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Psychiatric Trinity

Fifth cup of coffee in this overwhelming atmosphere of the October evening, cold and wheezing wind casts small drops of rain from the greyhound sky towards windowpane… Reverie and flying ideas about the future of psychiatry. Is it possible to find a solution for all of the human mind’s problems?

If we only could look inside all of the neurons in our prefrontal cortex, identify and describe all of these complicated and fascinating structures, receptors and mediators, which cooperate and connect together aiming to process information and stimuli. How many new drugs could we invent? Maybe a variety of neurosurgical approaches to selectively, and without damaging of a human brain, delete the source of painful symptoms, just switch off …

Electrical lanes of our consciousness, beautiful dance, where cognition processes complement together like parada and sacada in tango. All we need is to find lacking notes in the music script and play.

 

What a terrible kakophonia ..?

 

Who dares to disturb me in my successful mental treatise with this noise?

 

Neurological hammer is my only weapon, I take it and run downstairs passing affective and psychotic

ward of our interdisciplinary hospital, where patients recover towards better future.

Glass doors opened widely, in the emergency some people crowd waiting for a doctor, between them I see reflective uniforms with the word “police”.  Coming into intervention room I notice the young agitated guy, which still screams and tries to offend anyone, who appears near to his bed.

“Look! He is pimpled and is a doctor !”- scanned and returned to his “word lettuce” about taxi and his phone. I am accustomed to such allegations, I just smiled and stepped forward: How can I help you, please tell me what happened?  The answer was not satisfying, but it wasn’t necessary, psychiatric examination and the social interview got from police officers indicated clearly the intoxication with MDMA. That’s all.

Toxicological treatment in the hospital, after recovery, psychiatric assessment and trying to help this young man to solve this terrible problem with drug abuse…  Seems to be not so complicated, but I decided to stay with him for a minute and try to talk with overstimulated patient’s brain. Maybe it is a way to calm down the patient and help him?

When I asked about the history of abuse I crossed the border of terra incognita.

“ Matt? Why Am I here? Oh no, you are still standing here doctor, Ann? Tell me where is my phone? Where is a doctor, he came out ?”

All of these words were spoken looking into my eyes. I was three(or maybe more?) persons in that time, I changed the identity,  after few seconds I was Matt and later I was Ann, and finally, I was a doctor, but only for a minute, over and over again. Circulus vitiosus of metamorphoses.

 

Who are you? Who, who, who, who…

 

These funny words of The Who’s flagship song really constitute serious problems in patients with dementia, schizophrenia, or brain injuries and we call it Delusions of Misidentification.

Probably the first person, who described such symptoms was French psychiatrist Joseph Capgras in 1923.

In his publication, d’illusion des sosies, he presented a case of a woman with dementia and delusional belief that persons from her nearest family are replaced with someone other, like with a double.

It is interesting that patient recognizes the person, but ignores his identity, what often causes troublesome, embarrassing situations and also aggressive behaviours, which cause a destruction of the family and social life and leads to alienation. We can imagine the situation, like this from 1923, when,

for example, our grandpa says:

il lui ressemble mais ce n’est pas lui”,  He looks like him, but it’s not he, his not my grandson, it’s a mistake…

A little opposite situation is met in the Fregoli’s delusion. In this case, sick person thinks that a lot of different people met in daily life activities, like shopping, travelling on a train, or going to work is the same one person, who only changes her, or his appearance, like changing clothes, disguise. Patients, on canvas of that, develop secondary delusions of persecution, it was also such in the case of a young woman described by Leopoldo Fregoli.

When we meet all the time the same person it is really simple to think that we are tracked, such situation seems to be for the patient very dangerous and also may cause bizarre behavioural reactions. Third, interesting delusional syndrome encompasses claiming that during the conversation person changes identity, this situation is called intermetamorphosis. For example, people with Alzheimer Disease could think that they are talking with a friend and after few minutes with mother, next with son and next with police officer, while they are really talking all the time with one person…

Well, somewhere I’ve seen it.

 

Introducing the brain into psychiatry

 

Aforementioned psychiatric conditions are delusional like neurological syndrome popularized by Oliver Sacks in his book: A man who mistook his wife for a hat. There exist a particular brain area responsible for recognizing of faces, called fusiform gyrus- impaired function of it results in prosopagnosia (the word from Greek πρόσωπον= face αγνωσία = inability ).

In prosopagnosia patients can’t identify a face and also by mistake perceive different stuff as human faces, like in case of dr. M. from the cited book, where he recognized bars along the road as people and greeted them.

Most current psychiatrists think that there is an anatomic base for all mental disorders. Also, in this case, some reported examples of patients suggest that delusions of misidentification may have specific brain localization. Putative place in the human brain is built up of the mentioned fusiform gyrus, parahipoocampal gyrus and lower- anterior part of temporal gyrus. It is thought that disconnections between these areas, due to brain injuries, tumours, inflammation, or psychiatric disease, results in problems with recognition of faces.

It is believed that these three areas cooperate together in visual perception and share the work, like craftsmen in a car factory (See in the figure). Fusiform gyrus recognizes the face, parahippocampal area gives a meaning to the face, and lower- anterior temporal cortex stores visual memory. As an example for this theory, Hirstein and Ramachandran in 1997 described the patient with Capgras syndrome and showed that there is no difference for his brain between familiar people and strangers, what suggest impaired creating of memory. It is worth noticing that misidentification in psychiatric diseases is often resistant for treatment (dopamine antagonists), on the other hand, the main neurotransmitter in our circuit is… Dopamine, maybe it is a next side effect of pharmacological treatment, or maybe delusions are primary to pathological processes leading to psychosis. We still don’t know…

 

Figure Memory Production Line: 1 Fusiform Gyrus: Recognizes the face ( like proper elements to make a car), 2 Perihippocampal area: Gives meaning “a colour”, 3 inferior- anterior temporal cortex: a storage of visual memory.

About the author


Przemyslaw Zakowicz

Przemyslaw Zakowicz

Przemyslaw is a sixth-year medical student at Poznan University of Medicine. He is particularly interested in neuropharmacology, anaesthesia, psychiatry and addictions. Privately, he is a thriving multi-instrumental musician and a poetry-empowered classicist. FNS since 2015.

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