A Puzzling Amnesia: Where Am I and What Am I Doing?

A Surgery That Went Off the Rails

Imagine having major surgery at a reputable hospital. You are under general anesthesia. In the middle of the operation, your surgeon has a sudden and unexpected memory problem. Not something minor, like who is he going to lunch with; rather, whether he is opening you up, suturing you closed, and what organ he is operating on.

This happened several decades ago in a major Chicago hospital. Harold Klawans, the staff neurologist there, described this fascinating episode in his book (Klawans, 1988).

The difficulty came on suddenly in mid-surgery when the surgeon abruptly stopped what he was doing. He then turned to his assistant to ask, “Where am I? What am I doing?” After she answered him, he almost immediately asked these same two questions, over and over again. Although the staff was a bit unnerved, his nurse luckily had assisted him with many similar operations and knew the procedure well. She carefully guided him through completing the surgery, one stitch at a time, as the gallbladder had already been removed. Strangely unphased by his sudden confusion, the physician successfully finished up, thanks to his over-rehearsed skills and his very capable assistant.

Immediately following the operation, he was escorted to Klawan’s office for evaluation. The diagnosis: Transient global amnesia, or TGA. Happily, the surgeon completely recovered from his amnesic episode within a few hours following the operation, and later had no recollection of what had occurred during his TGA. (Presumably, the patient never found out about this, although Klawans didn’t say.)

What Is Transient Global Amnesia?

As a cognitive psychologist attracted to offbeat phenomena, stumbling across TGA was quite fascinating. After several decades in the field, I had never come across a pure memory dysfunction that was not readily connected with a serious physical or psychological malady. I found out that TGA is short-lived and completely recoverable. Most episodes span only a few hours and are normally over within a day. Fortunately, even the possible embarrassment experienced about being confused and acting weird is also forgotten.

Especially intriguing is that TGA is a memory mystery; it's an amnesia with no clear and consistent cause and no long-term consequences. Victims retain basic information about their identity—name, address, age, occupation—but become temporarily confused about what is happening at the moment: Where they are, what they are doing, and how they got there.

What Does the Typical TGA Episode Look Like?

The several hundred professional publications on this topic exist primarily in the medical literature (Brown, 1998), which is why most of my psychology colleagues and I had not heard about it. I ran across TGA quite by accident, browsing through books on neurological disorders.

The typical episode of TGA comes on suddenly and lasts about six to eight hours. The victim is thrust into a serious state of confusion about what they are doing. Most repeat the same questions in the same order, perhaps a dozen times, with the most common being “What am I doing?” “Why am I here?” “How did I get here?” Questions are asked as if in an audio loop, repeated every few minutes regardless of the answers received earlier.

Given that their working memory seems to be seriously impaired, any new information that they experience is not encoded and lost fairly quickly. Following a TGA, most patients remember nothing of what occurred during the episode (anterograde amnesia), as well as the hour or two preceding it (retrograde amnesia).

What Causes TGA?

Intense experiences often trigger TGA:

• Physical – too-hot bath; strenuous exercise; polar plunge; sexual intercourse; dental extraction
• Psychological – stressful social event; death in the family; threatening email; impending surgery; financial crisis

Information about what preceded the TGA is frequently hard to gather because victims are often alone and later amnesic for what happened immediately preceding the incident. If witnesses happen to be present, they tend to be disturbed by the episode and understandably reticent to report what happened for fear of creating difficulty for the victim.

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Many causes have been proposed for TGA, including epilepsy and migraine, but the most likely is a temporary restriction of the blood supply (ischemia) to the brain, which is limited to the temporal lobe. Thus, the victim remains conscious and functional but experiences memory impairment. The key structures supporting memory (amygdala and hippocampus) are located in this part of the brain, and the severe and temporary restriction in blood flow hampers their function. The intense experiences noted above may precipitate such a temporary ischemic episode in this part of the brain (Brown, 1998).

What Happens After the TGA?

Nearly everyone fully recovers. Only about one in 30 have a repeat episode and, if so, at least they now know what to expect. The only lasting effect is no memory of what transpired during or just before the TGA. When you think about it, this may be a blessing. It might be nice to erase the memory of an awkward experience in your life (see my previous post) and the TGA automatically does this for you. And if you did something illegal, you could provide the court with a legitimate biological excuse for why you don’t recall what you did. In actuality, the victim of TGA rarely has the presence of mind to pull off anything nefarious.

Why Is Knowing About TGA Important?

The odds are low that you will ever experience a TGA. However, if someone you know does have one, it is helpful to know about it. A few years ago, my neighbor told me about her TGA during a road trip with her spouse. She became suddenly unable to figure out why they were in the car, where they had come from, or where they were going. It was helpful for me to talk with her about it and provide some reassurance, and also to recommend that she see a neurologist, just in case.

While the victim is typically unphased during the TGA, it can distress those around them. If you happen to be there:

• The person is not in jeopardy, but stick around for support.
• TGA may take a few hours before it is totally resolved.
• Complete recovery is normal.
• Just to be safe, the individual should still go to an emergency room.

Summary

Like you, I certainly would be concerned if my surgeon had a TGA during my appendectomy. It is comforting, however, to know that procedural, or automatic, memory remains intact. Although disoriented and acting a bit goofy, a person can still drive a car, mix a margarita, and even complete a surgery (with assistance).

It does, however, present some intriguing possibilities. If you are at a poker table and someone says, “What am I doing?” “How did I get here?” this might present a golden opportunity to re-evaluate your bet.