RESEARCH REPORT POLYOPIC HEAUTOSCOPY: CASE REPORT AND REVIEW OF THE LITERATURE Peter Brugger1, Olaf Blanke4, Marianne Regard1, David T. Bradford3 and Theodor Landis2 (1Department of Neurology, University Hospital Zürich, Zürich, Switzerland; 2Department of Neurology, University Hospital Geneva, Geneva, Switzerland; 31207 West 12th, Austin, TX, USA; 4Laboratory of Cognitive Neuroscience, Brain Mind Institute, Ecole Polytechnique Fédérale de Lausanne – EPFL, Lausanne, Switzeland) 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/doppelgänger, polyopsy/polyopia, unilateral hallucinations, body schema, reduplication, self INTRODUCTION et al., 1998) and supporting the notion of the doppelgänger as a “phantom of the entire body” Autoscopic hallucinations and heautoscopy are (Brugger, 2006). There is considerable variation in two variants of a reduplication of one’s own body the reported duration of heautoscopy; it may last and self (Blanke et al., 2004; Bradford, 2005; for seconds or for hours, and even cases of the Brugger et al., 1997). In the former, an exact double as a steady companion are not exceptional mirror image of oneself, occasionally only of one’s (Conrad, 1953; Engerth and Hoff, 1929; Pearson face or bust, is perceived visually (Maillard et al., and Dewhurst, 1954). Heautoscopy has been 2004; Zamboni et al., 2005). Such hallucinations described in a broad range of neurological are usually of very brief duration and often disorders such as epilepsy, migraine, neoplasia, accompanied by other types of visual hallucinations infarction, and infection (Menninger-Lerchenthal, or illusions. In the latter variant, i.e. heautoscopy 1935, 1946; Lippman, 1953; Devinsky et al., 1989; proper, a person is confronted with his or her Dening and Berrios, 1994; Brugger et al., 1997), double, or doppelgänger, which may or may not and also in pychiatric disorders such as mirror the person’s appearance. Regardless of its schizophrenia, depression, anxiety, and dissociative visual features, the hallucinatory figure is felt to be disorders (Bychowski, 1943; Carp, 1952; Todd and a double of one’s self. The feeling of belonging Dewhurst, 1955; Lukianowicz, 1958; Damas Mora toward one’s double is usually accompanied by et al., 1980; Dening and Berrios, 1994). Based on alterations in bodily awareness; for example, the an analysis of autoscopic phenomena after focal person feels an unusual lightness of the body, brain lesions, Blanke et al. (2002, 2004) experiences vestibular illusions, or describes a emphasized the specific importance of lesions at feeling of detachment. Frequently, heautoscopic the temporo-occipito-parietal junction. While echopraxia, i.e., the imitation of bodily movements autoscopic hallucinations have almost exclusively by the double, gives rise to the illusion that it is been reported in neuropsychiatric patients, the doppelgänger that “contains the real mind” heautoscopy also occurs in the healthy population, (e.g., Lukianowicz, 1958, cases A and D; Dewhurst especially in the framework of a preoccupation and Pearson, 1955, cases 1 and 2; Brugger et al., with one’s own self and its place in the world or as 1994). Echopractic movements may sometimes a pathological grief reaction (Menninger- follow actual body movements with a time lag Lerchenthal, 1935; Hécaen and de Ajuriaguerra, (e.g., Lance, 1976), an observation also reported in 1952; Wells, 1983; Dening and Berrios, 1994). patients with supernumerary phantom limbs (Hari Among both types of autoscopic phenomena, Cortex (2006) 42, 666-674 Polyopic heautoscopy 667 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. 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” 2. 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. 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. 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. Ley and Stauder (1950) Male, n.r. Encephalitis in the Patient sees and feels three identical doubles of himself lying to (case 2) course of M. Bang his left side. Delusional elaboration; transitivism 6. Dewhurst and Pearson Male, 57 Post-traumatic In his left visual field, the patient sees “crowds of tiny figures (1955); Russel and Whitty epilepsy; right [head and shoulders, only], all the colors of the rainbow – all (1955) temporal lobe lesion myself” 7. Hécaen and Badaraco (1956) Male, n.r. Tuberculous Patient is lying on his side and sees two identical doubles, one in (case 50); also in Hécaen meningitis the left and one in the right visual field. Feels that both doubles and Green (1957) (case 4) possess some body weight 8. 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. Heintel (1965) Female, 32 Post-traumatic Patient sees multiple mirror images of herself in different sizes. epilepsy; right-sided Autoscopic images are localized in the interior of the patient’s hemianopia body 10. Craske and Sacks (1969) Female, 32 Healthy (during Patient sees a non-pregnant double straight ahead of herself. A puerperium) 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 and Okamoto Female, 21 Focal epilepsy; Patient sees “multiple selves as shadows moving from left to right (1982) left-sided focus in visual space” 14. Chabrol and Bonnet Female, 12 Panic attacks with Patient feels threatened by several identically looking doubles (1995) Capgras syndrome “polyopic” cases, involving a multiplication rather in the medical-psychological literature. Out-of-body than simply the reduplication of one’s own body, experiences, conceptually closely related to have been reported. Probably the first account of heautoscopy (Blanke et al., 2004; Brugger et al., polyopic heautoscopy is to be found in Müller’s 1997) can also involve an illusory multiplication of (1826/1967) seminal work on visual hallucinations. one’s body. Cases of such multiple out-of-body Returning home late from work, an exhausted experiences are reviewed in Green (1967, 1983). university professor suddenly found himself Tschaikowskaja (1982) discusses the motif of the confronted with some 15 persons, all clearly multiple self-portrait in the visual arts. Multiple recognized as doubles of himself although they doubles in folklore are considered in Krauss (1920) were of different ages and wore clothes he himself and Panoff (1968). only wore in the past. A case of an autoscopic The 14 instances of polyopic autoscopic hallucination with multiple images is reported by phenomena noted in Table I may be characterized Roubinovitch (1893; cited by Parish, 1894 p. 16), as follows. Eight patients were female (57%) and 6 whose patient saw three identical mirror images of male (43%). Their mean age was 38.9 years himself which he compared with the reflections he (range: 12-62 years). With respect to etiology, 64% would have seen standing in front of a mirror with of the cases of polyopic heautoscopy were of three wings. Passing reference to other early cases neurological origin and 29% of psychiatric origin of a polyopic nature can be found in Winston [1 case (7%) was during puerpurium]. Of the (1908), Oesterreich (1910), Schneider (1931), neurological cases, 88% were of focal origin and Nadeau (1972), and in Leischner’s (1961) review due to a traumatic lesion, vascular infarction, or article on autoscopic phenomena. While these early focal epilepsy. Of these focal neurological cases cases have a somewhat anecdotal character, our the lesion was localized as often in the right as in Table I summarizes certain features of polyopic the left hemisphere.