Aseem Mehra1, Sandeep Grover2, Manoj Kumar3
1Assistant Professor, Department of Psychiatry, Post Graduate Institute of Medical Education and Research Institute, India.
2Professor, Department of Psychiatry, Post Graduate Institute of Medical Education and Research Institute, India.
3Junior Resident, Department of Psychiatry, Post Graduate Institute of Medical Education and Research Institute, India.
Corresponding Author: Aseem Mehra, Assistant professor Department of Psychiatry Nehru Hospital, Cobalt Block 3rd Floor, Dept. of Psychiatry PGIMER, Chandigarh India.
Received Date: May 13, 2019
Published Date: Jul 4, 2019
Autoscopic hallucination is an interesting phenomenon since the past many years but has not been reported much in a clinical setting. It is a psychic visual hallucination in which a person experienced a part or whole body in the external space. It has been reported in various organic conditions and specifically in the male gender. However, it has rarely been reported in the case of primary psychiatric illness. Here we are reporting a female patient presenting with the autoscopic hallucination presented with Schizophrenia. A Psychiatrist should be familiar with this kind of unique phenomenology.
Keywords: Autoscopic; Hallucination; Schizophrenia.
Autoscopic hallucination is the rarest psychopathology which has not been reported as much as like other psychopathology. Though it has been described since ancient times, not much attention paid by the researchers.
Autoscopy is the word derived from the Greek words ‘Autos’ (self) and ‘skopeo’ (looking at) . It is a visual hallucination in which an individual experiences, all or part of the person’s own body appeared within the external space, viewed from his/her physical body . This phenomenon has been reported in association with organic pathology like meningitis, seizures, space-occupying lesions, brain tumours, migraine, delirium, posttraumatic brain lesions etc [1,3-7]. Two cases of autoscopic hallucinations are reported which were associated with alcohol and drug-induced respectively [8,9]. A case is reported in a young male who had schizophrenia with a history of substance use10. All the cases were reported in the male. The autoscopic hallucination is never reported in a female, suffering from primary psychiatric illness without having any comorbid physical illness or substance use.
In the indexed case report, we present here a case of a young schizophrenic female who presented with rare phenomenon of autoscopic hallucination since last five years.
A 27-year young single female belongs to urban nuclear family from upper socio-economic status presented with insidious onset of symptoms since last five years characterised by auditory hallucination; voices were discussing and threatening type. In addition to hearing voices, the delusion of persecution, delusion of reference, poor self-care, and poor social interaction were also present. Gradually her condition deteriorated, stopped going out of the home, and would remain fearful, not participating in household chores. For these symptoms, was taken to various faith healers and local quake but had no relief. Since the last two and half years, she started crying on and off the pattern for about 5-10 minutes about 3-4 times in a day. While crying, she would point out her figures toward the wall. Later on, she revealed that “she would see herself, i.e. almost the photocopy of her, i.e. “double” in front of her about 2-3 feet away from her body. She would describe her double with the similar facial features, colour and style of hair, complexion in fact “it was another me”. She would say that her double would appear naked to her; it was like her “mirror image” or “self”. She would say that a man would come and would rape with the “self”. She would have guilt that she could not save the “self” being raped by someone. As her “self” would ask for help in a loud volume and would cry. She denied having any sensation to hers’ original body. It would occur at any point in time. She visited various psychiatrists, started on antipsychotic but had not much relief. Compliance was not so good, citing the reason of no improvement with the drugs.
Apart from the above symptoms, she also had a significant decline in scholastic performance and stopped going to college. She would not attend social gatherings, would not participate in festivals too.
She was brought to our outpatient clinic, diagnosed with schizophrenia. There was no remarkable family or history of psychiatric illness, sexual abuse or childhood emotional trauma. On mental status examination, fearful, auditory hallucination discussing and commenting type, delusion of persecution, and impaired judgment with poor insight were present. There was no history of seizures, brain insult etc. She was conscious, co-operative and well oriented to time place and person. On Mini-mental state examination scored 30/30. Her physical and Neurological examinations were unremarkable. Visual field was intact. All routine investigation like complete blood count, liver function, renal function, serum electrolytes, chest.
X-ray (P/A view), and ECG, calcium, vitamin B12, vitamin D were within normal limit. Contrast Enhanced Magnetic Resonance Imaging (MRI) Brain, Electro-encephalography (EEG) was within normal limit.
An ICD-10 diagnosis of schizophrenia was made and started on Tab Risperidone up to 6 mg/day started. She improved about 30-40% over 5-6 months and later on lost to follow up.
Autoscopic hallucination has been known since ancient times. Being a rare phenomenon not much exact clinical description is available. It is the hallucinatory experience of perception of the self-body part/image projected into the real external space like a mirror image . The sufferer usually retains the insight into the unreality of the experience. In the patient with autoscopic hallucination, the image of the self is disliked by the person . Even Freud had a personal experience of this unique phenomenon and described it in the “The Uncanny”. Freud stressed that distress arose from the “uncanny” effect of seeing one’s self in the external space . In 1953, another author defined it as a “delusional dissociation of the body image into the visual sphere”. Lippman  defined it as “hallucination of physical duality.”
There are two other phenomenons which are similar to the autoscopic hallucination, i.e. out of body experience and Heautoscopy. The unique character of autoscopic hallucination which differentiates it from others is the observer’s perspective is clearly body centred, and the visual image of one’s own body appears as a mirror reversal [16,17]. The experience of “double” is also experienced in other disorders like Capgras syndrome. The main characteristics feature of the Capgras is the patient’s delusional conviction that the “double” in his environment is not his “real self” but of some other person .
As described in the introduction, autoscopic hallucination seems to follow a wide range of substance use as well as organic etiologies but neither of which can be positively ascribed to the index patient [6-9]. The special feature of the index case is the occurrence of the autoscopic hallucination in a schizophrenic patient. According to our knowledge, the index case report is the first case of autoscopic hallucination reported in a female schizophrenic patient. The observed psychopathology is quite a rare reported in a clinical setting. The current discussion also emphasised that there is a need to spend more time and detailed questioning of a schizophrenic patient to explore such unique psychopathology.
Conflict of interest: None
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