Self Comes to Mind

have provided important pointers in the delineation of a neuroanatomy of consciousness, and they have suggested aspects of the mechanisms proposed for the construction of core and autobiographical selves. Perhaps it is helpful to close by establishing a transparent link between human pathology and the hypotheses presented earlier.
    Leaving aside the alterations of consciousness that arise naturally from sleep or are induced by anesthetics under medical control, most disturbances of consciousness result from profound brain dysfunction of one sort or another. In some instances, the mechanism is chemical; this is the case with overdoses of various drugs, including insulin given for the treatment of diabetes, as well as with excessive blood levels of glucose in untreated diabetes. The effect of these chemical molecules is both selective and generalized. Given prompt and adequate treatment, however, the conditions are reversible. On the other hand, structural damage caused by head trauma, stroke, or certain degenerative diseases often produces disturbances of consciousness from which complete recovery is unlikely. Moreover, in some situations, brain damage can also lead to seizures, during or after which altered states of consciousness are a prominent symptom.
    Cases of coma and of vegetative state due to brain-stem damage compromise both the core self and the autobiographical self. In essence, the main protoself structures are either destroyed or severely damaged, and neither primordial feelings nor “feelings of what happens” can be generated. An intact thalamus and an intact cerebral cortex are not sufficient to compensate for the collapse of the core self system. Such conditions testify to the hierarchical precedence of the core self system and to the entire dependence of the autobiographical self system on that of the core self. This is important to note since the inverse is not true: the autobiographical self can be compromised in the presence of an otherwise intact core self.
    Cases of coma or persistent vegetative state in which the brunt of the damage, rather than affecting the brain stem, compromises the cortex, the thalamus, or the connection of these structures to the brain stem may render the core self dysfunctional rather than destroy it, thus explaining the progression of some of these cases toward “minimal” consciousness and the recovery of some nonconscious mind-related activities. Cases of akinetic mutism and postseizure epileptic automatism cause reversible compromises of the core self system and a consequent alteration of the autobiographical self system. Some appropriate behaviors are present and, albeit automatic, suggest that mental processes are by no means abolished.
    When autobiographical self disturbances appear independently, with an otherwise intact core self system, the cause is some aspect of memory dysfunction, an acquired amnesia. The most important cause of amnesia is the condition just discussed, Alzheimer’s; other causes include viral encephalitis and acute anoxia (loss of brain oxygenation) as can occur in cases of cardiac arrest. In cases of amnesia, there is a considerable disruption of the unique memories that correspond to one’s past and one’s plans for the future. Obviously, patients with damage to both hippocampal-entorhinal regions, whose ability to make new memories is compromised, suffer from a progressive loss of scope in their autobiographical self because the new events of their lives are not properly recorded and integrated into their biographies. More serious is the situation of patients whose brain damage encompasses not only the hippocampal-entorhinal regions but also the regions around and beyond the entorhinal cortices, in the anterior sector of the temporal lobe. Such patients appear to be entirely conscious—their core self operations are intact—so much so that they are even conscious of their failures of recall. However the degree to which they can evoke their biographies, along with all the social information they carry, is diminished to a smaller or greater extent. The material with which an autobiographical self can be assembled is impoverished, either because it cannot be brought out of past records or because whatever is brought out cannot be properly coordinated and delivered to the protoself system, or perhaps both. The extreme case is that of patient B, whose biographical recall is largely confined to his childhood and is quite schematic. He