Altered Egos: How the Brain Creates the Self, 1st Edition


Missing Pieces; Familiar Places

And you may ask yourself, How do I work this? And you may ask yourself, Where is that large automobile? And you may tell yourself, This is not my beautiful house! And you may tell yourself, This is not my beautiful wife!

--Talking Heads, Once in a Lifetime, 1978

The Margins of the Ego

We all have a natural sense of where we as selves end and the environment begins. It is from our inside point of view, our inner personal perspective, that we experience the world. Under most conditions, the distinction between self and the world is obvious. I feel that I am not the chair on which I sit. While it may seem as if the boundaries of the self are obvious, they are in actuality more dynamic than rigid. They are not fixed; they are relative. Things or other persons can be relatively close to the inner core of the self's experience, or they can be quite removed. In this way, an object can be “ego-close” or “ego-distant.”1

For example, your shoes on your feet are objects that are to me egodistant. I do not feel they are a part of me, connected to me in any way, or bear any particular personal relevance to me. Now, what about the shoes on my feet? My shoes are to a certain extent felt to be part of me. They are not as close to being part of me as my feet themselves, but they are certainly closer to me personally than your shoes. I might to a certain extent identify with my shoes and my clothing in general. They may be incorporated into myself.

The persons, places, objects, and events that one's self experiences are imbued with feeling—the feeling of how one relates to things in a personal sense. Our identities are built around this sense of relatedness. Personal relatedness provides the structure within which the self is anchored in the world. The self is a continuum of relationships. An individual's own body, spouse, and family members are “ego-close.” They


bear a particular personal relationship to the self, identity with the self; we care about these items, these events, these people, in particular ways. They are significant. The objects of the world, which for us have no personal significance, could be considered “ego-distant.” The impersonal world, the stranger on the street, is less likely to be imbued with any sense of personal significance.

To what extent identification with objects takes place becomes clearer whenever the degree of closeness with a particular object is altered.For instance, when wearing a favorite article of clothing, one to which you are particularly attached, it is commonplace not to notice the degree to which it has become worn and torn over the years. I have found that after wearing a new pair of shoes, I am startled at how worn down my old pair appear when I rediscover them a week later. As soon as one has lost the normal relatedness to the object, the degree to which one is identified with it is altered. The object is no longer apprehended as part of the self. It is no longer ego-close.

The process of going from a sense of relatedness to one of distance is commonly known as alienation. To become alienated from something, we have first to be close to it. In this way, there is a continuum of the self: from the ego-closeness of the pure “I”to the ego-distance of impersonal objects. The individual ego encompasses this continuum of personal relatedness in ways that reflect both the brain and its experience.

The conditions of jamais vu (where the familiar appears strange) and déjŕ vu (the opposite condition, where the unfamiliar appears familiar) are examples of alterations in relatedness. The psychologically healthy individual enjoys an integrated and comfortable relation of the self and the world. Our boundaries between the world and other people are held in delicate balance, however. This balance is maintained automatically and in large part unconsciously. We are not generally aware of these boundaries until they are violated, until someone or something gets too close or too distant, until one feels merged with or alienated from the world. This degree of relatedness also helps define what is real; it defines our reality. The peculiar, uncomfortable feeling of the loss of reality, of loss of one's psychological foothold when confronted with a deja vu or jamais vu experience, is significant. It demonstrates how personal relatedness structures our feeling of what is real and establishes our identity in the world.

The neurological damage that we have considered perturbs ego structure in various ways, creating an alteration in the identity of the individual in the world. Remember Mirna in chapter two, the patient who misidentified her left arm as belonging to her deceased husband? The


neurological lesion led to a withdrawal of personal relatedness or alienation of her limb. It no longer felt like her own arm, yet it was recognized as an element in the world that should have been her arm. No matter how connected she once was to it, no matter how impossible it might seem to us to be that her limb could be viewed as not belonging to herself, it is quite common for the arm to be disavowed under these conditions. There can also be an insertion of relatedness involved with asomatognosia. Just as this patient called it her husband's arm, many patients misidentify the paralyzed arms as belonging to a close friend, a relative, a mother-in-law, or some other part of the patient's own body, like a breast. Thus, we see an insertion of personal relatedness as well as withdrawal, and we can view the misidentification of the asomatognosic patient as both a withdrawal and an insertion of personal relatedness.

In this chapter, we will explore two more syndromes that are examples of perturbations of the self in relation to the world. The first of these, Capgras syndrome, is an example of a loss of personal relatedness; the second, Frégoli syndrome, represents an insertion of personal relatedness. By considering these disorders we may further decipher the mysteries of asomatognosia, and the relationship between the brain and self.

Capgras Syndrome

Alienation from onself or one's life is surely common. Who has not experienced the loss of the familiar at one time or other? But some patients have this experience on an enduring basis. In 1923, Joseph Capgras, a French psychiatrist, and his intern, J. Reboul-Lachaux, described the unusual case of Mme. M., a fifty-three-year-old woman who complained that imposters (“sosies”) had replaced her husband, children, even herself. Her husband, according to her account, had been murdered, and the men who came to see her in his guise were his doubles. She recounted that there must have been at least eighty imposters who appeared in this fashion, and asserted: “I can assure you that the imposter husband that they are trying to insinuate is my own husband, who has not existed for ten years, is not the person who is keeping me here.” Mme, M. claimed that more than two thousand doubles of her daughter had passed before her eyes: not only close family members, but eventually policemen, a concierge, doctors, nurses, and neighbors were impersonated. Eventually, she reported that there were even doubles of the doubles! Capgras and Reboul-Lachaux called her case “L'Illusion des sosies.”2



The name they chose is derived from Greek mythology, which gives us the story of Zeus, who physically transforms himself in order to take on the appearance of Amphitryon. He performs this ruse in order to seduce Amphitryon's wife, Alcmena. Fearful that Alcmena's servant, Sosia, will alert her to the deception, he arranges for Mercury to impersonate Sosia as well. The charade is successful, and Alcmena eventually has twins: one twin is the son of Zeus and is named Hercules; the other twin is the son of Amphitryon and is named Iphicles. This myth served as the basis for the play, Amphitrio, by the Roman playwright Plautus, and was much later the subject of Moličre's play,Amphitryon. The word “sosie,” after Alcmena's servant, came to mean“a double” in French. It was employed to characterize someone who bears a strong twin-like resemblance to another person. The disorder subsequently became known as the Capgras syndrome.3

The Capgras syndrome is an example of a delusional misidentification syndrome. The term “delusional misidentification syndrome” applies to several clinical disorders in which a patient confuses the psychological or physical identity of a person, place, or thing.4 The patient with Capgras syndrome knows that a certain individual looks like the misidentified person, but there has been a change in the psychological identity of the individual.

Capgras syndrome may be caused by psychiatric or neurological illness. The cause of Mme. M.'s delusional misidentification was psychiatric. Her doctor diagnosed Mme M. as suffering from “chronic psychosis”; Capgras and Reboul-Lachaux described Mme M. as a “paranoid megolamaniac.” In patients with a psychiatric background, schizophrenia is a common cause of the delusion. This is especially true of patients in whom paranoia is prominent. In neurological patients, the most common causes of Capgras syndrome are head injury, stroke, or illnesses that cause dementia such as Alzheimer's disease.5

The person who is misidentified may be a close relative or a person significant in the patient's life. Married patients who develop Capgras syndrome often claim that an imposter has replaced their wife or husband. The patient's explanation regarding the fate of the “original” varies from case to case. When asked specifically where the original has gone, some patients simply profess that they have no idea, while other patients may hold more paranoid beliefs and claim that the original was murdered or was the object of a kidnapping plot. Some patients do not seem particularly upset about the substitution; in fact, some patients are very pleased! Others are disturbed and can become quite paranoid. I have found that women with Alzheimer's disease, especially those who have outlived


their husbands, tend to misidentify a daughter. This was the case with my patient Emma.


Emma was an eighty-year-old woman who reported that there were two “versions” of her daughter: one, the actual daughter, Betty, and the other one, Betty's “assistant.” Emma described at length how her daughter told her, “I'm Betty,” but she reported:

EMMA: It wasn't my daughter. Her name was Betty. . . So I said. . . her name can't be Betty because two Jewish sisters aren't called Betty.

FEINBERG: You thought it was her sister?

EMMA: No. . . I thought she worked for her. But the two girls named Betty. I mean it just. . .

FEINBERG: So there were two. . .

EMMA: Two girls both named Betty.

The two “Bettys” were similar in most respects, except the “other” version of Betty wasn't as tall as the original, didn't wear glasses, and had shorter hair than the real Betty. The other Betty had cooked for her and took her on trips, while the real Betty wasn't around. On one of these outings, Emma reported she had bought two hats, one for the daughter Betty and one for the other Betty. There was no doubling of any of her other relatives, doctors, or friends.

EMMA: And she had all the information about everybody in my family. . .

FEINBERG: The other one?

EMMA: The other one. . . knew everything. And she knew everyone's friend and who they were married to, and I questioned. . . because I couldn't. . . [holding her temples as if perplexed]. . . and then she said, If you're my mother I'd love for you to feel the same way as maybe I felt about Betty. . . maybe she saw how close we were. . . I came over, and then I was beginning to realize, maybe the girl, maybe I left her. . . as a. . . you know, had her adopted or something.

She became concerned that perhaps she had done something to the other Betty as a child, maybe that she had abandoned her. She was quite upset over the substitution and asked “Why did this happen?” while crying to her daughter in perplexity. There was frequent mention of possible trickery involved. She suspected that the other Betty wanted to get rid of the original. It disturbed her to think that her daughter might also


be part of this conspiracy of deception. She added that the real Betty was “nicer” than the other one. She added, “I never loved the other Betty.”

As was the case with Emma, patients with Capgras often perceive differences between the original and the imposter. A well-known case reported in 1931 by Larrivé and Jasienski described a French woman who complained about her poorly endowed, inadequate, and sexually awkward lover.6 Fortunately for her, he possessed a double, whom she described as rich, virile, handsome, and aristocratic and was a rival for her affections. Davidson also described a patient with Capgras syndrome, a thirty-year-old man with an extensive psychiatric history who reported that the woman who claimed to be his wife was an imposter:

He had the idea that his wife was not the person he married, that she was a double, that she was not a Catholic but a Jewish woman. Also, he declared there were certain differences in temperament, and he felt even that the formations of the sexual organs of his wife and her double were different.7

Feelings and fears about a spouse were reflected in the Capgras delusion of my patient Louise.


I treated another eighty-year-old woman, Louise, who presented with poor memory due to the onset of Alzheimer's disease. Aside from her memory problems, however, Louise was quite intact in most respects. She was pleasant in demeanor and immaculately groomed. If you met her on the street, you would not think there was anything wrong with her. She held to no odd beliefs except one about her husband Murray, whom she claimed was not the original man she had married. Louise explained when she realized something was not right with Murray:

LOUISE: I have found myself looking at a picture we have. . . a picture in the living room, of myself and my husband. And I made sure I picked that picture up and looked at it. . . and looked at the face, to see whether there was any form of nose or mouth or anything that was different looking and I can't see it. I can't see it on the picture.

FEINBERG: You can't see any difference between the picture and his face.

LOUISE: [In agreement.] No, no.

FEINBERG: They look identical?

LOUISE: They look identical.



FEINBERG: Now, when you look at the picture, you feel that that's him in the picture. But when you look at him. . .

LOUISE: I get the feeling. . . that he doesn't look quite the same as Murray would have looked. . . many years back.

FEINBERG: Doesn't look the same as Murray would have looked many years back. Now, do you ever have the feeling there's two of them?

LOUISE: Yes I have. . . I've had it at night, when I was alone. When I had these feelings, I did have a feeling, that there were two of them. And it's very scary so I didn't think long about it.

FEINBERG: Uh-huh. But you have this feeling there could be two Murrays? But when you see him and you have this feeling that that's not him, did you ever have a belief that the other Murray must be somewhere else?

LOUISE: I have believed that, because I've worried certain times, about that he was out in the rain. . . he's alone. . . and nobody's taking care of him. . . and he's by himself. And I was very concerned.

Louise's comments reveal something about the basis of the Capgras delusion. When Louise stares at the picture of Murray, she realizes she is looking at a picture of a face. She doesn't mistake Murray for a hat, for example. Nor does she show evidence of any problem recognizing objects, such as keys and combs, in the world around her. We know from these observations that Louise does not suffer from visual agnosia.Visual agnosia is a global disorder of visual recognition in which the patient cannot recognize objects from vision alone, but may recognize the same objects through other means, such as touch.

Louise also had no difficulty with visual recognition of other members of her family, her therapists, or myself. From this we may surmise that Louise does not have the syndrome of prosopognosia. In prosopognosia, the patient can recognize objects in general, but has particular difficulty with assigning proper identity to faces. The patient who suffers from prosopognosia knows a face when she sees one; she just doesn't know whose face it is. Prosopognosics often compensate for their difficulty in visual face identification by using other sensory cues, such as hairstyle, voice, or clothing to improve their ability to identify people. They also do not deny a person's correct identity once it is pointed out. Moreover, prosopognosics have a problem with all faces: their problem is not selective for a particular face. Therefore, Louise knew which person was supposed to be Murray; it just didn't seem to her that this Murray was the real Murray. There was a conflict between her current perception of Murray and her feelings about him.



The term Capgras syndrome usually refers to the misidentification of persons, but some patients may disavow and misidentify locations, buildings, or inanimate objects. This situation was the case with my patient Oliver.


Oliver was a distinguished gentleman in his seventies. He was a holocaust survivor who immigrated to the United States where he enjoyed great success in business. He suffered a small stroke and was admitted to the hospital. His hospitalization was uneventful, and he survived the entire episode with no obvious neurological effects.

Upon returning to his much-loved apartment, he was dismayed to find that it had been substituted for another nearly identical apartment. In other words, he was convinced that he had two apartments at the same exact address. The second apartment was“two rooms smaller than the original.” When I asked him how two apartments nearly identical could be located at the same address, he calmly reported, “I have not had the opportunity to discuss it with the super(intendent) or any other official. . . about the feasibility of that apartment. . . both buildings were taken care of by the same super(intendent).”

Some patients claim that inanimate objects are substitutes, the socalled delusion of inanimate doubles. This syndrome represents a form of Capgras syndrome for objects. Anderson reported a fascinating example of this disorder.8 He described a seventy-four-year-old man, hospitalized in Liverpool, who claimed that more than 300 items, including Wilkinson Sword razor blades, a Black & Decker electric drill, and assorted men's underwear, had been removed from his home and replaced by nearly identical doubles. The perpetrators of this heinous crime were his wife Mrs. B. and her nephew Mr. C. who were plotting to ruin him. While the substituted items bore great resemblance to the originals, the patient noted that some of the substituted items were of inferior quality to the originals. For example, there were replacement paint brushes that had “fewer bristles” than the original, a pair of replaced black Wellington boots that appeared “more worn,” and a pair of replaced swimming trunks that “did not fit properly.” A CAT scan of his brain revealed the patient had a large brain tumor five centimeters in diameter.

A patient of mine, Marianne, was admitted to the psychiatric ward. She reported an experience similar to Dr. Anderson's patient.




Marianne, a woman in her seventies, had become quite agitated when she realized her apartment had been substituted for its original “just like in a mystery novel.” All the furniture, posters, and even the dishware had been substituted with exact facsimiles.

MARIANNE: And in the kitchen closet I noticed a difference.

FEINBERG: What was that?

MARIANNE: Well, first of all, the types of dishes that were there were arranged as I would never arrange it.

FEINBERG: In what way?

MARIANNE: Well, I basically size them, and then there were cups and glasses that were not quite the same.

FEINBERG: What were the differences? Different . . .

MARIANNE: Patterns.

FEINBERG: Different patterns that you wouldn't have picked? Or not yours?

MARIANNE: I'm a little fastidious. And, it's a mistake.

FEINBERG: What else was different about the. . . ?

MARIANNE: I don't use dishwash cloths that way.

FEINBERG: Why? What was wrong with them?

MARIANNE: I don't use them. I use sponges.

FEINBERG: Cleaner? Or different? Or . . .

MARIANNE: Cleaner. Different. Nothing important. But I would notice they were not the same.

During the time Marianne was on the psychiatric service, her psychosis was treated and amazingly she began to realize that there really was only a single apartment. As she described it, “Because as the film disappears, the dreamlike experience dissolves. I know that there is one, but there must have been the illusion of two.”

The Family Romance

The estrangement, disavowal, denial, or alienation from persons or objects often with their accompanying devaluation and their subsequent reduplication in fantasy is a theme that reverberates not just throughout neurology, but also throughout the study of child development, religion, literature, and, as we have just seen, mythology. In the psychology literature, the basic structure of the Capgras delusion can be found in the family romance—the fantasy of not belonging to one's family.



The term family romance of neurotics is derived from the writing of Freud.9 He described how the child in his early developmental years tends to view his parents in an idealized fashion. As the child grows intellectually, the realization of the imperfections in his parents—whether imagined or real—promotes the fantasy that the child is either adopted, a stepchild, or in some fashion not actually the true biological child of his parents. When this fantasy takes on particular prominence or intensity, Freud described it as Der Familienroman der Neurotiker. The actual family is rejected as not the real family, and a “real” family is imagined to be elsewhere: the child has in essence a developmental Capgras syndrome.

The same story can be found in mythological literature. In 1909, Otto Rank, one of Freud's pupils, wrote a classic work entitled, Der Mythus von der Geburt des Helden (The Myth of the Birth of the Hero), apparently at Freud's suggestion.10 Rank's work is based on the observation that most of the great civilizations, including the Babylonians, Egyptians, Hebrews, Hindus, Persians, Greeks, and Romans, glorified their heroes, religious leaders, kings, and founders of their cities in legend and myth. These legends, despite the wide separations in space and time of the various cultures, bore a remarkable similarity regarding the circumstances of the hero's birth.

In the story, the hero is originally born of aristocratic or royal parents; he is often the son of a king. The pregnancy is preceded by extreme difficulties (i.e., a prohibition against intercourse or prolonged barrenness). During the pregnancy, a prophecy is delivered in the form of a dream or oracle that cautions against the birth and often threatens the father with misfortune should it occur. In response to the threat, the child is “surrendered to the water” in a box, but ultimately saved by either animals, lowly people, or a humble woman—in other words, the exact opposite of the child's original noble family.

As the child grows up, he experiences great adversity and many challenges; ultimately, he may take revenge upon the father for his desertion, and the hero achieves his original noble position and becomes the king himself. Freud and Rank agreed:

The entire endeavor to replace the real father by a more distinguished one is merely the expression of the child's longing for the vanished happy time, when his father still appeared to be the strongest and greatest man, and the mother seemed the dearest and most beautiful woman.11

Rank lists fifteen such stories that fit the formula, including the oldest from ancient Babylon that concerns the birth of the founder of Babylon,


Sargon the First. Similar hero myths mentioned by Rank are the stories of Oedipus, Paris, Perseus, Romulus, Jesus, and none other than Hercules, where this chapter began.

It is interesting and important in the context of a discussion of the Capgras syndrome that Rank included the story of Hercules as an example of one of these hero-birth myths. Zeus is considered the royal father of Hercules, in this case the “original”father of high birth. Zeus takes on the appearance of Amphitryon, a mortal of lower birth. The two versions of Zeus—one in his original form and the other in the form of Amphitryon—correspond to the two versions of the family in the “family romance”and, by analogy, to the two versions of the person doubled in a Capgras delusion. While the French chose the word “sosies”based on the character Sosia to represent the word “double,” perhaps the “Illusion des Amphitryons” would be a more accurate designation for the syndrome.

Literary references to the Capgras syndrome abound as well. One of the best known references to Capgras's syndrome is contained in The Possessed, by Fyodor Dostoyevsky.12 In the book, Stravrogin, who has been secretly married to Marya Timofeyevna, fails to acknowledge her at a gathering in their hometown and, in so doing, claims he is but a stranger—not her husband, nor her betrothed. Stravrogin later visits Marya, who in turn refuses to recognize him. She tells Stravrogin, “You're like him, very like, perhaps you're a relation—only mine is a bright falcon and a prince and you're an owl and a shopman.”Interestingly, not unlike the patients described in Capgras syndrome, she accuses him not only of being an imposter but of having murdered the original Stravrogin.

In the 1950s, the Invasion of the Body Snatchers in its many versions became a popular theme, and it too is a Capgras variant, albeit one with a paranoid flavor. Aliens from outer space take over the bodies of earthlings and possess their physical beings, masquerading as the original. As in the real Capgras syndrome, subtle personal or physical characteristics can be a tip-off to the deception. While these alien invaders have nefarious goals, another contemporary version of the Capgras delusion, the Heaven's Gate Cult, welcomed the possession. The Heaven's Gate Cult was a group led by a charismatic leader who committed mass suicide in 1997. The members believed that they were originally descended from alien beings from outer space and put on earth for a period of time, during which their bodies were merely the “vehicles” of their spirits. They had completed their time on earth, and a ritual suicide enabled them to be spiritually transported back to the “mother-ship” of their origin. This


is a collective family romance in which the cult members’ origins are denied and replaced by the fantasy of an alien, and, in their minds, a higher birth.

Capgras and Reboul-Lachaux proposed in their original article an explanation for the “illusion des sosies” in their patient Mme. M. These authors found that Mme M. had intact memory for faces and she showed no evidence of perceptual disturbance; however, the faces that she misidentified no longer evoked the usual emotional reaction in her. They

. . .are nevertheless no longer accompanied by this feeling of exclusive familiarity which determines direct perception, immediate recognition. The feeling of strangeness is associated with recognition which conflicts with it. The patient, whilst picking up on a very narrow resemblance between two images, ceases to identify them because of the different emotions they elicit. Quite naturally she attributes to these similar beings, or rather to this unique, unknown personality, the name of doubles. With her, the delusion of doubles is not therefore really a sensory delusion, but rather the conclusion of an emotional judgement.13

For Mme. M., intact perception of certain persons bumps up against a “feeling of strangeness,” and an emotional conflict is created. She then justified the lack of emotional response to the misidentified person with the confabulation that the original person has been replaced by a double, and the “illusion of sosies” is the result. What kind of brain damage could lead to the separation of intact recognition from the appropriate emotional response? I will consider this question at the end of this chapter, but first I will describe another disorder related to the Capgras syndrome.

Frégoli Syndrome

While some patients lose their sense of personal relatedness, others seem to gain the same quality. Four years after the publication of Capgras and Reboul-Lachaux's report, two other French physicians, Courbon and Fail, published a paper entitled“Syndrome d'illusion de Frégoli et schizophrénie.”14 In this report, they described a case of “delusion of doubles.” But while patients with Capgras syndrome found imaginary differences between people, their patient found imaginary likenesses in the people around her—the opposite of Capgras syndrome.

Courbon and Fail described a twenty-seven-year-old woman who was diagnosed with schizophrenia. The woman developed a series of delusions


in which she believed that her enemies were persecuting her. Chief among her persecutors were the famous actresses Robine and Sarah Bernhardt, both of whom she had actually once seen in the theater. She felt that these two actresses were pursuing her and were taking on the appearance or physical form of her acquaintances. Robine was able to enter the body of her neighbors or passersby, and she could force other friends and neighbors to do the same. Although the patient reported that the persons who were being impersonated, such as the nurses on her psychiatric floor, bore no physical resemblance to the actresses Robine and Bernhardt, they were still in a sense “possessed” by them or had been “psychologically occupied” by the actresses.

Courbon and Fail named the disorder after Leopoldo Frégoli, an Italian actor famous in France for his uncanny abilities of mimicry, in which he seemed to take on the physical appearance of others. Unlike the Capgras syndrome, which involves the alienation or disavowal of identity and personal relatedness, the Frégoli syndrome is actually an avowal or insertion of identity, a creation of personal relatedness. While patients with Capgras syndrome more often than not misidentify people close to them, patients with Fregoli syndrome usually misidentify people they hardly know, such as acquaintances or neighbors. The most dramatic and florid forms of Frégoli are seen in psychiatric patients with serious illness, particularly schizophrenia.

Burnham described such a patient who after a period of acute mental disorganization perceived members of the hospital staff and fellow patients as people he knew from his past, including celebrities he knew only through news and television.15 The misidentifications were sometimes composites of more than one person. For example, the patient misidentified an aide on the floor as a combination of Art Linkletter, Lester Borden (identified as an axe murderer like his sister Lizzy Borden), and other persons from the patient's hometown, including his landlord. Another aide on the floor was misidentified as a composite of the patient's father, Abraham Lincoln, and a psychiatric aide. Other celebrity misperceptions by this patient included Walter Winchell, Dorothy Parker, Bert Lahr, Tallulah Bankhead, Gladys George, Lawrence Tibbett, Loretta Young, Alfred Gwynne Vanderbilt, William Vanderbilt, Franklin D. Roosevelt, Charlie Chaplin, and Albert Einstein. In some instances, the actual persons misidentified bore some physical similarity to their celebrity imposters: a man believed to be Roosevelt had a large head and a crippled arm, and the Vanderbilt imposters were spoken of as being aloof. My patient Fannie had Frčgoli syndrome for one of her fellow patients.




Fannie, a fifty-four-year-old executive, was admitted to the hospital for the gradual onset of a change in her personality. The CAT scan done on admission revealed bilateral brain tumors involving the frontal lobes (Figure 3-1). The lesions were diagnosed as brain metastasis from a lung cancer. She denied being ill, although she had been told many times. She claimed that her hospital roommate (whom she did not know) was familiar to her.

FEINBERG: How are you today?

FANNIE: Pretty good. I've got a bit of a headache, though.

FEINBERG: Do you know where you are now?

FANNIE: In the hospital.

FEINBERG: You told me before you knew someone here.

FANNIE: Yes, the lady in the bed over there [points to the next bed] is the double of someone I work with! She's just like her!


FANNIE: Yeah. Except this one has a different lifestyle. She's a swinger. And she has a different family. Also, this one has brain cancer!

Fannie inserted the identity of a coworker into her hospital roommate. She denied being ill, but reported her roommate as having “brain cancer,” which was the patient's own diagnosis, which Fannie had been told. Fannie actually had no knowledge of why her roommate was in the hospital. Interestingly, she later told me that even though the roommate was the double of an office coworker, she had the same initials as


Figure 31. This CAT scan shows the focal damage incurred to Fannie's brain as a result of two bilateral tumors involving her frontal lobes. Notice that the right tumor is nearly two times the size of the left.



the patient herself. This was significant in light of the fact that while the patient appeared unaware of her illness, she attributed a false diagnosis to her roommate, albeit her own diagnosis, implying some implicit awareness of her own illness. My friend and colleague neuropsychologist Joe Giacino brought to my attention the most florid case of Fregoli syndrome I have ever seen.16


Bart is a gentleman in his sixties. He is married and has several sons. Bart suffered a major head injury that resulted in extensive hemorrhages in his right frontal lobe, as well as smaller left temporoparietal brain contusions. He was extremely lethargic when first admitted to the hospital, but had made good improvement over the ensuing weeks.

When I spoke to Bart, he seemed fine. There was no hint of agitation or confusion. He spoke in a clear and confident voice, and his behavior gave no hint of the fact that he suffered from profound neuropsychological impairments, especially in the areas of memory and frontal lobe functions such as organization, mental flexibility, and self-monitoring.

Bart made a total of thirteen misidentifications during his hospital stay. In his mind, the hospital was populated with family, friends, and coworkers. There were five misidentifications in which Bart claimed that persons barely known to him on the hospital unit were one of his sons or daughters-in-law. Four fellow patients or visitors to the hospital were identified as coworkers or business contacts. An administrator was called the town mayor, a social worker was referred to as an old boss, and some visitors were identified as family friends. At one point, Bart even claimed that a professional ice skater on television was actually himself.

Some patients claim that their entire environment, including people, is overfamiliar. My patient JP was quite convinced that he was attending a business meeting despite substantial evidence to the contrary.


JP, an insurance salesman and someone who impeccably resembled the famous financier, J. Pierpont Morgan, was hospitalized for blood clots that were compressing his frontal lobes (Figure 3-2,). Despite evidence to the contrary—his supine position in a hospital bed, moaning patients in his room, the beeping of heart monitors, staff pagers, pungent antiseptic, meal trays—he insisted that we were in a conference hall. What's more, his speech was peppered with references to money.




Figure 32. Blood clots, known as subdural hematomas, led to the equally distributed compression of JP's frontal lobes, as depicted in this CAT scan, resulting in the bizarre belief that JP was attending a sales conference, when in fact he was lying in a hospital bed clothed only in a gown.

FEINBERG: What are you doing here, where we are right now? Tell me what you're doing here?

JP: Well, this is a meeting that occurs every year set up by the sponsors. The head of that outfit this year is [he names his boss.]

FEINBERG: He's the head of that outfit? What's the name of the meeting?

JP: The name of the meeting is A Meeting for Integrated Friendship to the Poor in This Country.

The patient reported that he was currently attending this meeting.

FEINBERG: Are the people here. . . what are they receiving?

JP: They receive standard wage to my knowledge. . . very little more and I don't think much less!

FEINBERG: What kind of work do I do, sir?

JP: I take you for the vice-president for marketing for a major corporation.

JP reported all these improbable circumstances, yet he seemed unaware of his own difficulties. He held to his misidentifications in spite of being interviewed while laying in the bed wearing a hospital gown and wrapped up in white hospital sheets.

FEINBERG: OK, now, but one might call this a white lab coat. [I gestured to my coat.] And um. . . this name tag with the hospital's name on it. Do you have any other idea what I might do? Could I have another occupation? An alternative occupation? I'm asking you, Can you think of anything else I might do?

JP: I expect that you spend most of your time trying to sell your product.

FEINBERG: Trying to sell my product?

JP: Yes. And trying hard!



FEINBERG: Sir, it's not possible that you're a patient here is it? Could you be a patient?

JP: No, no,

FEINBERG: You're positive. . . There's nothing wrong with you. You feel 100%.

JP: Let's put it this way. I'm an ad patient.

The character Dorothy, as portrayed by Judy Garland in the movie The Wizard of Oz, is perhaps the best-known fictional case of the Fregoli syndrome. When we first meet Dorothy, she is at home in Kansas with her family and friends and her beloved dog, Toto. Almost immediately Dorothy faces psychological disaster. The nasty and merciless Miss Gulch, armed with a sheriff's order appears at Uncle Henry and Aunt Em's farm and takes Toto away. Although Toto manages to escape from Miss Gulch, Dorothy decides that if she is to save Toto's life, she must run away from home.

Not far into her journey, however, Dorothy meets Professor Marvel, who encourages her to return to her family. But it is already too late. By the time she arrives at the farm, a fierce twister is brewing, and the farmhands Hunk, Hickory, and Zeke along with Henry and Em are already safe in the storm cellar. Dorothy, now alone and exposed to the terrible winds of the cyclone, suffers a severe blow to her head and lapses into a coma. She then dreams that she travels to the mysterious and alien land of Oz.

Just as Dorothy desperately attempted to reunite with her family during the cyclone in Kansas, when she is in the Land of Oz she fervently wishes to return to her loved ones at home. But when Dorothy finally does “return home” and wakes up from unconsciousness, Auntie Em informs her that she never really left Kansas. Although Dorothy cannot accept that her experience in Oz was just a dream, she senses that many of the people in Oz were “actually” people she knew from Kansas. Rubbing the bump on her head, she protests: “No . . . but it wasn't a dream. It was a place . . . and you . . . and you . . . and you . . . and you were there!” Dorothy now realizes that the Scarecrow, the Tin Woodman, and the Cowardly Lion were transformed versions of the farmhands Hunk, Hickory, and Zeke and, further, that the Wizard was an alternative version of Professor Marvel. And we know, although Dorothy does not say it, that the recently deceased Wicked Witch of the West was in reality a duplicated Miss Gulch. Therefore, just as in a Frégoli delusion, many of the individuals Dorothy encountered in Oz were transformed versions of her personal acquaintances from Kansas. It turns out that Dorothy really never left Kansas, literally or figuratively.



Environmental Reduplication

By far the most common Frégoli-like misidentification in neurology involves the insertion of a place of personal significance into relatively unfamiliar surroundings. This often occurs in the setting of patients who have sustained serious head injury as a result of traumatic accidents, or in patients who have suffered bleeding into frontal brain areas from ruptured vessels. Disoriented patients tend to mislocalize themselves to a point closer to their own home. Sometimes the patient claims that there are two versions of a particular place, one in their own neighborhood, and another in the correct location. When a patient states that there are two or more versions of a particular place, the syndrome is called environmental reduplication.

The first report of environmental reduplication was described in 1903 by German neurologist Arnold Pick.17 Dr. Pick described a sixty-seven-year-old woman who was admitted to hospital suffering from what at the time were called “psychopathic symptoms,” which included depression, forgetfulness, delusions, disordered memory, nightmares, and disorientation for time. The memory disturbance appeared to be particularly prominent, and the patient demonstrated lively confabulation. While actually hospitalized in Prague, she reported that the clinic was located in her hometown of “K.” When asked how Professor Pick had come to “K” and how the clinic and other doctors could have come there as well, she exclaimed, “Why, good God! Everything can go round about and back again.” She spoke of two clinics, the “town” clinic and the “suburb” clinic. She tended to locate herself in the suburb clinic, nearer to her home.

Patterson and Zangwill described another interesting patient in Edinburgh, Scotland.18 A twenty-two-year-old man fell from a height of twenty feet and sustained a severe head injury that resulted in a two-day coma. He gradually regained consciousness in the Brain Injury Unit and awoke restless, confused, and disoriented. He was diagnosed with bilateral brain damage, with most of the damage involving the right hemisphere. While he would say he was in Scotland, his behavior made it clear that he felt he was at home in Grimsby, England. Shortly thereafter, he reported that he was in a hospital two miles outside of Grimsby. When the good doctors pointed out that he could not be in both Grimsby and Scotland, he explained that Grimsby and Scotland were the same place. He even suggested that Grimsby could be a part of Scotland. He reported, “If it comes to the map, this part is the north of Scotland . . . but if people say, ‘Do you live here?’ I say, ‘Yes


Grimsby!’ . . . I feel I'm right . . . I know by my own language, by my own town streets.” He suggested that there was a dividing line between England and Scotland that ran through Grimsby. At another point he reported, “I call it Grimsby and you call it Scotland. . . on the map it's Scotland.” He also reported that the doctors in Grimsby were also the doctors in Scotland.

Certainly one of the most ironic twists of neurological fate occurred to a physician, Dr. Max Levin, who was a clinical professor of neurology at New York Medical College with a practice in what was at the time the Flower and Fifth Avenue Hospital. Dr. Levin wrote frequently about the nature and causes of delirium and delirious thinking.19 He was fascinated by how the brain operated under states of confusion and paid particular attention to the delirium caused by an overdose of bromide, which was apparently a fairly common occurrence when bromide was in widespread use as a medicinal. The confusion that results from bromide intoxication became known as a “bromide delirium” or “bromide psychosis.”20 It resembles the diffuse types of brain impairment that we have already seen results in disorientation and misidentification after other generalized brain insults.

Levin was an adherent of Hughling Jackson's view of hierarchical thinking.21 According to Jackson (who is also widely considered the father of modern neurology), the most automatic kinds of actions—those that require the least amount of complex thought—would predominate in states of brain disorganization. Under these conditions, whatever is unfamiliar to the patient, such as hospital surroundings and strangers, should be mistaken for things more familiar. In other words, the brain-damaged patient resorts to primitive, reflexive, automatic modes of thought, in which the least flexible, most overlearned association would predominate. Levin called this the law of the unfamiliar mistaken for the familiar.22 Levin became quite an authority on this subject and wrote multiple papers and chapters on the topic. The Encyclopaedia Britannica even asked him to write an article on delirium for its 1961 edition. And all was well and good for Dr. Levin until, as he later put it, “Fate played a trick on me.” Dr. Levin himself ran into a case of delirium in which he was the patient.

On a Wednesday afternoon in May 1966, Dr. Levin felt ill, took his temperature, and found he had several degrees of fever. It turned out that his symptoms were the onset of a severe case of cerebral meningitis due to pneumococcal infection. He was admitted to Presbyterian Hospital in New York and for several days fluctuated between coma and delirium. After a period of severe confusion, Dr. Levin reported the following experience.23



He had been told that he was in Presbyterian Hospital, and he knew he was in Presbyterian Hospital, but he had what he called the “remarkable misconception” that the hospital was located much closer to his home than it was in reality. His home was on Central Park West at 94th Street. The hospital is located on Broadway at 168th Street. This would place the hospital several miles from his house. During this period of disorientation, Dr. Levin thought that he was in a small “branch” of Presbyterian Hospital, on Broadway at 98th Street, which would place it less than a mile from his home. In Dr. Levin's mind, there were two Columbia Presbyterians: one, a small branch located near his home on 98th Street and Broadway, where he was hospitalized; and the real Columbia Presbyterian, in its usual location on 168th Street in Upper Manhattan. Dr. Levin had known of an observation made by Drs. Weinstein and Kahn that patients in states of confusion would often reduplicate the hospitals and erroneously mislocate themselves at a location closer to their home or place of business, often referring to this other location as an “annex” or “branch.” When he recovered from his illness, he was stunned at the confirmation of their findings provided by his own experience.

When a patient misidentifies a stranger as a relation, we call it Frégoli syndrome. When the patient mislocates the hospital in his or her own backyard and doubles the place, we call it environmental reduplication. However, both syndromes represent a change in the self, in the sense that one's relatedness to the world undergoes a transformation. The boundaries of the self are altered, and one's personal world draws nearer.

The Capgras-Frégoli Dichotomy

How do these disorders relate to one another, to the self and its boundaries? The clinical material suggests that the Capgras-Frégoli dichotomy can serve as a unifying principle in understanding many perturbations of the self. We first note the similarity between the Capgras syndrome and jamais vu phenomena. Everyone has had the experience of seeing a familiar place, or person, or being involved in a familiar activity, yet feeling a strange, somewhat disturbing sensation of a lack of personal relatedness. Put another way, one might say that this entails an alienation from or estrangement from something that one knows should be familiar. The emotional force of such an experience is derived from the fact that the individual knows that a personal relationship to whatever object is involved should exist, yet the feeling of relatedness is gone.

In this sense, the Capgras syndrome is an alteration of relatedness, as


opposed to an alteration in familiarity per se: the entity involved looks familiar, it appears familiar, the memory necessary for familiarity is present, but the personal relatedness is lacking. The patient recognizes the spouse as the person who should be the spouse, but the patient disavows the spouse because he or she does not feel like the spouse. It is a withdrawal of personal relatedness—a disavowal or alienation—that sets the stage for the Capgras-like misidentification.

In the same way that one can lose relatedness to a spouse or family member, asomatognosia can be interpreted as a loss or withdrawal of personal relatedness to the body. This is not to say that sensory loss, weakness, paralysis, neglect, confusion, and a myriad of other factors do not contribute to the loss of relatedness or alienation. These are important ingredients, but they do not account for the psychological reaction of the patient to this loss. The neurological conditions set the stage for the perturbation of the relatedness of the self to the misidentified entity.

Frégoli syndrome, on the other hand, represents the opposite side of the continuum. Frégoli syndrome repesents overrelatedness to something. In this sense, it resembles déjŕ vu, where something relatively unfamiliar or unrelated to the patient is interpreted as bearing a particular personal significance. In contrast to Capgras, which represents withdrawal of personal relatedness, one can interpret a Frégoli-like disturbance as an insertion of personal relatedness. Here, items unfamiliar to the patient are interpreted as imbued with personal relatedness that in reality does not exist.

Whether it is an arm, as in asomatognosia, or a spouse, as in Capgras, the self has withdrawn its involvement. The personal relatedness to the body part, person, place, or event is lost. There is also, however, often a compensatory insertion, a simultaneous avowal, a creation of identity with the same entity. This is how many perturbations of the self in neurology are simultaneous withdrawal and insertion of personal relatedness.24

It is intriguing how malleable the boundaries of the self are. The self does not exist as a rigid structure, in the way our outer skin separates us from the world. Rather, like the amoeba, the self displays an uncanny ability to change its shape, alter its margins, reform and regenerate new parts as needed. The patients described in this chapter reveal the hidden potential for an altered permeability between the self and the world, a fracture in the self-boundary. There is loss of self, but due to an increased permeability of the self-boundary, the self may expand as well.



These patients produce narratives that suggest their personal relatedness to the world has gone awry. Their self, their sense of identity, has either merged or diverged from their personal world. These patients teach us that the stuff of the self is inextricably bound up with that which has personal significance. It may be true that we are what we eat, but truer, where the mind is concerned, that we are what we love.

Disorders of Personal Relatedness and the Anatomy of the Self

Because the self displays this ability to change and adapt with existing circumstances, it is sometimes difficult to be precise regarding its neurological, material basis. In spite of this, some clues regarding the neurological basis of these conditions are emerging. The overwhelming majority of patients who misname, reject, or disown a paralyzed arm have lesions of the right hemisphere. This is partly explained by the greater frequency of neglect in patients with damage to the right hemisphere. In the patient with neglect, the left arm is ignored in the manner that all stimuli on the patient's left side are ignored. But this cannot be the whole story. If it was, when the left arm is shown to the patients on their side, in their right visual field, and viewed by the patients’ left hemisphere, the arm is still rejected. Something more is going on.

There are other possible reasons why asomatognosia is more common in the presence of damage to the right hemisphere. When a patient explicitly misidentifies a limb, or calls it by another name, or personifies it, or talks about taking it home in a valise, these verbal behaviors depend in part on an intact left hemisphere. Asomatognosia is not the outcome of right hemisphere damage only, but rather results from the interaction between a damaged right hemisphere and a relatively intact, but altered, left hemisphere.

Right hemisphere damage is a factor in the production of other misidentification syndromes as well. Reduplicative paramnesia, for instance, has been found to be more common after damage to the right hemisphere. In one study, Benson and his associates analyzed a small series of patients with reduplicative paramnesia and found, in all cases, damage to posterior portions of the right hemisphere.25 The association between right hemisphere damage and reduplicative paramnesia was corroborated in a similar study done by Ruff and Volpe.26 In order to explore this relationship further, a colleague and I reviewed a series of sixtynine published cases of cases of reduplicative paramnesia. We also found a strong association between this syndrome and right hemisphere damage.27



Some well-known cases of Capgras syndrome have been linked to right hemisphere injury. Staton and colleagues described a young man who at age twenty-three sustained extensive brain damage as the result of a serious car accident.28 A CAT scan of his brain confirmed extensive damage to his right hemisphere, including the parietal and temporal lobes. This unfortunate young man had a major change in personality, and over the months following his injury he became withdrawn, irritable, and displayed an explosive temper. Eight years after the injury, he became convinced that his friends and relatives were “look-alikes” of the originals. He even claimed his cat wasn't “real” as evidenced by a new scar on its ear. In another case, Alexander and coworkers described a forty-four-year-old man with a head injury and damage to his right hemisphere.29 Before the injury the patient had displayed paranoid delusions about his job; after the head injury the patient became convinced that he had two nearly identical families.

What factors could produce distorted personal relatedness in these cases? Many neuroscientists who have emphasized the right hemisphere's role in these disorders have done so on the basis of its vast temporolimbic connections—that is, the pathways that connect the temporal lobe, which is important for memory, to the limbic system, the portion of the brain linked to emotion, pain, pleasure, and motivation. Alexander and coworkers suggested that both Capgras syndrome and reduplication could result from “a distorted yet irresistible sense of familiarity, but not identity, about a place or a person.”30 This could be attributed to lesions of the right temporal and frontal lobes that disrupted the normal temporolimbic connections.

Staton and his colleagues made a similar argument to explain Capgras syndrome in their patient with right hemisphere injury.31 These authors suggested that their patient with Capgras syndrome had a disconnection between his past memory stores and his current experience. The functional disconnection of memory and current experience was the result of an anatomical separation between the patient's hippocampus, a structure known to be important in forming new memories, from other brain areas important for past memory stores.

Although not specifically implicating the right hemisphere, Ellis and Young offered another suggestion regarding the origin of Capgras syndrome.32 These authors suggested that there are two anatomically distinct routes that are involved with visual facial recognition. A “ventral route” is important for explicit recognition of facial identity. This route is crucial for matching the perceptual features of a face to stored memories, and damage to this route leads to the condition of prosopognosia.


A second “dorsal route” is necessary for the recognition of the emotional significance of faces. This route connects visual areas of the brain with the limbic system, an area of the brain that is important for emotional processing. Because the patient has an intact ventral route, faces are recognized, but a disconnection of the dorsal route leaves the patient without the proper emotional response to the face. The patient develops the Capgras delusion in an effort to resolve the conflicting perceptual and emotional information.

There are other lines of evidence that support the notion that patients with right hemisphere lesions may indeed experience a distorted sense of familiarity. Landis and his colleagues reported a series of cases, all with at least a right hemisphere lesion, and all who had lost a feeling of familiarity with their environments.33 These patients tended to get lost in familiar surroundings, and found a lack of relatedness to their world. There is also experimental evidence that provides support for the right hemisphere's greater involvement in discerning the familiar and the personally relevant. In a series of studies, Van Lancker and colleague have demonstrated a right hemisphere superiority in a range of tasks, assessing a subject's ability to discern familiar from unfamiliar voices.34 There is a similar right hemisphere specialization for recognizing familiar names, whether spoken or written.

Analysis of these cases appears to suggest a special role for the right hemisphere in maintaining identity. But many cases of delusional misidentification do not have selective damage to the right hemisphere. For example, Dr. Levin, who displayed environmental reduplication, suffered from pneumococcal meningitis, a bacterial infection of the outer covering of the entire brain. Meningitis most often affects brain physiology in a generalized way. The patient so affected shows decreased alertness and mental confusion, symptoms that suggest that the brain is diffusely affected by the pathological process. Many patients with environmental reduplication have diffuse brain disorders. Many patients with Capgras syndrome suffer from early Alzheimer's disease; a disorder that may affect widely distributed brain areas. A large number of patients with Frégoli or Capgras syndromes have psychiatric illness whose underlying brain pathology is unknown, but probably the disease process is not confined to the right hemisphere.

Different disorders, with a variety of underlying brain pathologies, can result in alteration of the ego. However, all the theories discussed here that consider the origin of the delusional misidentification syndromes posit that accurate recognition of the personal significance of persons, places, and things must involve multiple brain regions. Furthermore,


these different brain regions have to be connected through complex pathways that integrate diverse regions of the brain. How does the brain unify these different regions in a manner that enables the creation of a coherent sense of self and personal relatedness? This is one of the many questions that must be addressed if we are to understand how the brain creates a unified ego.

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