he describes the story of a man who loses his memory, forgets the name of his wife but continues to believe that the stranger who lives with him is the woman of his life, and asks her to remarry. Why do memories related to emotional experiences last the longest? Emotions have played a key role in the survival of our species. It is as if emotion implicitly carries a code to which our brain attributes great adaptive value. From a more evolutionary perspective, remembering something close related to an intense emotion may mean surviving or, conversely, disappearing from the world. The brain prioritizes this information associated with high emotional content. And not only does it prioritize it, but the way it stores it follows a different course, to the point where a brain can forget pretty much anything, yet still emotionally charged memories persist. A very simple example that everyone uses: we all remember what we were doing on 9/11 when the twin towers were attacked, because there was such a huge emotional impact.
He also explains that in normalized disorders such as anxiety or depression, there can be brain problems. When is it like this? I believe a lot of work has been done when it comes to normalizing the existence of mental health issues, but that should not be confused with the fact that sometimes a depressive or anxiety disorder is a manifestation of an organic problem. How can I achieve? I’m not exploring the presence or absence of an anxiety disorder and that’s it, but I’m looking at those symptoms while exploring many other things. For example, it is not normal for a person to have an anxiety disorder that is sudden onset, without apparent cause, persists over time, and also has visual hallucinations. This set of elements warns me that this scenario could be more complex.
Sometimes depression or anxiety is a manifestation of an organic problem, so the full spectrum of symptoms should be explored
What could it be? An early form of Lewy body disease [un tipo de demencia]where the manifestations of anxiety are sometimes the first symptom or an accompanying symptom of the disease on many occasions.
He warns that Alzheimer’s disease is a disease that often presents itself in disconcerting ways. How? All degenerative diseases are very heterogeneous. I often say that manual cases usually only happen in textbooks. This is why it is so important to study patients. The most frequent form of presentation of Alzheimer’s disease is a progressive amnesic picture, and what usually accompanies it also has a very particular aspect. However, the size varies greatly from patient to patient. We can find patients who do not have an amnesic picture, but little by little they are no longer able to perform mental operations, they cannot read, they become disoriented… This can be a form of atrophy posterior cortex in Alzheimer’s disease. A person whose character changes, becomes uninhibited, rude, violent: this can be a frontal form of Alzheimer’s. And this heterogeneity in Alzheimer’s disease is found in other common degenerative diseases, such as Lewy or frontotemporal degeneration.
You are very keen to go further in the search for what is happening to the patient, not to be left alone with “it’s depression” or “anxiety”. There are many philosophical and theoretical currents on how to conceptualize the problems of the human mind. That’s good, but basically my ideology is useless because what happens to people can have a completely different cause. Depression can be the manifestation of a relational problem with the context, but it can also be many other things. And, only if you consider that there could be many more things, you will explore if any of them is the one that explains this depression. If you consider that there are no other reasons because your positioning does not envisage it, you are not going to explore it. This is, in my view, an act of negligence. And then you have a lot of surprises: people who have been pigeonholed with X for a long time, treated a certain way, only to find that they had a problem of another nature.
Patients with Huntington’s disease, a neurodegenerative disease, have taught me that they can use knowing they will die
Give an example. The very clear example and where Catalonia has played a central role are autoimmune diseases. Professor Josep Dalmau of Hospital Clínic, Barcelona, was one of the great discoverers of many autoimmune diseases that cause psychiatric disorders, especially in women. Diseases that condemned many women to be hospitalized in a psychiatric hospital, but in reality what they had was a tumor in the ovaries, which triggered an autoimmune response that attacked a type of neuron that gave rise to a form of encephalitis that is called anti-NMDA encephalitis, which has a psychiatric clinic. And the problem is not how to diagnose it, but that it has a treatment and is cured. But, if you don’t consider it, you’re not going to treat it and you’re not going to cure it.
He also talks about the Huntington’s disease, that he investigates. How did it happen to her? I am fortunate to work in a movement disorder unit at the Hospital de Sant Pau, where Huntington’s disease was in the minority. I got to know her through books. It is an incurable disease, genetically determined, which makes it possible to study it in healthy individuals but carriers of the mutation. When patients discover that this is going to happen to them, they experience a very brutal psychological impact. However, [conocer la mutación] offers the possibility of studying neurodegeneration before it occurs. From a clinical point of view, it is an extremely flowery disease: any imaginable neurological syndrome can be found in a patient with Huntington’s disease. It is such a spectacular disease that I wanted to devote myself to it. I pushed for us to create a multi-disciplinary Huntington practice to provide quality to these families and I believed that if we did that a lot of people would come. And that’s how it is: people come from other communities, and we’re in the most pioneering clinical trials and interventions.
What can be done for a patient with an incurable disease? All. A lesson I learned is that we live life ignoring a reality, which is that something very difficult is going to happen to us at some point. And we don’t pay attention to it. It will affect us all. When you can’t avoid finding out what’s going to happen, if you don’t limit yourself to a fatal diagnosis but to transcendental information for your life, a lot can be done. Your way of life is very different. Huntington’s patients taught me that it helps to know that they are going to die of this disease. The disease is not suffered by an isolated individual, but also by those around him, who need to understand why things happen, to anticipate and to take care of themselves. Medicine cures very few diseases, it cures many, but cures very few, and we do the same.