Fekete, Sándor

Kovács, Attila

Nagy, Ágnes

Tényi, Tamás

Vörös, Viktor

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Eur. J. Psychiat. Vol. 23, N.° 3, (141-146)2009Keywords: Delusional misidentification syndromes;Clonal pluralization; Autoscopy; Capgras syndrome;Dementia.Clonal pluralization, as an interpretative delusionafter a hallucinatory form of autoscopyAgnes NagyTamas TenyiAttila KovacsSandor FeketeViktor VorosDepartment of Psychiatry andPsychotherapy, University of PecsHUNGARYABSTRACT – Background and Objectives: Delusional misidentification syndromes arewidely present in several major psychiatric and neurological disorders. After reviewingthe recent terminology and psychopathology of the double phenomenon in the literature,the authors present a case of a patient with dementia, vascular type, where clonal plural-ization of the Self appeared as a secondary, interpretative delusion after a hallucinatorytype of autoscopic experience. Methods: Review of the literature and a case report. Results: In the presented case the linear evolution and the interpretative aspect of thearising misidentification phenomena are predominant. The differential diagnosis and thedistinctive characteristics of the presented case from other potential delusional misidenti-fication syndromes are also discussed. Brain lesions and neuropsychological impairmentsseem necessary, but the full development of these syndromes depends upon the individ-ual’s responses to his or her defects as much as the defects themselves. Conclusions: Overviewing the broad spectrum of concepts on delusional misidentifica-tion syndromes, the authors emphasize the importance of those approaches which enhancethe disappearance of the classical organic-functional dichotomy on the double phenomenonand which try to clarify the neurocognitive background of delusional misidentifications.Received 8 September 2008Revised 16 February 2009Accepted 27 February 2009IntroductionDelusional misidentification syndromes(DMS) –characterized by a belief in dupli-cates and replacements– can occur in severalorganic and major psychiatric disorders1-3.Recently, approaching an agreement on aclarifying classification of the misidentifi-cation phenomena, several authors4-6 con-ceptualise two essentially different types ofdelusional misidentification syndromes, asthe Capgras type (misidentificational dis-turbance with replacements) and the clonalpluralization type (pluralizational delusionwith duplicates).In the Capgras type (including Capgrassyndrome, Frégoli syndrome, intermetamor-phosis and the syndrome of subjective dou-bles)7-9 the significant issue is the misidenti-fication of a real person. In the first threeclassic forms the patients’ delusion exclu-sively refer to other people, while in thecase of ‘subjective double’ patients misiden-tify another existing person, as if he or shewas his own self. Unlike in the Capgras typeof DMSs, in the clonal pluralization type in-cluding clonal pluralization of a person(CPP) and clonal pluralization of the Self(CPS) the basic feature is the delusionalview on one’s existing in plural numbers4-6. The phenomenon of clonal pluralization(CP) is based on the classical term of redu-plicative paramnesia (RP), first describedby Arnold Pick in 190310. In the original de-scription RP referred to delusions of redu-plication of a certain familiar place or per-son, later however, RP was often used inseveral meanings in the related literature.Recently its definition was narrowed downto the misidentification of places occuringin certain organic cerebral disorders, there-fore it has been discussed as a neurologicalsyndrome. Murai et al.4 have published thefirst case describing the delusional view onreduplication in functional psychosis andproposed the term clonal pluralization.When pluralization refers to the patient’sown identity, the term clonal pluralization ofthe Self is used5.Concerning the complex psychopatholo-gy of the ‘double’ phenomenon, autoscopyshould be mentioned, which is mainly de-fined as a perceptional disturbance, involv-ing the boundaries of the Self11-13. Duringautoscopic experience subjects see an imageof themselves in the external space, which isviewed from within their own physicalbody. Several types of autoscopy have beendescribed, like the depersonalizational (feelone’s own body), the hallucinatory (seeone’s own body), and the delusional (knowone’s own body) forms14. MethodsWe reviewed the recent terminology andpsychopathology of the double phenome-non in the literature. We present a case of apatient with dementia, vascular type, whereclonal pluralization of the Self appeared as asecondary, interpretative delusion after ahallucinatory type of autoscopic experience.We also discuss the differential diagnosisand the distinctive characteristics of the pre-sented case from other potential delusionalmisidentification syndromes.Case reportThe 86-year-old patient was referred toour department by his general practitionerbecause he was talking continuously to his142 AGNES NAGY ET AL.so-called ‘twin’. He had no history of previ-ous psychiatric treatment, and there were nopsychiatric disorders in his family. He hadbeen a high school teacher for 40 years.Since his wife’s death he has been livingalone. According to his children, the patient’sbehaviour has changed during the few weeksbefore admission. He was talking to himselfand reported about his ‘twin brother’, he gotexcited apparently without reason. The pa-tient’s sensorium remained clear, he was ori-ented in time and place, and amnesia couldnot be detected for the events described. During a detailed exploration, the patientreported with intense emotions that his‘twin brother’ he had not ever known aboutbefore, stands continuously by him, whichhe considered as a miracle to be investigatedby a special medical staff. He stated that hehad seen this ‘twin’ a few weeks ago on anexcursion, which was organised by the highschool he had been employed previously. Inthe beginning he saw and talked to him inthe hostel they were lodged at. First, the pa-tient was surprised by the astonishing simi-larity in their physical appearance: the twinlooked exactly identical to him, he had thesame voice, he wore the same clothing.Later on he started to think that this mancould not be else than his own twin brother,and believed that his ‘twin’ used the samefirst and last name. He firmly stated duringhis exploration that he felt, he saw, he heardand said the same as his ‘twin brother’ did inthe next room to him. He did several trials toprove his unusual experience. They solvedcross-words independently and found exact-ly the same solutions as the other. He askedthe ‘twin’ to enumerate the paintings on hiswall while the ‘twin’ was outdoor - and thetwin could do it as well.After his admission risperidone 2 mg/daywas started. Two days later he developed theidea that he and his twin got fusioned in oneperson and they were two personalities inone body. By this time, he modified hisoriginal experience in the followings: ‘anannouncement came out in the local news-paper where they were searching for a twinbrother, a son of my father. Due to this arti-cle a certain secret group made the ‘twin’show up and organised the meeting betweenme and my twin on that excursion’. During his clinical examination the pa-tient’s sensorium was vigil and clear, he wasoriented in time and place, no attention deficitor agnosia was seen. Perceptual disturbancescould not be explored and his behaviour didnot refer to them. Under the influence of hisdelusional beliefs he was still excited andanxious. Long-term memory deficits and dis-turbances of abstract thinking could be seenas symptoms of cognitive decline. Detailed physical and laboratory investi-gations, electroencephalography (EEG) andcomputerised tomography (CT) were per-formed. The CT scan displayed abnormali-ties corresponding to vascular encephalopa-thy. The vascular lesions affected mainly themediotemporal gyri bilaterally and the leftcapsula interna. EEG basic diagram waswell organized without epileptic discharges.Laboratory results were normal. In the MiniMental State Examination (MMSE) the pa-tient scored 23/30, in the Addenbrooke’sCognitive Examination (ACE) he scored76/100 points, the VL/OM (verbal fluency+language/orientation+memory) ratio was28/7. The loss of points was mainly in thesub-domains of memory and verbal fluency,whereas he scored well in orientation, atten-tion, language and visuo-spatial subdomainsof the testbattery.Although the patient was treated continu-ously with a low dose of second-generationantipsychotic medication (risperidone 2mg/day), the delusional belief on the identi-CLONAL PLURALIZATION AFTER AUTOSCOPY 143cal ‘twin’ was resistant to therapeutic inter-ventions throughout his 12 days of hospital-ization. At his discharge he talked to himselfas to the delusional twin less frequently, hewas not agitated any more, and his behav-iour became conventional.DiscussionIn our present case clonal pluralization ofthe Self (pluralization type of DMS) ap-peared as an interpretation of an autoscopicexperience. Considering the widely usedclassification of delusive misidentificationsyndromes by Weinstein2, the majority ofthe common features that link to DMSs arepresent in our case as follows. Duplication,as his twin is his duplicate; selectivity, thatan exceptional person (he duplicated him-self) is involved; dissociation, in spite of thedelusion the patient has an implicit knowl-edge of his true identity; derealization, asthe patient had the impression of living in adream; and adaptive aspect, as the companyof a ‘twin’ is an alternative to loneliness andongoing isolation due to ageing and growingsensory deprivation (difficulty in hearing).Furthermore, in the presented cases of theliterature, the clear differentiation and themany times common co-existence of severaltypes of DMSs (Capgras syndrome, Frégolisyndrome, intermetamorphosis, delusionsof subjective double and inanimate double,autoscopic phenomena and reduplicativeparamnesia) were described2. In contrast tothis approach, recently Margariti and Kon-taxakis15 proposed a potential commonpathogenetic factor underlying delusionalmisidentifications and described these syn-dromes as disorders of the sense of unique-ness. In the light of this current discourse,our case can be considered interesting, asthis is the first case in the literature, in whichnot the co-existence, but much more the lin-ear evolution and the interpretative aspect ofthe arising DMSs were predominant. In the following, we discuss further dis-tinctive characteristics of the presented casefrom other potential DMSs. There is a cleardistinction between the phenomena of clon-al pluralization of the Self and subjectivedoubles (Capgras type of DMS). In the latterthe patient’s delusion of experiencing him-self refers to a real, existing person, which isa consequence of misidentification9, so he orshe recognizes physically identical doublesof the self in other people. Contrary, in clon-al pluralization, as in our presented case,there was no misidentified person, but thedelusion on pluralization (reduplication) ofthe patient himself, where his ‘twin’ or‘clone’ was in all senses, physically andpsychologically identical to the patient. Fur-thermore, reduplicative paramnesia, as apossible interpretation should also be dis-cussed. Reduplicative paramnesia is preced-ed by the disturbance of consciousnessand/or delirium, and is often associated withshort-term memory deficits, confabulationand disorientation7. It has to be highlightedthat in our case there were disturbances nei-ther in the above mentioned mental func-tions, nor in the level of consciousness. Con-sequently, delirium syndrome and amnesticsyndrome with confabulation could also beexcluded. We suppose that our patient dis-played a secondary, interpretative delusionidentical to clonal pluralization of the Self,which he developed after an autoscopic ex-perience caused by dementia, vascular type.We also point out that there was no misiden-tification of the own mirror image at con-frontational testing in our patient, which iscommon in dementia16. Additionally, inorder to differentiate reduplicative paramne-sia and autoscopic experience, we should144 AGNES NAGY ET AL.bear in mind that in reduplicative paramne-sia there is a co-existence of the double; thepatient does not see the double, nor experi-ence the double simultaneously in the samespace as himself. In autoscopic phenome-non the double is mainly seen or felt, whilein RP the double is claimed or assumed13.Finally, there is a major difference betweenclonal pluralization of the Self following ahallucinatory form of autoscopic experience(presented in our case) and the delusionalform of autoscopy. In the former, the patientdevelops delusions as secondary interpreta-tive thought contents, while in the latter thedelusions are primary and do not appear asan interpretation on perceptual phenomena.Referring to the debates around the clas-sical dichotomy of psychiatric literaturedealing with Capgras symptom and DMSs,and the neurological literature dealingmainly with reduplicative paramnesia17 nu-merous studies witness growing evidence oforganic background in different misidentifi-cation syndromes3,18-20. Nevertheless, someof them underline that no single brain lesionis specifically associated with reduplica-tions21. Feinberg22 points out the impor-tance of the personality in all the phenome-na of alteration of the Self. He claims thatbrain lesions and neuropsychological im-pairments are necessary, but the full devel-opment of these syndromes depends uponthe individual’s responses to his or her de-fects as much as the defects themselves.Questioning the central importance of thesequential stages in different forms of delu-sional misidentifications described by Ellisand Young18,23, recently Margariti and Kon-taxakis15 suggested a collective approach, inwhich they regard DMSs as disorders of thesense of uniqueness, presuming that the co-occurrence of different subtypes implies acommon pathogenetic substrate of delusion-al misidentification syndromes. We supposethat in the future careful phenomenologicalevaluation of patients with delusionalmisidentification syndromes is needed forproper classification of the discussed issue.References1. De Pauw KW. Delusional Misidentification: A pleafor an agreed terminology and classification. Psychopatho-logy 1994; 27: 123-129.2. Weinstein EA. The classification of delusional misi-dentification syndromes. Psychopathology 1994; 27: 130-135.3. Ellis HD, Luauté JP, Rettelstol N. Delusionalmisidentification syndromes. Psychopathology 1994; 27:117-120.4. Murai T, Toichi M, Yamagishi H, Sengok A. What ismeant by ‘misidentification’ in delusional misidentifica-tion syndromes. Psychopathology 1998; 31: 313-317. 5. Voros V, Tenyi T, Simon M, Trixler M. ’Clonal plural-ization of the self’: a new form of delusional misidentifica-tion syndrome. Psychopathology 2003; 36(1): 46-48.6. Ranjan S, Chandra PS, Gupta AK, Prabhu S. Clonalpluralization of self, relatives and others. Psychopathology2007; 40: 465-467.7. Weinstein EA, Burnham DL. Reduplication and thesyndrome of Capgras. Psychiatry-Interperson Biolog Proc1991; 54: 78-88.8. Christodoulou GN. The syndrome of Capgras. Brit JPsychiatry 1977; 130: 556-564.9. Christodoulou GN. Syndrome of subjective doubles.Am J Psychiatry 1978; 135(,2): 249-251.10. Pick A. On reduplicative paramnesia. Brain 1903;26: 242-247. 11. Dening TR, Berrios GE. Autoscopic Phenomena.Brit J Psychiatry 1994; 165: 808-817.12. Damas Mora JMR, Jenner FA, Eacott SE. On heau-toscopy or the phenomenon of the double: Case presenta-tion and review of the literature. Brit J Medical Psychology1980; 53: 75-83.13. Brugger P, Regard M, Landis TH. Illusory redupli-cation of one’s own body: phenomenology and classifica-tion of autoscopic phenomena. Cognit Neuropsychiatr1997; 2: 19-38.CLONAL PLURALIZATION AFTER AUTOSCOPY 145146 AGNES NAGY ET AL.14. Alonso-Fernandez F. Fundamentos de la psiquiatriaactual. Madrid: Paz Montalvo, 1972.15. Margariti MM, Kontaxakis VP. Approaching delu-sional misidentification syndromes as a disorder of thesense of uniqueness. Psychopathology 2006; 39: 261-268.16. Hemphill RE. Misinterpretation of mirror image ofself in presenile cerebral atrophy. J Mental Science 1948;94: 603-610.17. Joseph AB. Focal central nervous system abnormal-ities in patients with misidentification syndromes. BiblPsychiatr 1986; 164: 68-79.18. Ellis HD, Young AW. Accounting for delusionalmisidentifications. Br J Psychiatry 1990; 157: 239-24819. Ellis HD. The role of the right hemisphere in theCapgras delusion. Psychopathology 1994; 27: 177-185.20. Signer SF. Localisation and lateralization in thedelusion of substitution. Psychopathology 1994; 27: 168-176. 21. Bouvier-Peyrou M, Landis TH, Annoni JM. Self-du-plication shifted in time: A particular form of delusionalmisidentification syndrome. Neurocase 2000; 6: 57-63.22. Feinberg TE. Some interesting perturbations of theself in neurology. Semin Neurol 1997; 17: 129-135.23. Tenyi T, Abraham I, Lenard K, Trixler M. Frégolidelusion rooted in sexual behavior. Psychiatr Danub 1999;11: 61-63.Address for correspondence:Viktor Voros MD.Department of Psychiatry and PsychotherapyFaculty of Medicine, University of PecsH-7623 Pecs, Ret u. 2.HungaryPhone: +36-72-535-900Fax: +36-72-535-951E-mail: viktor.voros@aok.pte.hu

Clonal pluralization, as an interpretative delusion after a hallucinatory form of autoscopy

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