It all started on Twitter. Years ago, Saül Martínez-Horta (Barcelona, 1981), clinical neuropsychologist at the Hospital de la Santa Creu i Sant Pau (Barcelona), began to publish on this social network the clinical cases that most attracted his attention. A publishing house, Kailas, approached him about the possibility of writing a book with them and now he has just published ‘Broken Brains, emulating ‘The Man Who Mistook His Wife for a Hat’, the classic written in 1985 by the celebrated British neurologist. Oliver Sacks. Martínez-Horta is also the director of the Neuropsychology Unit of the Neurocognitive Diagnostic and Intervention Center. (CDINC) in Barcelona.
What is a broken brain? It’s a metaphor. Brains don’t break, but for various reasons they stop functioning as they should. The curious part, when this happens, is how the behavior or cognition of the human being is expressed.
What does losing memory entail? We are our memories. Reality makes sense because we have a memory. If I contemplate the world without knowing how to attribute meaning to what I observe, to my person, to my environment, to objects, it has no meaning. There is a very immediate memory that gives life to my consciousness and another one, more distant in time, that gives meaning to my whole existence. The memory can be spoiled in its entirety or only in parts. And the way it breaks down can profoundly transform a person’s reality. One of the first things you see when memory is fragmented is how the individual loses his or her essence.
To what extent is it normal to lose one’s memory? Cognitive decline has been trivialized and normalized as an unequivocal consequence of aging. Many people assume that, as we age, it is normal to deteriorate in a significant way. And it is obvious that, as we get older, we are slower, more clumsy, our memory is not the same…. But within certain parameters. Everything that has an impact on a person’s life and that draws attention from a cognitive point of view – be it memory, language, behavior – in his or her family is not attributable to age. And it is worth having a specialist explore it, but never normalize this change, because aging does not bring that. Aging brings with it an increased risk of things happening that can mess up a brain, but not that.
One of the first things you see when memory is fragmented is how the individual loses his or her essence
And in 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 that makes the memory dysfunctional. And it is a reason for consultation in many, many people.
He describes in one chapter the story of a man who loses his memory, forgets his wife’s name but still believes that the stranger who lives with him is the woman of his life, and asks her to marry him again. Why do memories linked to emotional experiences last the longest? Emotions have played a key factor in the survival of our species. It is as if emotion carries an implicit code to which our brain attributes a great adaptive value. From a more evolutionary perspective, remembering something intimately related to an intense emotion possibly means surviving or, on the contrary, disappearing from the world. The brain prioritizes that information associated with a strong emotional content. And not only does it prioritize it, but the way in which it stores it follows a different route, to the point that a brain can forget practically everything, but nevertheless memories with a strong emotional character 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 a great emotional impact.
He also explains that underneath normalized disorders such as anxiety or depression there may be brain problems.When is this the case? I think a very important job has been done in normalizing the existence of mental health problems, but that should not be confused with the fact that sometimes a depressive disorder or anxiety is the manifestation of an organic problem. How do I become aware of it? I don’t just explore the presence or absence of an anxiety disorder and that’s it, I look at those symptoms while exploring many other things. For example, it is not normal for a person to have an anxiety disorder of sudden onset, with no apparent cause, persistent over time, and also to have visual hallucinations. That set of elements warns me that this scenario could be more complex.
Sometimes a depression or anxiety is the manifestation of an organic problem, so the whole set of symptoms needs to be explored
What could it be? An early form of a Lewy body disease. [un tipo de demencia]where anxiety manifestations are sometimes the first symptom or an accompanying symptom of the disease on very many occasions.
He warns that Alzheimer’s is a disease that often presents itself in a puzzling way. How? All degenerative diseases are very heterogeneous. I often say that textbook cases usually only happen in textbooks. That is why it is so important to study patients. The most common form of presentation of Alzheimer’s disease is a progressive amnestic picture, and what usually accompanies it also has a very specific appearance. However, the extent varies greatly from patient to patient. We can find patients who do not have an amnestic picture, but who are gradually no longer able to perform mental operations, cannot read, become disoriented… This may be a form of posterior cortical atrophy of an Alzheimer’s disease. A person whose character changes, becomes uninhibited, rude, violent: this may be a frontal form of Alzheimer’s disease. And this heterogeneity in Alzheimer’s can be seen in other common degenerative diseases, such as Lewy’s disease or frontotemporal degenerations.
You insist a lot on going further in the search for what is happening to the patient, in not remaining only in “it is depression” or “anxiety”. There are many philosophical and theoretical currents of how to conceptualize the problems of the human mind. That’s fine, but at bottom my ideology is useless because what is happening to people may have a completely different cause. Depression can be a manifestation of a relationship problem with the context, but it can also be many other things. And, only if you contemplate that it could be many other things, you will explore if any of them is the one that explains that depression. If you consider that there are no other reasons because your positioning does not contemplate it, you are not going to explore it. That, in my view, is an act of negligence. And then you get a lot of surprises: people who have been classified for a certain amount of time with a certain diagnosis, treated in a certain way, who turn out to have a problem of a different nature.
Patients with Huntington’s, a neurodegenerative disease, have taught me that they can make it useful to know they are going to die.
Give an example. The very clear example and where Catalonia has played a central role is autoimmune diseases. Professor Josep Dalmau of the Hospital Clínic, in Barcelona, has been one of the great discoverers of many autoimmune diseases with psychiatric disorders, especially in women. Diseases that used to condemn 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 called anti-NMDA encephalitis, which has a psychiatric clinical manifestation. And the problem is not not knowing how to diagnose it, but that it is treatable and curable. But, if you don’t look at it, you’re not going to treat it and you’re not going to cure it.
He also talks about the Huntington’s disease, which he investigates. How did he come to it? I have the great good fortune to work in a movement disorders unit at the Hospital de Sant Pau, where Huntington’s disease was in the minority. I knew it from books. It is a disease without a cure, genetically determined, which allows you to study it in healthy individuals who have the mutation. When patients find out that it is going to happen to them, they suffer a very brutal impact at the psychological level. However, [conocer la mutación] offers the possibility of studying neurodegeneration before it happens. From the clinical point of view it is an extremely florid disease: any neurological syndrome you can imagine you can find in a patient with Huntington’s. It is such a spectacular disease that I wanted to dedicate myself to it. It is such a spectacular disease that I wanted to dedicate myself to it. I insisted that we create a multidisciplinary Huntington’s practice, to offer quality care to these families, and I believed that if we did that, many people would come. And so it is: people are coming from other communities, and we are in the most pioneering clinical trials and interventions.
What can you do for a patient with a disease with no cure? Everything. One lesson I have learned is that we live life obviating one reality, which is that something very hard is going to happen to us at some point. And we don’t pay attention to it. It’s going to happen to all of us. When you can’t avoid discovering that it’s going to happen, if you don’t limit it to a fatal diagnosis but to a transcendent information for your life, you can do a lot of things. The way you live is very different. Huntington’s patients have taught me that they can make use of knowing that they are going to die from this disease. The disease is not suffered by an isolated individual, but also by his or her environment, which needs to understand why things happen, to anticipate, to take care of themselves. Medicine cures very few diseases, treats many, but cures very few, and we do the same.