Sunday, October 30, 2016

Haunting Delusions of Identity

Bugs Bunny in Hyde and Hare (1955)

Delusional misidentification syndromes have fascinated filmmakers and psychiatrists alike. Afflicted individuals suffer under the false belief that persons or things around them have changed their identities or appearance. Classification schemes have varied, but a general outline includes:

from Table 1 (Ellis et al., 1994). Classification and description of the four principal delusional misidentification syndromes (DMS).

Bugs Bunny isn't delusional in the image above, because the mild mannered Dr. Jekyll has actually morphed into the monstrous and hideous Mr. Hyde. Or has he?

 Ever have one of those days?

Cartoon interpretations of Strange Case of Dr. Jekyll and Mr. Hyde portray the mad scientist's transformation as literal, and why not? It's visually arresting. We needn't dwell on the duality of good vs. evil within, or the harmful effects of repressive Victorian [or 1950s American] mores (although Kevin McCorry makes a convincing case that Hyde and Hare is An Overlooked Masterpiece).

The real syndrome of intermetamorphosis was first described by Courbon and Tusques in 1932 (English translation, 1994):

We present here a woman who, not content with seeing doubles, sometimes has the delusion that people around her are transformed physically and psychologically into other people.

Sylvanie G., 49 years of age (nothing to note from her family history) was admitted to Vaucluse on 9 February 1924 for melancholic depression and paranoia with ideas of persecution. She improved and was discharged on March 1924 but was readmitted 8 years later on 9 March 1932, never having lost her delusions, says the record.
. . .

Objects and animals which she owns appeared to her to be altered or simply displaced: ’They have changed my hens, they’ve put two old ones in the place of two young ones, they had large combs instead of small ones.’ People were transforming her clothes, she goes out in a brand new coat, and everyone around her looking at it is saying that she has a dirty and ripped coat (that is what she perceives). The people that she met were also changing: ’They stretch their ears... I have seen women change into men, young women into old men...’

Here's an incident involving transformation of Sylvanie G.'s husband, who reverted to his actual self just in time to repair the electrical supply:
Her husband changed in appearance, in behaviour, facially and took on the characteristic expression of some neighbour or other; it was this neighbour who had become embodied in him. “In a second my husband is taller, smaller or younger. It’s the individual into whom he is transformed who lives, who is in his skin, who moves. It’s as if you put yourself into his skin, it was you and not him. It was not merely a change, but a true transformation: 'I have changed with age, but have not transformed, I am still the same person.' One day, he changed into young M. Panier. He took on his mannerisms and face, spoke like him; but there was an electricity breakdown and M. Panier, who is not an electrician, tried in vain to repair it.”

The next documented case of intermetamorphosis wasn't published until 1978 (Malliaras et al.). Note the co-occurrence of several delusions, a common theme in these case reports.1
Ms. A, an introverted, shy, and stubborn woman of 19 with high moral standards, is the eldest of two children born to an introverted farmer and a cyclothymic housewife. Her childhood was uneventful and free from neurotic symptoms.

Her illness began when she was 18; she had difficulty in concentration, thought blocks, loosening of associations, and deterioration in scholastic achievement, followed by overt anxiety with psychomotor restlessness, insomnia, feelings of depersonalization and derealization, false memories of familiarity, auditory hallucinations, religious ideas of grandeur, and erotic delusions. Her behavior became strange and unpredictable. Later, delusional misidentifications of the intermetamorphosis type appeared and dominated the clinical picture. They consisted of her conviction that various persons (a taxi driver, a salesman, a pedestrian, a priest) were in fact Mr. B, her theology instructor, who she believed was in love with her. She insisted that these persons were physically and psychologically identical with Mr. B, and her delusional misidentifications continued even after Mr. B left the town to work elsewhere.

The patient was treated with “high doses of [unnamed] major tranquilizers” and started to improve after 6 weeks. Then after 3 months of inpatient treatment, “she was symptom-free and had developed insight into her past psychopathology.” Routine laboratory investigations were considered normal, but her neuropsych testing and EEG were not normal. Her verbal IQ was 120 but her performance IQ was only 82. This 38 point discrepancy strongly suggested that her visual perception, reasoning, memory, and other visual abilities went awry. These deficits are presumably related to her propensity for visual misidentification.

Her EEG showed diffuse abnormalities and frequent paroxysmal slow and sharp waves, especially in the temporal lobes. Stimulation with light produced high amplitude spikes, “associated with jerky movements of the upper and lower extremities (photomyoclonic response).” So even if she wasn't having frank seizures, her EEG activity was similar to what is observed in epilepsy. The authors discussed an organic contribution to her delusions, which was an era-appropriate but now quaint way of saying that something “neurological” was wrong with her brain (as opposed to something purely “psychiatric”). Although delusional misidentification syndromes can occur after brain injury and substance abuse (Silva et al., 1991), they are most often observed in the context of schizophrenia.

Silva and colleagues (1991) reported on 15 cases of intermetamorphosis, which were often accompanied by violent behavior including murder (n=2), attempted murder (n=1), and other physically harmful behaviors (n=9). In one detailed case report, the authors described a 30 year old male who was recently jailed for violent behavior. He had been experiencing psychotic symptoms for several years. He held the delusional belief that...
...physical duplicates of his family who had different minds wanted to kill him and turn him into robot. ... The beings that inhabited the bodies of his parents and 2 sisters often transformed themselves into animals, including werewolves, vampire bats, snakes, dogs and monkeys. Frequently, he believed these animals wanted to kill him.

The poor man stabbed his sister when he believed she was transformed into a half-sister, half-snake hybrid truly a living American Horror Story.
After the attack, he indicated that his sister was both a demon and spirit as well as a space creature that wanted to devour his head and replace it with an animal's head. He also reported that she had the power of possession.

Fortunately, his sister survived the attack. But unfortunately, the man didn't respond to antipsychotic medications. He had a history of alcohol abuse, including drinking on the day of the incident. His diagnosis was chronic schizophrenia, paranoid type.

Reverse Intermetamorphosis

Also fascinating are cases of reverse intermetamorphosis, where individuals believe they themselves have undergone transformation. Clinical lycanthropy, the delusion that one has been transformed into a wolf or other animal, is a special instance of reverse intermetamorphosis.

In Silva et al.'s clinical series, three of the 15 patients believed they were changing their own physical and psychological identities. Religious, social and cultural factors almost certainly influence the content of self-shifting, as is the case for other types of delusions.


1 See these papers, for example:

The co-occurence of reduplicative paramnesia, intermetamorphosis and capgras syndrome: a case presentation.

The Comorbidity of Reduplicative Paramnesia, Intermetamorphosis, Reverse-Intermetamorphosis, Misidentification of Reflection, and Capgras Syndrome in an Adolescent Patient.

Coexistence of Reverse Capgras Syndrome, Subjective Double and Cotard Syndrome.

2 See these blog posts:

Psychopharmacology of Lycanthropy

Werewolves of London, Ontario

Ophidianthropy: The Delusion of Being Transformed into a Snake


Courbon, P., & Tusques, J. (1994 English translation of 1932 French text). Illusions d'intermetamorphose et de charme. History of Psychiatry, 5 (17), 139-146 DOI: 10.1177/0957154X9400501711

Ellis, H., Luauté, J., & Retterstøl, N. (1994). Delusional Misidentification Syndromes Psychopathology, 27 (3-5), 117-120 DOI: 10.1159/000284856

Malliaras DE, Kossovitsa YT, Christodoulou GN. (1978). Organic contributors to the intermetamorphosis syndrome American Journal of Psychiatry, 135 (8), 985-987 DOI: 10.1176/ajp.135.8.985

Silva, A., Leong, G., & Shaner, A. (1991). The Syndrome of Intermetamorphosis. Psychopathology, 24 (3), 158-165 DOI: 10.1159/000284709

Silva, A., & Leong, G. (1994). Delusions of Psychological Change of the Self. Psychopathology, 27 (6), 285-290 DOI: 10.1159/000284885

From Bergman's Persona (via maudit)

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