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Thursday, January 21, 2021, 5:30 PM Eastern Standard Time

The world-famous neurophysiology professor/physician frowned.

He did not like giving advice to anonymous on-line video callers, even in a pandemic, even if referred by close and trusted friends as “a high-level military physician with a special problem.”

“So, what you are saying to me is, this patient seems to be suffering from either, or both, amphetamine psychosis or frontotemporal dementia, but remains functional in his job?”

“I would not say that exactly, Doctor,” the caller answered. “His job, due to its high level, corresponds very well to the delusions that are brought about by amphetamine psychosis. So it’s impossible to tell what is psychosis and what is maybe only some level of paranoia.”

“But he is able to function despite these conditions?”

“Again, I have been unable to directly physically examine the subject, aside from swabs and blood tests for the virus. And he has forbidden any sharing of test results, even between members of his medical staff. Therefore, I cannot say for certain that he is suffering from these two maladies.”

“You have been unable to physically examine the subject, despite being his personal physician?”

“It is a unique case.”

The professor took a long pause, tapping a pen against his desk nervously. “What you tell me does not make complete sense.”

“I understand your hesitancy. As I say, it is a unique case. I have never encountered such a situation in all my practice.”

The video caller shifted in his seat. The professor thought, Does everyone have the same library set up behind them now? It almost looks exactly the same as mine. He thought about taping the encounter so he could check the book titles later, but dismissed this idea with an impatient shake of his head.

“Why can you not confront your patient? Tell him that you cannot continue to act as his physician unless you can do a full physical examination?”

“There are particular issues with respect to this patient that limit my ability to confront him in this way.”

“Does it have to do with…military duties?”

Relieved to be able to frame the issue in this way, Dr. Bloombach grabbed this hypothesis as a drowning man would grasp a life preserver.

“Yes. Exactly.”

“Still, I believe there are procedures that you should be able to follow to address this case,” the professor said.

“I feel a sense of duty to continue treating this patient,” Dr. Bloombach said. “I feel that if I simply resign, my replacement is likely not even to be troubled by the ethical qualms that I feel. Either that, or he or she would be…” he chose his words carefully here… “…selected precisely because of some compromising personal quality that would make him or her amenable to pressure from the patient to dispense with normal examination.”

The professor turned on his speaker phone and walked to the window.

“What evidence do you have of amphetamine use?”

“Well, the patient very often has a runny nose and sniffling, unrelated to allergy season or known physical maladies. Especially in situations that seem to require extra energy or concentration, such as speeches or high-stakes confrontations with rivals. This leads me to the conclusion that he is crushing amphetamine tablets and inhaling them nasally.”

“And amphetamine psychosis?”

“Well, as you know, the most prominent features of amphetamine psychosis are auditory and visual hallucinations, grandiosity, delusions of persecution, and delusions of reference concurrent with both clear consciousness and prominent extreme agitation. The delusions of reference are, of course, mistaken impressions that everything that happens must have some special relevance to oneself. In his case, I believe my patient to be particularly vulnerable to this kind of thinking. Grandiosity might be seen as an occupational hazard of this patient’s particular profession, which is very prominent. And delusions of persecution, I would say, are an absolutely constant feature of the patient’s mental landscape. I don’t know about auditory or visual hallucinations. I have never witnessed them personally.”

“But you cannot attribute these symptoms to amphetamine psychosis without a blood test to confirm his amphetamine use.”

“No. All I have to go on are his visible symptoms.”

“You know it is against the ethical norms of my – and your – profession to diagnose people based merely on observation from afar.”

“I know that. Which is why I come to you, asking your advice.”

“You have another theory as well. Frontotemporal dementia. Tell me about that.”

“That one is less grounded in evidence. Simply a theory, as you say. My research work in neurology acquainted me with von Economo or spindle neurons. I have an ill-formed hypothesis with respect to this patient and his spindle neurons.”

“Very speculative. But explain.”

“Spindle neurons, as I think you know, are the newest form of neuron, and only occur in a few very advanced creatures.”

“Primates, cetaceans, elephants.”

“Yes. Spindle neurons seem to be central to empathy. And they are the very first neurons to die in cases of frontotemporal dementia. They also seem to be central to the mind’s ability to think metaphorically, and to distinguish symbols from reality. They are found in the anterior cingulate cortex, where empathy arises; and they also exist in the insula, where they are related to disgust – a very prominent feature of my patient’s mental landscape.”

“But frontotemporal dementia presents with far more fundamental symptoms.”

“Yes; though they present gradually, so I cannot entirely rule it out. Loss of social awareness and poor impulse control. Semantic dementia, usually destroying word comprehension – my patient has occasionally insisted that he invented words or phrases that have been in common use for decades or even centuries. Progressive difficulties in speech production – progressive nonfluent aphasia. He has increasingly often shown himself to be unable to pronounce the names of common objects – ‘hamberder’ for ‘hamburger,’ for instance, or ‘nipple’ for ‘Nepal.’ I have come to believe that FTD may not be a correct diagnosis in this case, though I cannot rule it out entirely. FTD classically presents in slightly younger patients. Yet I do think von Economo neurons may well figure in this patient’s psychophysiology and psychopathology.”

“You say ‘psychopathology.’ Do you mean to suggest he is a psychopath?”

“I cannot rule it out. Sociopathy is a safer diagnosis at this point.”

“Either is a very serious diagnosis, for what I can only assume is a very important person?”

“That is a safe assumption.”

“But you had some further point to make about spindle neurons?”

“Yes, the von Economo neurons are very vulnerable. And very rare in the animal kingdom. Very recent. I wonder whether there might be a variability in the number and effectiveness of spindle neurons across the individuals within species, for example, human beings. If this patient never had many spindle neurons to begin with, presumably his capacity to think metaphorically, and to empathize, would be affected?”

“You are asking me?”

“I am. I realize this is very speculative.”

“It’s possible, I suppose.”

“If so, it would be entirely possible that this person could lack the von Economo neurons to think in other than a very concrete literal way, and he could be prone to misinterpreting metaphorical speech or thought as literal reality. This was the focus of my neurological research during my fellowship. My hypothesis was that the ability to understand metaphor was related both to the capacity for empathy, and the capacity for advanced abstract thought. Now, this patient has quite a popular following, as it happens. My sense is, it is this cognitive deficit – perhaps the result of a lack of von Economo neurons – that causes him to be particularly popular with a certain segment of the public that has limited patience for intellectualism and abstraction, may see empathy as weakness, and prefers literalism to symbols. And maybe has an elevated level of disgust with the unfamiliar.”

“You must be careful. This is far over the line into speculation.”

“I am aware. But if this particular physiological explanation, a deficit in spindle neurons, does not explain this phenomenon, then the explanation may well be something very similar in the deep structure of the brain. By the way, I do not make a value judgment here. I must assume that an abundance of spindle neurons brings its own cognitive deficits. Being in love with metaphor, and being over- empathetic, can both result in some very serious miscalculations.”

“No doubt. A very interesting hypothesis. But certainly not any basis for diagnosis, which, I am sad to say, must in the final analysis be the result of direct physical examination.”

“I agree. And some of the symptoms could be lingering effects from the virus, which he contracted a few months ago. The question is, how to obtain such an examination when the patient refuses it.”

“Does the patient present with any other particular issues that you might use to persuade him to submit to, for example, a scan of some sort?”

Dr. Bloombach thought for a moment. Then he answered. “I can’t think of one at the moment.”

“All right. Here is my suggestion. Wait until the patient seems to have a physical malady that would require medical treatment. A sprain, or a bad back, or something like that. Does he have hobbies that might be interfered with by such conditions?”

“He golfs,” Dr. Bloombach said. “He just recently started up again since recovering from the virus.”

“All right,” the professor said. “Here is what I advise. Watch to see if he has any pain or stiffness or anything else – a bad shoulder, a knee problem – then suggest to him that professional golfers use MRIs to keep themselves at the top of their game. Then once you are able to get him in the machine, you may have enough information to dispense with rank speculation and make some sort of an educated and evidence-based diagnosis.”

“Thank you, Doctor. This is exactly the sort of advice I was looking for.”

“Of course, my real advice is for you to confront the patient and either persuade him to cooperate in his own health, or resign as his physician.”

“That day may come,” Dr. Bloombach said. “But for the moment, I believe my professional duty is to continue. And your other suggestion, I think, may do the trick. You have been very helpful.”

“I hope this ends well,” the professor said.

“I as well,” Dr. Bloombach said. “I as well.”