Astonishingly, we have found that the reduplication seen in Capgras syndrome can even involve the patient’s own self. As previously noted, the recursive activity of mirror neurons may result in a representation not only of others’ minds but of one’s own mind as well.13 Some mix-up of this mechanism could explain why our patient David pointed to a profile-view photo of himself and said, “That’s another David.” On other occasions he referred to “the other David” in casual conversation, even asking, poignantly, “Doctor, if the other David comes back, will my real parents disown me?” Of course, we all indulge in role playing from time to time but not to the point where the metaphorical (“I am in two minds,” “I’m not the young man that I once was”) becomes literal. Again, bear in mind that despite these specific dreamlike misreadings of reality, David was perfectly normal in other respects.
I might add that the Queen of England also refers to herself in the third person, but would hesitate to ascribe this to pathology.
FREGOLI SYNDROME: DOCTOR, EVERYONE LOOKS LIKE AUNT CINDY
In Fregoli syndrome, the patient claims that all people seem to resemble a prototype person he knows. For example, I once met a man who said everyone looked like his aunt Cindy. Perhaps this arises because the emotional pathway 3 (as well as links from pathway 2 to amygdala) has been strengthened by disease. This could happen because of repeated volleys of signals accidentally activating pathway 3, as in epilepsy; it is sometimes called kindling. The outcome is that everyone looks strangely familiar rather than unfamiliar. Why the patient should latch onto a single prototype is unclear, but it may arise from the fact that “diffuse familiarity” makes no sense. By analogy, the diffuse anxiety of the hypochondriac seldom floats free for long, but latches onto a specific organ or disease.
Self-Awareness
Earlier in this chapter I wrote that a self that is not aware of itself is an oxymoron. There are nevertheless certain disorders that can seriously distort one’s self-awareness, whether by causing patients to believe that they are dead or by inspiring the delusion that they have become one with God.
COTARD SYNDROME: DOCTOR, I DON’T EXIST
If you do a survey and ask people—whether neuroscientists or Eastern mystics—what the most important puzzling aspect of the self is, the most common answer would be the fact that the self is aware of itself; it can contemplate its own existence and (alas!) its mortality. No nonhuman creature can do this.
I often visit Chennai, India, during the summer to give lectures and see patients at the Institute of Neurology on Mount Road. A colleague of mine, Dr. A. V. Santhanam, often invites me to lecture there and draws my attention to interesting cases. On one particular evening after giving a lecture, I found Dr. Santhanam waiting for me in my office with a patient, a disheveled, unshaven young man of thirty named Yusof Ali. Ali had suffered from epilepsy starting in his late teens. He had periodic bouts of depression, but it was hard to know whether this was related to his seizures or to reading too much Sartre and Heidegger, as many intelligent teenagers do. Ali told me of his deep interest in philosophy.
The fact that Ali was acting strangely was obvious to nearly everyone who knew him long before his epilepsy was diagnosed. His mother had noticed that a couple of times a week there were brief periods when he would become somewhat detached from the world, appear to experience a clouding of consciousness and engage in incessant lip smacking and postural contortions. This clinical history, together with his EEG (electroencephalograph, a record of his brain waves), led us to diagnose Ali’s miniseizures as a form of epilepsy called complex partial seizures. Such seizures are different from the dramatic grand-mal (whole-body) seizures most people associate with epilepsy; these miniseizures, in contrast, mainly affect the temporal lobes and produce emotional changes. During his long seizure-free intervals Ali was perfectly lucid and intelligent.
“What brings you to our hospital?” I asked.
Ali remained silent, looking a me intently for nearly a minute. He then whispered slowly, “Not much can be done: I am a corpse.”
“Ali, where are you?”
“At the Madras Medical College, I think. I used to be a patient at the Kilpauk.” (Kilpauk was the only mental hospital in Chennai.)
“Are you saying you are dead?”
“Yes. I don’t exist. You could say I am an empty shell. Sometimes I feel like a ghost that exists in an another world.”
“Mr. Ali, you are obviously an intelligent man. You are not mentally insane. You have abnormal electrical discharges in certain parts of your brain that can affect the way you think. That’s why they moved you here from the mental hospital. There are certain drugs that are very effective for controlling seizures.”
“I don’t know what you’re saying. You know the world is illusory as the Hindus say. Its all
“Ali, what are you saying? Are you saying
Ali appeared confused and a tear started forming in his eye. “Well, I am dead and immortal at the same time.”
In Ali’s mind—as in the minds of many otherwise “normal” mystics—there is no essential contradiction in his statement. I sometimes wonder whether such patients who have temporal lobe epilepsy have access to another dimension of reality, a wormhole of sorts into a parallel universe. But I usually don’t say this to my colleagues, lest they doubt my sanity.
Ali had one of the strangest disorders in neuropsychiatry: Cotard syndrome. It would be all too easy to jump to the conclusion that Ali’s delusion was the result of extreme depression. Depression very often accompanies Cotard syndrome. However, depression alone cannot be the cause of it. On the one hand, less extreme forms of depersonalization—in which the patient feels like an “empty shell” but, unlike a Cotard patient, retains insight into his illness—can occur in the complete absence of depression. Conversely, most patients who are severely depressed don’t go around claiming they are dead. So something else must be going on in Cotard syndrome.
Dr. Santhanam started Ali on a regimen of the anticonvulsant drug lamotrigine.
“This should help you get better,” he said. “We are going to start you on a small dose because in a few rare cases patients develop a very severe allergic skin rash. If you develop such a rash, stop the medicine immediately
