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Dr. Gary Small’s The Naked Lady Who Stood on Her Head: Brain Fog

(Editor’s Note: what follows is an excerpt from Dr. Gary Small and Gigi Vorgan’s new book, The Naked Lady Who Stood on Her Head: A Psychiatrist’s Stories of His Most Bizarre Cases)


Brain Fog

Summer 1990

Gigi and I had moved to Studio City, about a forty-minute commute to UCLA. On weekends, we often went to the movies at Universal CityWalk, a replication of Los Angeles within Los Angeles. Why people couldn’t just walk down the real streets of Los Angeles made no sense to me, yet there we were, on a Friday evening, eating ice cream and strolling down a simulated street.

We had just seen Total Recall, Arnold Schwarzenegger’s new sciencefiction film about a construction worker who undergoes a false memory transplant that takes him on an imaginary trip to Mars. But things go wrong, and when he comes out of it, he can’t tell what’s real and what’s imagined.

“When he first got back from Mars, there were so many signs that he was from the future that I believed it,” I said.
“But honey, before he had that memory implant done, he was perfectly happy living in the present—on Earth. Then he got all paranoid.”
“Of course he did. How do you know what’s reality if you can’t trust your memory?” I asked.
“I don’t know; you’re the memory expert. I want to go into this shop for a minute.” Gigi disappeared into a record store.

As I ate my ice cream and watched the crowds, I kept thinking about those questions. If two realities seem equally true, how would you know which version to believe? Many of my patients struggled with similar issues, whether they were psychotic, demented, or simply having memory problems.

Over the past few years, I had begun to concentrate a large part of my practice on memory issues—not just in older patients with Alzheimer’s disease but in middle-aged people who were worried about their increasing forgetfulness. My research was also focusing on early detection of dementia and age-related memory decline, and I was developing brain imaging as a diagnostic tool.

Gigi came back with a bag of CDs and said, “Let’s get the car.” Thankfully, she remembered where we had parked.

The following Monday, I got to the office early and checked my phone machine as usual. There was a message from one of my UCLA mentors, Dr. Larry Klein. He wanted me to see a VIP studio executive, Greg Wiley, who was complaining about his memory. That name rang a bell—I had just read about him in the L.A. Times business section. He had been promoted to head of production at a major movie studio.

Two days later he showed up at the office for his first appointment.

He was in his mid-fifties, lean and fit, and had an air of authority. He wore an expensive suit and carried a leather briefcase. As we shook hands, he looked me straight in the eyes, but then his gaze flitted about the room, as if he was sizing up my territory. I pulled up a chair across from the sofa, but rather than sitting on the sofa as most patients did, he positioned the other chair opposite mine—he wasn’t going to let me forget who was head of production.

Greg crossed his legs, and I noticed his alligator shoes—they probably cost more than my monthly mortgage. Maybe I wasn’t charging him enough, but as soon as that thought crossed my mind, I wondered if I felt intimidated by him and was cracking jokes to myself to defend against the feeling.

I had just gotten a new Mr. Coffee machine for the office. I went to pour myself a cup and asked Greg if he wanted some. He declined and pulled an Evian bottle out of his briefcase. “Larry Klein tells me you’re the go-to guy in your field. For a newcomer, you’ve made quite a name for yourself.”

“Larry tends to exaggerate.” I sipped my coffee.
“Maybe I should hire you away from all this glamour,” he said sarcastically, gesturing around my sparsely furnished hospital office.
I smiled and said, “Larry tells me you’ve noticed some memory changes.”
Greg leaned in, suddenly serious. “Now, this is completely confidential, right?”
“Of course,” I answered.
“I haven’t told this to anybody, not even my wife, but there are moments when my mind doesn’t feel as sharp as it used to. And it tends to get worse later in the day and evenings.”
“What do you think brings on these episodes?” I asked.
“It could be overwork or stress, I don’t know.” He took a swig of his water.
“Tell me more about what you’re experiencing.”
“It’s not so much my memory—in fact, most of the time my memory is pretty good. But I have these moments of . . . not confusion necessarily, but my brain starts thinking in slow motion. You know what it’s like when you drive through a thick fog at night? That’s what it feels like.”
“Like a brain fog?” I asked.
“Exactly,” he said as he gulped down more water.
“Let me see if I understand this,” I said. “When you have these episodes toward the end of the day, your thinking slows down and the
thoughts aren’t as clear.”
“Sort of . . . it takes more time to organize what I want to say, and I suppose it’s harder to remember things.”
“How often does this happen?” I asked.
“A few times a week . . . maybe every other day.”

My mind jumped to an inventory of possible causes for Greg’s lateday brain fog. Hypoglycemia was at the top of the list. It also could have been transient ischemic attacks or TIAs, ministrokes that don’t lead to lasting brain damage. But when I asked him about his diet and medical history, neither fit. In fact, Greg had just had a complete medical checkup, and his blood pressure, cholesterol level, and glucose tolerance were all normal. I did learn that he had a family history of Alzheimer’s disease.

“We used to just call it getting senile,” he said. “My grandmother was really out of it, and so was her brother. Now my uncle is totally confused, and his doctor says it’s Alzheimer’s. I guess that’s another reason I wanted to meet with you. Maybe I’ve inherited a predisposition for it, and it’s already starting.”

(Editor’s Note: to learn more and order, you can click on The Naked Lady Who Stood on Her Head: A Psychiatrist’s Stories of His Most Bizarre Cases)

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