Mario, a man who resides in a psychiatric clinic, has no memory of the last 22 years of his life and cannot form new memories. Paloma, a new psychiatrist believes that Mario has Korsakoff’s Syndrome, a neurological illness characterized by both retrograde and anterograde amnesia. Paloma suspects that the first forgotten years of Mario’s retrograde amnesia were not caused by his illness but rather by a traumatic event and sets out to uncover these buried memories. Under the effects of increasingly larger doses of a stimulant medication, Mario remembers details of his dark past and begins forming new memories.
Sé Quién Eres (I Know Who You Are)
Sé Quién Eres (I Know Who You Are), is a Spanish film that presents an interesting story concept through it’s examination of Korsakoff’s syndrome, psychiatric amnesia and the methods used to treat these conditions, but it blurs the lines between various types of memory problems it is attempting to portray.
At the beginning of the film we are introduced to Mario, a man whose fluid conversational style masks the presence of memory deficits (7:11), so much so that the new psychiatrist Paloma is surprised to learn that he is a patient at the psychiatric clinic where she works. After uncovering a history of alcoholism, Paloma theorizes that Mario has a diagnosis of Korsakoff’s Syndrome.
Korsakoff’s Syndrome (KS), a neurological illness often brought on by prolonged alcohol abuse, is characterized by anterograde and retrograde amnesia (Thompson, Guerrini, & Marshall, 2012). Consistent with the KS literature, Mario’s chart states that when he was first hospitalized in 1980 he was “confused and disoriented” (19:37), common symptoms of Wernicke’s encephalopathy, an acute neuropsychiatric condition that precedes development of KS. Wernicke’s encephalopathy, also known as a Wernicke episode, is caused by a thiamine (B1) deficiency in the brain brought on by prolonged alcohol abuse. It is characterized by among other symptoms, confusion and disorientation to place and time (Kopelman, Thompson, Guerrini & Marshall, 2009). Mario’s amnesia patterns are also consistent with a KS diagnosis. Mario can recall as far back as his childhood with vivid details (10:59) but his memories stop three years prior to the onset of his KS (retrograde amnesia)(12:43). In KS patients, memory for the distant past is relatively spared compared with memory for the more recent past (e.g., the years immediately preceding the onset of illness)(Race & Verfaellie, 2012). Mario’s intellectual ability is generally intact (14:00) except that he is unable to acquire new memories once distracted (anterograde amnesia)(8:17, 9:48). Additionally, Mario displays the preserved procedural memory of knowing how to fight (27:33). Procedural memories or memories of how to perform particular actions (e.g., tying your shoes) are typically preserved in patients with KS (Kopelman et al., 2009).
Although KS symptomatology was accurately introduced in the beginning, it is not consistently maintained throughout the film. Contrary to the typical KS clinical picture, Mario navigates new environments and interacts with new people with ease, never asking questions like “where am I?” or “who are you?” Unlike KS patients who require constant supervision due to wandering, Mario is often left alone and surprisingly does not wander away in search of more familiar places/people. Lastly, although patients with KS show atrophy in multiple brain regions (e.g., mamillary bodies, thalamus, frontal lobes) that are visible via CT scans (Kopelman et al., 2009), the CT scan of Mario’s brain performed at the hospital did not reveal any physical problems with his brain (37:10).
Further inaccuracies in the film develop around Mario’s psychiatrist’s unfounded theories and treatment of Mario’s retrograde amnesia. Paloma theorized that because Mario’s amnesia began in 1977 and his KS did not appear until 1980, he must have suffered an emotional trauma in 1977 that caused him to forget the missing 3 years- years during which he drank heavily to the point of developing KS (34:30). It should be noted that Paloma’s theory contains a series of fundamental errors involving both KS and psychogenic or psychologically-based amnesias. As previously stated, retrograde amnesia for years and even decades prior to illness onset is a defining feature of KS and therefore a more reasonable explanation for Mario’s forgotten years than amnesia due to an emotional trauma. Additionally, KS usually develops over many years (decades even) of alcoholism, therefore 3 years of alcohol abuse would not be sufficiently long enough for Mario to develop KS. In her interviews with Mario, Paloma never inquires into his drinking, when it began, etc.
The second fundamental error in Paloma’s theory of psychogenic amnesia is the belief that a single traumatic event in 1977 could have caused Mario to forget 3 years of his life. Psychologically-based amnesias tend to be either situation specific or global. Situation-specific amnesia refers to memory loss for a particular incident or part of an incident (e.g., an emotionally traumatic incident) and global psychogenic amnesia is characterized by a sudden loss of autobiographical memories of one’s past together with the loss of personal identity (Corno, & Kopelman, 2012). Mario’s amnesia does not fit either the situation-specific or global models of psychogenic amnesia but rather the amnesia patterns in KS.
In an effort to uncover buried memories of emotional trauma, Paloma performs a dangerous pharmacological experiment on Mario- administering large doses of Rubifen, a stimulant medication whose active ingredient is methylphenidate. Rubifen is a real medication that is considered to be the European equivalent of Ritalin. Paloma theorizes that Rubifen will help Mario to focus and this will allow him to remember forgotten traumatic memories. Interestingly, although retrograde psychogenic amnesia is the target of Paloma’s experiment, the first sign that Rubifen is working comes in the form of Mario remembering that he made a drawing of his wife (43:20). Although this memory consolidation of a recent event indicates improvements in Mario’s anterograde amnesia, Paloma does not acknowledge this unexpected effect. As Mario starts remembering past traumatic memories (improved retrograde psychogenic amnesia) this lack of acknowledgement further blurs the lines between these two forms of amnesia which differ in basis (psychological vs. neurological) as well as in type (retrograde vs. anterograde).
Interestingly, as soon as Mario recalls fragments of forgotten trauma memories, Paloma readily believes them without further testing or probing although confabulation is one of the clinical features of KS. In the context of KS, confabulation refers to distorted memories resulting from patients confusing true memories with untrue ones because of deficits in memory retrieval, monitoring and verification (Race & Verfaellie, 2012). Additionally, research shows that uncovered memories of trauma are particularly fallible and suggestible and that therapeutic procedures possess considerable potential to create false memories (Loftus & Davis, 2006).
With increasingly larger doses of Rubifen, Mario continues to recall past memories in greater detail and simultaneously forms new memories- mainly of Paloma and her role in his life (59:01). A final and massive dose of approximately 20 Rubifen pills (drastic measure) leaves Mario unconscious (1:28). At their last meeting Mario is silent and detached while Paloma discusses his future, leading viewers to assume he no longer remembers and to wonder whether the high doses of Rubifen have further damaged him cognitively. As Paloma turns to leave the room however, Mario claims to “know” who she is, alluding that his amnesia is cured.
To most viewers, the film’s concept of using a Ritalin-like psychostimulant to treat amnesia may sound bizarre and unfounded however, methylphenidate has been researched for those specific purposes. The film Sé Quién Eres (I Know Who You Are) takes place in 1999, a year after a series of human subject studies using methylphenidate to treat amnesia were published. The first study to use methylphenidate on patients with anterograde amnesia was a randomized, double-blind placebo-controlled study conducted in Argentina in 1998. Various forms of neurologically-based amnesias were treated with methylphenidate but no significant benefits were identified (Tiberti et al., 1997). A second 1998 study conducted in the Netherlands also reported a lack of improvement in anterograde amnesia with methylphenidate use (Unrug, Gorissen, van Luijtelaar, & Coenen, 1998). To date, methylphenidate is not recognized as an effective treatment for amnesias of any kind and the anterograde and retrograde amnesia seen in KS remains irreversible.
In conclusion, Sé Quién Eres (I Know Who You Are) is lacking in neuropsychological accuracy because of the film's inaccurate portrayal of KS and waning ability to maintain Mario’s credibility as a KS patient. Additional inaccuracies included the film’s portrayal of psychogenic amnesia, the impermanence/curability of amnesias and most importantly, the constant blurring between psychogenic vs. neurologically based amnesias and anterograde vs. retrograde amnesias. Despite the film’s inaccuracies it his highly useful educationally because of its coverage of various neuropsychological concepts and because the inaccuracies themselves are thought-provoking and potentially useful to educators for discussion/debate-based learning. Lastly, I give Sé Quién Eres (I Know Who You Are) gives reasonable entertainment value because the film’s plot of searching for a hidden truth that would set things right managed to incorporate an entertaining mixture of neuropsychological illness, romance, mystery, action, political conspiracy and corruption. Given that the film contains some nudity and violence I would rate it for adults only.