mourning

Temurah 16a ~ Transient National Amnesia

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תמורה טז, א

אמר רב יהודה אמר שמואל שלשת אלפים הלכות נשתכחו בימי אבלו של משה

Rav Yehuda says that Shmuel says: Three thousand halakhot were forgotten during the days of mourning for Moses.

Three thousand laws were forgotten when Moses died. Gone. Or maybe it was only seventeen hundred:

אלף ושבע מאות קלין וחמורין וגזירות שוות ודקדוקי סופרים נשתכחו בימי אבלו של משה 

One thousand and seven hundred a fortiori inferences, and verbal analogies, and minutiae of the scribes were forgotten during the days of mourning for Moses.

Or maybe it was only a thousand:

תשש כחו של יהושע ונשתכחו ממנו שלש מאות הלכות ונולדו לו שבע מאות ספיקות

Joshua’s strength weakened, and three hundred halakhot were forgotten by him, and seven hundred cases of uncertainty needed to be resolved.

Whatever the number, the rabbis of the Talmud identified the death of Moses with a period of transient national amnesia. And the rabbis were correct. Psychological trauma and memory are intricately linked.

Psychological Trauma and Memory

As Professor Kristin Samuelson points out in her review of the relationship between memory and psychological trauma, patients with post traumatic stress disorder (PTSD) “often complain of experiencing everyday memory problems with emotionally neutral material.” In other words stress can make you forget things that have little or nothing to do with the stressful event itself. However, “PTSD most significantly impacts the initial acquisition and learning phases of memory, as opposed to the retention phase.” Two psychologists from the University of Bergen in Norway analyzed no fewer than 28 clinical studies and concluded there was marked verbal memory impairment in the PTSD groups compared to healthy controls. And while we commonly associate PTSD with combat, child abuse, rape and political violence, the everyday grief of losing a loved one can also mess with your mind. Here is Helen Macdonald, in her New York Times bestseller H is for Hawk describing what happened to her after her father’s sudden and unexpected death.

I started crashing my father’s car. I didn’t mean to do it: it just happened. I backed up against bollards, scraped wings against walls, heard the sound of metal squealing in agony over and over again…I couldn’t keep the dimensions of the car in my head. Or my own, for I kept having accidents. I cracked cups. I dropped plates. Fell over. Broke a toe on a door-jamb. I was as clumsy as I had been as a child…

The effect of stress on brain chemistry

Although as many as 8% of Americans will have PTSD at some point in their lives, we are only just beginning to understand the ways in which that stress interferes with the functioning of the brain. The hippocampus, which is involved in verbal declarative memory, is very sensitive to the effects of stress. For example, Vietnam veterans with PTSD have a smaller right hippocampal volume based relative to controls, and combat severity is correlated with volume reduction. Interestingly, hippocampal atrophy and hippocampal-based memory deficits might be reversed with treatment with anti-depressants such as the selective serotonin reuptake inhibitor (SSRI) paroxetine, which has been shown to promote the growth of neurons in the hippocampus. Stress also interferes with the release of brain transmitters such as norepinephrine. It will take many more decades of research to figure it all out, but there is no doubt that stress causes very real changes in both the anatomy and the function of the brain.

Lasting effects of trauma on the brain, showing long-term dysregulation of norepinephrine and cortisol systems, and vulnerable areas of hippocampus, amygdala, and medial prefrontal cortex that are affected by trauma. GC, glucocorticoid; CRF, corticotropin-releasing factor; ACTH, adrenocorticotropin hormone; NE, norepinephrine; HR, heart rate; BP, blood pressure; DA, dopamine; BZ, benzodiazapine; GC, glucocorticoid. From Bremner J.D.Traumatic stress: effects on the brain .    Dialogues in Clinical Neuroscience     2006; 8 (4): 445-461.

Lasting effects of trauma on the brain, showing long-term dysregulation of norepinephrine and cortisol systems, and vulnerable areas of hippocampus, amygdala, and medial prefrontal cortex that are affected by trauma. GC, glucocorticoid; CRF, corticotropin-releasing factor; ACTH, adrenocorticotropin hormone; NE, norepinephrine; HR, heart rate; BP, blood pressure; DA, dopamine; BZ, benzodiazapine; GC, glucocorticoid. From Bremner J.D.Traumatic stress: effects on the brain. Dialogues in Clinical Neuroscience 2006; 8 (4): 445-461.

Transient Global Amnesia

One of the most fascinating clinical conditions I have encountered working as a physician in the emergency room is called transient global amnesia, or TGA. It is uncommon, but once you’ve seen it it is hard to forget. In its classic presentation, the syndrome consists of the abrupt onset of a temporary, severe inability to form new memories (called in medicalese an anterograde amnesia), usually accompanied by repetitive questioning, in the absence of any focal neurologic features that would suggest other problems like a stroke. Behavior is otherwise normal; the patient remains alert and cognition is not impaired, but he or she is often disoriented to time and place. The vast majority of attacks last between 1 and 8 hours and after the attack the patient's the ability to form new memories gradually returns, although she remains amnestic to events that took place during the episode. Patients may feel "something is wrong," but in many cases there is a profound lack of insight and the patient may have had to be coaxed by a worried observer into coming to the ED. That’s what happened with one particularly memorable (sorry) case I saw: a man who raced his sail boat around the island on Nantucket while being observed to have what turned out to be TGA. His daughters finally got him to agree to go to the ER, where I diagnosed, reassured and discharged the patient. I am still waiting for the boat trip he promised me.

Detailed neuropsychologic examination of patients during an attack of TGA shows that personality, complex cognition, problem-solving, semantic knowledge, language, and visuospatial function are all normal. Patients can learn a list of words and retain them when they are able to rehearse but rapidly forget when distracted. Although distant memories tend to be preserved, semantic memory (long-term memory responsible for the storage and integrity of knowledge about the world, including the meaning of words and objects) and "metamemory" (the awareness of what one should know) are usually preserved.

Bad news wipes out memory

No one knows why it occurs, but as one brilliant physician explained in a paper on the Emergency Department treatment of TGA “in approximately one third of cases TGA is precipitated by an emotional experience, intense pain or cold, or strenuous physical activity. Well-described precipitating factors include…emotionally taxing episodes such as being robbed, hearing bad news, or experiencing painful medical procedures.” Transient global amnesia is often caused by emotionally taxing episodes, including hearing bad news, like, presumably, the death of a loved one. And in today’s page of Talmud, it is as if transient global amnesia followed the death of Moses on a national level. Thousands of rulings in Jewish law were forgotten, only to be restored some time later:

אמר רבי אבהו אעפ"כ החזירן עתניאל בן קנז מתוך פלפולו

Rabbi Abbahu says: Even so, Othniel, son of Kenaz, restored them through his sharp mind

Never Forget

In his seminal work on Jewish Memory Zachor, Yosef Chaim Yerushalmi (d. 2009) noted that the command to remember -zachor - is repeated one-hundred and sixty-nine times in the Bible. Remember the Sabbath day, remember what Amalek did to you; remember what God did to Miriam; remember the exodus from Egypt, and on and on. “And as Israel is enjoined to remember” he wrote, “so it is adjured not to forget. Both imperatives have resounded with enduring effect among the Jews since biblical times.” We are one week from Tisha Be’Av the Fast of the Ninth of Av, the day on which Jewish calamities are re-membered, the day on which Jews are reminded: Never Forget. But if grief can cause us to forget parts of our national heritage, it can also spurn us to recall them too. The laws that were forgotten when Moses died were restored through hard work. The amnesia was transient. The rebuilding began once the period of mourning was over. And that is the story of the Jews writ large.

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