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Neurocase: The Neural Basis of Cognition
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Mirrored-self misidentification in a patient
without dementia: evidence for right hemispheric
and bifrontal damage
a

a

a

Alberto Villarejo , Verónica Puertas Martin , Teresa Moreno-Ramos , Ana
a

b

Camacho-Salas , Jesús Porta-Etessam & Félix Bermejo-Pareja
a

a

Department of Neurology , Hospital Universitario ‘12 de Octubre’ , Madrid, Spain

b

Department of Neurology , Hospital Clínico San Carlos , Madrid, Spain
Published online: 01 Sep 2010.

To cite this article: Alberto Villarejo , Verónica Puertas Martin , Teresa Moreno-Ramos , Ana Camacho-Salas , Jesús
Porta-Etessam & Félix Bermejo-Pareja (2011) Mirrored-self misidentification in a patient without dementia: evidence
for right hemispheric and bifrontal damage, Neurocase: The Neural Basis of Cognition, 17:3, 276-284
To link to this article: http://dx.doi.org/10.1080/13554794.2010.498427

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NEUROCASE
2011, 17 (3), 276–284

NNCS

Mirrored-self misidentification in a patient
without dementia: evidence for right hemispheric
and bifrontal damage
Alberto Villarejo,1 Verónica Puertas Martin,1 Teresa Moreno-Ramos,1
Ana Camacho-Salas,1 Jesús Porta-Etessam,2 and Félix Bermejo-Pareja1

Mirrored-Self Misidentification in a Patient Without Dementia

Downloaded by [University of Chicago Library] at 08:38 28 September 2014

1
2

Department of Neurology, Hospital Universitario ‘12 de Octubre’, Madrid, Spain
Department of Neurology, Hospital Clínico San Carlos, Madrid, Spain

Mirrored-self misidentification, often referred as the ‘mirror sign’, is a delusion characterized by the inability to
recognize one’s own reflected image, often associated with the intact capacity to recognize others in the mirror. It
has been described mainly in moderate or severe dementia, especially Alzheimer’s disease. In the few reported
cases without global cognitive impairment, right hemispheric and frontal dysfunctions have been described. We
report a 90-year-old man with abrupt onset of the mirror sign after a minor right hemispheric ischemic stroke.
Neuropsychological testing revealed preserved cognitive capacities, except for mild to moderate impairment of
visuospatial skills, suggesting right hemisphere dysfunction. Neuroimaging showed a small right dorsolateral
frontal infarct, and bifrontal encephalomalacia, consistent with a past history of head trauma. Scattered ischemic
white matter lesions in posterior periventricular regions were also seen. It seems that the mirror sign is a multifactorial phenomenon that usually requires right hemispheric dysfunction (perceptual abnormalities, loss of familiarity) and frontal damage (loss of judgement and inability to correct wrong beliefs). The right frontal dorsolateral
prefrontal cortex seems to have a crucial role in self-recognition.
Keywords: Mirror-sign; Delusion; Misidentification; Frontal.

INTRODUCTION
Some of the most interesting disorders in neurology
involve alterations of the self and self-awareness as a
result of brain disease (Feinberg, 1997). One of
them is the mirrored-self misidentification, the inability to recognize one’s own image in the mirror,
usually in the presence of an intact ability to recognize others (Foley & Breslau, 1982). Often called
the ‘mirror sign’, it has been included among the
delusional misidentification symptoms (DMS)
(Joseph, 1986), a group of conditions in which a
patient consistently misidentifies persons, places,

objects or events. Capgras syndrome or, more
correctly, symptom (Förstl et al., 1994), is the most
common DMS reported. It is characterized by the
delusional belief that a person, commonly a relative, has been replaced by an impostor. Other
forms of DMS include the Frégoli syndrome
(known person seen in the guise of others), subjective ‘doubles’ and reduplicative paramnesia (a
place exists in two different locations). Some of
them, like reduplicative paramnesia and the
mirrored-self misidentification, almost always
occur in patients with focal brain damage or generalized cerebral dysfunction, while others, like Capgras’

Conflict of interest: none.
Address correspondence to Dr Alberto Villarejo, Servicio de Neurología, Hospital Universitario Doce de Octubre. C/ Andalucía,
Km 5,4. E-28041, Madrid, Spain. (E-mail: avgalende@yahoo.es).
We are very grateful to MM and his family, and to Joseph Healey for comments about the manuscript.

© 2010 Psychology Press, an imprint of the Taylor & Francis Group, an Informa business
http://www.psypress.com/neurocase
DOI: 10.1080/13554794.2010.498427

Downloaded by [University of Chicago Library] at 08:38 28 September 2014

MIRRORED-SELF MISIDENTIFICATION IN A PATIENT WITHOUT DEMENTIA

symptom, can be seen both in neurological or
psychiatric conditions, especially schizophrenia
(Cutting, 1991). It has been pointed out that the
DMS share some features (Feinberg, Deluca,
Giacino, Roane, & Solms, 2005; Weinstein, 1994),
which allow the clinician to distinguish them from
simple confabulation. According to Feinberg et al.
(2005), the DMS: (1) reflect alterations in personal
significance (the person, place or object misidentified is personally related to the patient); (2) they are
selective and consistent; (3) the patients with DMS
are usually unaware of their neurological or neuropsychological impairments; (4) they are refractory
to correction; and (5) right hemisphere dysfunction
is especially implicated in these disorders.
The mirrored-self misidentification has been
mainly described in Alzheimer’s disease patients,
with a prevalence in epidemiological studies that
varies between 2 and 22% (Burns, Jacoby, & Levy,
1990; Förstl, Osvaldo, Owen, Burns, & Howard,
1991a; Förstl et al., 1994; Mendez, Martin, Smyth,
& Whilehouse, 1992; Rubin, Drevets, & Burke,
1988). These differences in prevalence may be
based on different criteria for the definition of the
mirror sign, and on the degree of dementia of the
patients included, because the mirrored-self misidentification usually appears in patients with moderate or severe dementia, and is rare in mild
Alzheimer’s disease. There are only a few case
reports of the mirror sign as a symptom of fixed
and focal nature, independent of a global dementia
(Spangenberg, 2005). These cases suggest that the
mirrored-self misidentification is not only a manifestation of global cognitive deterioration, but a
distinct delusion with neuroanatomical and neuropsychological correlates. We report the case of a
patient with a past history of head trauma with full
recovery, who experienced the mirrored-self misidentification shortly after a mild right hemispheric
stroke. Evidence of right hemispheric dysfunction
and asymmetrical bifrontal damage were found in
this patient without dementia.

CASE REPORT
Patient MM
MM is a 90-year-old right-handed patient, a widower with three children. He attended primary
school until 14 years of age, with 8 years of formal
education, and worked most of his life as a farmer.
He lived alone in a rural area of central Spain, but

277

in the last 10 years he has spent the winter months
in Madrid with his daughters. His past medical history included mild arterial hypertension and a radical nephrectomy for renal carcinoma when he was
60 years old. He served as a soldier during the
Spanish Civil War, and had a politraumatism with
head trauma in a battle action. We lack any medical
record of that time, and do not know the type of
head trauma or the duration of the loss of consciousness. He was in a hospital for 6 months and apparently he made a full recovery, but he was discharged
from duty, resuming his civil life. There was no other
history of neurological or psychiatric disease.
One year before the initial consultation, he had
an episode of sudden onset of clumsiness of the left
hand and paresthesias in the left extremities that
lasted for 3–4 days. A few days later, the family
observed that MM started to believe that his own
reflection in the mirror was his father and, 5 days
later, his father-in-law, who had died 60 years ago,
and would be the object of the misidentification for
the following months. He could see him in any
reflecting surface, and believed that he was following him around. He tried to talk to him, and recognized that the presence did not answer because ‘he
is mute’. When his family tried to reason with him,
saying that his father-in-law was long dead, he
would answer: ‘That is true, but he has resuscitated
like Jesus Christ’. The mirror sign appeared continuously when he was in Madrid, but only sporadically (about once a week) when he was in his
village. He had preserved knowledge of what a
mirror was and provided examples of different uses
of mirrors. He continued to shave using a mirror.
The first 6 months, MM was calm and even
joked about the presence of his father-in-law in the
mirror, saying ‘something must be wrong in my
head when nobody else sees him’. Later, he
developed paranoid ideas about the mirror presence, believing that he wanted to harm him or his
family, arguing with the mirror, or asking his family to ‘feed the father-in-law’. Finally, his daughters decided to cover all the mirrors and reflecting
surfaces in the house and asked for a medical evaluation. Neither the patient nor his family had
other cognitive or behavioural complaints. He had
no other misidentifications, illusions or hallucinations. He never incorporated the reflection of other
persons in the mirror delusion. He was independent for all basic and instrumental activities of daily
living, and continued living alone in his village for
part of the year. Looking for a psychological
explanation, we asked his daughters about his

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VILLAREJO ET AL.

relationship with his father-in-law, and they did
not remember any conflict between them. The
father-in-law had died years before the patient’s
wedding, but MM was angry with him now
because ‘he did not come’.
When he was first evaluated in our memory
clinic, the patient had been experiencing the
mirrored-self misidentification for 1 year. The general and neurological examinations were unremarkable. He was a pleasant man, looking
younger than his age. Bedside language, orientation and memory testing were normal. Fundoscopy, visual fields and acuity were normal. He had
a bilateral hyperreflexia with down-going toes.
Sensation, coordination and gait showed no
abnormality.

1987b), Test Barcelona – revised (Peña-Casanova,
2005), the Boston Naming Test (Kaplan et al.,
1983), the Sunnybrook Neglect Battery (Leibovitch
et al., 1998), and a test for phonemic verbal fluency
(Ramier & Hècaen, 1977). Results are shown in
Table 1. The MMSE score (Folstein, Folstein, &
McHung, 1975) was 29/30. The patient had a normal intelligence and had preserved attention, executive function, verbal memory, praxis and
perceptual skills. He presented mild problems with
naming and category fluency. Visuoconstructional
tasks were mild to moderately impaired, suggesting
right hemispheric damage. There were no signs of
prosopagnosia in a face recognition test, and he
showed no problems in identifying famous persons, family members or himself in different photographs provided by his daughter.

Neuropsychological study
Evaluation of the mirror sign
Neuropsychological tests included the Wechsler
Adult Intelligence Scale – revised (Wechsler, 1987a),
the Wechsler Memory Scale – revised (Wechsler,

Formal assessment of recognition of objects, family members and different examiners reflected in

TABLE 1
Neuropsychological study
Hability
Cognitive status
Visual inattention
Verbal Attention
Visual Attention
Verbal Working memory
Visual working memory
Concept formation
Verbal fluency
Verbal memory

Language
Category fluency
Visuoconstruction
Copying tasks
Gestural praxis
Dimensional construction
Visual recognition

SubTest
MMSE (1)
Sunnybrook neglect battery (2)
Forward span digits (3)
Forward block span (4)
Reversed span digits (3)
Reversed block span (4)
Similarities (3)
FAS (5)
Words list, learning slope (4)
First Delayed recall. 5′min (4)
Second delayed recall, 20′min. (4)
Recognition (4)
Orders comprehension (6)
Naming (7)
Animals (6)
Clock drawing test (8)
Copy house-cube (6)
Bilateral Praxias (6)
Block desing (3)
Faces (6)
Overlapping line-drawn (6)
Family photo test
Famous people photo test

Direct Score
29
1
5
3
3
2
14
21
1-3-4-7
1
3
18
16
26
8
1
0
4
6
6
19
10
8

Percentile Score

50
63
16
47
45
91
9
25
9
63
15
55
10
15
1
1
1
9
50
63

(1) MMSE: Mini-Mental State (Folstein MF et al, 1975), spanish data: Lobo A, 1999. (2) Sunnybrook neglect
battery (Black E et al, 1990 and Leibovitch FS, 1998). (3) WAIS:Wechsler Adult Intelligence (Wechsler D,
1987), spanish data: Tea Ediciones, 2001. (4) WMS: Wechsler Memory scale (Wechsler D, 1981), spanish data:
Tea Ediciones, 2004. (5) FAS (Ramier AM et al, 1977), spanish data: Rami L, 2007. (6) Barcelona Test (PeñaCasanova J, 1991). (7) BNT: Boston Naming Test (Kaplan E et al, 1983), spanish data: García-Albea JE, 1986.
(8) Clock drawing test (Freedman M et al, 1994), spanish data: Del Ser T, 2004.

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MIRRORED-SELF MISIDENTIFICATION IN A PATIENT WITHOUT DEMENTIA

the mirror showed no abnormality. Many times
during the examination, he could point to his own
image in the mirror and recognize it as himself, but
at times he would also identify his father-in-law,
who the patient said did not particularly resemble
himself. Surprisingly, when asked to describe the
facial features of the father-in-law, he made an
accurate description of himself, but said that the
mirror presence ‘is much younger than me’. When
asked to provide more details about the presence,
the delusion became gradually more elaborated.
We can provide an example of a videotaped conversation:
EXAMINER: What kind of clothes does your
father-in-law wear?
MM: My clothes: my shirt, my pants, my
jacket.
EXAMINER: Why is he wearing your clothes?
MM: Because I wear them myself.
EXAMINER: And what happens if you are not in
front of the mirror?
MM: He stays there.
EXAMINER: What about his clothes?
MM: He stays there, naked.
EXAMINER: And what is he doing there if
nobody invited him?
MM: The moment I arrive, he arrives.
He lives in our apartment building
and he has a house like our house.
I can see it through the mirror, and
he can see us through his windows.

279

encephalomalacia, with more involvement of the
right frontal lobe, and a small right dorsolateral
frontal infarct, with a triangular shape and cortical
involvement. Scattered periventricular white matter
T2 hyperintensities were seen, especially around the
posterior horns of the lateral ventricules (Figure 1).
Hemogram, blood biochemistries, vitamin B12,
folic acid, TSH, electrocardiogram and chest X-ray
were normal. EEG showed mild symmetric slowing
in cerebral activity and a carotid ultrasound study
revealed mild ateromathosis without stenosis.
Evolution of the disease
The initial sudden episode of left hand clumsiness
and paresthesia was considered a right hemispheric
ischemic stroke, and treatment with clopidogrel
was begun. In the following year, no episodes of
focal neurological findings recurred. The mirror
sign remained stable, and the tendency to appear in
the big city persisted, and not in his village. Two
offers of treatment with atypical neuroleptics were
declined by the patient and his family because of
concerns about side-effects. Two years after the
onset of the mirrored-self misidentification, the
patient remains stable and no dementia symptoms
have appeared.
DISCUSSION
Summary of findings

This reduplicative paramnesia had not been
described by the family and was elicited during the
examination, but remained as a feature of the delusion during follow-up, saying that the house was
‘exactly like ours’. This delusion of a house in the
back of the mirror suggested some degree of mirror
agnosia, and we decided to examine this possibility. With a test based on that by Ramachandran,
Altschuler, and Hillyer (1997), we placed four
objects, one at a time, behind his right or left
shoulder, when the patient was standing in front of
the mirror. When asked to grasp the object with his
own hand, the patient appropriately reached for
the object behind his shoulders, showing no sign of
mirror agnosia.

We describe the case of a patient with mirrored-self
misidentification and associated reduplicative paramnesia after a minor right frontal ischemic
stroke. The delusion was strikingly modified by
changes in the patient’s surroundings, being more
frequent in unfamiliar places. Neuropsychological
evaluation revealed mild to moderate visuospatial
impairment, suggesting right hemispheric dysfunction, with no evidence of prosopagnosia or mirror
agnosia. Neuroimaging showed a small right frontal hemispheric infarct, bilateral asymmetrical
encephalomalacia of presumed traumatic origin,
and sparse white matter ischemic damage in posterior periventicular regions.

Neurorradiological and other ancillary tests

Findings in the context of the literature

A Magnetic Resonance Imaging (MRI) of the
brain showed bilateral frontal postraumatic

The ability to recognize oneself in the mirror has
acquired theoretical importance as a potential way

VILLAREJO ET AL.

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280

Figure 1. T2 weighted axial MRI showing bilateral frontal posttraumatic encephalomalacia, a right frontal dorsolateral infarct (yellow
arrow) and scattered periventricular white matter hyperintensities.

of testing self-awareness (Gallup, 1970), yet little is
known about how the brain achieves it. Apart
from humans, mirrored-self recognition is a stable
trait only in chimpanzees and a few other species,
and may be subject to decline with age (De Veer,
Gallup, Theall, van den Vos, & Povinelli, 2003). In
comparison with recognition of other people, selfrecognition in humans has received little attention
(Brédart & Young, 2004). Infants begin to show

mirror self-recognition between 18 and 24 months
of age (Amsterdam, 1972). Several lines of evidence suggest that self-recognition forms a separate
process, accomplished by a ‘self-network’ within
the brain, and it is not simply a part of the ‘facenetwork’ (Bredart & Young, 2004). Although studies suggesting left hemisphere involvement in selfrecognition also exists (Kircher et al., 2001; Turk
et al. 2002, 2003), a growing body of literature

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MIRRORED-SELF MISIDENTIFICATION IN A PATIENT WITHOUT DEMENTIA

points towards selective activation of a right
fronto-parietal network, with a bias in the right
prefrontal cortex, during tasks of self-recognition
or self-other discrimination. Consistent data supporting this idea has been obtained with the Wada
Test (Keenan, Nelson, O’Connor, & Pascual-Leone,
2001a), transcranial magnetic stimulation (Keenan
et al., 2001a) and functional neuroimaging (Devue
et al., 2007; Kaplan, Aziz-Zadeh, Uddin, &
Iacoboni, 2008; Keenan, McCutcheon, & PascualLeone 2001b; Platek et al., 2006; Sugiura et al.,
2005; Uddin, Kaplan, Molnar-Szakacs, Zaidel, &
Iacoboni, 2005). Studies with functional MRI have
shown that viewing one’s own face leads to greater
signal changes in the right inferior frontal gyrus,
the right inferior occipital gyrus and the right inferior parietal lobe (Uddin et al., 2005). In addition,
the right inferior frontal gyrus also shows greater
signal change when hearing one’s own voice compared to hearing a friend’s voice. Thus, the preference for self-related stimuli in the right inferior
frontal gyrus is not restricted to visual stimuli, and
this result supports the theory that the right prefrontal cortex supports an abstract self representation (Kaplan et al., 2008). Likewise, evidence from
patients with frontotemporal dementia suggests
that those with asymmetric loss of function in the
right hemisphere show dramatic changes in selfconcept (Miller et al., 2001).
The study of patients with the mirrored-self misidentification, in addition to its clinical relevance,
offers the possibility to analyze a lesional model
of self-recognition in humans. Instances of selfmisrecognition can occur in normal people, but
they are usually quickly corrected (Bredart &
Young, 2004). Self-misrecognition in the mirror
also appears in patients with prosopagnosia, but
using gestures and mimicking they readily infer that
the reflected face is their own, even though they do
not recognize the facial pattern itself (Damasio,
Tranel, & Damasio, 1990). In contrast, a patient
with mirrored-self misidentification may deny that
the reflected image is him or herself, although overt
recognition of faces is well preserved (Breen, Caine,
& Colheart, 2000). Mirrored-self misidentification
has rarely been described in the literature (Foley &
Breslau 1982; Burns et al., 1990). Most of the
reported patients have global dementia of the
Alzheimer type, making it difficult to infer the anatomical basis of this disorder. The only study with a
significant number of patients was perfomed by
Förstl, Burns, Jacoby, and Levy (1991b), using brain
computed tomography planimetric measurements in

281

Alzheimer’s disease patients, with and without misidentification symptoms, including misidentification of the mirrored-self. They found that patients
with misidentification symptoms had significantly
larger left frontal lobes, and larger right anterior
horns, indicating a right frontal atrophy. The
authors ‘hypothesize’ that misidentification in
Alzheimer’s disease may arise from a combination
of right hemisphere atrophy and a relatively wellpreserved left hemisphere that would allow patients
to verbalize their ‘sense of lost familiarity’.
To our knowledge, only four patients with
mirrored-self misidentification as a focal phenomenon have been reported before (Breen, Caine, &
Colheart, 2001; Feinberg & Shapiro, 1989; Spanenberg, Wagner, & Bachman, 1998). The most important clinical, neuropsychological and radiological
features are summarized in Table 2. All patients were
old and had neuropsychological and/or radiological
evidence of multifocal cerebral involvement. The
description of the mirrored-self misidentification was
somewhat different in every case, with two patients
claiming to see themselves as an ‘other self’ (Feinberg & Shapiro, 1989) or as a young girl (Spanenberg et al., 1998), two patients describing a stranger
in the mirror (Breen et al., 2001) and our patient seeing a relative. The influence of the environment on
the appearance of the delusion is not detailed in
every patient, but we can infer from the descriptions
that it usually occurs in unfamiliar surroundings, like
a hospital (Patient MH in Spanenberg et al., 1998) or
moving to a new house (present report and Patient
FE in Breen et al., 2001). Neuropsychological evaluation of the five patients disclosed signs of right hemispheric dysfuntion and, interestingly, two patients
had facial processing deficits (Breen et al., 2001;
Feinberg & Shapiro, 1989), and one patient mirror
agnosia (Breen et al., 2001). Thus, both mirror agnosia and mild facial recognition deficits have been
considered contributing factors for the mirror sign,
but they are not found in every patient. In neuroradiological studies, only the patient described by Feinberg and Shapiro (1989) had an isolated finding like
right temporoparietal atrophy, although they also
described ‘some generalized atrophy of the brain’.
All the other patients had multiple lesions, most of
them of vascular origin and with preferential
involvement of the right hemisphere. Interestingly,
our patient and patient TH described by Breen et al.
(2001) had small cortical infarcts in the right frontal
lobe, a region that has been involved in self-recognition in different studies (Uddin et al., 2005). Both
patients had an associated reduplicative paramnesia,

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VILLAREJO ET AL.
TABLE 2
Case reports of mirror-self misidentification in patients without global dementia

Reference

Name / Sex / Age

Feinberg and
SM / F / 77 y
Shapiro, 1989

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Spanenberg
et al, 1998

MH /F / 82 y

Breen et al, 2001 FE/ M/87

TH/M/77

Present report

MM / M /90

Mirror sign

Neuropsychological
findings

Focal RH impairment
Other version of
and mild diffuse
herself (Capgras for
cerebral dysfunction.
her mirror image)
Borderline
performance in a task
of facial recognition
Young girl who
RH findings
looked like her

Neuroradiological findings
MRI: mild atrophy and
right temporoparietal
atrophy

CT: Watershed infarction,
particularly R posterior
parietal; MRI: R basal
ganglia infarcts,
bilateral thalami
Stranger in the mirror RH findings; facial pro- CT: Multiple
cessing deficits
periventricular lacunar
after moving to a
infarcts. MRI: atrophy
new house
and scattererd white
matter high signal
intensity
RH findings; mirror
CT: normal. MRI: diffuse
“Dead ringer” for
agnosia
atrophy, ischemic white
himself. Associated
matter changes, small
reduplicative
cortical infarct
paramnesia
posterior right frontal
lobe
RH findings
MRI: Bilateral frontal
Father (5 days);
postramatic
Father-in-law.
encephalomalacia.
Associated
Right Dorsolateral
reduplicative
frontal infarct
paramnesia

Diagnosis
None provided

Mild vascular
dementia

Mild vascular
dementia

Atypical AD vs.
dementia with
lewy bodies.

Right frontal
ischemic stroke.
Postraumatic
brain injury

F: female; M: male. RH: Right Hemispheric; CT: computed tomography; MRI: magnetic resonance imaging; AD: Alzheimer’s disease.
Modified from: Spanenberg K. The mirror sign delusional misidentification symptom. In: Feinberg T, Keenan JP: The lost self.
Pathologies of the brain and identity. Oxford University Press; New York. 2005.

another delusional misidentifiction symptom usually
described in right hemispheric lesions (Benson,
Gardner, & Meadows, 1976).

Interpretation
Delusions are false, sustained beliefs based on
incorrect inferences about the self or environment
that cannot be overturned by refuting evidence.
The right hemisphere and frontal lobes are considered critical lesion sites for delusions (Devinsky,
2000). In the peculiar delusion of the mirrored-self
misidentification, different mechanisms seems to
be involved, but we can summarize them in four
ways: (1) abnormalities in perception; (2) loss of
familiarity; (3) lesion of a putative center for selfrecognition; and (4) loss of judgement and inability
to correct wrong beliefs.

Abnormalities in perception, like mild or
moderate deficit in facial recognition, loss of visuospatial skills or mirror agnosia have been
described in patients with the mirror sign as a focal
symptom, and they are very common in
Alzheimer’s disease, the condition most frequently
associated with it. These perceptual abnormalities
are probably related to right hemispheric dysfunction, described in every patient with the mirroredself misidentification.
Loss of familiarity plays a crucial role in other
DMS like the Capgras symptom (Devinsky, 2009).
In three out of five patients the with mirror sign as a
focal symptom, an unfamiliar environment was a
frequent trigger, and this is also common in
Alzheimer’s disease delusions. It is not clear how the
brain encodes familiarity, but it seems that the right
hemisphere dominates in analyzing whether a stimulus is familiar or not. Impairment of this function

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MIRRORED-SELF MISIDENTIFICATION IN A PATIENT WITHOUT DEMENTIA

could contribute to deficits in autobiographical
memory, source memory or false recognition of faces
or information (Rapcsak, Polster, Comer, &
Rubens, 1994; Schacter, Curran, Galluccio, Milberg,
& Bates, 1996; Tulving, Kapur, Craik, Moskovitch,
& Houle, 1994), as well as delusional reduplication
syndromes associated with right hemisphere lesions.
In addition, the ictal hallucination of familiarity
(déjà vu) is much more common with right than left
temporal lobe seizure foci (Gupta, Jeavons, Hughes,
& Covanis, 1983; Mullan & Penfield, 1959).
The existence of a center for self-recognition in
the right prefrontal cortex is supported by different
studies in healthy volunteers (Uddin et al., 2005).
In our patient, the mirror sign appeared immediately after a right hemispheric stroke. There was
radiological evidence of a small infarct in the right
prefrontal cortex, a feature already described in
another patient (Breen et al., 2001). These two cases
provide further evidence for a self-recognition
center in the right frontal lobe, and although we
consider that a lesion in this area is not enough to
elicit the mirrored-self misidentification, it probably impairs the ability to recognize one’s own
image in the mirror, playing a crucial role in the
genesis of the delusion.
Finally, a delusion cannot be fixed and sustained
in the presence of preserved judgement and ability
to correct wrong perceptions or beliefs. DMS have
been linked with clinical syndromes that appear in
right hemisphere-injured patients, like neglect or
asomatognosia (Feinberg, 1997). For example, in
these patients, the wrong beliefs of the own left
arm not belonging to the body become fixed despite rational arguments to the contrary. Something
similar happens in patients with the mirror sign.
Thus, right hemisphere and bifrontal damage
could lead to the inability to revise a distorted perception or interpretation of one’s own face
reflected in the mirror, producing one of the most
bizarre and fascinating symptoms in neurology.

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