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.