The man who walked into the examination room — I’ll call him William — was the picture of vigorous health; you’d never know, by looking at him, that he was suffering from a profoundly terrible type of dementia. A few inches over six feet tall, in his early 60s, he carried himself like an athlete. He was a guy who was very good at a lot of things, and he wanted us to know it.
“I’m a great runner,” he said. “In fact, I’m in the top percentile of runners in my age group.”
The nurse who was examining him — I’ll call her Victoria — hadn’t asked him about his running triumphs. She was trying to make her way through a checklist of questions that were meant to help assess his cognitive state: What city he was in? What building? What year was it? But it was a compulsion with William: he had to keep letting her know how great he was, at … well … everything.
I was riveted. As a fellow at the Global Brain Health Institute (GBHI), based at UCSF’s Memory and Aging Center, I’d just begun my clinical rotation — which involved shadowing Victoria and (with the permission of the patients and their family caregivers) being an observer as she examined people with various types of brain disease.
William had been showing symptoms of frontotemporal dementia (FTD). Unlike Alzheimer’s Disease, which devastates the brain’s memory centers, FTD frequently leaves people’s memory intact — and instead robs them of their empathy, as well as severely diminishing many of their inhibitions. Because of the work of people like my GBHI mentor, Dr. Bruce Miller, there is growing awareness of FTD. (It also was in the news recently that Bruce Willis suffers from it.) But in the meantime, this disease (of which there are several variants) is frequently going undiagnosed. Beloved community members are, for no apparent reason, now acting selfish and aggressively uninhibited in their dealings with friends and strangers alike. Some lose their marriages and their jobs. Many end up living on the streets, untreated. Dr. Miller has described FTD patients to me as the ultimate underdogs.
But William — who kept denying to his wife and children that there was anything wrong with him — didn’t consider himself an underdog. How could he be, when he was the best at seemingly everything he attempted?
He kept trying to verbally parry Victoria’s rather basic diagnostic questions — which he clearly felt to be unworthy of him — by bragging about his many exploits.
“I was the best attorney in Milwaukee!”
“I was the most brilliant student my university had ever seen!”
At one point, Victoria noted that William certainly seemed to know a lot about a lot of things. This got him talking about his vast personal library: “I have the greatest book collection in the world!”
Most disturbing, to me, was how aggressively William kept edging into Victoria’s space. Frequently, as if to emphasize a point, he’d reach out and touch her arm. He also made a number of insinuating comments, alluding to how he found her attractive. She handled his misbehavior with great professionalism. But for my part, I desperately wanted him to get the hell out of there and go back to where he came from. I mean, what an asshole!
Finally, to my great relief, this first portion of the cognitive exam ended, and Victoria briefly left the room. Suddenly it was just me and William. There was, at first, an awkward silence. Unlike Victoria — who, despite William’s braggadocio towards her, he clearly saw as a threat, as someone who might identify weaknesses that, deep down, he was terrified of having — I was just an observer, and not a medical expert either. Plus, I was another guy.
Eventually he smiled at me — with an openness that I hadn’t seen in him thus far — and said, “Hey, how’s it going?”
“Um, good,” I said.
And then he said something that startled the bejeezus out of me: “So how about that Donald Trump?”
Wow, this felt tricky! Because to me, this guy pretty much was Donald Trump.
Trump had become president a few months earlier, despite my best efforts — and I knew in my bones that William, who was “the greatest” at everything he set his mind to and who clearly had no respect for women’s boundaries, had to be a diehard MAGA guy. But again, I was just there to observe — not to possibly get into a political shouting match with a patient.
And yet, I couldn’t just dodge his question. So I came up with the mildest locution I could muster.
“I, uh, don’t like Donald Trump,” I said.
To which William replied: “I hate Donald Trump! I’d do anything to stop him!”
Which totally took me aback! I wanted to reply, “But you are Donald Trump!”
But then I remembered: William was there because frontotemporal dementia had caused his brain’s empathy circuitry to go dark. I later learned what a sweet man he had been — caring, kind, even modest. As a lawyer, he’d advocated for the poor. And then the wiring in his brain had become diseased, and his outward persona had been almost entirely transformed. And his family members, who loved him so, were now scared to death of him. He had, in many ways, become a stranger to them.
This experience got me to thinking a lot about empathy — more specifically, about how and when I feel empathy. Even though I’d known, heading into that examination room, that William was suffering from FTD, I’d quickly come to see him as a bad person — a total jerk, at minimum. I’d “othered” him. But what had happened to him could just as easily have happened — could still happen — to me, if my neural wiring, through no fault of anyone, happened to get triggered to go berserk in the same way. Feeling how I reacted to William gave me even greater respect for medical practitioners like Victoria, who afterwards, as she debriefed me, expressed great empathy and understanding toward a man who had treated her with blithe contempt.
Do I believe that Donald Trump suffers from dementia? Hey, that is way above my pay grade! Do I believe that the MAGA faithful are victims of an FTD epidemic (and I don’t mean the flower company)? No — I think they have been led to believe (so far, at least — I never give up hope!) that empathy should be applied only to a circumscribed group of “us,” against a vicious horde of “them.” As I talk about in my solo show Citizen Brain, I believe that the empathy circuit of our country’s collective brain (what I call our “citizen brain”) has been broken; for our democracy to survive, it needs to be healed.
But thinking back to the experience I had in that examination room at UCSF, I am reminded that my own empathy circuit needs to be continually strengthened as well. As it happens, there’s an exercise for doing just that. If you want to learn about it, you can watch the video below (the first in my “Citizen Brain” video series).
If you’re interested in attending my “Citizen Brain” solo show, which will be at The Marsh in Berkeley from June 10 through July 29, you can click here for info. Use code PREFRONTAL for half-price ($12.50) tickets to the June 10 and 17 performances.