Self Comes to Mind

new to me, so unexpected, and so disquieting. In the middle of our conversation, the patient stopped talking and in fact suspended moving altogether. His face lost expression, and his open eyes looked past me, at the wall behind. He remained motionless for several seconds. He did not fall from his chair, or fall asleep, or convulse, or twitch. When I spoke his name, there was no reply. When he began to move again, ever so little, he smacked his lips. His eyes shifted about and seemed to focus momentarily on a coffee cup on the table between us. It was empty, but still he picked it up and attempted to drink from it. I spoke to him again and again, but he did not reply. I asked him what was going on, and he did not reply. His face still had no expression, and he did not look at me. I called his name, and he did not reply. Finally he rose to his feet, turned around, and walked slowly to the door. I called him again. He stopped and looked at me, and a perplexed expression came to his face. I called him again, and he said, “What?”
    The patient had suffered an absence seizure (a kind of epileptic seizure), followed by a period of automatism. He had been both there and not, awake and behaving, for sure, partly attentive, bodily present, but unaccounted for as a person. Many years later I described the patient as having been “absent without leave,” and that description remains apt. 5
    Without question this man was awake in the full sense of the term. His eyes were open, and his proper muscular tone enabled him to move about. He could unquestionably produce actions, but the actions did not suggest an organized plan. He had no overall purpose and made no acknowledgment of the conditions of the situation, no appropriateness, and his acts were only minimally coherent. Without question his brain was forming mental images, although we cannot vouch for their abundance or coherence. In order to reach for a cup, pick it up, hold it to one’s lips, and put it back on the table, the brain must form images, quite a lot of them, at the very least visual, kinesthetic, and tactile; otherwise the person cannot execute the movements correctly. But while this speaks for the presence of mind, it gives no evidence of self. The man did not appear to be cognizant of who he was, where he was, who I was, or why he was in front of me.
    In fact, not only was evidence of such overt knowledge missing, but there was no indication of covert guidance of his behavior, the sort of nonconscious autopilot that allows us to walk home without consciously focusing on the route. Moreover, there was no sign of emotion in the man’s behavior, a telltale indication of seriously impaired consciousness.
    Such cases provide powerful evidence, perhaps the only definitive evidence yet, for a break between two functions that remain available, wakefulness and mind, and another function, self, which by any standard is not available. This man did not have a sense of his own existence and had a defective sense of his surroundings.
    As so often happens when one analyzes complex human behavior that has been broken down by brain disease, the categories one uses to construct hypotheses regarding brain function and to make sense of one’s observations are hardly rigid. Wakefulness and mind are not all-or-none “things.” Self, of course, is not a thing; it is a dynamic process, held at some fairly stable levels during most of our waking hours but subject to variations, big and small, during that period, especially at the tail ends. Wakefulness and mind, as conceived here, are processes too, never rigid things. Turning processes into things is a mere artifact of our need to communicate complicated ideas to others, rapidly and effectively.
    In the case just described, one can assume with confidence that wakefulness was intact and the mind process was present. But one cannot say how rich that mind process was, only that it was sufficient to navigate the limited universe the man was coping with. As for consciousness, it was clearly not normal.
    How do I interpret the man’s situation with the advantage of what I know today? I believe his assembling of a self function was severely compromised. He had lost the ability to generate, moment by moment, most of the self operations that would have given him, automatically, a proprietary survey of his mind. Those self operations would also have included elements of his identity, of his recent past and his intended future, and