JP’s role in ID of strange disorder
The patient had cracked his skull in a fall at his home. Now he couldn’t remember almost any new information he heard. Amnesia blanked out the name of his doctor, even the name of the president of the United States. That’s why he was wheeled in to the specialized neurology unit of the Jamaica Plain Veterans Affairs Medical Center at 150 S. Huntington Ave. that day more than 30 years ago.
The patient improved within a few days, finally able to understand what had happened and where he was. And then, just when all looked well, something very strange happened.
“While he quickly learned and remembered that he was at the Jamaica Plain Veterans Hospital,” the patient’s doctors later wrote, “he insisted that the hospital was located in Taunton, Massachusetts, his home town.”
In fact, he eventually claimed that the JP hospital was in a spare bedroom of his house.
“Under close questioning, he acknowledged that Jamaica Plain was a part of Boston and admitted that it would be strange for there to be two Jamaica Plain Veterans Hospitals,” the doctors wrote. The patient also freely acknowledged that the hospital is 14 stories high.
Still, he said, it was in his bedroom in Taunton. It made perfect sense to him.
After touring his house with doctors and family members, the patient was forced to acknowledge that the hospital was not there. But, he protested, he “still remembered it that way.” It took six weeks for the delusion to fade.
The man was one of three VA patients—all of them calmly, logically insisting that the JP hospital ex-isted somewhere far away—whose cases now serve as the classic definition of a bizarre psychiatric disorder known as reduplicative paramnesia.
The cases were described in a 1976 issue of the medical journal “Neurology” by the late Dr. D. Frank Ben-son and his colleagues. In the 1960s and ’70s, Benson conducted groundbreaking research at the JP hospital, where he identified several unusual mental disorders.
Benson was not the first doctor to notice reduplicative paramnesia. He did not even invent its mouthful of a name. But his close study made for the best definition and explanation of the disorder so far. It is still the basic reference in psychiatric literature.
“Paramnesia” means that memory is distorted or altered instead of just being blanked out as it is in full amnesia. “Reduplicative” refers to any delusion where the patient believes that an existing object or person has been duplicated—relocated or rebuilt somewhere else.
In all three JP cases, the reduplicative paramnesia delusion was focused only on the location of the hos-pital. The other two patients—both car-crash victims—respectively put the JP hospital in Sault Ste. Marie, Mich. and Great Falls, Mont. Both had served on military bases in those cities.
The delusion was remarkably strong in all cases, standing up to daily questioning by doctors and even trips outside the hospital. The worst case lasted five months.
Benson found that even when the delusion seemed to go away, the right sort of questioning would reveal it again. When both car-crash patients got to the point of acknowledging that the hospital is in Boston, doctors asked them how far Boston was from their hometowns. Both patients answered correctly—the distance being no more than 85 miles. But when doctors then asked how far the JP hospital was from their hometowns, both patients said it was more than 1,000 miles away—clearly meaning they still believed it somehow existed out-of-state.
The patient who believed the hospital was in Great Falls was taught to remember and repeat the information that the hospital is actually in Boston and that it was an error to think otherwise. Then, as Benson later wrote, doctors asked him for travel directions from the hospital to Montana:
“He immediately answered that he would go out the front door of the hospital, turn right, walk about two blocks, make another right turn and continue straight [a short distance] until he reached the downtown section of Great Falls.”
Despite being constantly challenged by doctors saying they were wrong about such a basic fact, all three patients were unusually calm and unemotional about the disagreement.
Benson found that the patients typically improved in stages. First they would go from total belief in the delusion to acknowledging the disagreement: “[B]ut you say I’m in Boston.” Then they would understand where they (and the hospital) really were, but still remember that they “used to think” otherwise. Finally, the delusion would disappear completely, and the patients had normal perceptions of their location.
In some cases, the patients found it impossible to believe or recall that they once had such a bizarre delusion. Benson said it was like an adult’s inability to recall common childhood delusions, such as the belief that one’s parents are all-powerful. We can be told such facts, even see it in children, but the ac-tual state of mind is gone.
Inside the brain
Amnesia and delusions come in many forms and can be caused by many factors. For example, a person may subconsciously bury memories to avoid recalling a traumatic experience.
But the usual big-picture explanations didn’t seem to apply to Benson’s cases of reduplicative paramne-sia. Why was the delusion focused just on the hospital? Why was it the patients’ only memory problem?
Benson couldn’t answer those questions for sure. But he made some educated guesses.
All of the patients had recovered from brain injuries that caused major amnesia. Their lack of emotion when challenged about the hospital location, and the fact that the delusion got better over time, suggest that lingering brain injury was a factor in the reduplicative paramnesia. There was also some evidence that the original injuries included part of the brain devoted to processing visual-spatial information—part of the way we figure out where we are.
Benson noted that the brain is constantly working to make sense of the world. We don’t just take in information—our brains build meaning out of interpretations of what we perceive and what we remember. Various forces can influence that interpretation—and the interpretation can be wrong. That’s why we can be fooled, falling prey to scams and illusions.
Some things take more work to figure out than others. A person’s physical location, which usually changes frequently, is one of those things. It may not seem like hard mental work when you’re sitting on your couch at home. But when you get lost in the woods or an unfamiliar city, it becomes clear how much information and memories matter in telling us where we are at every moment.
Benson noted that hospitals are especially disorienting places. All of his patients transferred there from other hospitals while suffering from amnesia. They woke up somewhere completely unfamiliar.
Benson guessed that brain injuries affected their ability to make sense of where they were just enough to mess it up. They knew they were in JP, but then mixed that up with memories of “place[s] that had been significant earlier in their lives.”
That still does not fully explain the JP cases. In fact, the causes of all delusional mental disorders remain poorly understood.
Reduplicative paramnesia is rare, but continues to be reported among victims of head injuries and sufferers from Alzheimer’s disease. Benson’s guesses about its cause remain the best theory 30 years later. And the JP hospital where his groundbreaking observations were made still stands on S. Huntington Avenue—despite any delusions to the contrary.
Sources: “Reduplicative Paramnesia” by D. Frank Benson, Howard Gardner and John C. Meadows, “Neurology” 1976 26:147; “Theories of Delusional Disorders: An Update and Review,” by Hanns Jürgen Kunert, Christine Norra and Paul Hoff, “Psychopathology” 2007 40:191; “University of California: In Memoriam, 2001” at www.calisphere.universityofcalifornia.edu.