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Autoscopic phenomena: case report and review of literature

Autoscopic phenomena: case report and review of literature Background: Autoscopic phenomena are psychic illusory visual experiences consisting of the perception of the image of one’s own body or face within space, either from an internal point of view, as in a mirror or from an external point of view. Descriptions based on phenomenological criteria distinguish six types of autoscopic experiences: autoscopic hallucination, he-autoscopy or heautoscopic proper, feeling of a presence, out of body experience, negative and inner forms of autoscopy. Methods and results: We report a case of a patient with he-autoscopic seizures. EEG recordings during the autoscopic experience showed a right parietal epileptic focus. This finding confirms the involvement of the temporo-parietal junction in the abnormal body perception during autoscopic phenomena. We discuss and review previous literature on the topic, as different localization of cortical areas are reported suggesting that out of body experience is generated in the right hemisphere while he-autoscopy involves left hemisphere structures. Background Narcissus and the description made by Plautus in his The term autoscopy comes from the Greek words Amphitryon: here the double (represented by the god “autos“ (self) and “skopeo“ (looking at). Autoscopic phe- Mercury) is an entity completely distinct from the char- nomena are psychic illusory visual experiences defined acter Sosia who shares with his double only the physical by the perception of the images of one’s own body or aspect, but not the psychological and intellective atti- one’s face within space, either from an internal point of tudes. At difference with Narcissus, Sosia is frightened view, as in a mirror or from an external point of view. by the double: he believes that the double could have Autoscopic experiences were first described by the stolen his identity or, worse, that the appearance of the Greek philosopher Aristotele, but it was subsequently double could have been caused by the death. As it admirably described in its ambiguous presentation by appears from the descriptions the theme of the death is Ovid in the third book of its Metamorphoses where the often strictly linked with the theme of the double. Auto- author narrates the myth of Narcissus, a beautiful boy scopic phenomena are considered at the basis of many who falls in love with his image reflected in a water self-portrait paintings [1]: Durer, Rembrandt, Velazquez, source. In the first place he mistakes his own image Schiele seem to have painted during autoscopic with another person, but when he suddenly realizes that experiences. he is looking at the image of himself, desperate for the Dostoevsky made this phenomenon more popular in hopelessness of his love he is forced to commit suicide. the nineteenth century in his novel “The Double”, where the doppelganger (i.e. haunting double of the self) of The variable presentations of the autoscopic phenom- ena, which will be extensively addressed below in their German legends was the background. scientific meaning and correlates, clearly appear in the The German word “Doppelganger” was brought into comparison between the aforementioned myth of the language, and simultaneously, into the literary tradi- tion by the novelist Jean Paul Richter, who in 1796 defined the word in a one sentence footnote: “So heissen * Correspondence: f.anzellotti@unich.it Leute, die sich selbst sehen” (So people who see them- Department of Neuroscience and Imaging, Aging Research Centre, Ce.S.I., “G. d’Annunzio” University Foundation G. d’Annunzio University, Chieti, Italy selves are called). Full list of author information is available at the end of the article © 2011 Anzellotti et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Anzellotti et al. Behavioral and Brain Functions 2011, 7:2 Page 2 of 11 http://www.behavioralandbrainfunctions.com/content/7/1/2 The first medical report dates back to Wigan’s “double” or “doppelgänger” in their descriptions. An out description in 1844. Subsequently, the term autoscopy of body experience is defined by the presence of three was used to describe various phenomena of various phenomenological characteristics: disembodiment (loca- aetiologies and mechanisms. tion of the self outside one’s body), the impression of see- Brugger was one of the first authors to study auto- ing the world from a distant and elevated visuo-spatial scopic phenomena [2]. He proposed a classification perspective (extracorporeal egocentric perspective) and the impression of seeing one’s own body (or autoscopy) scheme based on phenomenological criteria. Along with from this elevated perspective [11]. examples of illustrative cases, he outlined the main fea- The theme of the separation between self and body is tures of six types of autoscopic phenomena: the feeling of a presence, the negative heautoscopy, the inner heau- frequently found in philosophy. Hume claimed that toscopy, the autoscopic hallucination, the out of body “when he introspected, he was unable to catch his self experience and the he-autoscopy also defined as heauto- without a perception and was unable to observe ‘any- scopic proper. thing but the perception’ itself”. He concluded that the The feeling of a presence, first described by Jasper in self (or the observing introspective subject) is simply a 1913, is the distinct feeling of the physical presence of collection of different perceptions. The interest of occi- another person or being in the near extracorporeal dental philosophy for the body was also exemplified in space. No visual impressions are involved but frequently Descartes’ effort to separate mind and body. thepresenceisfelttobe “at thefringeof vision”.Like The he-autoscopy is rare but probably more frequent he-autoscopy, it is usually accompanied by alterations in than pure autoscopic hallucinations. The term “Heautos- the experience of one’s own body. It can be reported by kopie” was proposed by Menninger-Lerchenthal [13] to healthy persons in conditions of sensory deprivation or denote the experience of seeing one’s self and to desig- social isolation [3]. The feeling of a presence is often nate the classical doppelgänger experience described in confined to one hemispace particularly when associated literary accounts [14,15]. The double usually appears with a seizure disorder [4]. colorless ("foggy”, “pale”,or “as through a veil”), can Negative heautoscopy refers to the failure to perceive behave autonomously, may or may not mirror the per- one’sown bodyeitherinamirrororwhenlookedat son’s appearance and maintains sidedness. The expres- directly. In the latter form the confinement of the (nega- sion heautoscopic “echopraxia” means imitation of tive) hallucination to one’s own body and the frequent bodily movements by the double, giving rise to the illu- coexistence of depersonalisation are considered evi- sion that the doppelgänger contains the real mind dences of its close relatedness with the positive forms of [16,17]. Among autoscopic phenomena, “polyopic” autoscopic experiences. [18,19] and “heterosexual” [20] cases have also been In inner heautoscopy, a type of experience frequently published. There is considerable variation in the treated by French Authors of the early 20th century [5], reported duration of heautoscopic experiences; they may the inner organs of one’s own body are visually halluci- last for seconds or hours and even cases of persistence nated in the extra corporal space. of the double as a steady companion are not exceptional In the French psychiatry literature of the late 19th and [21]. Depersonalization may be experienced as a feeling early 20th centuries, the typical autoscopic hallucination of strangeness towards one’s own body or as the impres- was also labelled as “mirror hallucination” [6-10] and sion that one’s own mind is contained by the doppel- consists of a visual perception of an exact mirror image ganger, as in the heautoscopic echopraxia. As in out of of oneself, occasionally only one’s face or trunk is per- body experience, patients describe the image of the self ceived. Patients with autoscopic hallucination do not as a highly realistic experience. In addition to mere localize themselves at the position of the illusory body. visual impressions, as in autoscopic hallucination, he- Commonly, autoscopic hallucination lasts only a few autoscopy involves somaesthetic and vestibular sensa- minutes or seconds, often followed by flash-like tions. A feeling of detachment or of extreme lightness of reoccurrences. one’s body is regularly present and often vertigo is In out of body experience, localization of the psycholo- reported. Patients describing heautoscopic experiences gical self to an extrapersonal space is completely disso- always reveal significant changes in the awareness of ciated from the perception of one’s body, implementing their body, generally do not report clear disembodiment the “dissociation of egocentric” from “body-centred-per- but they are often unable to localize their selves. He- spectives” [11,12]. In this form of autoscopic phenomena autoscopy is the encounter with one’sown “doppelgan- the subject sees himself and the world from a location ger” who appears as an alter ego; patients may experi- different from his physical body (parasomatic visuo-spa- ence themselves to be localized at the position of the tial perspective, disembodied location). People explaining illusory body (bilocation); it is difficult to decide for the their out of body experience never use the words patient whether he/she is disembodied or not and Anzellotti et al. Behavioral and Brain Functions 2011, 7:2 Page 3 of 11 http://www.behavioralandbrainfunctions.com/content/7/1/2 whether the self is localized within the physical body or recurred, and were accompanied by two suicide attempts in the autoscopic body. The ego, however, remains loca- by poisoning. After the last suicidal attempt, an EEG was lized within the natural boundaries of one’s own body. recorded in the intensive care unit and the observation of Partial epilepsy, particularly parietal and temporal lobe widespread slow wave activity prompted her referral to seizures, is considered the most frequent aetiology our clinic. Her cognitive performances were normal [22-24], but autoscopic phenomena may also occur in (Mini-Mental State Examination score: 30/30). During patients with psychiatric disorders and migraine [11,16]. psychological assessment, beyond a logorrheic and anxious Conrad [21] described an unusual case of autoscopic attitude, a history of peculiar events could be evicted even though the patient manifested initial severe resistance to phenomenon associated with a tumour of the hypophy- sis. Other authors reported similar episodes in various express the reason of her distress. She reported to experi- organic diseases [10,11,16,17] and some evidenced preci- ence daily symptoms consisting of seeing the image of her pitating factors and neural correlates [12]. Descriptions entire body as in a mirror or from an external point of of out of body experience are often reported in patients view. She saw herself not from an elevated visuo-spatial undergoing resuscitation procedures [25,26]. perspective, as in out of body experience, but in front of To date the central mechanism for autoscopic phe- her in normal size and colour without a definable facial nomena are not completely understood. The more con- expression. The patient could not clearly define her locali- vincing hypothesis is a failure to integrate multisensory zation in space. She reported unclear changes in the signals at the temporo-parietal junction, resulting in a awareness of her body describing herself as projected out breakdown of the spatial unity between self and the of her body with a feeling of dissociation of mind and body. While the contribution of visual and somatosen- body for a few seconds. When she saw her double from an sory cues of self-location is largely attested by clinical external view she maintained sidedness, i.e. right and left and experimental data [27-29], little is known about the sides were represented as in the real body, unlike images contribution of vestibular cues. reflected by a mirror: if she held an object with the right With the present report we aim to discuss and review hand her autoscopic image would hold the same object previous literature on the topic and we present a case of with the right hand. Her heautoscopic experience lasted a woman experiencing with he-autoscopy during epilep- for less than one minute. These experiences occurred tic seizures. We could record a video-EEG during one independently of daily activities, either when she was quiet of the ictal episodes. During the recording we took alone or working. When the double appeared, it kept act- notes of the patient impressions. We had the opportu- ing the patient’s activities. She explained that the experi- nity to describe a rare semiology of he-autoscopy, ence to see her double was terrifying and that the accompanied by suicidal behaviour and depression and attempted suicides were prompted by this distressing to link it with a specific brain activity pattern. experience. She reported to have access to the autoscopic body’s thoughts, words and actions and that the experience Case report of bilocation was petrifying and shocking. She explained The patient is a right-handed, 40 year old woman that these experiences had occurred since her early adoles- employed as a teacher in primary school. She was referred cence, had never subsided and were still present when to our neurological centre for sporadic generalized epilep- she was receiving carbamazepine and fenobarbital. These tic seizures and reactive depressive syndrome. Early medi- episodes were interpreted as he-autoscopic seizures. cal history reported depressive-apathetic episodes during In a previous brain MRI performed in another neuro- adolescence and early adulthood lasting for some months logical institution, an abnormal signal from the splenium and treated with benzodiazepines. The first generalized of corpus callosum was suspected. But an MRI-based seizure occurred at the age of 26 and was accompanied by tractography performed in our institution showed integ- attention and memory deficits for one week. Three further rity of white matter tracts. MRI scans were performed generalized seizures occurred in 9 years and interictal using a 3T Philips Achieva scanner. Diffusion tensor EEGs showed widespread slow wave activity. She reported images were acquired in the axial plane with diffusion several unsuccessful therapeutic attempts with carbamaze- sensitization gradients applied in six non-collinear direc- pine (1000 mg/day) and fenobarbital (150 mg/day). Per- tions with b-value of 1000s/mm .Allimagevolumes sonality disorder with several cyclic episodes of depression were acquired with six optimized directions using six and maniacal excitation were reported by the patient and repetitions to increase the number of measures. In addi- in the past ten years she had been treated with paroxetine tion NMR spectroscopy evidenced no alteration in the by outpatient psychiatric services. In the last six years right and left temporo-parietal junction (Figure 1). she did not experience further seizures and she sponta- Interictal brain SPECT with 99mTC-ECD showed cer- neously decided to withdraw carbamazepine. In the last ebral hypometabolism in both right and left parietal and year further episodes of depression and anxiety had occipital lobes (Figure 2). Anzellotti et al. Behavioral and Brain Functions 2011, 7:2 Page 4 of 11 http://www.behavioralandbrainfunctions.com/content/7/1/2 Figure 1 Proton MR spectra from left and right temporo-parietal junction. The major metabolite peaks correspond to cholines (Cho) at 3.22 ppm, creatines (Cr) at 3.02 ppm, N-acetylaspartate (NAA) at 2.02 ppm. Axial T2 weighted MR image showing the voxel position at temporo- parietal junctions used for proton MR spectroscopy. Note that the splenium of corpus callosum is normal. A previous interictal EEG showed sporadic posterior channels and then the left parieto-occipital channel. The discharge lasted about 30 seconds. The final critical bilateral slow wave activity 3-3.5 Hz (Figure 3F). During her repeated evaluations the patient was instructed to activitywasrepresented bya3.5-4Hz spikeand slow signal verbally or by hand gestures the possible occur- wave complexes overlapping to widespread slow activity. rence of her hallucinations. We recorded a video-EEG No ictal automatisms or motor signs were present. during one of her autoscopic experiences showing an During the video-EEG recording, before the onset of the epileptic activity (Figure 3) consisting of a brief (about 1 seizure, the patient reported an unclear change in the second) and slow (3.5 Hz) right centro-parietal activity awareness of her body, with feelings of derealisation. Then followed by abrupt discharges represented by fast activ- she signalled by hand gesture the abrupt appearance of ity of polyspikes and sharp-waves of 100-120 uV ampli- her entire body exactly in front of her, in upright position tude and in reversal phase at the P4 lead. After a few and in the same perspective of her previous experiences. seconds the discharge involved right fronto-temporal This sensation was coincident with the seizure. During an a posteriori interview she reported the impression of bilo- cation. In this episode the double was motionless and silent. This view of herself in normal size, with the same clothing and facial expression was concomitant to the right centro-parietal discharge characterized by fast activ- ity of polispikes and sharp-waves in reversal phase at the P4 lead. When the discharges involved right fronto-tem- poral channels we noted an impairment of consciousness: the patient, with fixed eyes, stopped answering our ques- tions, even though she did not report clouding of con- sciousness in the a posteriori interview. No ictal automatisms or motor signs were observed. During the widespread slow EEG activity the patient reported again an unclear perception of her body, but she signalled that the autoscopic image had disappeared. We aimed to study functional connectivity by means of functional magnetic resonance imaging (fMRI) [30], but the patient expressed her unavailability to further examinations. We prescribed Levetiracetam (3000 mg/day) which resolved her he-autoscopic seizures. Levetiracetam was Figure 2 Interictal brain SPECT with 99mTC-ECD showed a administered following the evidence of the seizures. cerebral hypometabolism in both right and left parietal and In the following two months the reported that the sei- occipital lobes. zures did not recur, but depression was evidenced in Anzellotti et al. Behavioral and Brain Functions 2011, 7:2 Page 5 of 11 http://www.behavioralandbrainfunctions.com/content/7/1/2 Figure 3 Autoscopic seizures. A: slow (3.5 Hz) right centro-parietal activity. Patient reported an unclear change in the awareness of her body, a feeling of strangeness. B: abrupt discharges constituted by polyspikes and sharp-waves of 100-120 uV in amplitude and in reversal phase at P4 lead. Patient reported a sudden appearance of her entire body exactly in front of her, in upright position. The double was at the same level of her real body, i.e. the real body was not felt elevated relatively to her double (unlike in out of body experience). She reported a bilocation state. The double was motionless and silent. C-D: after a few seconds the discharge involved right fronto-temporal channels and then left parieto- occipital channel. The discharge lasted about 30 seconds. We noted an impairment of consciousness. E: the final critic activity was constituted by right temporo-parietal spike and slow wave complexes (3.5-4 Hz). Patient reported again un unclear perception of her body, but the double had vanished. F: slow generalized interictal activity recorded by a previous EEG (3-3.5 Hz). repeated evaluations, with apathy, anaedonia and types of autoscopic phenomena presenting a classification anxious agitation. We decided to address the patient to scheme based on phenomenological criteria. Depersonali- psychiatric care due to severe depressive symptoms and sation symptoms are absent only in autoscopic hallucina- to the high risk of further suicidal attempts. tion and can be described as a reduced awareness of own body in negative heautoscopy, as a sense of empty body in Discussion and review of the literature inner heautoscopy, as a subjective meaningfulness and Autoscopic phenomena are illusory own body perceptions enhanced reality of the experience in out of body experi- that affect the entire body and lead to conspicuous ence and as a sense of familiarity with the external pre- abnormalities in embodiment as well as in body owner- sence in the feeling of a presence. Table 1 summarizes ship. Brugger [2] focused on the main features of the six some features of the six types of autoscopic phenomena. Anzellotti et al. Behavioral and Brain Functions 2011, 7:2 Page 6 of 11 http://www.behavioralandbrainfunctions.com/content/7/1/2 Table 1 Main features of different autoscopic phenomena AH h-A FOP OBE Nh-A Ih-A SEE ONE’S OWN ONLY PARTS OF MIRROR IMAGE, MAINTAINED OFTEN ILLUSION OF THE SEPARATION FROM ONE’S OWN FAILURE TO PERCEIVE ONE’S THE INNER ORGANS ARE BODY AS THE DOUBLE ARE SIDEDNESS, DOUBLE IS PRESENCE AT THE FRINGE BODY AS THE CORE OF THE OWN BODY EITHER IN A VISUALLY HALLUCINATED SEEN IN EXACT COLOURLESS, ECHOPRAXIA OF VISION, h-A WITHOUT EXPERIENCE; FROM ELEVATED MIRROR OR WHEN LOOKED IN THE EXTRAPERSONAL MIRROR IMAGE BILOCATION OPTICAL IMAGE PERSPECTIVE AT DIRECTLY SPACE DURATION SECONDS/MINUTES SECONDS/HOURS SECONDS SECONDS/MINUTES SECONDS/MINUTES SECONDS/MINUTES DISEMBODIMENT - +/- +/- ++ +/- +/- MAINTAINED - + NA + NA NA SIDEDNESS PSYCHOLOGICAL -++ + ++ - - PHENOMENOLOGY INVOLVED PO (RIGHT?) TPJ (LEFT?) ? TPJ (RIGHT?) SPLENIUM (ONE ? CEREBRAL DESCRIPTION) [69] CORTEX PREDOMINANT VISUAL VISUAL AND SOMAESTHETIC SOMAESTHETIC ONLY VISUAL AND SOMAESTHETIC VISUAL AND SOMAESTHETIC VISUAL AND INVOLVED SOMAESTHETIC MODALITIES ACCOMPANYING MICROPSIA D D D, SENSATION OF FLOATING OR D, ASCHEMATIA D SYMPTOMS HEMIANOPIA FLYING, AUDITORY ASOMATOAGNOSIA HALLUCINATIONS OR ILLUSIONS OF VIBRATION VESTIBULAR -+ - ++ - - DISTURBANCE AH = autoscopic hallucination, h-A = he-autoscopy, FOP = feeling of a presence, OBE = out-of-body experience, Nh-A = negative heautoscopy, Ih-A = inner heautoscopy, PO = parieto-occipital cortex, TPJ = temporo- parietal junction, D = depersonalitation, - = absent, + = present, NA = not applicable; ? = not known; maintained sidedness indicate no shift from left to right in the autoscopic image. Anzellotti et al. Behavioral and Brain Functions 2011, 7:2 Page 7 of 11 http://www.behavioralandbrainfunctions.com/content/7/1/2 Phenomenological aspects of he-autoscopy where the self is” could justify the association with sui- We could report a case of he-autoscopy in which the cide attempts, as in our patient. Our case can be consid- affected patients have a vague feeling of detachment ered as an example of he-autoscopy in which, typically, from the body accompanied by the sensation of a “dou- the autoscopic body acts exactly like the real body ble consciousness”. He-autoscopy involves visual and (maintaining sidedness) and interacts with it: the patient somaesthetic modalities and, similar to out of body experienced to have access to the autoscopic body’s experience, localizes the self in an illusory body at an thoughts and sometimes could verbally communicate extra personal space although the point of localization with it. Typically the patient had the impression of of the ego remains within the natural boundaries of being at two locations at the same time (bilocation) and one’s own body. There are some variables that can help positive or neutral emotions never accompanied her to differentiate among autoscopic phenomena: the pre- autoscopic experience. She also experienced the he- sence of vestibular hallucinations or body schema dis- autoscopy in the typical upright position, while the view turbances, the position of the autoscopic and the of the self always in front of her (as in out of body physical body, the kind of view, the sense of bilocation experience) in the same visuo-spatial perspective, is less and finally the sharing of thoughts and words or actions commonly reported [2]. of the autoscopic body. Among the described variables Vestibular sensations were not reported by the patient: five phenomenological characteristics of the autoscopic in the Blanke and Mohr analysis [31], vestibular halluci- body allow to distinguish he-autoscopy from the other nations and body schema disturbances are comparatively abnormal experiences: frequent in out of body experience and he-autoscopy (about 60% of patients). Our case report suggests that 1) the “view": in he-autoscopy subjects see the auto- vestibular symptoms are not specific of he-autoscopy scopic body in front-, side- or back-views. and that their absence does not exclude he-autoscopy or 2) the “actions": the autoscopic body can act only in out of body experience. he-autoscopy (activities of the autoscopic body appear to be specific to he-autoscopy and almost He-autoscopy, epilepsy, depression and suicide absent in out of body experience). Psychological phenomenology differs among different 3) the experience of “sharing of thoughts and words” autoscopic experiences: he-autoscopy and out of body which are often associated with he-autoscopy and experience are experienced as profoundly significant are less frequent in out of body experience. events and in he-autoscopy the quality of emotional 4) the “perspective": in he-autoscopy patients fre- impact considerably varies: one’s doppelgänger can quently experienced to see the double from several sometimes be experienced as highly supportive [14], but different visuo-spatial perspectives that, in contrast, in general is offensive or overtly aggressive. A classical were unequivocally localized and experienced as uni- case was reported by Wigan [32], who described the tary by all out of body experience patients. first non-fictional account of a man who could induce a 5) the “bilocation": only he-autoscopy subjects visual hallucination of himself. Gradually the double reported to be split into two parts of selves. became more and more autonomous appearing without being evocated. Utterly distraught, the man shot himself. In addition positive and neutral emotional experiences Significantly our patient attempted suicide twice, but are especially rare in he-autoscopy [12,17]. specific risks linking he-autoscopy and suicide are not Thus he-autoscopy significantly differs in these com- statistically supported. The association between suicide plex variables from other autoscopic phenomena, sug- and he-autoscopy is a common theme in dramatic gesting that different central mechanisms are romances and the appearance of the doppelgänger, a underlying. The phenomenological variability of the ghostly double of a living person, often announces the autoscopic body (with respect to views and actions) and hero’s death that is usually a death by suicide. In Breton the increased frequency of shared thoughts, voices, and myths the doppelgänger is a version of the Ankou, a actions between autoscopic and physical body might be personification of death; in a tradition of the Hebrew due to different involvements of kinesthetic/propriocep- Talmud, to meet himself means to meet God. There are tive information processing in he-autoscopy. The shar- also several literary examples: in Dostoyevsky’snovel ing of thoughts, voices and actions might make difficult “The Double” when the protagonist experienced his first for the patient to decide where the physical agent is autoscopic experience, he began to think to kill himself located and leads to the experience of two observing by drowning. In Edgar Allan Poe’sshort story “William selves. Therefore he-autoscopy is not only the reduplica- Wilson”, probably the most dramatic image, the main tion of one’s physical body, but also the reduplication of character, of questionable morality, is dogged by his one’s self. The terrifying experience of “not knowing doppelgänger most tenaciously when his moral fails. Anzellotti et al. Behavioral and Brain Functions 2011, 7:2 Page 8 of 11 http://www.behavioralandbrainfunctions.com/content/7/1/2 But also Oscar Wilde ("The portrait of Dorian Gray”), common triad than previously recognized [41], we know Franz Werfel ("Spiegelmensch”) and Friedrich von Ger- little about the mutual correlation, but the description stäcker ("Der doppelgänger”) had their heroes commit of the survivors, as in our case, would rather favour a suicide to escape the horror of being haunted by their causal relation between the double experience and the second selves. Some of these authors have not only had impulse to kill oneself. Suicide attempts are not infre- epilepsy but have also known he-autoscopy from perso- quent in depressed subjects and depression is commonly associated with epilepsy [42]. In severely depressed nal experience [33,34]. There are several notable reports patients “heautoscopy of the Cotard type” (seeing a dead about documented autoscopic experiences: Percy Bysshe doppelgänger during the hallucinatory attendance of Shelley, an English poet, drowned in the Bay of La Spe- zia near Lerici and Abraham Lincoln, known to be a one’s own funeral) is not a rarity. The suicidal risk is superstitious man, recognised a special meaning to an further increased by psychiatry comorbidity and drug autoscopic experience which he seems to have had in use [43-45]. The epileptic focus in the right hemisphere the evening of his election [35]. A rare and dubious and the severe depressive symptoms presented by our example of a doppelgänger which was both benign and patient, support recent hypothesized links between reassuring is described by Johann Wolfgang von Goethe depression and inter-hemispheric imbalance. Depression in his autobiography “Truth and Fiction” ("Dichtung is believed to be associated with a hyperactive right- und Wahrheit”). More recently Otto Rank, a Freudian hemisphere and a relatively hypoactive left-hemisphere Austrian psychoanalyst, in his book “The Double” [36], [46]. Yet, the underlying mechanisms which can explain suggested a possible explanation for the frequent recur- the involvement of the right side remain elusive. There rence of the image of the double in the artistic produc- is evidence that the right hemisphere is selectively tion and folklore. He believes that the double is an involved in processing negative emotions, pessimistic artist’sstrategytoexorcisetheterribleideaofdeath. thoughts and unconstructive thinking styles. Addition- “Heautoscopic suicide” also includes cases of attempts ally, it mediates vigilance and arousal and had also been to kill one’s double or, in the most obviously transitivis- linked with self-reflection, accounting for the tendency tic manner, observing one’s doppelgänger committing of depressed individuals to withdraw from their external suicide [37]. environments and focus attention inward [46]. The Keppler observed that “Often the conscious mind tries involved hemisphere is also important to explain possi- to deny its unconscious through the mechanism of “pro- ble language deficits, but ictal speech disorders were not present in our patient in agreement with the involve- jection”, attributing its own unconscious content (a ment of non dominant hemisphere as showed by EEG murderous impulse, for example) to a real person in the world outside; at times it even creates an external hallu- recording. Word finding difficulties are often reported cination in the image of this content” [14]. by epileptic patients and peri-operative and post-surgical Brugger examined the “hostile interactions between electro-cortical stimulation evidences have highlighted a body and self” [38] indicating four major variants of role for the anterior part of the dominant temporal lobe “heautoscopic suicide” as an actively imposed or pas- in oral word production [47]. In previous reviews sively experienced form of self-injurious behaviour: self- [23,48,49], autoscopic experiences are mentioned as a injury/suicide in an attempt to escape the double, fenes- rare but classic symptom in parietal lobe epilepsy. How- tration in order to get rid of the double, self-injury/sui- ever it has been reported in association with temporal cide claimed to be inflicted by the double, self-injury/ lobe epilepsy [50]. There are few reported cases of post- suicide in an attempt to kill the double and the observa- ictal autoscopic phenomena [51]. Autoscopic experi- tion of the doppelgänger’s self-injury/suicide. He dis- ences have been described not only in focal seizures, but cussed neuropsychiatric and psychodynamic approaches in a broad range of neurological disorders such as to disembodiment concluding that, although there is no migraine, neoplasia, infarction and infection [11,12,52] direct clinical or neuroanatomic evidence for a primary and also in psychiatric disorders such as schizophrenia, callosal pathology, it is not entirely implausible to depression, anxiety and dissociative disorders [16,17]. In assume an inter-hemispheric disconnection at the basis some cases it is difficult to distinguish the autoscopic of heautoscopic aggression. Of note, in our patient an experiences from a dreamy-state in which the self is early MRI study reported the presence of enlarged sple- seen in more complex, dream-like or memory-like nium callosi. Our MRI study however, including tracto- scenes without actually seeing the image of one’s face or graphy examination, did not evidence any abnormality. body [53]. Our measurements were, in our patient, inside the Our patient experienced typical he-autoscopy and the range reported for female subjects, who have commonly autoscopic episodes were the only ictal symptom. The larger splenial bodies than males [39,40]. Even though ictal EEG performed during the autoscopic experience, heautoscopy, epilepsy and suicide may be a more showed a right parietal origin in non-dominant Anzellotti et al. Behavioral and Brain Functions 2011, 7:2 Page 9 of 11 http://www.behavioralandbrainfunctions.com/content/7/1/2 hemisphere, with rapid bilateral posterior involvement. originates in the right temporo-parietal junction. It These data were confirmed by SPECT findings that might be argued that the only evidence of the he-auto- revealed a hypometabolism in parietal and occipital scopy corresponding to EEG discharge is obtained from areas but no brain abnormality was detected by means the patient, subjectively signalling the presence of auto- of MRI. In contrast with neurophysiological data, patient scopic image of the self during the seizure and by her reported neither macroasomatognosia, a symptom that detailed description “aposteriori”. Thus exact timing of can result from an involvement of the parietal lobe the different feelings might appear uncertain: nonethe- less EEG discharge was observed and he-autoscopy was [23,48,49], nor palinopsia (consistent with an involve- reported. We believe it would be difficult to obtain bet- ment of the visual associative area) nor luminous flashes in the visual fields (consistent with an involvement of terevidencethen the one weare reporting, as averbal the primary visual area) nor motor symptoms. description of symptoms during the seizure would alter the EEG due to glosso-kinetic artefacts. Possible cerebral mechanisms: multisensory processing Several studies [11,12,31,54-56] proposed that auto- and cortical hyperconnectivity scopic phenomena are a double failure to integrate pro- Defining the mechanism of autoscopic phenomena is a prioceptive, tactile and visual information with respect challenge. Menninger-Lerchental [13] first speculated on to one’s own body (disintegration in personal space), different anatomical substrates suggesting that auto- along with an additional vestibular dysfunction leading scopic hallucination originate at the junction of the par- to disintegration between personal (vestibular) space ietal and occipital lobe, he-autoscopy from the angular and extrapersonal (visual) space. Disintegration of perso- and supramarginal gyrus and out of body experience nal space is present in he-autoscopy and out of body from the superior parietal lobe. Blanke and Mohr [31] experience but differences are mainly due to the level summarized anatomical findings of their analysis eviden- and type of vestibular dysfunction. In more detail: out of cing that he-autoscopy seems to primarily involve the bodyexperiences areassociated withspecificvestibular, left temporo-parietal junction and out of body experi- graviceptive and otholithic sensations that are character- ence the right. More recently Blanke and Arzy [54] have ized by a variety of sensations including feeling of eleva- unexpectedly reproduced an effect strongly reminiscent tion and floating, he-autoscopy is associated with a of the doppelgänger phenomenon via electromagnetic moderate and more variable vestibular disturbance while stimulation of the left temporo-parietal junction. Their no vestibular disturbance is evidenced in autoscopic hal- analyses showed that out of body experiences and he- lucination, feeling of a presence, negative heautoscopy and inner heautoscopy. Moreover, the high frequency of autoscopy are primarily associated with electrical stimu- lation, probably inhibition, of the temporo-parietal junc- visual hallucinations and hemianopia in patients with tion and autoscopic hallucination with electrical autoscopic hallucination suggests that defective visual stimulation in parieto-occipital cortex. Moreover these processing of bodily information is the main causing experimental data suggest that out of body experiences factor for disintegration in personal space in autoscopic are associated with damage to the right temporo-parietal hallucination. junction and he-autoscopy to the left temporo-parietal Therefore according to Blanke we speculated that the junction [31,54], whereas autoscopic hallucination is different forms of autoscopic phenomena are related to associated with damage to the right parieto-occipital different degrees of vestibular dysfunction. We hypothe- cortex [55]. Corporal awareness and experience of the size that autoscopic seizures occur because of ictal dis- body ownership are more likely dependent on the right turbances of the normal integration process of body hemisphere [28]. However with regard to hemispheric representation within parieto-occipital networks in asymmetries no firm conclusion can be drawn. Our case which the right inferior parietal region plays a signifi- shows an epileptic focus in the right temporo-parietal cant role. The integration of proprioceptive, tactile and junction: the patient report suggests that the hallucina- visual information with respect to one’s body with ves- tion perception was an he-autoscopy, as it presents tibular information is important for the constant updat- most of the peculiar characteristics reported by litera- ing of the movement and position of single body parts ture in he-autoscopy. Therefore our report might sug- and entire body. In order to create a central representa- gest that he-autoscopy can possibly arise also from tion of one’s own body, the brain must integrate and epileptic foci of the right hemisphere. The epileptic dis- weigh the evidence from different sensory sources. charge (Figure 3A-E) shows a definite localization and Electrophysiological [57] and neuroimaging [27,29] studies showed that the vestibular cortex is a multisen- the involvement of the left hemisphere occurs only sory cortex receiving not only vestibular information, when the patient subjectively reports that the hallucina- but also visual, proprioceptive and tactile cues from tory image has disappeared. In our case report, there- fore, the EEG shows an epileptic discharge that the whole body. We believe that these multisensory Anzellotti et al. Behavioral and Brain Functions 2011, 7:2 Page 10 of 11 http://www.behavioralandbrainfunctions.com/content/7/1/2 interactions are fundamental for integrating signals understanding of autoscopic phenomena. Because of about body movements and body position in space with the severe psychiatric symptoms presented in our respect to other body segments and to the ground. The patient, we could not perform the combined EEG/fMRI implication of temporo-parietal junction in embodiment analysis that recently allowed to identify the cortical and in self processing is suggested by neuroimaging stu- connection network sustaining persistent symptoms in dies in healthy subjects [29,58-60]. These studies exam- epilepsy [30], yet we believe that this approach might be ideally suited to understand the mechanism of auto- ining visuo-spatial pathways showed the involvement of scopic phenomena. many other cortical areas such as prefrontal, parietal and temporal cortex. The “cortical midline structures” have been recently identified as intimately related to the Consent experience of the self [61]. Therefore the temporo-parie- Written informed consent was obtained from the patient tal junction might be a crucial structure for conscious for publication of this case report and accompanying experience in a widely distributed network of cortical images. A copy of the written consent is available for areas. review by the Editor-in-Chief of this journal. In conclusion it is not known which of the many senses are primarily involved in the generation of he- Author details autoscopy. Data in literature shows that visual theories Department of Neuroscience and Imaging, Aging Research Centre, Ce.S.I., cannot entirely explain autoscopic phenomena and “G. d’Annunzio” University Foundation G. d’Annunzio University, Chieti, Italy. points to the importance of non visual, body-related, University Ospedale San Raffaele, Milan, Italy. mechanisms such as proprioceptive and/or kinaesthetic Authors’ contributions processing. A further aspect in favor of tactile and pro- FA performed clinical evaluations and prepared the manuscript. MO prioceptive mechanisms was given by the different body provided the case and designed the overall paper. VO, LB and AT revised the manuscript for important intellectual content and provided positions reported by patients, upright for he-autoscopy bibliographical research. VM, LR, RF were involved in analysing EEG, MRI and and supine for out of body experience, suggesting differ- SPECT data and in providing technological support. All authors read and ential influences of proprioceptive and tactile processing approved the final manuscript. in different types of autoscopic experiences. Blanke and Competing interests Mohr [31] summarized anatomical findings of their ana- Financial competing interests: The authors declare that they have no lysis evidencing that he-autoscopy seem to primarily competing financial interests. Non-financial competing interests: The authors declare that they have no involve the left temporo-parietal junction and out of competing non-financial interests. body experience the right. The evidence of the temporal lobe involvement in body-distortion processing and Received: 25 June 2010 Accepted: 10 January 2011 Published: 10 January 2011 impairments in own-body transformations was high- lighted in a recent report [62]. Yet self-representation References has been shown to depend also on the prefrontal cortex 1. 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Autoscopic phenomena: case report and review of literature

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Biomedicine; Neurosciences; Neurology; Behavioral Therapy; Psychiatry
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Abstract

Background: Autoscopic phenomena are psychic illusory visual experiences consisting of the perception of the image of one’s own body or face within space, either from an internal point of view, as in a mirror or from an external point of view. Descriptions based on phenomenological criteria distinguish six types of autoscopic experiences: autoscopic hallucination, he-autoscopy or heautoscopic proper, feeling of a presence, out of body experience, negative and inner forms of autoscopy. Methods and results: We report a case of a patient with he-autoscopic seizures. EEG recordings during the autoscopic experience showed a right parietal epileptic focus. This finding confirms the involvement of the temporo-parietal junction in the abnormal body perception during autoscopic phenomena. We discuss and review previous literature on the topic, as different localization of cortical areas are reported suggesting that out of body experience is generated in the right hemisphere while he-autoscopy involves left hemisphere structures. Background Narcissus and the description made by Plautus in his The term autoscopy comes from the Greek words Amphitryon: here the double (represented by the god “autos“ (self) and “skopeo“ (looking at). Autoscopic phe- Mercury) is an entity completely distinct from the char- nomena are psychic illusory visual experiences defined acter Sosia who shares with his double only the physical by the perception of the images of one’s own body or aspect, but not the psychological and intellective atti- one’s face within space, either from an internal point of tudes. At difference with Narcissus, Sosia is frightened view, as in a mirror or from an external point of view. by the double: he believes that the double could have Autoscopic experiences were first described by the stolen his identity or, worse, that the appearance of the Greek philosopher Aristotele, but it was subsequently double could have been caused by the death. As it admirably described in its ambiguous presentation by appears from the descriptions the theme of the death is Ovid in the third book of its Metamorphoses where the often strictly linked with the theme of the double. Auto- author narrates the myth of Narcissus, a beautiful boy scopic phenomena are considered at the basis of many who falls in love with his image reflected in a water self-portrait paintings [1]: Durer, Rembrandt, Velazquez, source. In the first place he mistakes his own image Schiele seem to have painted during autoscopic with another person, but when he suddenly realizes that experiences. he is looking at the image of himself, desperate for the Dostoevsky made this phenomenon more popular in hopelessness of his love he is forced to commit suicide. the nineteenth century in his novel “The Double”, where the doppelganger (i.e. haunting double of the self) of The variable presentations of the autoscopic phenom- ena, which will be extensively addressed below in their German legends was the background. scientific meaning and correlates, clearly appear in the The German word “Doppelganger” was brought into comparison between the aforementioned myth of the language, and simultaneously, into the literary tradi- tion by the novelist Jean Paul Richter, who in 1796 defined the word in a one sentence footnote: “So heissen * Correspondence: f.anzellotti@unich.it Leute, die sich selbst sehen” (So people who see them- Department of Neuroscience and Imaging, Aging Research Centre, Ce.S.I., “G. d’Annunzio” University Foundation G. d’Annunzio University, Chieti, Italy selves are called). Full list of author information is available at the end of the article © 2011 Anzellotti et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Anzellotti et al. Behavioral and Brain Functions 2011, 7:2 Page 2 of 11 http://www.behavioralandbrainfunctions.com/content/7/1/2 The first medical report dates back to Wigan’s “double” or “doppelgänger” in their descriptions. An out description in 1844. Subsequently, the term autoscopy of body experience is defined by the presence of three was used to describe various phenomena of various phenomenological characteristics: disembodiment (loca- aetiologies and mechanisms. tion of the self outside one’s body), the impression of see- Brugger was one of the first authors to study auto- ing the world from a distant and elevated visuo-spatial scopic phenomena [2]. He proposed a classification perspective (extracorporeal egocentric perspective) and the impression of seeing one’s own body (or autoscopy) scheme based on phenomenological criteria. Along with from this elevated perspective [11]. examples of illustrative cases, he outlined the main fea- The theme of the separation between self and body is tures of six types of autoscopic phenomena: the feeling of a presence, the negative heautoscopy, the inner heau- frequently found in philosophy. Hume claimed that toscopy, the autoscopic hallucination, the out of body “when he introspected, he was unable to catch his self experience and the he-autoscopy also defined as heauto- without a perception and was unable to observe ‘any- scopic proper. thing but the perception’ itself”. He concluded that the The feeling of a presence, first described by Jasper in self (or the observing introspective subject) is simply a 1913, is the distinct feeling of the physical presence of collection of different perceptions. The interest of occi- another person or being in the near extracorporeal dental philosophy for the body was also exemplified in space. No visual impressions are involved but frequently Descartes’ effort to separate mind and body. thepresenceisfelttobe “at thefringeof vision”.Like The he-autoscopy is rare but probably more frequent he-autoscopy, it is usually accompanied by alterations in than pure autoscopic hallucinations. The term “Heautos- the experience of one’s own body. It can be reported by kopie” was proposed by Menninger-Lerchenthal [13] to healthy persons in conditions of sensory deprivation or denote the experience of seeing one’s self and to desig- social isolation [3]. The feeling of a presence is often nate the classical doppelgänger experience described in confined to one hemispace particularly when associated literary accounts [14,15]. The double usually appears with a seizure disorder [4]. colorless ("foggy”, “pale”,or “as through a veil”), can Negative heautoscopy refers to the failure to perceive behave autonomously, may or may not mirror the per- one’sown bodyeitherinamirrororwhenlookedat son’s appearance and maintains sidedness. The expres- directly. In the latter form the confinement of the (nega- sion heautoscopic “echopraxia” means imitation of tive) hallucination to one’s own body and the frequent bodily movements by the double, giving rise to the illu- coexistence of depersonalisation are considered evi- sion that the doppelgänger contains the real mind dences of its close relatedness with the positive forms of [16,17]. Among autoscopic phenomena, “polyopic” autoscopic experiences. [18,19] and “heterosexual” [20] cases have also been In inner heautoscopy, a type of experience frequently published. There is considerable variation in the treated by French Authors of the early 20th century [5], reported duration of heautoscopic experiences; they may the inner organs of one’s own body are visually halluci- last for seconds or hours and even cases of persistence nated in the extra corporal space. of the double as a steady companion are not exceptional In the French psychiatry literature of the late 19th and [21]. Depersonalization may be experienced as a feeling early 20th centuries, the typical autoscopic hallucination of strangeness towards one’s own body or as the impres- was also labelled as “mirror hallucination” [6-10] and sion that one’s own mind is contained by the doppel- consists of a visual perception of an exact mirror image ganger, as in the heautoscopic echopraxia. As in out of of oneself, occasionally only one’s face or trunk is per- body experience, patients describe the image of the self ceived. Patients with autoscopic hallucination do not as a highly realistic experience. In addition to mere localize themselves at the position of the illusory body. visual impressions, as in autoscopic hallucination, he- Commonly, autoscopic hallucination lasts only a few autoscopy involves somaesthetic and vestibular sensa- minutes or seconds, often followed by flash-like tions. A feeling of detachment or of extreme lightness of reoccurrences. one’s body is regularly present and often vertigo is In out of body experience, localization of the psycholo- reported. Patients describing heautoscopic experiences gical self to an extrapersonal space is completely disso- always reveal significant changes in the awareness of ciated from the perception of one’s body, implementing their body, generally do not report clear disembodiment the “dissociation of egocentric” from “body-centred-per- but they are often unable to localize their selves. He- spectives” [11,12]. In this form of autoscopic phenomena autoscopy is the encounter with one’sown “doppelgan- the subject sees himself and the world from a location ger” who appears as an alter ego; patients may experi- different from his physical body (parasomatic visuo-spa- ence themselves to be localized at the position of the tial perspective, disembodied location). People explaining illusory body (bilocation); it is difficult to decide for the their out of body experience never use the words patient whether he/she is disembodied or not and Anzellotti et al. Behavioral and Brain Functions 2011, 7:2 Page 3 of 11 http://www.behavioralandbrainfunctions.com/content/7/1/2 whether the self is localized within the physical body or recurred, and were accompanied by two suicide attempts in the autoscopic body. The ego, however, remains loca- by poisoning. After the last suicidal attempt, an EEG was lized within the natural boundaries of one’s own body. recorded in the intensive care unit and the observation of Partial epilepsy, particularly parietal and temporal lobe widespread slow wave activity prompted her referral to seizures, is considered the most frequent aetiology our clinic. Her cognitive performances were normal [22-24], but autoscopic phenomena may also occur in (Mini-Mental State Examination score: 30/30). During patients with psychiatric disorders and migraine [11,16]. psychological assessment, beyond a logorrheic and anxious Conrad [21] described an unusual case of autoscopic attitude, a history of peculiar events could be evicted even though the patient manifested initial severe resistance to phenomenon associated with a tumour of the hypophy- sis. Other authors reported similar episodes in various express the reason of her distress. She reported to experi- organic diseases [10,11,16,17] and some evidenced preci- ence daily symptoms consisting of seeing the image of her pitating factors and neural correlates [12]. Descriptions entire body as in a mirror or from an external point of of out of body experience are often reported in patients view. She saw herself not from an elevated visuo-spatial undergoing resuscitation procedures [25,26]. perspective, as in out of body experience, but in front of To date the central mechanism for autoscopic phe- her in normal size and colour without a definable facial nomena are not completely understood. The more con- expression. The patient could not clearly define her locali- vincing hypothesis is a failure to integrate multisensory zation in space. She reported unclear changes in the signals at the temporo-parietal junction, resulting in a awareness of her body describing herself as projected out breakdown of the spatial unity between self and the of her body with a feeling of dissociation of mind and body. While the contribution of visual and somatosen- body for a few seconds. When she saw her double from an sory cues of self-location is largely attested by clinical external view she maintained sidedness, i.e. right and left and experimental data [27-29], little is known about the sides were represented as in the real body, unlike images contribution of vestibular cues. reflected by a mirror: if she held an object with the right With the present report we aim to discuss and review hand her autoscopic image would hold the same object previous literature on the topic and we present a case of with the right hand. Her heautoscopic experience lasted a woman experiencing with he-autoscopy during epilep- for less than one minute. These experiences occurred tic seizures. We could record a video-EEG during one independently of daily activities, either when she was quiet of the ictal episodes. During the recording we took alone or working. When the double appeared, it kept act- notes of the patient impressions. We had the opportu- ing the patient’s activities. She explained that the experi- nity to describe a rare semiology of he-autoscopy, ence to see her double was terrifying and that the accompanied by suicidal behaviour and depression and attempted suicides were prompted by this distressing to link it with a specific brain activity pattern. experience. She reported to have access to the autoscopic body’s thoughts, words and actions and that the experience Case report of bilocation was petrifying and shocking. She explained The patient is a right-handed, 40 year old woman that these experiences had occurred since her early adoles- employed as a teacher in primary school. She was referred cence, had never subsided and were still present when to our neurological centre for sporadic generalized epilep- she was receiving carbamazepine and fenobarbital. These tic seizures and reactive depressive syndrome. Early medi- episodes were interpreted as he-autoscopic seizures. cal history reported depressive-apathetic episodes during In a previous brain MRI performed in another neuro- adolescence and early adulthood lasting for some months logical institution, an abnormal signal from the splenium and treated with benzodiazepines. The first generalized of corpus callosum was suspected. But an MRI-based seizure occurred at the age of 26 and was accompanied by tractography performed in our institution showed integ- attention and memory deficits for one week. Three further rity of white matter tracts. MRI scans were performed generalized seizures occurred in 9 years and interictal using a 3T Philips Achieva scanner. Diffusion tensor EEGs showed widespread slow wave activity. She reported images were acquired in the axial plane with diffusion several unsuccessful therapeutic attempts with carbamaze- sensitization gradients applied in six non-collinear direc- pine (1000 mg/day) and fenobarbital (150 mg/day). Per- tions with b-value of 1000s/mm .Allimagevolumes sonality disorder with several cyclic episodes of depression were acquired with six optimized directions using six and maniacal excitation were reported by the patient and repetitions to increase the number of measures. In addi- in the past ten years she had been treated with paroxetine tion NMR spectroscopy evidenced no alteration in the by outpatient psychiatric services. In the last six years right and left temporo-parietal junction (Figure 1). she did not experience further seizures and she sponta- Interictal brain SPECT with 99mTC-ECD showed cer- neously decided to withdraw carbamazepine. In the last ebral hypometabolism in both right and left parietal and year further episodes of depression and anxiety had occipital lobes (Figure 2). Anzellotti et al. Behavioral and Brain Functions 2011, 7:2 Page 4 of 11 http://www.behavioralandbrainfunctions.com/content/7/1/2 Figure 1 Proton MR spectra from left and right temporo-parietal junction. The major metabolite peaks correspond to cholines (Cho) at 3.22 ppm, creatines (Cr) at 3.02 ppm, N-acetylaspartate (NAA) at 2.02 ppm. Axial T2 weighted MR image showing the voxel position at temporo- parietal junctions used for proton MR spectroscopy. Note that the splenium of corpus callosum is normal. A previous interictal EEG showed sporadic posterior channels and then the left parieto-occipital channel. The discharge lasted about 30 seconds. The final critical bilateral slow wave activity 3-3.5 Hz (Figure 3F). During her repeated evaluations the patient was instructed to activitywasrepresented bya3.5-4Hz spikeand slow signal verbally or by hand gestures the possible occur- wave complexes overlapping to widespread slow activity. rence of her hallucinations. We recorded a video-EEG No ictal automatisms or motor signs were present. during one of her autoscopic experiences showing an During the video-EEG recording, before the onset of the epileptic activity (Figure 3) consisting of a brief (about 1 seizure, the patient reported an unclear change in the second) and slow (3.5 Hz) right centro-parietal activity awareness of her body, with feelings of derealisation. Then followed by abrupt discharges represented by fast activ- she signalled by hand gesture the abrupt appearance of ity of polyspikes and sharp-waves of 100-120 uV ampli- her entire body exactly in front of her, in upright position tude and in reversal phase at the P4 lead. After a few and in the same perspective of her previous experiences. seconds the discharge involved right fronto-temporal This sensation was coincident with the seizure. During an a posteriori interview she reported the impression of bilo- cation. In this episode the double was motionless and silent. This view of herself in normal size, with the same clothing and facial expression was concomitant to the right centro-parietal discharge characterized by fast activ- ity of polispikes and sharp-waves in reversal phase at the P4 lead. When the discharges involved right fronto-tem- poral channels we noted an impairment of consciousness: the patient, with fixed eyes, stopped answering our ques- tions, even though she did not report clouding of con- sciousness in the a posteriori interview. No ictal automatisms or motor signs were observed. During the widespread slow EEG activity the patient reported again an unclear perception of her body, but she signalled that the autoscopic image had disappeared. We aimed to study functional connectivity by means of functional magnetic resonance imaging (fMRI) [30], but the patient expressed her unavailability to further examinations. We prescribed Levetiracetam (3000 mg/day) which resolved her he-autoscopic seizures. Levetiracetam was Figure 2 Interictal brain SPECT with 99mTC-ECD showed a administered following the evidence of the seizures. cerebral hypometabolism in both right and left parietal and In the following two months the reported that the sei- occipital lobes. zures did not recur, but depression was evidenced in Anzellotti et al. Behavioral and Brain Functions 2011, 7:2 Page 5 of 11 http://www.behavioralandbrainfunctions.com/content/7/1/2 Figure 3 Autoscopic seizures. A: slow (3.5 Hz) right centro-parietal activity. Patient reported an unclear change in the awareness of her body, a feeling of strangeness. B: abrupt discharges constituted by polyspikes and sharp-waves of 100-120 uV in amplitude and in reversal phase at P4 lead. Patient reported a sudden appearance of her entire body exactly in front of her, in upright position. The double was at the same level of her real body, i.e. the real body was not felt elevated relatively to her double (unlike in out of body experience). She reported a bilocation state. The double was motionless and silent. C-D: after a few seconds the discharge involved right fronto-temporal channels and then left parieto- occipital channel. The discharge lasted about 30 seconds. We noted an impairment of consciousness. E: the final critic activity was constituted by right temporo-parietal spike and slow wave complexes (3.5-4 Hz). Patient reported again un unclear perception of her body, but the double had vanished. F: slow generalized interictal activity recorded by a previous EEG (3-3.5 Hz). repeated evaluations, with apathy, anaedonia and types of autoscopic phenomena presenting a classification anxious agitation. We decided to address the patient to scheme based on phenomenological criteria. Depersonali- psychiatric care due to severe depressive symptoms and sation symptoms are absent only in autoscopic hallucina- to the high risk of further suicidal attempts. tion and can be described as a reduced awareness of own body in negative heautoscopy, as a sense of empty body in Discussion and review of the literature inner heautoscopy, as a subjective meaningfulness and Autoscopic phenomena are illusory own body perceptions enhanced reality of the experience in out of body experi- that affect the entire body and lead to conspicuous ence and as a sense of familiarity with the external pre- abnormalities in embodiment as well as in body owner- sence in the feeling of a presence. Table 1 summarizes ship. Brugger [2] focused on the main features of the six some features of the six types of autoscopic phenomena. Anzellotti et al. Behavioral and Brain Functions 2011, 7:2 Page 6 of 11 http://www.behavioralandbrainfunctions.com/content/7/1/2 Table 1 Main features of different autoscopic phenomena AH h-A FOP OBE Nh-A Ih-A SEE ONE’S OWN ONLY PARTS OF MIRROR IMAGE, MAINTAINED OFTEN ILLUSION OF THE SEPARATION FROM ONE’S OWN FAILURE TO PERCEIVE ONE’S THE INNER ORGANS ARE BODY AS THE DOUBLE ARE SIDEDNESS, DOUBLE IS PRESENCE AT THE FRINGE BODY AS THE CORE OF THE OWN BODY EITHER IN A VISUALLY HALLUCINATED SEEN IN EXACT COLOURLESS, ECHOPRAXIA OF VISION, h-A WITHOUT EXPERIENCE; FROM ELEVATED MIRROR OR WHEN LOOKED IN THE EXTRAPERSONAL MIRROR IMAGE BILOCATION OPTICAL IMAGE PERSPECTIVE AT DIRECTLY SPACE DURATION SECONDS/MINUTES SECONDS/HOURS SECONDS SECONDS/MINUTES SECONDS/MINUTES SECONDS/MINUTES DISEMBODIMENT - +/- +/- ++ +/- +/- MAINTAINED - + NA + NA NA SIDEDNESS PSYCHOLOGICAL -++ + ++ - - PHENOMENOLOGY INVOLVED PO (RIGHT?) TPJ (LEFT?) ? TPJ (RIGHT?) SPLENIUM (ONE ? CEREBRAL DESCRIPTION) [69] CORTEX PREDOMINANT VISUAL VISUAL AND SOMAESTHETIC SOMAESTHETIC ONLY VISUAL AND SOMAESTHETIC VISUAL AND SOMAESTHETIC VISUAL AND INVOLVED SOMAESTHETIC MODALITIES ACCOMPANYING MICROPSIA D D D, SENSATION OF FLOATING OR D, ASCHEMATIA D SYMPTOMS HEMIANOPIA FLYING, AUDITORY ASOMATOAGNOSIA HALLUCINATIONS OR ILLUSIONS OF VIBRATION VESTIBULAR -+ - ++ - - DISTURBANCE AH = autoscopic hallucination, h-A = he-autoscopy, FOP = feeling of a presence, OBE = out-of-body experience, Nh-A = negative heautoscopy, Ih-A = inner heautoscopy, PO = parieto-occipital cortex, TPJ = temporo- parietal junction, D = depersonalitation, - = absent, + = present, NA = not applicable; ? = not known; maintained sidedness indicate no shift from left to right in the autoscopic image. Anzellotti et al. Behavioral and Brain Functions 2011, 7:2 Page 7 of 11 http://www.behavioralandbrainfunctions.com/content/7/1/2 Phenomenological aspects of he-autoscopy where the self is” could justify the association with sui- We could report a case of he-autoscopy in which the cide attempts, as in our patient. Our case can be consid- affected patients have a vague feeling of detachment ered as an example of he-autoscopy in which, typically, from the body accompanied by the sensation of a “dou- the autoscopic body acts exactly like the real body ble consciousness”. He-autoscopy involves visual and (maintaining sidedness) and interacts with it: the patient somaesthetic modalities and, similar to out of body experienced to have access to the autoscopic body’s experience, localizes the self in an illusory body at an thoughts and sometimes could verbally communicate extra personal space although the point of localization with it. Typically the patient had the impression of of the ego remains within the natural boundaries of being at two locations at the same time (bilocation) and one’s own body. There are some variables that can help positive or neutral emotions never accompanied her to differentiate among autoscopic phenomena: the pre- autoscopic experience. She also experienced the he- sence of vestibular hallucinations or body schema dis- autoscopy in the typical upright position, while the view turbances, the position of the autoscopic and the of the self always in front of her (as in out of body physical body, the kind of view, the sense of bilocation experience) in the same visuo-spatial perspective, is less and finally the sharing of thoughts and words or actions commonly reported [2]. of the autoscopic body. Among the described variables Vestibular sensations were not reported by the patient: five phenomenological characteristics of the autoscopic in the Blanke and Mohr analysis [31], vestibular halluci- body allow to distinguish he-autoscopy from the other nations and body schema disturbances are comparatively abnormal experiences: frequent in out of body experience and he-autoscopy (about 60% of patients). Our case report suggests that 1) the “view": in he-autoscopy subjects see the auto- vestibular symptoms are not specific of he-autoscopy scopic body in front-, side- or back-views. and that their absence does not exclude he-autoscopy or 2) the “actions": the autoscopic body can act only in out of body experience. he-autoscopy (activities of the autoscopic body appear to be specific to he-autoscopy and almost He-autoscopy, epilepsy, depression and suicide absent in out of body experience). Psychological phenomenology differs among different 3) the experience of “sharing of thoughts and words” autoscopic experiences: he-autoscopy and out of body which are often associated with he-autoscopy and experience are experienced as profoundly significant are less frequent in out of body experience. events and in he-autoscopy the quality of emotional 4) the “perspective": in he-autoscopy patients fre- impact considerably varies: one’s doppelgänger can quently experienced to see the double from several sometimes be experienced as highly supportive [14], but different visuo-spatial perspectives that, in contrast, in general is offensive or overtly aggressive. A classical were unequivocally localized and experienced as uni- case was reported by Wigan [32], who described the tary by all out of body experience patients. first non-fictional account of a man who could induce a 5) the “bilocation": only he-autoscopy subjects visual hallucination of himself. Gradually the double reported to be split into two parts of selves. became more and more autonomous appearing without being evocated. Utterly distraught, the man shot himself. In addition positive and neutral emotional experiences Significantly our patient attempted suicide twice, but are especially rare in he-autoscopy [12,17]. specific risks linking he-autoscopy and suicide are not Thus he-autoscopy significantly differs in these com- statistically supported. The association between suicide plex variables from other autoscopic phenomena, sug- and he-autoscopy is a common theme in dramatic gesting that different central mechanisms are romances and the appearance of the doppelgänger, a underlying. The phenomenological variability of the ghostly double of a living person, often announces the autoscopic body (with respect to views and actions) and hero’s death that is usually a death by suicide. In Breton the increased frequency of shared thoughts, voices, and myths the doppelgänger is a version of the Ankou, a actions between autoscopic and physical body might be personification of death; in a tradition of the Hebrew due to different involvements of kinesthetic/propriocep- Talmud, to meet himself means to meet God. There are tive information processing in he-autoscopy. The shar- also several literary examples: in Dostoyevsky’snovel ing of thoughts, voices and actions might make difficult “The Double” when the protagonist experienced his first for the patient to decide where the physical agent is autoscopic experience, he began to think to kill himself located and leads to the experience of two observing by drowning. In Edgar Allan Poe’sshort story “William selves. Therefore he-autoscopy is not only the reduplica- Wilson”, probably the most dramatic image, the main tion of one’s physical body, but also the reduplication of character, of questionable morality, is dogged by his one’s self. The terrifying experience of “not knowing doppelgänger most tenaciously when his moral fails. Anzellotti et al. Behavioral and Brain Functions 2011, 7:2 Page 8 of 11 http://www.behavioralandbrainfunctions.com/content/7/1/2 But also Oscar Wilde ("The portrait of Dorian Gray”), common triad than previously recognized [41], we know Franz Werfel ("Spiegelmensch”) and Friedrich von Ger- little about the mutual correlation, but the description stäcker ("Der doppelgänger”) had their heroes commit of the survivors, as in our case, would rather favour a suicide to escape the horror of being haunted by their causal relation between the double experience and the second selves. Some of these authors have not only had impulse to kill oneself. Suicide attempts are not infre- epilepsy but have also known he-autoscopy from perso- quent in depressed subjects and depression is commonly associated with epilepsy [42]. In severely depressed nal experience [33,34]. There are several notable reports patients “heautoscopy of the Cotard type” (seeing a dead about documented autoscopic experiences: Percy Bysshe doppelgänger during the hallucinatory attendance of Shelley, an English poet, drowned in the Bay of La Spe- zia near Lerici and Abraham Lincoln, known to be a one’s own funeral) is not a rarity. The suicidal risk is superstitious man, recognised a special meaning to an further increased by psychiatry comorbidity and drug autoscopic experience which he seems to have had in use [43-45]. The epileptic focus in the right hemisphere the evening of his election [35]. A rare and dubious and the severe depressive symptoms presented by our example of a doppelgänger which was both benign and patient, support recent hypothesized links between reassuring is described by Johann Wolfgang von Goethe depression and inter-hemispheric imbalance. Depression in his autobiography “Truth and Fiction” ("Dichtung is believed to be associated with a hyperactive right- und Wahrheit”). More recently Otto Rank, a Freudian hemisphere and a relatively hypoactive left-hemisphere Austrian psychoanalyst, in his book “The Double” [36], [46]. Yet, the underlying mechanisms which can explain suggested a possible explanation for the frequent recur- the involvement of the right side remain elusive. There rence of the image of the double in the artistic produc- is evidence that the right hemisphere is selectively tion and folklore. He believes that the double is an involved in processing negative emotions, pessimistic artist’sstrategytoexorcisetheterribleideaofdeath. thoughts and unconstructive thinking styles. Addition- “Heautoscopic suicide” also includes cases of attempts ally, it mediates vigilance and arousal and had also been to kill one’s double or, in the most obviously transitivis- linked with self-reflection, accounting for the tendency tic manner, observing one’s doppelgänger committing of depressed individuals to withdraw from their external suicide [37]. environments and focus attention inward [46]. The Keppler observed that “Often the conscious mind tries involved hemisphere is also important to explain possi- to deny its unconscious through the mechanism of “pro- ble language deficits, but ictal speech disorders were not present in our patient in agreement with the involve- jection”, attributing its own unconscious content (a ment of non dominant hemisphere as showed by EEG murderous impulse, for example) to a real person in the world outside; at times it even creates an external hallu- recording. Word finding difficulties are often reported cination in the image of this content” [14]. by epileptic patients and peri-operative and post-surgical Brugger examined the “hostile interactions between electro-cortical stimulation evidences have highlighted a body and self” [38] indicating four major variants of role for the anterior part of the dominant temporal lobe “heautoscopic suicide” as an actively imposed or pas- in oral word production [47]. In previous reviews sively experienced form of self-injurious behaviour: self- [23,48,49], autoscopic experiences are mentioned as a injury/suicide in an attempt to escape the double, fenes- rare but classic symptom in parietal lobe epilepsy. How- tration in order to get rid of the double, self-injury/sui- ever it has been reported in association with temporal cide claimed to be inflicted by the double, self-injury/ lobe epilepsy [50]. There are few reported cases of post- suicide in an attempt to kill the double and the observa- ictal autoscopic phenomena [51]. Autoscopic experi- tion of the doppelgänger’s self-injury/suicide. He dis- ences have been described not only in focal seizures, but cussed neuropsychiatric and psychodynamic approaches in a broad range of neurological disorders such as to disembodiment concluding that, although there is no migraine, neoplasia, infarction and infection [11,12,52] direct clinical or neuroanatomic evidence for a primary and also in psychiatric disorders such as schizophrenia, callosal pathology, it is not entirely implausible to depression, anxiety and dissociative disorders [16,17]. In assume an inter-hemispheric disconnection at the basis some cases it is difficult to distinguish the autoscopic of heautoscopic aggression. Of note, in our patient an experiences from a dreamy-state in which the self is early MRI study reported the presence of enlarged sple- seen in more complex, dream-like or memory-like nium callosi. Our MRI study however, including tracto- scenes without actually seeing the image of one’s face or graphy examination, did not evidence any abnormality. body [53]. Our measurements were, in our patient, inside the Our patient experienced typical he-autoscopy and the range reported for female subjects, who have commonly autoscopic episodes were the only ictal symptom. The larger splenial bodies than males [39,40]. Even though ictal EEG performed during the autoscopic experience, heautoscopy, epilepsy and suicide may be a more showed a right parietal origin in non-dominant Anzellotti et al. Behavioral and Brain Functions 2011, 7:2 Page 9 of 11 http://www.behavioralandbrainfunctions.com/content/7/1/2 hemisphere, with rapid bilateral posterior involvement. originates in the right temporo-parietal junction. It These data were confirmed by SPECT findings that might be argued that the only evidence of the he-auto- revealed a hypometabolism in parietal and occipital scopy corresponding to EEG discharge is obtained from areas but no brain abnormality was detected by means the patient, subjectively signalling the presence of auto- of MRI. In contrast with neurophysiological data, patient scopic image of the self during the seizure and by her reported neither macroasomatognosia, a symptom that detailed description “aposteriori”. Thus exact timing of can result from an involvement of the parietal lobe the different feelings might appear uncertain: nonethe- less EEG discharge was observed and he-autoscopy was [23,48,49], nor palinopsia (consistent with an involve- reported. We believe it would be difficult to obtain bet- ment of the visual associative area) nor luminous flashes in the visual fields (consistent with an involvement of terevidencethen the one weare reporting, as averbal the primary visual area) nor motor symptoms. description of symptoms during the seizure would alter the EEG due to glosso-kinetic artefacts. Possible cerebral mechanisms: multisensory processing Several studies [11,12,31,54-56] proposed that auto- and cortical hyperconnectivity scopic phenomena are a double failure to integrate pro- Defining the mechanism of autoscopic phenomena is a prioceptive, tactile and visual information with respect challenge. Menninger-Lerchental [13] first speculated on to one’s own body (disintegration in personal space), different anatomical substrates suggesting that auto- along with an additional vestibular dysfunction leading scopic hallucination originate at the junction of the par- to disintegration between personal (vestibular) space ietal and occipital lobe, he-autoscopy from the angular and extrapersonal (visual) space. Disintegration of perso- and supramarginal gyrus and out of body experience nal space is present in he-autoscopy and out of body from the superior parietal lobe. Blanke and Mohr [31] experience but differences are mainly due to the level summarized anatomical findings of their analysis eviden- and type of vestibular dysfunction. In more detail: out of cing that he-autoscopy seems to primarily involve the bodyexperiences areassociated withspecificvestibular, left temporo-parietal junction and out of body experi- graviceptive and otholithic sensations that are character- ence the right. More recently Blanke and Arzy [54] have ized by a variety of sensations including feeling of eleva- unexpectedly reproduced an effect strongly reminiscent tion and floating, he-autoscopy is associated with a of the doppelgänger phenomenon via electromagnetic moderate and more variable vestibular disturbance while stimulation of the left temporo-parietal junction. Their no vestibular disturbance is evidenced in autoscopic hal- analyses showed that out of body experiences and he- lucination, feeling of a presence, negative heautoscopy and inner heautoscopy. Moreover, the high frequency of autoscopy are primarily associated with electrical stimu- lation, probably inhibition, of the temporo-parietal junc- visual hallucinations and hemianopia in patients with tion and autoscopic hallucination with electrical autoscopic hallucination suggests that defective visual stimulation in parieto-occipital cortex. Moreover these processing of bodily information is the main causing experimental data suggest that out of body experiences factor for disintegration in personal space in autoscopic are associated with damage to the right temporo-parietal hallucination. junction and he-autoscopy to the left temporo-parietal Therefore according to Blanke we speculated that the junction [31,54], whereas autoscopic hallucination is different forms of autoscopic phenomena are related to associated with damage to the right parieto-occipital different degrees of vestibular dysfunction. We hypothe- cortex [55]. Corporal awareness and experience of the size that autoscopic seizures occur because of ictal dis- body ownership are more likely dependent on the right turbances of the normal integration process of body hemisphere [28]. However with regard to hemispheric representation within parieto-occipital networks in asymmetries no firm conclusion can be drawn. Our case which the right inferior parietal region plays a signifi- shows an epileptic focus in the right temporo-parietal cant role. The integration of proprioceptive, tactile and junction: the patient report suggests that the hallucina- visual information with respect to one’s body with ves- tion perception was an he-autoscopy, as it presents tibular information is important for the constant updat- most of the peculiar characteristics reported by litera- ing of the movement and position of single body parts ture in he-autoscopy. Therefore our report might sug- and entire body. In order to create a central representa- gest that he-autoscopy can possibly arise also from tion of one’s own body, the brain must integrate and epileptic foci of the right hemisphere. The epileptic dis- weigh the evidence from different sensory sources. charge (Figure 3A-E) shows a definite localization and Electrophysiological [57] and neuroimaging [27,29] studies showed that the vestibular cortex is a multisen- the involvement of the left hemisphere occurs only sory cortex receiving not only vestibular information, when the patient subjectively reports that the hallucina- but also visual, proprioceptive and tactile cues from tory image has disappeared. In our case report, there- fore, the EEG shows an epileptic discharge that the whole body. We believe that these multisensory Anzellotti et al. Behavioral and Brain Functions 2011, 7:2 Page 10 of 11 http://www.behavioralandbrainfunctions.com/content/7/1/2 interactions are fundamental for integrating signals understanding of autoscopic phenomena. Because of about body movements and body position in space with the severe psychiatric symptoms presented in our respect to other body segments and to the ground. The patient, we could not perform the combined EEG/fMRI implication of temporo-parietal junction in embodiment analysis that recently allowed to identify the cortical and in self processing is suggested by neuroimaging stu- connection network sustaining persistent symptoms in dies in healthy subjects [29,58-60]. These studies exam- epilepsy [30], yet we believe that this approach might be ideally suited to understand the mechanism of auto- ining visuo-spatial pathways showed the involvement of scopic phenomena. many other cortical areas such as prefrontal, parietal and temporal cortex. The “cortical midline structures” have been recently identified as intimately related to the Consent experience of the self [61]. Therefore the temporo-parie- Written informed consent was obtained from the patient tal junction might be a crucial structure for conscious for publication of this case report and accompanying experience in a widely distributed network of cortical images. A copy of the written consent is available for areas. review by the Editor-in-Chief of this journal. In conclusion it is not known which of the many senses are primarily involved in the generation of he- Author details autoscopy. Data in literature shows that visual theories Department of Neuroscience and Imaging, Aging Research Centre, Ce.S.I., cannot entirely explain autoscopic phenomena and “G. d’Annunzio” University Foundation G. d’Annunzio University, Chieti, Italy. points to the importance of non visual, body-related, University Ospedale San Raffaele, Milan, Italy. mechanisms such as proprioceptive and/or kinaesthetic Authors’ contributions processing. A further aspect in favor of tactile and pro- FA performed clinical evaluations and prepared the manuscript. MO prioceptive mechanisms was given by the different body provided the case and designed the overall paper. VO, LB and AT revised the manuscript for important intellectual content and provided positions reported by patients, upright for he-autoscopy bibliographical research. VM, LR, RF were involved in analysing EEG, MRI and and supine for out of body experience, suggesting differ- SPECT data and in providing technological support. All authors read and ential influences of proprioceptive and tactile processing approved the final manuscript. in different types of autoscopic experiences. Blanke and Competing interests Mohr [31] summarized anatomical findings of their ana- Financial competing interests: The authors declare that they have no lysis evidencing that he-autoscopy seem to primarily competing financial interests. Non-financial competing interests: The authors declare that they have no involve the left temporo-parietal junction and out of competing non-financial interests. body experience the right. The evidence of the temporal lobe involvement in body-distortion processing and Received: 25 June 2010 Accepted: 10 January 2011 Published: 10 January 2011 impairments in own-body transformations was high- lighted in a recent report [62]. Yet self-representation References has been shown to depend also on the prefrontal cortex 1. 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