From the archive, originally posted by: [ spectre ]

ON THE INSIDE

“Because the presence closely mimicked the patient’s body posture and
position, Dr. Blanke concluded that the patient was experiencing an
unusual perception of her own body, as a double. But for reasons that
scientists have not been able to explain, he said, she did not
recognize that it was her own body she was sensing.

The feeling of a shadowy presence can occur without electrical
stimulation to the brain, Dr. Brugger said. It has been described by
people who undergo sensory deprivation, as in mountaineers trekking at
high altitude or sailors crossing the ocean alone, and by people who
have suffered minor strokes or other disruptions in blood flow to the
brain.

http://www.nytimes.com/2006/10/03/health/psychology/03shad.html?ex=1317528000&en=d71c1fcd10396c37&ei=5090&partner=rssuserland&emc=rss

user: re_print / pass: re_print

Six years ago, another of Dr. Blanke’s patients underwent brain
stimulation to a different multisensory area, the angular gyrus, which
blends vision with the body sense. The patient experienced a complete
out-of-body experience.

Some schizophrenics, Dr. Blanke said, experience paranoid delusions and
the sense that someone is following them. They also sometimes confuse
their own actions with the actions of other people. While the cause of
these symptoms is not known, he said, multisensory processing areas may
be involved.

When otherwise normal people experience bodily delusions, Dr. Blanke
said, they are often flummoxed. The felt sensation of the body is so
seamless, so familiar, that people do not realize it is a creation of
the brain, even when something goes wrong and the brain is perturbed.

Yet the sense of body integrity is rather easily duped, Dr. Blanke
said.

And while it may be tempting to invoke the supernatural when this body
sense goes awry, he said the true explanation is a very natural one,
the brain’s attempt to make sense of conflicting information.”

http://www.cosmosmagazine.com/node/686

Scientists discover ‘shadow person’
Monday, 25 September 2006
by Erica Harrison
Cosmos Online

A ‘shadow person’ might reside in our left temporoparietal junction.

SYDNEY: Ever feel as though you’re being followed? As if someone is
behind you, shadowing your every move? It might be your ‘shadow
person’, created by unusual activity in a specific brain region, a new
study shows.

The paper, published in the British journal Nature, describes the case
of a 22-year-old woman with no history of psychiatric problems who was
being evaluated for treatment of epilepsy. When a region of her brain
called the left temporoparietal junction was electrically stimulated,
the woman described encounters with a ‘shadow person’ who mimicked her
bodily movements.

“Electrical stimulation repeatedly produced a feeling of the presence
of another person in her extra-personal space,” said Olaf Blanke,
co-author of the study conducted by a team of researchers from
University Hospital in Geneva, Switzerland.

When the patient was lying down, stimulation of this brain region
caused her to feel that someone was behind her. She described the
person as young, of indeterminate sex, “a shadow who did not speak or
move, and whose position beneath her back was identical to her own”,
according to the researchers.

When the patient sat up, leaned forward and clasped her knees, she felt
that the figure was also sitting, embracing her in its arms – a feeling
she described as “unpleasant”.

During a language task, in which the seated patient held a card in her
right hand, she described the person sitting next to her and trying to
interfere with the task. “He wants to take the card … he doesn’t want
me to read,” she said.

Because it was possible to induce the sensation repeatedly, and because
the ‘shadow person’ closely mimicked the patient’s posture and
movements, the researchers conclude that the patient was experiencing a
perception of her own body.

“The strange sensation that somebody is nearby when no one is actually
present has been described by psychiatric and neurological patients, as
well as by healthy subjects,” said Blanke. Until now, however, it was
not understood how the illusion was triggered in the brain.

The temporoparietal junction is known to be involved in creating the
concept of ‘self’, and the distinction between ‘self’ and ‘other’.
According to the researchers, stimulation of this region interfered
with the patient’s ability to integrate information about her own body,
leading to her experience of a ‘shadow person’.

Although the woman was aware of the similarity between her own
movements and those of her doppelganger, she didn’t recognise the
experience as an illusion of her own body.

Similar shadowy encounters have been described by people with
schizophrenia, as well as by healthy subjects, leading the researchers
to believe that: “Our findings may be a step towards understanding the
mechanisms behind psychiatric manifestations such as paranoia,
persecution and alien control.”

http://en.wikipedia.org/wiki/Shadow_people

CONTACT
Olaf Blanke
http://lnco.epfl.ch
email : olaf [dot] blanke [at] epfl [dot] ch

Cortex, (2006) 42, 000-000
RESEARCH REPORT
POLYOPIC HEAUTOSCOPY:
CASE REPORT AND REVIEW OF THE LITERATURE
Peter Brugger, Olaf Blanke, Marianne Regard, David T. Bradford and
Theodor Landis

(Department of Neurology, University Hospital Z=FCrich, Z=FCrich,
Switzerland; Department of Neurology, University Hospital Geneva,
Geneva, Switzerland; 1207 West 12th, Austin, TX USA)

TABLE I

Characteristics of 14 published cases of polyopic autoscopic phenomena
Case
Source
Patient
Etiology
Key contents of autoscopic experience
#
(chronological order)
(sex, age)

1=2E
Staudenmaier, 1912/1968
Male, n.r.
Schizophrenia
Patient sees 3 identical doubles in front of himself. “They stood
(Ahlenstiel, 1949) still whenever I stood still, lifted their arms
whenever I did, etc.”.

2=2E
Storch, 1924
Female, 34
Schizophrenia
Patient sees “seven forms coming out of me, one after the other. They
all looked like me; they did what I had in my thoughts”.

3=2E
Mayer-Gross, 1928
Female, n.r.
Psychosis
Depressed patient sees a crying double of herself. She closes her eyes,
and, after reopening them, sees the entire room crowded with doubles,
all identically looking and all crying.

4=2E
Ehrenwald, 1930
Male, 52
Posterior left
Patient identifies himself with a motionless giant double on which
(hemisphere infarction) many additional but tiny doubles are climbing
around.

5=2E
Ley & Stauder, 1950
Male, n.r.
Encephalitis in the Patient sees and feels three identical doubles of
himself lying to his left side. Delusional elaboration; transitivism.

6=2E
Dewhurst & Pearson,
Male, 57
Post-traumatic
In his left visual field, the patient sees “crowds of tiny figures, all
the colors of the rainbow – all temporal lobe lesion myself”.

7=2E
H=E9caen & Badaraco, 1956 Male, n.r.
Tuberculous
Patient is lying on his side and sees two identical doubles, one in the
left and one in the right visual field. Feels that both possess some
body weight.

8=2E
Klages, 1959 (case 1)
Male, 54
Gunshot lesion left Patient feels split into three persons. The actual
self observes two (parietal lobe) other selves represented by the left
and right body halves, macrosomatognosia; respectively.
depersonalization

9=2E
Heintel, 1965
Female, 32
Post-traumatic
Patient sees multiple mirror images of herself in different size;
right-sided Autoscopic images are localized in the interior of the
patient’s body.

10.
Craske & Sacks, 1969
Female, 32
Healthy
Patient sees a non-pregnant double straight ahead of herself. A second
double covers her body “like a mask but [is] separated from it by a
thin layer”.

11.
Lance, 1976
Female, 62
Right occipital
“Five or six” doubles imitate the patient’s actions she herself had
infarction performed “a short time beforehand”.

12.
Sengoku et al., 1981
Female, 33
Temporal lobe
As an ictal experience, patient sees two doubles of herself, one
epilepsy; right-sided with convulsions, the other supplying a
handkerchief to wipe focus patient’s saliva with.

13.
Kamiya & Okamoto, 1982 Female, 21
Focal epilepsy;
Patient sees “multiple selves as shadows moving from left to right
left-sided focus in visual space”.

14.
Chabrol & Bonnet, 1995
Female, 12
Panic attacks with Patient feels threatened by several identical
looking doubles.
Capgras syndrome

ABSTRACT
Heautoscopy, i.e., the encounter with one’s double, is a multimodal
illusory reduplication of one’s own body and self. In its polyopic
form, more than one double is experienced. In the present article, we
review fourteen published cases of polyopic heautoscopy and describe in
detail the case of a 41-year-old man with polyopic heautoscopy
resulting from a tumor in the insular region of the left temporal lobe.
Our case is illustrative in several respects: (1) The patient’s five
doubles were all confined to the right hemispace. Laterality in this
case is discussed with reference to previous cases of unilateral
heautoscopy after focal brain damage, which generally do not show a
hemispatial or hemispheric bias. (2) The patient’s psychological
affinity with his doubles, and also the extent of their echopraxia of
his movements, decreased as a function of their perceived spatial
distance from the patient’s body, corroborating previous observations
of associations between spatial and psychological phenomenologies
during autoscopic phenomena. (3) While classical heautoscopy (the
reduplication of a single body and self) is considered a breakdown in
the integrative processes that enable us to identify our self with our
body, the phenomenon of polyopic heautoscopy (a multiplication of body
and self) points to the multiple mappings of the body, whose
disintegration may give rise to the illusory experience of multiple
selves.

Key words: autoscopic phenomena/doppelg=E4nger, polyopsy/polyopia,
unilateral hallucinations, body schema, reduplication, self

INTRODUCTION
Autoscopic hallucinations and heautoscopy are two variants of a
reduplication of one’s own body and self (Blanke et al., 2004;
Brugger et al., 1997). In the former, an exact mirror image of oneself,
occasionally only of one’s face or bust, is perceived visually
(Maillard et al., 2004; Zamboni et al., in press). Such hallucinations
are usually of very brief duration and often accompanied by other types
of visual hallucinations or illusions. In the latter variant, i.e.
heautoscopy proper, a person is confronted with his or her double, or
doppelg=E4nger, which may or may not mirror the person’s appearance.
Regardless of its visual features, the hallucinatory figure is felt to
be a double of one’s self. The feeling of belonging toward one’s
double is usually accompanied by alterations in bodily awareness; for
example, the person feels an unusual lightness of the body, experiences
vestibular illusions, or describes a feeling of detachment. Frequently,
heautoscopic echopraxia, i.e., the imitation of bodily movements by the
double, gives rise to the illusion that it is the doppelg=E4nger that
“contains the real mind” (e.g., Lukianowicz, 1958, cases A and D;
Dewhurst and Pearson, 1955, cases 1 and 2; Brugger et al., 1994).
Echopractic movements may sometimes follow actual body movements with a
time lag (e.g., Lance, 1976), an observation also reported in patients
with supernumerary phantom limbs (Hari et al., 1998) and supporting the
notion of the doppelg=E4nger as a “phantom of the entire body”
(Brugger, in press). There is considerable variation in the reported
duration of heautoscopy; it may last for seconds or for hours, and even
cases of the double as a steady companion are not exceptional (Conrad,
1953; Engerth and Hoff, 1929; Pearson and Dewhurst, 1954). Heautoscopy
has been described in a broad range of neurological disorders such as
epilepsy, migraine, neoplasia, infarction, and infection
(Menninger-Lerchenthal, 1935, 1946; Lippman, 1953; Devinsky et al.,
1989; Dening and Berrios, 1994; Brugger et al., 1997), and also in
pychiatric disorders such as schizophrenia, depression, anxiety, and
dissociative disorders (Bychowski, 1943; Carp, 1952; Todd and Dewhurst,
1955; Lukianowicz, 1958; Damas Mora et al., 1980; Dening and Berrios, 1994).
Based on an analysis of autoscopic phenomena after focal brain lesions,
Blanke et al. (2004) emphasized the specific importance of lesions at
the temporo-occipito-parietal junction. While autoscopic hallucinations
have almost exclusively been reported in neuropsychiatric patients,
heautoscopy also occurs in the healthy population, especially in the
framework of a preoccupation with one’s own self and its place in the
world or as a pathological grief reaction (Menninger-Lerchenthal, 1935;
H=E9caen and de Ajuriaguerra, 1952; Wells, 1983; Dening and Berrios,
1994). Among both types of autoscopic phenomena, “polyopic” cases,
involving a multiplication rather than simply the reduplication of
one’s own body, have been reported. Probably the first account of
polyopic heautoscopy is to be found in M=FCller’s (1826/1967) seminal
work on visual hallucinations. Returning home late from work, an
exhausted university professor suddenly found himself confronted with
some 15 persons, all clearly recognized as doubles of himself although
they were of different ages and wore clothes he himself only wore in
the past. A case of an autoscopic hallucination with multiple images is
reported by Roubinovitch in 1893 (Parish, 1894, p. 16), whose patient
saw three identical mirror images of himself which he compared with the
reflections he would have seen standing in front of a mirror with three
wings. Passing reference to other early cases of a polyopic nature can
be found in Winston (1908), Oesterreich (1910), Schneider (1931),
Nadeau (1972), and in Leischner’s (1961) review article on autoscopic
phenomena. While these early cases have a somewhat anecdotal character,
our Table I summarizes certain features of polyopic autoscopy/heautoscopy
as described in more detail in the medical-psychological literature.
Out-of-body experiences, conceptually closely related to heautoscopy
(Blanke et al., 2004; Brugger et al., 1997) can also involve an illusory
multiplication of one’s body. Cases of such multiple out-of-body
experiences are reviewed in Green (1967) and Greene (1983).
Tschaikowskaja (1982) discusses the motif of the multiple self-portrait
in the visual arts. Multiple doubles in folklore are considered in Krauss
(1920) and Panoff (1968). The 14 instances of polyopic autoscopic
phenomena noted in Table I may be characterized as follows. Eight
patients were female (57%) and 6 male (43%). Their mean age was
38.9 years (range: 12-62 years). With respect to etiology, 64% of the
cases of polyopic heautoscopy were of neurological origin and 29% of
psychiatric origin [1 case (7%) was during puerpurium]. Of the neurological
cases, 88% were of focal origin and due to a traumatic lesion, vascular
infarction, or focal epilepsy. Of these focal neurological cases the lesion
was localized as often in the right as in the left hemisphere. Either two
or three doubles were noted in 43% of cases; more numerous doubles
were evident in 57% of cases. In some reports, the doubles filled the
entire room (Mayer-Gross, 1928) or, rather exceptionally, the interior
of the patient’s body (Heintel, 1965). In cases where polyopic heautoscopy
was characterized by a large number of doubles, these were generally
seen as quite small in size (Ehrenwald, 1930; Dewhurst and Pearson,
1955), whereas a small number of doubles was associated with a
size comparable to that of the patient. Echopraxia was noted in two
reports listed in Table I. In one case it was simultaneous with the
patient’s actual movements (Staudenmaier, 1912/1968), and in the
other there was a “delayed imitation” (Lance, 1976). Generally, the
doubles were localized in the central visual field or immediately in
front of the patient’s body (85%), and continuous lateralization in the
visual field/peripersonal space was described in only two cases
(Dewhurst and Pearson, 1955; Leyand Stauder, 1950). If mentioned at
all, the perceived distances to the doppelganger were generally small,
i.e. they were localized within or just beyond grasping distance, which
is the rule in heautoscopy. Yet, most reports (69%) did not indicate any
precise distance. We present here one more case of polyopic heautoscopy
that is informative in several respects. The patient’s five doubles were
confined to the right hemispace, and this experience was preceded by
the sensation of a split of the two halves of his body along the
midline. There was no similarity between the doubles’ and the
patient’s visual appearance; two doubles were male, three were
female. The most unique feature of the present case was that the extent
to which the patient identified himself with the single illusory
figures diminished with increasing perceived distance from his body.

CASE REPORT
PH (fictious initials, for ‘Polyopic Heautoscopy’), a 41-year-old
right-handed pottery maker, was seen at our clinic for presurgical
evaluation after three months of fatigue and dizziness and recurrent
seizures with gustatory sensations and inappentence. On admission,
neurological examination revealed, apart from a very mild right-sided
sensory hemisyndrome, no positive findings. In particular, position
sense was normal, and there was no visual field defect (Goldmann
perimetry). EEG showed spikes, spike-waves, and sharp waves as well as
pathological slowing over the left fronto-temporal region.
Neuropsychological examination revealed the following: The patient was
fully oriented; his sole spontaneous complaints concerned memory
problems and tiredness. He presented with an elevated mood (no affect
lability) with anosodiaphoria. He had a normal digit span, implicit and
explicit verbal learning were intact, active recall after one hour was,
however, reduced (spared recognition). Recall of the Rey complex figure
was quantitatively sufficient, but drawn with repetitious elements.
Receptive and productive language functions were normal, but there was
a marked logorrhoea during spontaneous speech. There were neither
apraxias nor any deficits of visual perception. Cognitive flexibility
(verbal and figural fluency), suppression of interferences (Stroop
task) and conceptual shifting were normal. CT indicated an expansive
lesion in the left insula extending into adjacent fronto-temporal
cortex compatible with an astrocytoma (Figure 1). Among the first
manifestations of his illness the patient recalled the following
incident: Upon awakening one night he noticed that he had split into
three distinct parts: (1) the left half of his Polyopic heautoscopy
body which felt quite normal; (2) the right half, which felt detached
from the left both physically and emotionally; and (3) he observed “a
man” in close proximity to his right side. To a confusing degree he
felt this man to be a part of himself. It was as if he and the man were
“sharing the same soul”. This feeling was convincing despite the
fact that there was no similarity in physical appearance (for instance,
the man was blond, while the patient’s hair was black). Puzzled, but
not frightened, by this altered bodily awareness, the patient began to
walk up and down in his bedroom. He repeatedly tried to catch a glimpse
of the man to his right in order to check whether, in accordance with
his feelings of identity with him, the man’s face would also look
like his own. As he did so, he at once discovered what he later spoke
of as “the family”. His account (c.f., Figure 2): “When I walked
around, I repeatedly looked towards the gentleman on my side and
wondered if I could recognize his face. This was impossible
since on looking towards the right side he also turned his head to the
right. I could note however, that the man was blonde and about
50-years-old. Once more trying to get a close look of him, I all of a
sudden noticed that, even more to the right, there was a whole group of
people. At a distance of 2 m I saw an approximately 50-year-old lady
with blond braids. Still another 4 m away, there were two girls [both
approximately age 20] and some 20 m from me, still in a straight line
with all the other persons, there was a boy [unspecified age]. I knew
right from the beginning that these persons were intimately linked with
one another, they were father, mother, daughters and son.” [In
actuality, the patient’s wife was younger than him and had dark
short hair. His only two children were two sons, aged 10 and 16].
PH said that, with the appearance of the “family”, the previously
evident space between the left and right halves of his body ceased
to exist. While he continued to feel a strong sense of belonging
towards the man at his right side, on discovery of the other persons
this sense gradually expanded to include the woman and, to a lesser
extent, the girls. The boy, who “played a very minor role in the whole
series of events”, was eventually only vaguely seen and at certain
times vanished in the darkness of the far right end of the bedroom.
Referring to his remark about his “son” standing at a distance of
20 meters, we asked PH about the actual size of his bedroom. He
insisted that 20 meters appeared a realistic estimate at that time; to
his right, the entire room including single pieces of furniture was
notably extended into the distance. All “family” members imitated
PH’s every movement. When PH was sitting down, “man” and
“lady” were sitting down as well (Figure 2). The “daughters”
and the “son” were also able to move independently; their positions
in space (i.e., their distance to PH’s body) remained invariant,
however. PH was impressed by the synchronization of his and the other
persons’ motor activity and, as a deliberate experiment; he
successfully tried to influence their movements by, for example, doing
push-ups.

“When I walked, the family walked with me; when I bent my knees, the
others bent theirs; when I looked to the right, so did all the others.
Exceptionally, however, the girls, who were commonly talking to one
another, would look towards me waving their hands as if inviting me to
join their world. […] Naturally, I could not see the persons any
longer on closing my eyes, but the feeling remained that pieces of
myself were located in precisely those places I knew the persons were
standing. It was a feeling of being awfully frittered away!” When the
patient’s wife was sitting at his right side, the “family” would
temporarily vanish, and simultaneously he perceived himself to be
one person in one place again. However, he noted a clumsiness and
weakness of the entire right half of his body. As soon as his wife
moved from his side, all imaginary persons would immediately reappear
in their respective places. Despite considerable agitation, PH managed
to fall asleep after some two hours. According to the retrospective
account of the patient’s wife, his speech was barely understandable
throughout and contained many neologisms.

Fig. 2 – Artist’s drawing according to PH’s verbal description of four
of his five doubles. All doubles were invariably located to the right
of the patient’s body. Despite nobody of the “family” of doubles
reflected the patients’ appearance, all members were felt to belong
to the own self. The degree of motor and psychological autonomy
of a double increased with increasing distance to PH’s body. The
presence of one additional figure was vaguely perceived (more
‘sensed’ than seen) at a distance of about 20 m from the patient (not
displayed). The space toward the patient’s right side appeared to
be stretched.

On being specifically questioned about details of his experience, the
patient reported that the initially present “gap” between the two
halves of his body was only felt, but not seen. Also later on, he always
saw his own body in a regular way, and the bodies of the illusory family
members were seen complete as well (i.e., visualization was not
restricted to their upper parts or to head and face). At no time did
the patient have the specific feeling of being separated from his body.
His perspective was thus continuously centered on his own body,
although the patient noted that by referring to “a feeling of being
awfully frittered away” (see above), he wanted to emphasize that his
general bodily awareness was “distorted” and the identity of body
and mind was “altered” (he had difficulties in finding the accurate
words to describe this state, which we will refer to as
‘depersonalization’ in the Discussion section). The next morning
the patient was brought to a local hospital. Initially, he was still
aphasic, and he continued to be accompanied by the “family”.
However, he could no longer see the different persons. He rather
felt their presence, that is, “some hardly describable sense” made
him aware that the “family” was still present and enabled him to
precisely localize the position of four persons in his room.
Specifically, he noticed that the “father” had moved to the right
while the distance to the “girls” had shrunk, such that the “family”
now gathered at a distance of 2 to 3 meters from his side with the
exception of the “son”, who had disappeared. The patient no longer
identified himself primarily with the “father” but felt that each
member of the “family” was equally a “part of [his] expanded self”.
They jointly continued to mirror his own movements. Later the
same day, they began to communicate with him (by transferring
their thoughts to him rather than by normal means of verbal
communication). Throughout, the messages he received consisted
of comforting statements preoccupied with the theme of death
and dying. The patient indicated that these communications reassured
him of the harmless character of his condition. Paradoxically, he also
noted that they made him seriously consider the possibility of an
afterlife. “Again and again they said I had such a lovely wife that,
should I die, she would find a new partner in no time. Rather than
making me jealous, these words really comforted me and reassured me in
my feeling that nothing really harmful could ever happen to me.” For
the rest of the day and during the second day in the hospital, the
invisible family remained to the patient’s right side except when
someone spoke with him. After awakening on the morning of the third
day, the patient noticed that all the imaginary persons had
disappeared. They did not reappear, either preoperatively or
postoperatively. A formal postoperative examination was denied by
the patient, who preferred to stay with his closest relatives “in
order to prepare himself for dying”. He passed away 16 months
following surgery.

DISCUSSION

The patient presented here experienced polyopic heautoscopy in the
right hemispace as the first manifestation of a left-sided tumor. The
clinical features are consistent with previous reports. Heautoscopy has
frequently been described in patients with focal seizures due to
cerebral neoplasias (e.g., Dewhurst and Pearson, 1955; H=E9caen and de
Ajuriaguerra, 1952). Although the primary lesion location may be the
parietal lobes (Menninger-Lerchenthal, 1935, 1946; H=E9caen and de
Ajuriaguerra, 1952), the temporal lobes (Devinsky et al., 1989; Dening
and Berrios, 1994), or occipital areas (Bhaskaran et al., 1990; Zamboni
et al., in press), focal damage to the temporo-parietal junction of
either hemisphere has been emphasized both in the classic literature
(Menninger-Lerchenthal, 1935, 1946) as well as in most recent case
studies (Blanke et al., 2004). The lesion of the present patient is
consistent with these findings. This invasive tumor probably originated
in the posterior insula, was especially destructive of the left
temporal lobe, but extended laterally into both parietal and frontal
lobe. Some of these areas have recently been identified as part of the
“cortical midline structures” intimately related to the experience of
the self (Northoff and Bermpohl, 2004). Damage to the insular cortex may be
particularly relevant since this region is reportedly involved in
action simulation and the adoption of a viewpoint different from the
regular, i.e., body-centered perspective (Ruby and Decety, 2001). Also,
both temporoparietal junction and posterior insula were identified as
key structures of vestibular projection areas (Fasold et al., 2002) and
thus important to visuo-spatial orientation and the localization of the
body in space. Several observations emphasize the importance of
non-visual, body-related mechanisms for the genesis of heautoscopy.
These include, first, the presence of depersonalization as a general
alteration of emotional and bodily self-awareness, which in the present
case was described as an alienation from his own body, accompanied by
dizziness and, later on, a feeling of being “awfully frittered
away”. Similar alterations in corporeal awareness were previously
reported as concomitants of heautoscopy (Menninger-Lerchenthal,
1935; H=E9caen and de Ajuriaguerra, 1952; Blanke et al., 2004).
Second, there were specific somatognosic disorders such as the
splitting of the own body at the median. The experience of oneself
as “inhabiting” two halves of a body, spatially separated by a gap,
is frequently associated with lesions of the parietal lobes (Critchley,

1955/1979, Polyopic heautoscopy; pp. 92-105; Gloning et al., 1954,
case 1), but also described in patients with a psychotic disorder,
either
with (M=FCller-Erzbach, 1951, p. 90) or without accompanying
episodes of heautoscopy (Bozik and Vujic, 1930). There may be a
gradual transition from the feeling of having one body split into two
halves to the personification of a split half-body as a double of
oneself.
Similar transformations can be observed in cases of hemiasomatognosia,
i.e. the illusion that one half of one’s body has ceased to exist
(e.g.,
Blanke et al., 2003; Lunn, 1970, cases 1 and 2; Menninger-Lerchenthal,
1946). In some cases, the apparent nonexistence of one-half of the
body is accompanied by somatoparaphrenic delusions about
“somebody else” taking its place (e.g., Ley and Stauder, 1950, p. 573;
Zingerle, 1913). The initial split into two distinct halves of the body

in our patient resembles the experience of Klages’ (1959) patient
with a focal left-parietal lesion (case 8 in our Table I). This patient

reported that it appeared to him “as if my self consists of three
parts, i.e., my proper self, a left and a right side, hence together
three parts that vehemently shy away from unification”. (p. 267).
Unlike in our case, this patient’s most prominent self observed the
struggle between the two remaining selves to become united from
an apparently disembodied perspective. A third point, emphasizing
the primarily non-visual nature of heautoscopy involves PH’s
identification with the different “family members” despite the
absence of visual similarity to the patient’s appearance. In this
context, Sollier (1903) coined the term “dissimilar heautoscopy”
(‘h=E9autoscopie dissemblable’), noting that the relative
unimportance of visual content differentiates heautoscopy from
autoscopic hallucinations (‘hallucinations sp=E9culaires’). An
earlier and analogous classification of autoscopic phenomena according
to the visual (dis)similarity between patient and double had been
proposed by Hagen (1837), who differentiated “autoscopy” from
“deuteroscopy”. In our case, three of the patient’s 5 doubles
were of the opposite sex (“heterosexual heautoscopy”, after
Letailleur et al., 1958). This lack of correspondence in the gender of
patient and doppelg=E4nger was previously described exclusively in the
course of a psychotic illness (e.g., Carp, 1952; Letailleur et al.,
1958), and we know of no other case of polyopic heautoscopy in which
some of the doubles were of the same sex as the patient and some of the
opposite sex (c.f., Table I). There were relatively few similarities
between our patient and his “closest” double (the ‘gentleman’
to his right). Yet, the patient had a strong “feeling of belonging”
towards him, and it appeared to him that the two of them shared
thoughts and feelings. A unique feature of the present case is the
functional relationship between spatial and psychological
phenomenology. In fact, the imaginary figures localized at greater
distances from the patient’s body were only detected after inspection
of the “closest” double and labeled “lady” (or, sometimes,
‘wife’) and “daughters”. Feelings of identity were less
pronounced for the “lady” (distance of 2 m) compared to the
“gentleman” along the right side of the patients body, and for the
“daughters” (distance of 6 m) they were even less prominent. The
“son” (20 m) had always played a minor role, was at a significantly
greater distance than the rest of the “family” and was also the
first figure to disappear completely. Autoscopic and heautoscopic
doubles are generally experienced in the near personal space (Blanke et
al., 2004) and only rarely localized at a distance far beyond grasping
space (Dewhurst and Pearson, 1955; Lukianowicz, 1958, case B; Arenz,
2001;
Blanke et al., 2004, case 1). For these more distant doubles,
self-recognition and self-identification were rather vague and often
only experienced once double and patient approached one another (e.g.,
Lubowska, 1892; McCulloch, 1992).

Most earlier cases of heautoscopic echopraxia (Dewhurst and Pearson,
1955, cases 1 and 2; Lukianowicz, 1958, cases A and D) concerned a
single double, and a correlation between perceived distance and the
extent
of echopraxia could not be assessed. In the present case, echopraxia
was explicitly tested by the intrigued patient and found to be
strongest
and most closely matching his own body movements for the “gentleman”
close by, followed by the “lady” and only occasionally by the two
“daughter-doubles” at a greater distance. The patient’s movements
were never imitated by the most distant “son”. This distance-related
relationship between the patient’s motor actions or intentions and
those
of his doubles may be causally related to the interdependence between
felt psychological identification and perceived physical distance. We
have pointed out that the spatial characteristics of heautoscopy may be

an important predictor of the psychological content of the
reduplicative
experience (Brugger, 2002). While we previously emphasized the aspect
of spatial and psychological perspective taking, we now propose that
experienced physical distance of illusory reduplications of one’s body
may systematically interact with motor, visual and cognitive variables.

Spatial-psychological interactions may be particularly evident in
polyopic
heautoscopy where multiple doubles with different characteristics are
experienced simultaneously at different locations in phenomenal space.

Another link between spatial and psychological phenomenology is
suggested by the present case. PH’s doubles had a clearly comforting
role. They made him feel secure by suggesting the possibility of a
personal afterlife and by assuring him that his real family would not
fall apart, even in the most serious case of his death. The patient’s
marked and lasting anosodiaphoria and the positive attitude of his
illusory companions seem to have nourished one another. Although
speculative, we wish to point to a possible association between
emotional content of a heautoscopic episode and the hemispace in
which the reduplication or multiplication takes place. In several
previous reports of unilateral autoscopic phenomena, affectively
positive or at least neutral interactions were described for a
doppelganger confined to the right hemispace (e.g., 1890, case
13; Pailhas, 1908, case 1; Sivadon, 1937, case 2; and de
Ajuriaguerra, 1952, case 83; Brugger et al., 1996, case 2). In
contrast, left hemispace lateralization is often accompanied with
hostile interactions between patient and double (Carp, 1952; van
Bogaert, 1934; Spiers et al., 1992) and associated with depressed mood
and suicidal ideation (Persinger, 1994). This interaction between the
left and the right sides of space on the one hand, and the emotional
valence of an experience on the other, is reminiscent of the morbid
dislike of and aggression toward a dysfunctional limb
(‘misoplegia’; Critchley, 1955/1979), which is more evident in
left-sided as compared to right-sided hemiplegia. Likewise,
in the syndrome of the anarchic limb (Marchetti and Della Sala, 1998),
self-destructive behaviors are more frequently ascribed to left-sided
compared to right-sided extremities (Brugger, 2001, for the
references).
Additional case analyses are needed to corroborate the present
conclusion concerning a relationship between lateralization and
affective meaning of illusory reduplications of one’s own body.
One alternative to this conclusion is to conceive of PH’s doubles
as a sign of transitivism (Wernicke, 1900), the comforting
externalization of self-threatening information and its projection onto
other persons, whether real or imaginary (Brugger, 2002 for overview).
We note that in 3 out of the 14 cases of polyopic heautoscopy listed in
Table I, transitivistic tendencies were apparent (case n. 3, 5 and 12).
In any case, the location of hallucinations in space, previously linked
to relatively low-level sensorimotor preferences of an individual
(e.g., Girard and Cheyne, 2004), may be associated in significant ways
with higher-order psychological states as well. We can only speculate
which mechanisms might have led to PH’s experience of multiple
doubles. It may be relevant that he observed initially only one
right-sided double. Yet, once he had moved his eyes beyond the
imaginary figure immediately adjacent to his body, he discovered the
additional doubles more to the right. In hemianopia, eye-movements
toward the visual field defect were shown to elicit polyopia (Gottlieb,

1992). On the other hand, impaired control of eye movements is
considered a major pathomechanisms in classical polypopia (Bender,
1945; but see Cornblath et al., 1998, for alternative mechanisms).

On this account, polyopia is assumed to result from aberrant
involuntary
eye movements that accompany fixation and thus lead to multiple
representations of an observed (or hallucinated) object. However,
similarities between polyopia in the sense of a purely visual
perseveration and the experience of multiple doubles in polyopic
heautoscopy should not be overemphasized. It is highly probable
that the primary multiplication originated in the somatosensory
domain, and that the present case thus represents an instance
of “polyesthesia”. What was visually experienced as the “family”
by our patient may thus represent the secondary visual interpretation
of a fragmentation of his bodily self (Zamboni et al., in press, for a
similar interpretation of a case of autoscopy). Heautoscopy,
whether a reduplicative or multiplicative experience, may
thus reflect a disintegration of those processes that normally allow
the continuous experience of having a body to which we “bind” our
self (Metzinger, 2003; Northoff and Bermpohl, 2004). As in the
phenomenon of the supernumerary phantom limb, where patients may
experience multiplications rather than duplications of an extremity
(Vuilleumier et al., 1997; Brugger, 2003, for an overview), “the
person within” (Damasio, 2003), set temporarily free during
autoscopic phenomena, may not necessarily be experienced as an
indivisible unit.