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



“Look here, you,” I blurted. “Don't you really see anything?” He rolled over and sat up. “What's the idea?” he asked, a frown of suspicion darkening his face. I said: “You must be blind.” For some ten seconds we kept looking at each other's eyes. Slowly I raised my right arm, but his left arm did not rise, as I had almost expected it to do. I closed my left eye, but both his eyes remained open. I showed him my tongue. He muttered again: “What's up? What's up?” I produced a pocket mirror. Even as he took it, he pawed at his face, then glanced at his palm, but found neither blood nor bird spat. He looked at himself in the skyblue glass. Gave it back with a shrug. “You fool.” I cried. “Don't you see that we two—don't you see, you fool, that we are—Now listen—take a good look at me. . .”

--Vladimir Nabokov, Despair

Patients with personal confabulation confuse the margins of the self, figuratively speaking. By this I mean, in the context of the confabulation, that the self makes a personal appearance in the guise of a character within a story of the patient's own making. Patients with asomatognosia, on the other hand, seem to lose a part of the self in a more literal sense. The arm in the patient with severe asomatognosia may be totally rejected and personified as if it belonged to someone else. I would now like to discuss another condition—mirror misidentification—in which the patient misidentifies not the actual body, but its mirror image.

Mirror Misidentification

It is somewhat surprising how vulnerable some aspects of self-recognition actually are. In the novel Despair, Nabokov's protagonist, Herman, engenders a double identity in a total stranger, Felix. Faking his own death—and thinking that others will believe that he is dead—Herman kills Felix in an attempt to cash in on his insurance policy and live the good


life. Like Herman, two of the more perplexing patients I have examined exhibited strange behaviors when confronted with mirrors: their reflections bore no resemblance to themselves. Both women, in their early seventies, showed signs of cognitive impairment due to either stroke or dementia. Both women demonstrated utterly fascinating misidentifications of their mirror images.


Susan, a woman in her sixties, was hearing impaired since the age of five and developed the ability to communicate by lip reading as well as sign language. She developed indications of right hemisphere dysfunction on her visual exam; this inference was confirmed by an MRI of the brain, which demonstrated atrophy of the right temporoparietal regions.

Over a period of time, Susan used sign language in front of the mirror in her bedroom. When asked what she was doing, she reported that she was communicating with the “other” Susan. She believed that there was another Susan who was identical to her in appearance, age, background, education, and so on. This other Susan was always seen in a mirror. Susan explained that the other Susan was also deaf and also used sign language to communicate. She and the other Susan had gone to the same grade school, but they “did not know each other” at that time. The other Susan had a child identical in appearance to the patient's own and she and her double were virtually identical in every respect, only the other Susan had a tendency to talk too much and did not communicate as well as the real Susan in sign language. She elaborated about the other Susan:

SUSAN: Well, she's all right . . .sounds funny for me talking from one Susan to another, because you know she was a new person to me, and I'm surprised. She was all right, but she's very nervous, she likes to do her own ways . . .she never knew that she couldn't hear so good, and she's not a very good lip reader. I had to do mostly in sign language for her, to make her understand . . .she copies every word I say like this, like this motion. . .she doesn't even know the sign language very well, and I was confused a little bit, you know, because I wanted her. I thought she knew the sign language very well, so I won't have to repeat it twice, but then I found out that she's not that bright. I hate to say that . . .I don't want to brag, but she's a nice person; but one thing about her . . .I see her everyday through a minor, and that's the only


place I can see her. When she sees me through the mirror, she looks a little then she comes over and talks to me, and that's how we began becoming friends through our sign language. She was very nice.

Like the cases of Capgras syndrome that were described in chapter 3, Susan does not demonstrate prosopagnosia. The person with prosopagnosia has a generalized disturbance in face recognition. Patients with prosopagnosia cannot identify anyone by looking at his or her face. In other words, it is a specific visual identification disorder, not a denial of identity. Susan was able to accurately identify other family members, physicians, and neighbors. She never misidentified anyone but herself in the mirror. If either a family member or I stood behind Susan as she looked in a mirror, she always correctly identified the other person's reflection as a mirror image. Thus, we cannot say that her failure to identify her own mirror image occurred on a purely perceptual basis.

Susan's condition is a Capgras syndrome for her mirror image.1 An early description of this condition was provided in 1968 by Gluckman.2 In this paper, Gluckman described a sixty-one-year-old woman who suffered from cerebral atrophy and a severe psychiatric condition that Gluckman diagnosed as paranoid schizophrenia. This patient complained that a woman who was the patient's double lived in her house and imitated her in every way. The patient was afraid of the double, and she referred to her as “an old hag” or “an ugly hag.” Gluckman described what happened when his patient stood in front of a full-length mirror:

When I stood beside her she could identify my mirror image but her own mirror image was always the thing. She would on request smile, look angry, make a fist, or comb her hair in front of the mirror. She could never identify these actions in the double. They were always a take-off or a means of mocking her or insulting her. Yet she could interpret the mirror image of every gesture or facial expression or action made by me perfectly normally.

Gluckman's patient had a very negative reaction to her mirror image and she threw a bucket of water and other objects at the mirror image in an attempt to get the double to leave the house. The patient's husband had to cover all the reflecting surfaces in the house with paper, and he could not take her in a car because she saw the double reflected in the paint and windows of their car. Another patient of mine, Rosamond, displayed a striking, frightening, and sometimes dangerous, misidentification of her mirror image.




A semiretired gentleman from a middle-class Italian neighborhood in Queens, Richard B., brings his wife to my office. Richard and his wife, Rosamond, have been married for more than thirty years and have successfully raised two children together. Just recently she has begun to exhibit an odd behavior that worries her husband and their two grownup children: Whenever Rosamond sees her reflection, she is convinced that a strange woman is following her. When she asks the woman to identify herself, she refuses to talk, so Rosamond—first verbally, then physically—attacks her reflection. Richard cannot let her stay alone in the bathroom because she attacks the mirror on the medicine cabinet. At night, she cannot pass the living room window without ranting and raving at the woman who is apparently outside looking in. She yells, “You tramp! Go on home!. . .Leave us alone!”

The woman appears in the windows of parked cars and in storefronts along the streets of their neighborhood. In broad daylight, Rosamond screams and wildly flails her arms at her. While Rosamond's family is quite embarrassed by her behavior, they are also afraid that she will harm herself.

Richard's account of his wife's behavior is at first quite surprising to me, since Rosamond's outward appearance is somewhat grandmotherly, prim, and proper. She adjusts the buttons on her cardigan sweater, firmly clasps her leather purse against her stomach, and brushes the lint off her pant legs while meekly answering my questions. She is obviously unaware of the wild behaviors that her husband reports to me.

During the course of my interview, Rosamond sat quietly listening while her husband described her symptoms; she didn't appear particularly agitated. I had a mirror hidden behind my back, anticipating her visit, and I presented it to her, so she could observe her own reflection. She looked at it for about ten seconds, then she stood up and down and raised her eyebrows and became quite angry and disturbed.

ROSAMOND: Did you hear the story? Eh? Did you hear it? Now you get out. . . get home where you belong. You don't belong here. . .you don't live here! Out! [Waving her hand.]

Her entire demeanor changed. Her face became almost contorted in agitation.

FEINBERG: Who is that?

ROSAMOND: [Screaming] That's her, that's her! Yeah, that's her. . .sure


that's her! She has no name. . .I never heard her name. . .never, never! I never! She never told me her name. No, no. . .you can't go in the house! No, you can't go in the house! She never let me know, had a lot of problems with her

Then her eyes intensified, her face got within one foot of the mirror.


FEINBERG: Does she remind you of anybody you know?

ROSAMOND: No. . . no, I never knew her.

She shook her hand as if to cast the mirror image away from her. Then she pointed to it, claiming,

ROSAMOND: Yeah, not this here one. Then she starts calling me these kind of names, street walker. . . cannot stand her.

Her poor husband sat there worrying with his brow furrowed. She hovered over the mirror:

ROSAMOND: You don't belong here. . . you don't belong here. Yeah, you. What are. . .you looking at? Tell them where you live. . .tell them today. Tell them where you live. . .heh? Yeah?

As she screamed at the mirror, she started to tidy herself up, pulling her sweater together in front to produce the proper presentation.

ROSAMOND: What do you mean we, we? Who are you? What's your name? Tell me your name? Heh? Do you know your name? Where do you live? Get the hell outta here!

FEINBERG: How old do you think she is?

ROSAMOND: I don't know, she's just an old bag. . .she's a bag. Yeah, and you, and you. Heh, I'm not afraid of you. Go ahead. . .I don't know she's just an old bag. Yeah, she's a bag. . .yeah, afraid to say it.

FEINBERG: You know, she looks a little like you.

ROSAMOND: No, she don't. . .come on, are you sure?

FEINBERG: Of course.

ROSAMOND: Look, she has no glasses. [The patient was wearing glasses.]

FEINBERG: Take a good look.

ROSAMOND: It's not. . .it's not me. . . it's not me! [Fingering the top button of her blouse, which was closed.]

FEINBERG: Where are your glasses? You don't have glasses?



I turned the mirror over, so that she was now looking at the cardboard backing.

FEINBERG: Where did she go?

ROSAMOND: I don't know.

FEINBERG: Is she gone?

ROSAMOND: No, not gone.

FEINBERG: How can I make her go away just by turning this mirror around? What is this here [tapping the back of the mirror].

ROSAMOND: It's a mirror. . .as if I'm some kind of idiot. Shut up.

I turn back to the reflected side and once again she looks right at it.

ROSAMOND: What's your name [talking back to the mirror]? Tell him what's your name [shaking her finger at her reflection]!

FEINBERG: Is she in the mirror?

ROSAMOND: Tell em where you live! Tell him where you live! You don't know where she lives. She's not in the mirror.

FEINBERG: Is she in the mirror?

ROSAMOND: She's not in the mirror. Heh, she's not in the minor.

FEINBERG: Hold it, here, take it, look, look. [I turned the mirror around, flipping it back and forth.]

ROSAMOND: You want to know who she is? You want to know who she is? Because you're a. . .that's what you are. We know where you live. Where do you live? You know what? You're a good for nothin'. You know what? You're a good for nothin'. Yeah, where you walk. . .yeah, you little bitch. . .yeah. Now you know where you're gonna go? You're gonna go home. . .and when we get home, you know what? We're gonna find her right around the. . .we'll find her walkin right around the windows. In the windows where she watches. . .listens to what we do. I can't stand her. . .she's been walking around the house, around the area for a long time. . .you know that? All the time she bothers everybody. I always wanted to hit her!

She eventually became so agitated that I had to take the mirror away from her to calm her down. She sat hunched over, rubbing her knees back and forth.

ROSAMOND: I'm gonna kill her. . .so mad at her.

Her husband became concerned that Rosamond was going to stand in front of the mirror with a knife and actually stab herself, so I needed to treat her immediately before she injured herself or her husband. The husband


reported that the misidentification occurred in any reflective surface, from glass in store windows to car mirrors. She did not, however, misidentify her reflection in the mirror of her cosmetic compact. It occurred to me that perhaps its small size made it less likely for the symptom to occur. So I first instructed her to take out the compact and asked her to identify her image, which she did correctly. Using a series of mirrors of increasing size, I was able to convince her as the reflection got larger, despite her initial protestations, that they represented her own reflection. I repeated this process over several days until her husband reported that the behavior had vanished.

The Self as Known and Knower

Susan, my first patient with mirror misidentification, claimed that this other version of herself in the mirror closely resembled her in all essential aspects of physical appearance, background, and education. Although Susan reported that she was looking in the mirror when she experienced this symptom, she did not seem aware or behave as if she were aware of this fact when using sign language in the mirror to communicate with the other Susan. Rosamond also was able to identify the mirror itself accurately. She could hold the mirror in her hands, examine it, identify it; yet she acted toward her image as if the reflection was another person. Susan and Rosamond acted as if their knowledge that they were looking in the mirror was dissociated from their behavior vis-a-vis the mirror. There is a separation of knowledge in a psychological sense: one domain of knowledge-perception of a person in the mirror-is not integrated with another-a self-concept. Susan and Rosamond have a pathological separation of the self as knower-the I that is the subjective aspect of the self that looks into the mirror and the self as known-the “me” that is the objective aspect of the self that is seen in the mirror.

These cases demonstrate that there may be some independence of the “I” from “me.” Psychologist William James did not believe there was an “I” that could be separated from the “me”; rather he saw the relationship between the self as subject and the self as object as two sides of the same coin. This is what William James had to say about the relationship between the subjective and objective aspects of the self:

Whatever I may be thinking of, I am always at the same time more or less aware of myself, of my personal existence. At the same time it is I who am aware; so that the total self of me, being as it were


duplex, partly known and partly knower, partly object and partly subject, must have two aspects discriminated in it, of which for shortness we may call one the Me and the other the I. I call these “discriminated aspects” and not separate things, because the identity of I with me, even in the very act of their discrimination, is perhaps the most ineradicable dictum of commonsense.3

All of us must maintain a delicate balance between the subjective and objective self in order to remain integrated selves. The boundaries of the self are in flux, however, and we may be more or less self-aware depending on the circumstances. Standing in front of a mirror makes us acutely self-aware; when asleep and dreaming, self-awareness is hardly present.

The ability to focus attention to the self, as assessed by mirror recognition, appears to be a complex mental state. The evidence suggests that this highest level of the self as an object to itself does not arise until relatively late in the history of evolution. Over twenty-five years ago, Gordon G. Gallup made a rather remarkable discovery.4 Most animals, up to the great apes, show no evidence of self-recognition when confronted with a mirror. For instance, monkeys, even after extended exposure to mirrors, react to them as if they were confronting another animal.

Gallup demonstrated how chimpanzees, when first exposed to a mirror, would initially react as if they were seeing another chimp and put on a display of social gestures directed toward her mirror image. After about two days, however, these animals began to use the mirror to groom themselves and view parts of their body they could not see using direct visual inspection. In other words, they came to act as if they were viewing themselves.

To be certain that these chimps had indeed developed a degree of self-awareness, Gallup marked the animals with bright red dye over an eye-brow and opposite ear and re-exposed them to the mirror. When marked in this fashion, the chimps showed clear efforts to inspect the marks on their own bodies, not on the image in the mirror. This response to mirrors has been reported to occur only in humans, chimps, and orangutans. Interestingly, gorillas show no ability to recognize themselves in the mirror.

A rhesus monkey does not recognize itself in the mirror. Yet when it sees itself “in the flesh,” when it directly sees its own hands, its own feet, or tail, it doesn't react with surprise or fear. So the category of “me” must be present in many animals. It would appear that, like consciousness


in general, it is just a more advanced, more complex me that enables self-recognition in the mirror.

Double Indemnity

Not every fictitious double is seen only in the mirror. In fact, the notion that each individual has a double that is dissociable from one's body is nearly a cultural universal. The ancient Egyptians believed in the existence of a “soul double.” They held that each individual had a spirit, or Ka, which was immaterial and distinct from the body. It served as an invisible double. Created at the time of an individual's birth and persisting after an individual's death, the Ka is prototypical of the belief that each person possesses a soul that is an immaterial double of each individual. The Nagas tribe, an Indo-Mongoloid group found in Asia, believe in a ghost who is an exact image of the deceased as he was at the moment of his death. They believed that all of the alterations of the body experienced during life such as scars, marks, tattoos, and mutilations were reproduced in the ghost of the individual.5

Literary references to doubling also abound. The idea appears in the work of Goethe, Guy de Maupassant, Edgar Allan Poe, Oscar Wilde, and Fyodor Dostoyevsky, among numerous other authors. The corpus of the myth of the Doppelganger is a prime example. The word “Doppelgänger” was first used by the German writer Jean Paul Richter.6 The Doppelganger in Richter's work appears as a pair of fellows, duplicates who together form a single individual but individually appear as half of an ego. Each half depends on the other “alter ego” for completeness. Richter writes in the novel Siebenkes:

Just as women friends like to wear the same sort of dresses, so did their souls wear life's Polish coat and morning dress, I mean two bodies with the same lapels, colours, buttonholes, trimmings and cut. . .7


Richter's work was undoubtedly influenced by the fact that he suffered from the disorder known as autoscopia. Autoscopia (also known as heutoscopia or hallucination speculaire) is the visual hallucination of the self projected into the outside world. Richter said of his own autoscopic hallucinations, “I look at him, he looks at me, and both of us hold our ego in horror.”8 Dostoyevsky, also fascinated by idea of the double, was an epileptic, and may have suffered from autoscopic hallucinations as


well, since epilepsy was one of the conditions that can cause autoscopic hallucinations.

Not surprisingly, Dostoyevsky, in his novel The Double, provides the most famous literary treatment of autoscopic hallucination. In this story, Petrovitch Golyadkin is an insecure bureaucrat in the midst of a period of acute anxiety and confusion. Petrovitch experiences both social and romantic rejection. On the verge of an emotional breakdown, he becomes suspicious and paranoid. During this period, Petrovitch is confronted by his double, which is presented as a palpable person, a separate visual entity. Unfortunately for poor Petrovitch, the double is a rather menacing presence. He manages to get Petrovitch in deep water with his colleagues and bosses, leaves him with bills to pay, and also gets him in trouble with women. In the end, Petrovitch has an apparition of dozens of Petrovitches and is taken off to an asylum.

Autoscopic hallucinations vary from case to case. The autoscopic vision is often semitransparent, ghost-like, or jelly-like. It has a realistic form, outline, shape, and density, but often does not approach the opacity of a real object, so that the person may be able to see through it. Some have described the autoscopic hallucination as very life-like, as if a real person were standing in front of oneself.9 An interesting feature of the autoscopic hallucination is that the illusion or hallucination frequently mimics the patient's own actions. Drs. Todd and Dewhurst treated a young woman who suffered from severe anxiety and depression and who had autoscopic hallucinations for four years. While hospitalized in a state of anxiety, she saw a vision of herself lying in a coffin. The double faithfully copied her movements. Sitting in a chair and knitting, she saw her autoscopic double similarly engaged. “[The] chimerical double looked solid and lifelike; it was usually dressed in the clothing that she herself was wearing, but occasionally affected a dress that she had recently admired in a shop window.”10

A central characteristic of autoscopic hallucinations is the close connection between the image and subject. There is a feeling of belonging to or of connection with the autoscopic hallucination that serves an important distinguishing feature. Unlike the Capgras patient, who denies or disavows the relationship between the image and relation, the hallucinating person feels a part of the autoscopic hallucination. There is a feeling of oneness with the hallucination. As Drs. Todd and Dewhurst put it, the hallucination is imbued with a “personal significance”; it bears a “sentiment of ownership with all the emotional and ideational accompaniments.”11

Autoscopic hallucinations can occur in patients who suffer from psychiatric


or neurological conditions. When the etiology of the autoscopy is neurological, epileptic disorders are the most common causes.12 Some of these patients have parietal lobe damage as a cause of their seizures. A fifty-seven-year-old World War I veteran who received a shrapnel wound to his right posterior parietal lobe began to have seizures several years after the injury. On an occasion during one of these spells, he reported, “I was in the doctor's surgery staring into the garden. Then I saw the man about four feet away to my left. It suddenly dawned on me who it was. It was me.” He saw a normal-sized image of himself, identical to himself, that lasted for approximately ten days. On another occasion he reported that he saw “crowds of tiny figures all the colors of the rainbow—all myself.”13

The former soldier experienced an externalized hallucination of himself. He still maintained his usual ego-centered point of view and was aware of the position of his body in space and remain embodied within it. There are other cases, however, where the patient has what might be called an “out-of-body experience,” and the person's physical self appears to be seen as if from an outside perspective.

For instance, Dr. Lippman describes a thirty-seven-year-old housewife and mother of three with autoscopic hallucinations that frequently occurred while she was serving breakfast.

There would be my husband and children, just as usual, and in a flash they didn't seem to be quite the same. They were my husband and children all right—but they certainly weren't the same. . .There was something queer about it all. I felt as if I were standing on an inclined plane, looking down on them from a height of a few feet, watching myself serve breakfast. It was as if I were in another dimension, looking at myself and them. I was not afraid, just amazed. I always knew that I was really with them. Yet, there was ‘I’, and there was ‘me’—and in a moment I was one again!14

I am not suggesting that there is an immaterial double, astral body, or psychic self that can physically leave the material body; however, there is a very real way in which people have experiences as if this were occurring. Such experiences are far from rare and are not confined to mentally unstable persons.

The list of the medical, neurological, and psychiatric conditions that can cause autoscopy is extensive. Besides epilepsy and migraine, autoscopia has been associated with typhoid fever, influenza, various forms of brain infections, alcoholism, drug intoxications, brain tumors, and brain hemorrhages. Not every patient who suffers from autoscopy, however,


has an obvious brain lesion. The symptom also has been reported in people with a variety of psychiatric conditions, including hysteria, obsessive-compulsive disorders, schizophrenia, or depression.

The Vision of the Self and the Soul

There is also a striking similarity between the autoscopic hallucination and the out-of-body experiences of the near-death survivor. And it is certainly more than coincidence that there is a common belief in folklore that the perception of a Doppelganger is premonitory of one's death. For instance, for the natives of Alsace, the perception of one's Doppelgänger means that death is near. In Teutonic folklore, seeing one's “angel” also was a portent of impending death. This relationship occurs over and over throughout the folklore traditions in different parts of the world. Todd and Dewhurst pointed out the intriguing similarity between this folklore tradition and the fate of Narcissus, who gazed at his own reflected double in a lake and met an untimely end.15 Consider this case described in 1890 by Barth:

. . .a bookbinder of Strasbourgh—a young and healthy man known not to be unduly superstitious—went down to the cellar to draw a tankard of wine with which to slake his thirst; on opening the door giving access to the cellar, he saw himself crouching in front of the cask and drawing the wine. On his approach, the specter glanced round with an air of indifference before disappearing. The vision had not lasted for more than an instance. He tottered up the stairs, pale, and tremulous. The same evening he was attacked by bouts of shivering; he retired to bed and died within a few days—carried off by an acute fever.16

Indeed, Otto Rank believed that there were strong connections between one's own mirror reflection, with the shadow, and with the belief in the soul. In his words:

We have seen that among primitives the designations for shadow, reflected image, and the like, also serve for the notion “soul,”and that the most primitive concept of the soul of the Greeks, Egyptians, and other culturally prominent peoples coincides with a double which is essentially identical with the body.17

The soul, according to this belief, will leave the body and take on a material form that Rank says may become visible under favorable conditions and represent an exteriorization of the soul.18 The double, particularly as


a harbinger of death, is a form of denial of death, a tangible manifestation of the continuing life of the soul when the mortal body passes away. The appearance of the double is a moment when the soul is preparing to leave the body and take on its eternal existence beyond the material world.

The vision of the self represents a projection of the self. The remarkable feature about autoscopy is that the self, the ego, the standpoint from which the world is psychologically perceived, coheres as an entity that can be experienced outside of the body. Autoscopy teaches us that the self can be split, and one can have a dual sense of awareness or viewpoint both as experiencing and observing entities. The widespread belief in “guardian angels,” the experience of the depersonalized self in out-of-body experiences in religious settings, the common occurrence of the idea of a presence under conditions of stress in normal persons, all suggest that fragmentation of the self represents a common human behavior.

Imaginary Companions and Guardian Angels

The patients with mirror misidentification demonstrate the imaginative and fantasy-like aspects of some confabulations. They bear a resemblance to another variety of doubling that occurs in the rather common childhood fantasy of the child's “imaginary companion.” The imaginary companion represents the belief or fantasy of a friend, or companion, or alter ego in the developing child. Some authors have suggested that nearly all children will at one point or another have some form of imaginary companion. Certainly all psychologists who have studied the issue agree that imaginary companions occur commonly and are not necessarily abnormal. Imaginary companionship usually appears between the ages of three and six. The imaginary companion may be nice or mischievous, may be a person, another child, or an animal. It serves many purposes, including being a playmate for the child, providing companionship, or serving as a ready scapegoat. The imaginary companions are spoken to, played with, and have an almost physical space in the child's world. Interestingly, imaginary companions tend not to live in the child's own home; the exact location of the companion's home is usually significant.19

Some imaginary companions can rightly be considered alter egos of the child. The psychiatrist O.E. Sperling provided a particularly good description of an imaginary companion as alter ego20 in the following case.

A boy named Rudy was brought to Sperling because his parents


thought he was hallucinating. Rudy had a particularly vivid imaginary companion, whom he called “Rudyman.” He demanded a chair for him to sit on and would ask permission from Rudyman to do certain things. If he was asked to eat his soup, he would report that he first had to consult Rudyman on the topic and then he would say, “Rudyman said I should eat the soup.”Whenever his parents would give him an order, Rudy always reported that he needed to have a consultation with Rudyman whether to obey. Sperling observed that the child's father's name was Herman and that Rudyman was a combination of Rudy and his father's name. He also noted that many of Rudyman's characteristics, such as his height and his loud strong voice, suggested that Rudyman had features of both the child and the father.

Although it is not always the case, the imaginary companion is often a projection of the child's own ideals. Thus, the child will often endow the double with attributes that the child wishes he or she possessed, such as strength, cleanliness, cleverness, and goodness. Alternatively, the imaginary playmate will also possess characteristics that the child wishes to disavow.

Most important, the imaginary companion provides companionship for the child. Child neurologist Nagera tells the story of Tony, whose first brother was born when Tony was three years old.21 Tony was apparently unprepared for the event and quite disturbed with the child's arrival. Right after the birth he pretended to have an imaginary friend named “Dackie.” Tony would talk to Dackie for hours and hours. Dackie was his constant companion. He got up with him in the morning and went to bed with Tony every night. Dackie stayed with him until he was about five years old. A very similar story is told about Caroline, who at the age of three years and eight months invented “Dooley” shortly after the birth of her brother Barry. Caroline would spend hours talking to Dooley. Like the case of Rudy and Rudyman, she claimed that Dooley made her do many of the naughty things that she did.

Sometimes the imaginary companion can be both a playmate and an alter ego or substitute for the child. Nagera describes another fascinating case concerning a child named Miriam. Miriam was the youngest of three children. Her parents divorced and shortly thereafter Miriam's imaginary companion, Susan, appeared. Her mother suffered what was described as a “mental breakdown” and was in the hospital for several months. The father ultimately left the family. Miriam became increasingly withdrawn from both her siblings as well as her schoolmates. Interestingly, according to reports provided, she was quite reality oriented and had an excellent grasp of the difference between reality and


fantasy. Despite this, she was able to maintain a fantasy life with her imaginary companion. On one hand, Miriam maintained what was described as a maternal relationship toward Susan. She reported that at night when she was cold she would put extra blankets on her. She would have to think about Susan at mealtimes because she might be hungry. It was felt that Miriam“mothered” Susan to a certain extent, and the interpretation was that the fantasy had restored to some degree Miriam's lost relationship with her then-absent mother, who was in the hospital. Interestingly, at the same time that Susan enabled Miriam to take a mothering role she simultaneously took on the identity of Susan herself. Miriam would report things like, “I think Susan is very unhappy these days” or “Susan has no family, poor Susan.” At other times, she said that Susan was angry, hated her teachers, even hated Miriam herself. It was clear that Susan was expressing many of her own feelings. According to Nagera, Miriam was expressing her own difficulties by attributing them to Susan. Upon reflection four years after the disappearance of her imaginary companion, the simultaneous fantasy and reality of Susan were succinctly put by Miriam when she reported, “I invented her. . .of course, she was real.”

Imaginary companions frequently occur in children who are undergoing stressful situations. L. B. Murphy provides an excellent example.22Three-year-old Sam had an imaginary companion named “Woody.” One day, Sam had an accident in the bathroom; he had the tip of his finger cut off when the door was closed on it. He had to have stitches that were ultimately removed, but, during the procedure, the child had to be taken forcibly from his mother. Subsequent to this episode, Sam invented a little elf named Woody. Sam reported that Woody was with him during the traumatic period when others could not be present. Woody served many purposes for Sam—as a companion, sometimes as a helper, and at other times as a scapegoat. In an incredible display of insight, Sam later reported to his mother, “You know, Mommy, Woody was really you.”

The point is, the existence of the imaginary child and the use of fantasy in the situations expressed can actually be a very healthy adaptation to otherwise stressful situations. According to Frailberg:

The child who employs his imagination and the people of his imagination to solve his problems is a child who is working for his own mental health. He can maintain his human ties and his good contact with reality while he maintains his imaginary world. Moreover it can be demonstrated that the child's contact with the real world is strengthened by his periodic excursions into fantasy.


It becomes easier to tolerate the frustrations of the real world and to accede to the demands of reality if one can restore himself at intervals in a world where the deepest wishes can achieve imaginary gratification.23

Emotional stress therefore appears to promote the appearance of the imaginary companion. At these times, one might suppose, there is a need for one.

A related adult phenomenon is what the English neurologist McDonald Critchley called the idea of a presence.24 This was described as a feeling or impression, sometimes amounting to a delusion, that one is “not alone.” There is a sense of a presence of someone beyond the self. It is not a visual hallucination, nor is it a misidentification; it is rather a feeling or sense of company. Both the imaginary companion and the idea of a presence appear under conditions of stress.

While serving with the Royal Navy during World War II, Critchley had an opportunity to examine sailors who had curious experiences during the war. Once such story came from shipwreck survivors. He described two Fleet Air Arm pilots, who crashed into the sea during the Battle of the Bismarck. While adrift aboard a rubber dinghy, they had the recurring feeling that there was a third person along with them. (The Antarctic explorer Shackleton, caught in a severe blizzard, also described a similar experience.) Critchley pointed out that the common features in these stories were extreme physical and mental stress. Factors such as fatigue, exposure to the elements, starvation, dehydration, and the slim chances of survival all played a role.

Similarly, he also described the story of two sailors adrift in a raft in the Straits of Malacca. One of the sailors was attacked and eaten by sharks. The surviving sailor reported, “For the whole voyage I'd had the strange feeling that someone else was with me, watching over me, and keeping me safe from harm. . .it was as if there were sometimes three people on the raft, not two. With [his companion] dead I felt it more strongly than ever.”

Critchley related the story of another patient he had seen in England, a woman with shrinkage of the parietal portion of the brain on both sides, who woke up in the night with a strong sensation that a person she was familiar with was standing near her in the room. It was someone whom she knew very well indeed: She eventually realized that this person was none other than herself. She described this person as her “alter ego”; it seemed to be located out of her sight, behind her, and to her left.

This presence, this alter ego or extension of the self, may be menacing,


but it also may provide a protective function, a companion, particularly when it appears under conditions of severe stress, as in the stories of the sailor during World War II. I think it is particularly insightful that Critchley compared these autoscopic experiences to a belief in a “guardian angel.”


Not every imagined presence is friendly, however. A patient of mine, Florence, is a fifty-eight-year-old woman. She suffers from mild Parkinson's disease for which she receives medication. Of late, she has been accusing her husband of infidelity. She imagines another woman in the house.25

FLORENCE: Well, she wasn't heavily made-up, but she had makeup on. . .

FEINBERG: Who did you see with your husband?

FLORENCE: This particular one.

FEINBERG: And what happened. What did you see?

FLORENCE: Well I came from a store. . .and I came in a little early. You know. I had thought, well I'll go home. . .but I went home, and here they were! But he said, there's really nothing there. It's like-how would you say it?-when you see a mirage.

FEINBERG: A hallucination?

FLORENCE: Yeah, a hallucination.

FEINBERG: What did you see them doing?

FLORENCE: Kissing, their mouths pressing. You know what I mean? And he, he really didn't think nothing of it. But I, I don't know why, but I feel very bad about it.

FEINBERG: What did you think was happening?

FLORENCE: Well I thought, you know, like a. . .you know. . .he was gonna go out with her, and things like that I thought. . .which my husband never did we've been married so many years, I mean this was a shock! But he thinks nothing of it. Just one of those things.

It came out that this symptom appeared soon after the patient's husband had a cancer operation, which made sexual relations difficult.

FEINBERG: How has this affected your relationship [this operation]?

FLORENCE: Well I just feel, you know, maybe, he is not ready for it.

FEINBERG: Ready for what?

FLORENCE: For you know, an act, you know, to have intercourse. He's not ready. Or maybe I don't want it. Maybe the time hasn't come yet.

FEINBERG: How do you feel about that?



FLORENCE: It's all right. I'm not one of the sex animals. I'm not! [laughing]

I discussed with Florence the relationship with her husband, and how to deal with the way his illness has made their more intimate moments difficult. She returned two weeks later.

FEINBERG: Some things that came up the last time. One issue was the way your relationship has changed with your husband since his illness.

FLORENCE: Yeah, and it even changed a week ago.

FEINBERG: In what way?

FLORENCE: For the first time, we had intercourse in a long time. . .very long. . .Was I supposed to tell you that? I don't know. Long time.

FEINBERG: Really? How did that happen?

FLORENCE: I don't know. All of a sudden it happened.

FEINBERG: It was the first time since ah. . .

FLORENCE: Oh my God, over two or three years.

FEINBERG: Since he had the operation?


FEINBERG: Very interesting. Who initiated it?

FLORENCE: I don't know. It just came about like we were talking, and this and that, and before you know it. . .

FEINBERG: Hum. . .So maybe the discussion we had the last time brought you two a little closer together?

FLORENCE: Probably yes. Yes, it did! Because how did that come about?

FEINBERG: So you feel good about this?

FLORENCE: Oh yeah. I thought he didn't like me anymore. . .

The imagined, the alter ego, the imaginary companion, or nemesis represent personifications, reifications of hopes or fears. The mind creates concrete representations of inner, sometimes hidden, emotions and gives them a life of their own.

If you find an error or have any questions, please email us at Thank you!