Baltimore, Maryland, United States
|Black-and-white drawing of a man scratching his head, from The Evening Ledger, Philadelphia, May 4 1916. scanned by Open Clip Art Library user Johnny Automatic. Via Wikimedia|
Bob T. had suffered a stroke. Not the kind of massive, devastating stroke that left him bereft of language (aphasia), or that rendered him paralyzed on one side of his body (hemiplegia). No, this was a very small stroke deep within his brain; in the medial-dorsal thalamus of the left hemisphere, to be specific. For Bob, the only lasting consequence of this damage was a severe amnesia for anything verbal. He was highly intelligent and had a good sense of humor, but he had great difficulty learning and remembering new names, stories, verbal directions, things that he read, or things he was told. Although testing revealed that his old memories were intact, his new learning disorder (anterograde amnesia) was so severe that Bob had to abandon his career in real estate.
I had been seeing Bob for about three months in a desperate attempt to rehabilitate his memory a bit. He was a highly motivated patient, and he tried valiantly to apply all the memory workarounds we practiced repeatedly. Since he could not remember my verbal instructions or strategies, our goal was to have him use memory prostheses (written reminders, wristwatch alarms, etc.) and acquire new memory habits that would circumvent his damaged episodic memory system.
Bob’s treatment was on my mind as I was driving home from the Baltimore-Washington International Airport. I was returning from a short trip to Boston, where I had presented a paper at the annual meeting of the Memory Disorders Research Society. It was a lively and stimulating scientific meeting, and I was contemplating how I could use some of the latest findings in my own research and clinical work.
While driving, I decided to check my office answering machine. (This was at a time when cell phones were relatively new and their use while driving was less egregious, though no less reckless and foolhardy.) The first message was from Bob.
“Hi, Dr. Brandt. This is Bob T. I don’t know when I’ll see you next [he had an appointment the following week, of which I would remind him the day before and hope he would show up], but I wanted to tell you a good joke I heard before I forgot it. Sam was an older man with a very bad memory. He and his wife were walking down the street one day when they encountered his friend, Mike. As usual, their conversation turned to their health . . . you know, who needed a hip replacement, who just had cataract surgery and so on. Then, Sam said, ‘You know, I just started working with a new doctor who is really helping my memory . . .’.” BEEP, the answering machine warned. “Damn, I’m out of time.”
A second message, also from Bob, was recorded just a minute or so later. This time, Bob spoke a bit faster.
“Hey, Dr. Brandt. Bob T. here. I heard this great joke I wanted to tell you. Sam and Mike were two old guys who were good friends. One day, Sam is walking down the street with his wife and sees Mike. They talk a little bit and then Sam says, ‘Hey, I have this new doctor who is really helping me with my memory. He taught me that it’s all about forming associations.’ I forgot to tell you that Sam has memory trouble like me. So, anyway, Mike says, ‘That’s great! Maybe he can help me too. What’s his name?’ And Sam says, ‘Let’s see . . . what’s that flower with a long stem that smells nice but has thorns?’ And Mike says . . .” BEEP “Shit, I did it again!”
Now this was getting comical. Not the joke; it is an old one and I knew the punchline. It was Bob’s delivery.
Call number three arrived a minute later, with my patient sounding absolutely frantic.
“Dr. Brandt, this is Bob. I gotta rush to get this out. Sam and Mike are old friends with bad memories. Sam and his wife are walking down the street when he sees Mike and he tells him that a new doctor is helping his memory. Mike says, ‘Yeah? That’s great. What’s his name so I can call him too?’ Sam says, ‘Let me see. What’s the name of the red flower with a long stem and thorns that smells good?’ Mike says, ‘Rose? Is his name Dr. Rose?’ Sam says, ‘No.’ He looks at his wife and says ‘Rose, honey, what’s the name of my new memory doctor?!’ That’s a good one, huh?”
What a curious set of monologues! Bob had no trouble remembering the joke; a witty, coherent story that resides in what psychologists call semantic memory. This type of information is typically preserved in patients with amnesia. What Bob could not remember is where he was in the story each time he was unceremoniously cut off by the answering machine. That is, his memory for the episodes was damaged, so he was compelled to replay the story from its beginning.
An alternative explanation of Bob’s peculiar joke-telling is that he did not appreciate that my memory could span the length of time between his phone messages. This would indicate an impairment in his metacognition; his ability to judge the adequacy of his own and others’ cognitive processes and respond accordingly. Additional in-depth neuropsychological testing of Bob indeed confirmed that he had trouble with many metacognitive tasks and could not deploy his retained memory skills and strategies effectively in everyday life.
Bob remained in neurocognitive therapy for another few months. Although his ability to cope with the memory demands of life improved a bit, he was never able to return to his work in real estate. Needless to say, he did not become a stand-up comedian either.
JASON BRANDT, PhD, is Professor of Psychiatry & Behavioral Sciences and Neurology at the Johns Hopkins University School of Medicine in Baltimore, MD. He is a clinical neuropsychologist who specializes in the analysis of memory and executive function disorders in adults with brain injuries, dementing illnesses, and other neurological conditions.