Neurocase (2005) 11, 212–215
Copyright © Taylor & Francis Inc.
ISSN: 1355-4794 print
DOI: 10.1080/13554790590944799

“Seeing oneself”: a case of autoscopy
Neurocase

GIOVANNA ZAMBONI, CARLA BUDRIESI, and PAOLO NICHELLI
Department of Neuroscience, University of Modena and Reggio Emilia, Italy

Autoscopy is the experience of seeing an image of one’s body in external space. We describe the case of a patient who reported
longstanding autoscopic hallucinations following post-eclamptic brain damage. The MR scan demonstrated damage involving the occipital
cortex and the basal ganglia bilaterally.
We hypothesize that the image was the result of aberrant plasticity mechanisms involving cortical areas that play a central role in high-order
body or representation of oneself.

Introduction

Case report

Autoscopy is the experience of seeing one’s own body or its
upper parts in external space, as though reflected in a mirror
(Féré, 1891). Like previous authors (Brugger, 2002), we distinguish autoscopy from heautoscopy and from out-of-body experiences. Heautoscopy, also called the phenomenon of the
double, is a reduplicative illusion: the belief that one has an
exact double, which may or may not be visible. In an out-ofbody experience, the subject appears to be awake and to see
himself and the world from a location outside his physical
body, usually from above. Autoscopy is usually experienced as
unreal and hallucinatory, whereas heautoscopic and out-ofbody experiences are mostly judged as vivid and veridical
(Blanke et al., 2004). These complex experiences of physical
duality are usually brief and transient, lasting only a few seconds.
Autoscopic experiences have been reported following
brain injury, brain tumors, stroke, and encephalitis. They also
have been described in patients suffering from psychiatric
disorders such as schizophrenia, depression, and dissociative
disorders (Blanke et al., 2004).
Most authors agree that the frequency of associated brain
pathology points to an organic substrate for autoscopy, heautoscopy, and out-of-body experiences. These phenomena
have been related to temporal (Devinsky et al., 1989), parietal
(Menninger-Lerchenthal, 1935; Lopez-Ibor, 1957), and parietooccipital lesions (Hécaen and Ajiuriaguerra, 1952). Very
recently Blanke argued that both out-of-body experiences and
autoscopy are due to a cerebral dysfunction of the parietotemporal junction (Blanke et al., 2004).

We present the case of B.F., a 30-year-old, right-handed
female, who developed gestosis and eclampsia, complicated
by hemorrhagic shock, cardiocirculatory arrest, and stillbirth. She regained consciousness following two days in a
comatose state.
Twenty days after cardiocirculatory arrest, B.F. was alert,
but on neurological examination showed cortical blindness
and tetraparesis, more severe in the lower limbs. Fifty days
after the onset, the MR scan showed bilateral occipito-polar
damage extending to the right parieto-occipital junction and
bilateral hyperintense signal alteration in the putamen, globus
pallidus, and the head of the caudate nucleus on T2-weighted
images (Figure 1). Insular cortex and thalamus were not
involved. One month later a (99m)Tc-ECD SPET demonstrated bilateral posterior hypoperfusion, more extended to
the right occipital lobe.
Three months after the onset, neuropsychological testing
demonstrated severe object agnosia and alexia without
agraphia. She was not able to recognize objects, famous
faces, or letters, to discriminate between similar shapes, or to
copy simple drawings. Visual acuity, visual fields, color discrimination and ability to detect a stimulus against a background were preserved. This picture was consistent with
apperceptive agnosia. She also showed optic ataxia, ocular
apraxia, impaired depth perception and deficit of spatial analysis, as simultanagnosia, with tendency to left side hemi-neglect.
B.F. performed well in language and verbal intelligence tests.
She showed a borderline performance in Babcok’s story
scale. Motor coordination, tactile and joint position sense
were spared. At this time, tetraparesis was greatly improved:
the patient was able to walk without assistance with a minimal
residual right lower limb weakness.
It was during this assessment, at three months, that the
patient first reported seeing her image as though it were
reflected in a mirror. Like a mirror image, the image replicated
her movements. In particular, any facial or arm movement she
executed was reproduced in real time by the image and

Received 21 June 2004; accepted 3 November 2004

We want to thank the two reviewers for their helpful comments
on our paper.
Address correspondence to Paolo Nichelli, MD, Department of
Neuroscience, University of Modena and Reggio Emilia, Via Del
Pozzo, 71, 41100 Modena Italy. E-mail: nichelli@unimo.it

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Autoscopy

Fig. 1. FLAIR MRI image showing bilateral occipito-polar damage
and bilateral hyperintense signal in the basal ganglia.

Fig. 2. Graphic representation of the autoscopic hallucination drawn
by one of the examiners (G.Z.) following the description by the
patient. Note the distance of the image, the perfect correspondence
of movements, the apparent left-right reversal attributed to mirrors,
the transparency of the image.

respected the apparent left-right reversal attributed to mirrors
(Figure 2).
Wherever she looked, B.F. saw her mirror image right in
front of her, at a distance that varied depending on where she
was looking. The image appeared at a distance of about 1
meter if she was looking into the distance, seemed to be lying
on the floor if she was looking down, or appeared on the ceiling if she was looking up. During the examination the image
was interposed between the patient and the examiner. If a
solid object, for example a sheet of paper, was placed
between the mirror image and the patient, she said that she
still saw the image, but nearer to her, on the surface of the
paper. According to her description, it was as though the
image, which was transparent, was set “on a sheet of glass”
resting against whatever object she was looking at. The autoscopic image was somewhat blurred and she could not make
out its colors or small details. It disturbed her vision of other
objects, even though she could see through it. The image was

life-sized, appeared fully face on and usually included head
and shoulders, but could extend as far as the legs if the patient
explored it by moving the gaze downward over the figure.
For example, the patient was able to see the legs if she looked
carefully at the lower part of the image. The autoscopic figure
was always dressed exactly like the patient.
If the examiner drew the outline of a circle on the patient’s
forehead with a black pencil she reported seeing something
dark and round tattooed on the image’s forehead. She
reported seeing the same when the examiner touched her
forehead with a capped pencil without inking her.
If the examiner put his hand on the patient’s shoulder she
said that she could perceive something on the image’s shoulder
similar to a hand.
The hallucinatory image had been present since B.F.
regained consciousness. At the beginning the patient saw
something similar to a person appearing on the ceiling of her
hospital room. In a couple of days she realized that the image
was always present if she paid attention to it. After one week,
when she was recovering from tetraparesis, she noticed that
the image imitated her own movements, in particular of the
upper limbs. Then she began to recognize that the image had
her own physical characteristics: for example, dark curly hair.
During the recovery from coma, in the first couple of days
after regaining consciousness, she also reported the hallucination of seeing the baby she had just lost.
B.F. reported perceiving her mirror image all the time.
However, she noticed that its appearance was modulated by
the degree of attention she paid to it. Thus, B.F. saw the
image every time she opened her eyes, was sometimes able to
"forget" it was there, yet would immediately see it again if
she once more focused her attention on it. It disappeared
when she closed her eyes.
The image was not associated with an emotional state and the
patient appeared somewhat indifferent to its presence. She was
conscious of the unreality of her visual experience and she was
able to discuss it critically and quite freely. She had never attributed feelings or thoughts to the image, nor had she ever experienced depersonalization or regarded the image as her double.
Six months after the onset, a second neuropsychological
evaluation showed improvement of the apperceptive agnosia.
Recognition of drawings and photographs was still impaired,
whereas recognition of corresponding objects was spared.
The patient performed better in letters and number reading.
Ocular apraxia was also improved but optic ataxia, simultanagnosia, and left side hemi-neglect were still present. Other
cognitive abilities and neurological exam were negative. During
this evaluation B.F. reported that her autoscopic image had
gradually disappeared.

Discussion
We found few cases in the literature meeting the definition of
autoscopy as a mirror hallucination without psychological
attributions. Most were associated with epilepsy (Nouet, 1923;

214
Genner, 1947; Hécaen and Ajiuriagverra, 1952; Blanke,
2004). Specifically, the more recent case report concerned a
patient with left temporal epilepsy (Blanke, 2004). One was secondary to right occipital ischemia (Bhaskaran et al., 1990), and
others were described in patients with psychiatric disorders
(Lukianowicz, 1958). In these cases the autoscopic hallucination
commonly lasts only a few seconds or minutes, even if it can
appear repeatedly, and it is related to alteration of consciousness.
Conrad (1953) reported the only case that, in terms of the
persistence over time of the autoscopic hallucination, can be
considered similar to the one we present here. He described a
man who, eight days after becoming blind, noticed a face in
front of him and slowly, after a few days, recognized himself.
The image did not change for seven years. As in our case, it
was possible to carry out simple experiments on the image and
the patient was somehow surprised about the results. Other
similar characteristics were the not immediate self-recognition
by the patient and the “attention related” appearence of the
image. The author termed the image “mirror phantom” to distinguish it from other brief hallucinatory phenomena and proposed a common origin for both the phantom limb and the
autoscopic image, on the basis of the persistence of the image
over time. We propose that this “mirror phantom” might be the
result of an aberrant plasticity mechanism.
West (1962) suggested that hallucinations are due to
decreased sensory input releasing spontaneous activity of the
CNS structures that normally mediate perceptual experience.
Neuroimaging studies (ffytche et al., 1998) confirmed an
increased activity of ventral occipital regions in blind patients
who experience spontaneous visual hallucinations. We would
speculate that the autoscopic image originated from hyperactivity of visual extrastriate areas deprived of complex visual stimuli
following bilateral occipital damage. This is consistent with the
presence of the hallucination together with visual agnosia. In line
with this hypothesis, the hallucination gradually disappeared
during the patient’s recovery from agnosia. To explain how this
“spontaneous hyperactivity” originates an image of one’s own
self we would argue that this mechanism should be coupled with
a sort of cross-modal plasticity. Cross-modal plasticity refers to
the concept that the part of the cortex normally responsive to one
sensory modality may become responsive to inputs from other
sensory modalities (Sadato et al., 1998).
Several investigations have suggested the existence of specific neural networks responsible for the representation of the
self and of its interactions with the external world. These selfrepresentational capacities of the brain are assumed to be distributed across several brain structures (Damasio, 2003;
Northoff and Bermpohl, 2004). Neural correlates of ownership of one’s body, as reflected in the body image, are
assumed to involve the right insula (Farrer and Frith, 2002;
Craig, 2003), ventromedial prefrontal cortex, and medial
parietal areas (Craik et al., 1999; Kelley et al., 2002). In
particular, other imaging studies have reported evidence of a
neural substrate underlying facial self-recognition involving
the right limbic system and left pre-frontal and temporoparietal cortices (Kircher et al., 2001).

Zamboni, Budriesi, and Nichelli
In order to create a central representation of one’s own
body those areas must realize multisensory integration
between different sensory source: vision, touch, proprioception, and so on (Maravita et al., 2003). Blanke (2004) speculates that illusory reduplications of one’s own body result
from a failure to integrate proprioceptive, tactile and visual
information in personal space. We would add that in case of
persistent autoscopic experience hyperactivity of high-order
cortical visual areas, deprived of their input, may have established "abnormal cross-talk" with cortical areas involved in
body-schema representation. They may have been activated
by integrated proprioceptive, tactile, and visceral integrated
information (the body-schema representation), giving rise to
a complex visual hallucination of one’s own self.
Thus, we would argue that autoscopy is a visual interpretation of the representation of the self, in which self-sensory or
proprioceptive information is transformed into a visual
image.

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