How the FBI sees the psychopath

06 Hare’s Psychopathy Checklist-Revised (PCL-R)
06 Hare’s Psychopathy Checklist-Revised (PCL-R)

“The latest FBI Law Enforcement Bulletin is a special issue on the criminal psychopath. Apart from the use of eye-scorching clip-art, it’s notable more what it tells us about how the FBI approaches the concept of psychopathy than necessarily being a great introduction to the topic. Some of the most revealing articles are written by agents and give advice on how to interrogate the ‘psychopath’ as if it was a single type of person and not a relatively consistent pattern of characteristics found within unique individuals…

Despite some overconfident conclusions, several of the articles do give some good accounts of actual cases and the issue remains an interesting peek into how the FBI sees the psychopath.” (Mind Hacks)

How the FBI sees the psychopath

Autoscopy

autism neuroimaging study

I’m posting a small literature review I wrote for some colleagues about a fascinating and unusual psychiatric symptom, autoscopy. FYI.

Autoscopy is a rare syndrome in which, while retaining insight into the unreality of the phenomenon, the individual while believing himself to be awake sees his or her body at another location. Autoscopy comes from the ancient Greek autos (“self”) and scopos (“watcher”). Autoscopy has intrigued humankind from time immemorial and is abundant in the folklore, mythology, and spiritual narratives of most ancient and modern societies. The related term Heautoscopy is defined as a reduplication not only of bodily appearance but also of aspects of one’s psychological self, and has been considered as one possible explanation for the doppelgänger phenomena. In an autoscopic hallucination the observer’s perspective is clearly body-centred, and the visual image of one’s own body is usually said to appear as a mirror reversal. Illness, injury, hospitalization, sleep deprivation and stress have long been associated with the disorder. Faguet, in 1979 (Gen Hospital Psychiatry 1:311-14), posited a relationship with persons with highly developed visual memories. Autoscopy is probably underreported, as Grotstein observed in 1983 (Hillside J Clin Psychiatry 5:259-304). There is limited medical literature referring to the phenomenon. It certainly seems as if much more attention has been paid to the phenomenon in European circles than in North American psychiatry.

In 1989, Devinsky et al (Arch Neurol 46: 1080-88) reported on a case series of 10 patients with seizures and autoscopic phenomena and reviewed 33 additional cases from the literature, noting that these experiences may be ictal symptoms of simple partial, complex partial or generalized seizures. They concluded that seizures may be more common in autoscopy than previously appreciated. In patients in whom a seizure focus could be identified, the temporal lobe was involved in 86%. There was no clear lateralization of lesions. Brugger et al, from University Hospital Zurich (1994, J Neurol Neurosurg Psychiatry 57:838-9),  noted the longstanding association of autoscopic phenomena (or doppelganger experiences) with epilepsy and suicidal behavior in literary accounts. In 1994, Dening and Berrios, from Cambridge UK (Br J Psychiat 165:808-17), reviewing 53 case reports of autoscopy published since 1935, found that 59% had identified neurological illness (commonly epilepsy) and 59% had psychiatric conditions (frequently delirium, depression or psychosis). If the images spoke, the patients were more likely to be male, younger, have psychotic illnesses, longer duration of the images, and association with hypnagogic or hypnopompic experiences. Arias et al, from Santiago Chile, described in 1996 (Neurologia, 11:230-32) a case of a woman with clinically established multiple sclerosis and autoscopic experiences. EEG and EEG-Holter studies were normal. MRI revealed multiple areas of bitemporal white matter hyperintensities. Episodes remitted with carbamazepine treatment. Podoll and Robinson, from Aachen, Germany (1999, Cephalalgia 19:886-96), examined migraine art and concluded that autoscopic and related perceptual disturbances could occur as migraine aura symptoms.

In 2004, Blanke et al from Geneva (Brain, 127[2]:243-58) described the phenomenological, neuropsychological and neuroimaging correlates of autoscopic (the subject sees an image of his body in extrapersonal space) and out-of-body (the subject seems to see the world and his body from a location outside the physical body) experiences, relating them to pathological sensations of position, movement and perceived completeness of one’s own body. In five of six patients, brain damage or dysfunction was localized to the temporoparietal junction. Also in 2004, Maillard et al from Nancy, France, reported on three epilepsy patients with autoscopy who had MRI lesions of the nondominant (right) parietal region and their autoscopic experiences occurred in association with other ictal signs supporting a right parietal seizure focus. Zamboni et al, from Modena and Reggio Emilia, Italy, described in 2005 a case of a patient with longstanding autoscopic experiences after post-eclamptic brain damage. The MRI showed lesions involving the occipital cortex and the basal ganglia bilaterally. A 2011 report by Anzellotti and associates, from d’Annunzio University in Italy (Behav Brain Funct 7:2) described a case in which EEG recordings during a patient’s autoscopic experiences showed a right parietal focus. In 2012, Hoepner et al, Mara Hospital, Bielefeld Germany (Epilepsy Behav, 23:360-3), reported on a series of seven patients, and reviewed another seven cases reported in the literature, with lateralizing autoscopic experiences. In 12 of the 14 cases, there was a well-defined epileptic focus contralateral to the side of the autoscopic images in space.

Brugger, from Zurich, in 2002 (Cogn Neuropsychiatry (7:179-94) placed these reduplicative phenomena on a phenomenological continuum depending on the subject’s point of view, positing a relationship between spatial perspective and psychological perspective:

In an autoscopic hallucination the observer’s perspective is clearly body-centred, and the visual image of one’s own body appears as a mirror reversal. Heautoscopy (i.e., the encounter with an alter ego or doppelgänger), is defined as a reduplication not only of bodily appearance, but also of aspects of one’s psychological self. The observer’s perspective may alternate between egocentric and ”alter-ego-centred”. As a consequence of the projection of bodily feelings into the doppelgänger (implying a mental rotation of one’s own body along the vertical axis), original and reduplicated bodies are not mirror images of one another. This also holds for OBEs, where one’s self is not reduplicated but appears to be completely dissociated from the body and observing it from a location in extracorporeal space.

Tadokoro et al, for Aichi Medical University in Japan, surveyed the literature of epilepsy-associated autoscopy and described a case of a patient with partial epilepsy who experienced postictal, rather than ictal, autoscopy for nearly 30 years. They suggested as a potential mechanism “wish-fulfilling fantasies released as a result of a shaken integrity regarding personal bodily image”. In 2010, Bolognini et al, from Bologna, Italy, reported a case of longlasting autoscopy in a patient with a right occipital lesion. Noting that, instead of the common frontal view, the patient saw her head and upper trunk laterally in profile view, suggesting a multisensory origin of the phenomenon and an important contribution from proprioceptive signals.

Autoscopy

Morgellons: What Is it?

morgellons forest
morgellons forest

This is a repost of a 2006 piece I wrote here, well, just because I liked it.

This MetaFilter query (http://www.metafilter.com/mefi/51559) prompted a reader (thanks, Stan) to ask my opinion about the controversial medical condition referred to as Morgellons Disease, written about on only one academic paper (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=16489838&dopt=Citation) by Savely, Leitao and Stricker in the American Journal of Clinical Dermatology in 2006. When I read the abstract —

“Morgellons disease is a mysterious skin disorder that was first described more than 300 years ago. The disease is characterized by fiber-like strands extruding from the skin in conjunction with various dermatologic and neuropsychiatric symptoms. In this respect, Morgellons disease resembles and may be confused with delusional parasitosis. The association with Lyme disease and the apparent response to antibacterial therapy suggest that Morgellons disease may be linked to an undefined infectious process. Further clinical and molecular research is needed to unlock the mystery of Morgellons disease.”

— I was struck by several details. ‘First described more than 300 years ago’ but obviously not developing much of a medical following; an outlandish and medically implausible lead symptom; the assertion that it is ‘confused’ with delusional parasitosis (but is not delusional parasitosis per se), an ‘association’ with Lyme Disease, which, although a real illness, attracts a large number of wannabees hoping to explain diverse symptoms, many of them in the emotional or psychiatric spheres; and the dramatic language about ‘unlocking the mystery’ — all of these combine to spell ‘histrionic’.

The ‘disease’ has its own foundation, the Morgellons Research Foundation, which keeps a tally of the number of ‘registered households’ (3492 as I write this). Its website (http://www.morgellons.org/) expands on the attributes of the condition, citing cardinal features of “disturbing crawling, stinging, and biting sensations”, non-healing skin lesions, and associated, striking fiber-like or filamentous projections as well as “seed-like granules and black speck-like material associated with their skin.” The website features a 10x magnified photo of the lip of an affected 3 year-old boy and an “object from the same lip” at 60x. The pictures make discussants of the condition on MetaFilter squirm, the only consensus emerging from the message thread there. (http://www.metafilter.com/mefi/51559)

In noting that “the most significant element of the infection appears to be the effect on the central nervous system”, the web site notes that concentration and memory problems are nearly universal, that mood disorders are very common, and that the majority of affected children have “ADHD, ODD, mood disorders or autism”. Only one direction of causality is considered — that the supposed infection has CNS effects. But it seemed more likely to me that the causal flow is in the opposite direction — from the emotional to the (imagined) physical. So many of the attributes of this condition smack of the other controversial syndromes of which I have written which patients adopt as explanations for their distress and dysfunction, with implausible and inconsistent core symptoms and definitions. Although many of these conditions have a medical reality at their core, diagnostic criteria are applied loosely and diffusely by wannabee sufferers and unrigorous clinicians swept up in the bandwagon effect. Interest in and information about them (much of it inaccurate and imprecise) is spread largely by the media and particularly the internet. An everchanging constellation of trendy syndromes or ‘diseases’ serve these roles. La plus ca change, la plus c’est la meme chose, as the saying goes…

Although searching academic resources such as Medline or Google Scholar for ‘Morgellons Disease’, (http://scholar.google.com/scholar?hl=en&newwindow=1&q=Morgellons+Disease&spell=1) as proponents dub it, yields only these few resources, a search on ‘Morgellons’ alone (http://www.google.com/search?q=Morgellons&start=0&ie=utf-8) is more revealing. Weeding out the sensationalistic and the partisan, the best overview of the status of Morgellons is the Wikipedia article here (http://en.wikipedia.org/wiki/Morgellons). Lo and behold, modern interest in Morgellons is largely the product of one evangelist, the aforementioned journal article author Mary Leitao, who coined the term in 2002 while investigating her son’s unexplained rash. Not a medical professional herself, she has a degree in biology and has worked as a chemist and electron microscope operator. Far from having a 300-year history, it is merely named after a condition described 300 years ago to which it is analogous but certainly not identical. Thus, it is a bit disingenuous to aspire to legitimacy by the claim to a legacy.

Leitao is the founder of the aforementioned Morgellons Research Foundation. It would be tempting to suggest that she seems to have a sense of mission about this condition and that it is somewhat self-serving now that nonprofit dollars and the preservation of her foundation are at stake. Most of the other Morgellons boosters are not medical doctors either. And, uh-oh, the sensationalism is fueled (http://www.mysanantonio.com/global-includes/printstory.jsp?path=/news/metro/stories/MYSA051106.morgellans.KENS.32030524.html) by one nurse practioner who claims to have identified and treated ‘the majority’ of these patients. Sure, you might argue that that is because she is a pioneer who recognizes a condition to which others are blind in a geographic area which for some inexplicable reason has a cluster of cases, but more likely it is because she sees what she wants to see in a self-fulfilling prophecy sort of way.

The Wikipedia article notes the extent to which the condition embodies indicators of delusional parasitosis:

  • The presentation of physical evidence such as skin scrapings and debris
  • Obsessive cleaning and use of disinfectants and insecticides
  • Rejection of the possibility of psychological or other explanations
  • Emotional trauma, desperation, social isolation.
  • Having seen numerous physicians, to no avail

While some clinicians report response of symptoms in several weeks with antipsychotic medication, I wonder whether it is necessary to invoke delusionality per se as an explanation. A delusion is a psychotic symptom representing a fixed disorder of thought not amenable to reasoning, and it is premature, even if one is debunking the disorder, to say that Morgellons sufferers are frankly delusional, rather than just insistent seekers of somatic explanations for emotional distress. Antipsychotics work in nonpsychotic conditions as well; most of them by the way are anti-pruritics, i.e. they have anti-itch properties. Using them in this condition, however, may be akin to using a sledgehammer to drive in a thumbtack.

This June, 2005 article (http://www.popularmechanics.com/science/medicine/1662162.html?page=1&c=y) in, of all places, Popular Mechanics, takes an expanded look at the phenomenon and ultimately shares my conclusion that sufferers convinced they have something real called Morgellons are leaping to conclusions. A number of doctors have sent samples from the skin lesions of affected patients to pathology labs and state health boards, standard practice in dermatological diagnosis. Investigations of samples uniformly fail to reveal any signs of infection or infectious organisms. Nevertheless, members of the Morgellons.org online community demand that the CDC investigate the condition as an infectious disease, a plaint recently taken up by Sens. Dianne Feinstein and Dick Durbin. Believers can write to Congress (http://www.morgellons.org/congress.html) from the website.

Circumspect practitioners report that the nonhealing skin lesions go away if the affected area is casted for several weeks, preventing sufferers from scratching and picking at their sores, as our mothers taught us not to do when we were children. And what of the bizarre core symptom of the spinous or filamentous extrusions from the skin lesions? One Morgellons debunker (http://morgellonswatch.blogspot.com/) found the photomicrographs touted by proponents to be almost identical to pictures at the same magnification of kleenex fibers stained with blood. It seems likely to me that most people would dab a weeping or oozing lesion with kleenex at least intermittently. I am tempted to elaborate that the absorptive properties of the fibers of kleenex would draw blood or serous secretions up and, as they dried, the fibers would stiffen. Probably the strands and fibers sufferers report are heterogeneous; perhaps some are fungal hyphae too, others clothing fibers and other adherent fiber fragments. The vehemence and histrionics with which the debunker’s explanation is dismissed in the comments by Morgellons proponents, unwilling to entertain any suggestion contradicting their fervent convictions, is quite telling. [See the same in the comments to this post. -FmH]

Morgellons is fascinating, but although certainly new medical syndromes are being discovered and/or codified all the time, it almost certainly does not belong among my occasional ‘Annals of Emerging Disease’ features here in FmH. Rather, I firmly believe it is of interest as a snapshot of medical sociology, illness subculture and the spread of trendy pseudodiagnosis in the age of the internet. Just as most fibromyalgia is chronic fatigue with muscle aches, this is chronic fatigue with skin lesions. And, although there may be a germ of truth (pun intended) at the core of all of these disorders, most sufferers have nothing very different than, yes, conditions described hundreds of years ago — neurasthenia, (http://en.wikipedia.org/wiki/Neurasthenia) depression and hysteria (http://en.wikipedia.org/wiki/Hysteria).

Update:

“The Morgellons Research Foundation (MRF) is no longer an active organization and is not accepting registrations or donations. The MRF donated remaining funds to the Oklahoma State University Foundation to support their Morgellons disease research. Click here to learn more about this research.”

Morgellons: What Is it?