A case of “Borrowed Identity Syndrome” after severe traumatic brain injury

Background

The traditional approach to disorders consequent to brain injury centers on the description of concrete symptoms that be shown to correlate significantly with injuries to particular brain regions. This approach began with the pioneering works of Broca [1] and Wernicke [2], and has continued in much contemporary work in neuropsychology [3–5]. A.R. Luria [6] tried to go beyond merely listing the particular symptoms observed, introducing the idea of the “basic defect,” i.e. a single underlying disorder that is presumably causing the manifold observable difficulties the patient manifests in performing the tasks involved in a neuropsychological examination. Thus a basic defect in phonemic hearing would affect performance in all tasks involved with that function, such as verbal memory, word repetition, reading, writing, etc., while performance should be unimpaired in tasks that do not require phonemic hearing. Only in this way would it be possible, in Luria’s view, to describe a syndrome characterized by a particular set of disorders following a specific brain lesion.

Luria’s approach was certainly a step forward, both in the better understanding of the nature of the symptoms observed in a particular patient and in conducting more effective therapy. Yet Luria’s approach was only able to explain some of the symptom changes observed in a patient during the process of recovery. It does not provide an explanation for the appearance of clinically distinct syndromes over the course of progressive deterioration, as observed in many post-TBI patients. One such patient will be described in the present report, with particular emphasis on some unusual disorders of personal identity in a former physician who sustained a serious brain injury due to a car accident in 1998. The injury resulted in focal injuries in the frontal and right temporal areas and coma lasting 63 days. The real purpose of this paper, however, is to explore the mind of a patient whose identity has been disrupted, and who has experienced the loss of his self image and relations with his immediate surroundings.

Case Report

MIRROR SIGN:

A physiotherapist named Jacek was helping PA stand in front of a full-length mirror:

Therapist (Th): Who is that, Peter? Who do you see there?

PA: I don’t know. Oh my God! That monster is staring at me [shouting].

Th: And who else do you see in the mirror?

PA: I don’t know, but maybe Jacek, I think you said so, isn’t that right?

Although he was not able to recognize himself in the mirror, he recognized and gave the name of the therapist. He also remembered his own name when asked. Ten minutes after this incident, however, he did not remember that he had been standing before a mirror or what the therapist’s name was.

DENIAL OF THE FAMILY:

Another feature of the disorder was denial of the family. Here is an extract from an interview with the patient in the presence of his parents, his wife and his oldest daughter, who was 19 at the time:

Th: You are pleased that you’ve been visited by your family, aren’t you?

PA: Me? Of course not! I don’t have a family. I don’t know these people. My family was all killed in an accident.

Th: And…

PA: I don’t know these people. They are body doubles… doubles of my entire family or I don’t know [shouting]!

This seems a very clear case of Capgras syndrome [7]. Neuropsychologists and psychiatrists have known for nearly 100 years that a small number of psychiatric patients become profoundly suspicious of their closest relationships, often cutting themselves off from those who love them and care for them. They may insist that their spouse is an impostor, that their grown children are body doubles; that a caregiver, a close friend, even the entire family is fake, a duplicate version.

DENIAL OF THE LOVER:

Another symptom we observed during this period was denial of the extra-marital relationship (supposedly “the love of his life”). Upon being visited by his former girlfriend in the hospital, he displayed complete non-recognition.

L: How are you feeling, darling? [attempts to kiss him]

PA: Don’t kiss me [shouting]!. I don’t know you!

After one hour the therapist asked him about the visit (which had been arranged by PA’s mother).

Th: So, you have been visited by your girlfriend?

PA: That hag is supposed to be my lover?

Th: She’s a beautiful woman, isn’t she?

PA: Perhaps I could consider that woman beautiful, yes… I would regard her as beautiful, she is about 40, isn’t she? No girlfriend of mine could be so old! Besides, I’ve never had a lover.

Although PA did not recognize his lover, a few minutes later in conversation he suddenly stated that it was not permissible for a physician to enter into such a close relationship with a patient – even though no one had yet said to him that the woman who was claiming to be his lover had previously been his patient, and in fact the subject of conversation had already changed. This might suggest that he recognized her as a former patient (which in point of fact is true), but not as his lover. On the other hand, his wife is also a doctor, so his “pangs of conscience” might be related to his marriage, though that seems rather far-fetched. It is nearly impossible to establish, in his cognitive state, to what extent his failure to acknowledge his lover is repressed guilt, and to what extent it should be called amnesia, or confusion.

About half an hour after his lover had left the room, the patient asked the therapist, “Aren’t you… hmm… my fiancée or something… she must be somewhere, but I don’t know where she is and nobody can find her.”

It is possible that he was remembering the unpleasant conversation with his fiancée and was somehow looking for her to make things right. Some traces may have been maintained In his memory, then, of his feelings for this woman, and these memories were activated, with a marked delay, by the visit of his girlfriend. In his state of cognitive confusion he misidentified his therapist as his lover, but the emotional memory indicating that the lover had been lost was essentially correct.

DENIAL OF THE DOG:

One of the most interesting aspects of PA’s problems with autobiographical memory is his complete denial of having ever had a dog, when before the accident he and the dog had been extremely close. This constitutes a first in reported cases of a similar nature.

T: Is this your dog? [in the presence of his pet, a dachshund, who is barking at him. Apparently, the dog does not exhibit positive feelings towards the patient here and now].

PA: Nothing of the kind! A lump of fur like that! I don’t own a dog. I wouldn’t want such a rubbishy thing! I’m afraid of this dog. It wants to bite me!

PA was able to recognize public figures, but during this period he was watching an excessive amount of television, and had become interested in politics only after the accident. It is quite possible, however, that these faces of public figures constitute islands of episodic or autobiographical memory, which excludes any assumption that his disturbances might be linked to difficulties in facial recognition per se. After being shown pictures of two important Polish politicians he stated:

“… here is the President and the Prime Minister… they have power… It’s them who changed the calendar… and everyone thinks that I’m 40 when I’m really 20…”.

IDENTITY MISIDENTIFICATION:

This last utterance showed another important characteristic of PA’s mental state, namely, the problems with identity. Not only was he unable to state his age, but he reacted with anger to an attempt by the therapist to specify his true identity, which is illustrated by the following conversation:

Th: Who are you?

PA: Who am I? I don’t know! Perhaps you could tell me?

Th: You are a doctor – a gynecologist.

PA: No! I’m too young to be a doctor.

Th: How old are you?

PA: Probably 7 or 8 years old.

It was eventually established that he possessed some murky recollections of childhood up to the age of eight. At that time he had dreamed of becoming a car mechanic, and now he sometimes claimed to be one. He also vaguely remembered his first year at school, but from the age of eight. He complained that he felt lost. This can be noted in his commentary accompanying his drawing of a ladybug (Figure 2):

“My inner self reminds me of a ladybug. It’s obviously looking for something because she feels foggy and empty… LIKE ME… everything has to be searched for”.

The loss of identity was accompanied by delusions, which is illustrated by the following utterance:

… the government has not only changed the money and I can’t recognize it, but also the calendar to avoid paying the life annuity… they added 30 years to the established calendar and as a result I am supposed to be 45 years old, but really, I’m 25. They want to get rid of me. I’m scared.

He would often change his stated age depending on the person with whom he found himself in contact.

Over time PA began to develop an “auto-Fregoli” syndrome. His lack of a personal sense of identity made him borrow the identity of others. Below are presented examples of some of the more interesting identities assumed by PA:

All these temporary acquired identities were based on situational stimuli: the identities borrowed by this patient are content-specific. It is also important to state that these identities have a temporal frame: for acquired identities, approximately 1–2 hours, which seems to be a factor of the maximum duration of his episodic memory. He would momentarily associate himself with an object or person which in some way attracted his attention, though what motivation there was for this particular object or person remains unknown, when other “opportunities” were ignored. The individuals selected were never older than their late 20s, and not infrequently they were children.

Of importance is the fact that after an hour (or sometimes two) PA would forget about his newly adopted identity, and again did not really know who he was. Sometimes he accepted his true identity, as suggested by a researcher. However, in general he would protest, and present himself as a car mechanic.

PA’s identity disturbances are persistent. The patient still does not know who he is. He continues to ascribe to himself the identity of those with whom he comes into contact. He believes that his family all died in an accident, but does not show any emotional reaction to this. He complains that he loves no one and no one loves him. He is totally alone, but he has no clear recognition of his situation. After reading about Cotard’s delusion, a rare psychiatric syndrome in which people consider themselves to be dead, he consequently claimed that he was just such a case and was in fact dead, or perhaps reincarnated [8].

It came as a surprise, however, to discover, 3 years after the accident, that his medical knowledge was very well preserved. After meeting a TBI patient who had been pregnant and had lost her child, he advised her in a very professional way, and told her what drugs she could take for the depression that had developed following the loss of the child. In a thematic picture completed half an hour later concerning his most important memories from childhood, he drew four pregnant women (Figure 3) and entitled the picture “Maternity”; he later stated:

“They could have been my patients. But I can’t really recall whether I had such patients. When I think about it I see a black hole, such a void”.

He was also able to recognize and describe the ultra sonogram of a baby shown to him by his daughter, commenting:

“…. it’s a baby in ultrasound 3D … it could be in the 29^thor 30^thweek of pregnancy. Do you think it’s that old? It looks very healthy!

Yet he protested with anger when his daughter said that this was his grandson, crying:

“… Oh no! Don’t try and pull the wool over my eyes! I can’t be a grandfather because I don’t have any children. My whole family died in an accident.

Moreover, he was able to give details of gynecological operations, but was extremely surprised to find that he could do so. He did not remember studying medicine, but was able to recognize the university building. This reflects a discrepancy between well-preserved medical knowledge and the lack of autobiographical memory. He had no recollection of having obtained a medical diploma even when it was shown to him, claiming that what he was seeing must have been counterfeit.

At the same time he proved to have preserved semantic memory, while autobiographical memory appeared to be lost. Thus he stated that people had children:

“to develop a so-called procreative family, to maintain the human species, to pass on their genes.

Yet he denied having children of his own, even when he was presented with their pictures:

“… These are children, but not mine. I’m 18 years old. I’m too young to have children, right? It’s not my blood and genes these children are carrying.

CHRONIC STATUS AND ONGOING REHABILITATION:

PA has been under neuropsychiatric and neuropsychological observation for 10 years, from January 1999 to June 2009. Treatment was based on a comprehensive model, including neuropsychological rehabilitation. In neuropsychological testing we found the following symptoms:

In this context it is perhaps significant that the metabolic changes in PA’s brain, measured by HMRS, are at present close to the spectrum seen in fronto-temporal dementia (FTD) [9,10]. Figure 4 shows a statistically significant drop in NAA concentration, and also in the relative NAA/Cr concentration.

At the same time there is a statistically significant growth in the concentration of mI, as well as the relative mI/Cr concentration. Another important indicator is the relative relation of the NAA/mI concentrations; this value shows a statistically significant drop when compared to age- and gender-matched norms. It should be added here that the localization of pathological changes in the case of the spectrum obtained from patient PA is similar to that of patients with FTD. In PA’s case, however, these changes are localized chiefly in the right frontal lobe, and not bilaterally, as in the typical FTD patient.

THE COLLAPSE OF FAMILY TIES:

Memory disturbances cannot totally explain forgotten family ties [11–13]. Prior to the accident, PA’s family had relatively normal family ties, though the bond between the patient and his wife was strained by the fact that he had a lover. Now the patient does not remember that he has loved anyone, and his family feels baffled by his strange behavior. His wife, his children, and his parents say he is quite a different man than he used to be. They say it is difficult to have warm feelings towards a man who is so quarrelsome, rude, and irresponsible. They feel his presence as a stranger among them. Moreover, the bonds that united and bound the remaining members of the family to each other have also collapsed, or have been seriously shaken.

It is also plausible that the dissociation of PA’s identity may be caused, at least to some extent, by his premorbid personality traits. Interviews with his family have revealed that his mother was a dominant person who used to made all her sons to act in accordance with her will despite their own wishes. We learn that PA dreamed of being a car mechanic but he became a doctor as his mother had wished. It is of interest to note that being a car mechanic is one of his adopted personalities now. It was also noted that the patient’s attitude towards his mother underwent considerable changes. He is disobedient and shouts at her, though she shows no emotional reaction to this kind of behavior. It may be concluded, then, that she was always a self-disciplined cold mother, and this – as we know – may lead to a number of emotional disorders in the child. In fact, childhood trauma is believed to be one of the causes of Dissociative Identity Disorder [14].

Another significant trait of PA’s personality was his tendency to lie. First of all he had a number of love-affairs, which meant he had to make various stories to hide this from his wife and family. Moreover, his wife reports that he tended to tell small lies to his friends just “to make life more interesting,” to use his own words. Naturally, this does not explain the nature of PA’s disorders, but they cannot be explained solely by memory disturbances as well, though memory, especially autobiographical memory, certainly plays an important role in integrating one’s concept of self.

At the same time, both linguistic functions and acquired knowledge (including medical skills) have remained intact to a considerable degree. It is worth noting here that these are functions that do not concern PA personally. In other words, he has lost mainly the emotionally loaded information, which may explain – at least to some extent – his emotional reactions to suggestions concerning his true personal relations.

SHORT-TERM MEMORY:

PA’s memory disorders include not only autobiographical memory, but also short-term memory. Some deficits were apparent on standardized memory tests, based on recall after 20–30 minutes of filled delay, but we observed clinically that he seemed unable to recall anything at all 2 hours after the event occurred. In order to measure this, we designed a simple experiment, which consisted in choosing a particular event that occurred during the ordinary hospital day (e.g. a visitor, a meal, a physiotherapy session or the like), and then asking PA what he remembered immediately after the event, and then again at four time points: 30 minutes, 60 minutes, 90 minutes, and 120 minutes. This experiment was repeated 6 times during PA’s hospitalization at the Cracow Rehabilitation Centre in summer of 2003, and again in the summer of 2004. The amount of information recalled immediately after the event was treated as 100% for baseline, and the amount of recall at subsequent time points was calculated in terms of information units.

As shown in Figure 5, the intensity of the effect achieved when PA records a given event in memory diminishes rapidly over time, in comparison to the effect that accompanied the event itself. The magnitude of the negative effect exceeds the dimensions of the positive effect. Considering the automatic scaling on the graph, the differences at a time of storage of 1.5 hours appear to be slight, but these differences – like the others – are statistically significant.

Two examples follow:

On one occasion, according to hospital schedule, PA was sent to kinesitherapy for 2 hours. When he returned to the ward, we asked PA what had happened, and he gave a reasonably full account of the exercises he had been through, which coincided in all essentials with the physiotherapist’s report. When asked for the same information 30 minutes later, some details were missing, but the essentials were in place. At one hour, however, he remember only the last half-hour of exercises, and insisted that he had been there only half an hour. His account at 90 minutes was extremely sketchy, and there were some confabulations. At two hours, he denied that he had ever been in physiotherapy. He did remember that he had already been asked several times for that information, but became agitated that we were pestering him about something that never happened. He began to express indignation that no one had remembered to take him to kinesitherapy, and all attempts to convince him that he had actually been there met with an increasingly aggressive reaction.

On another occasion, nearly a year later, he was visited one day by his wife, who spent an hour with him on a day when she usually was unable to come see him. Immediately after she left, he gave a reasonably full account of the event, which his wife later verified as substantially accurate. Within half an hour, he remembered only that his wife had “probably” been there, though he expressed uncertainty as to whether this had not happened the day before. At 90 minutes he remembered that someone had been there, but not who. At two hours he was insisting that he had been alone all day, with no visits.

Thus memory traces of emotionally laden material, both positive and negative, tend to diminish and disappear completely after a period of two hours. This would not be especially surprising, if the material forgotten consisted of a list of random numbers or words, or even a story read aloud by an examiner, as in most standard memory tests. In fact, however, PA forgets everything that happens to him, no matter how much it matters to him. Moreover, he does not remember that he has forgotten something, a state which occurs only in medium-to-late stages of dementia. This means that both long-term and short-term memory are severely disturbed.

Discussion

VARIABILITY OF SYNDROMES:

The changes that have occurred in the clinical picture of PA’s mental status are perplexing. He has passed through a mosaic of disturbances, which resulted in a continuous deterioration of his identity:

As illustrated in Figure 9, time has played an important role in the process of PA’s continuous deterioration. In fact, he has completely lost orientation in his surroundings, and his attempts to discover his true identity have ceased.

In a recent publication, the first author of the present study has described these changes in self-identity, which include many, if not most, of the syndromes of impaired recognition of self and others described in the literature [40,41]. The problem of personality and the self-concept can be approached, from the standpoint of pathology, in terms of patterns of transition from one symptom-complex to another in the same individual, and not as isolated defects in particular individuals within a population. Disorders of the self cannot be localized to separate brain areas, but constitute a spectrum in the process through which personality is preserved and sustained. The case described here provides convincing evidence that the stability and identity of the self depends, not on the association of discrete components, but on a recurrent process that maintains the self-concept over time, in aging, through sleep, and in the course of changing life events.

TIME, PERCEPTION, AND SELF:

As noted elsewhere by the first author of the present study [41,42] the basic components of identity, those that can be weakened or destroyed by brain damage, are the following:

It turns out that one of PA’s problems is the loss of the feeling of time, due mainly to the disturbances of autobiographic memory [43]. MacQueen [39] has suggested that when speaking of that type of memory we concentrate on “auto-”, and forget about the original meaning of “biography.” The ancient Greek word bios meant “life,” and grapho meant “to write.” Our autobiography is therefore essentially a story, composed of the events of our own life, and is therefore narrative in its very nature. It is not, however, an orderly and exhaustive story that includes literally all the events of our life, but rather a kind of sketch made up of only those events which are of importance to us. As a rule these are emotionally loaded events, as well as those which proved to be of vital consequence for our future. In this respect autobiographic memory is more like a play or a film, in which significant events (episodes, scenes, moments) are combined in a way to form a comprehensive and continuous story. The story gains its coherence due to the logical sequence of events, where the viewer is left to assume or infer a logical sequence from one event to the next. In the case of the autobiography (understood here as a mental construct, not a literary genre), such a sequence of events is ensured by our memory. Thus identity problems in TBI patients should hardly be surprising. Even if the sequence of symptoms presented by PA seems unique, the complaint that one is “a different person” after the injury is not [41,42].

This means that both long-term and short-term memory are severely disturbed. In consequence, he lives only in the present, since both past and future have ceased to exist for him. As pointed out by Brown [43], the past is an essential component of the feeling of the present, which develops out of the immediate state revived in the present moment, while the future does not exist other than as an idea, or a feeling of the surge forward to the present [30]. No wonder PA has lost his sense of self, as he has no elements to refer to.

To make matters worse, he also encounters difficulties in evaluating the surrounding world, which is blurred and difficult to comprehend. It is worthy to remind here that we create our picture of current reality on the basis of our previous knowledge and experience [40], and PA has lost an access to them. According to microgenetic theory the primary activity of mind is to ‘chunk’ experience into private and public objects or events [27–29]. In other words, we are able to perceive (or recognize) only those objects and events that correspond to models created in our mind by experience. The models sculpt a complex reality into meaningful and comprehensible wholes [44]. As Brown [15] puts it: “The inner connectedness of the world is not its ostensible relatedness in the world, but its formative trajectory in the mind/brain.” (p. 251).

Conclusions

PA is not able to “chunk” his experience, to create meaningful units out of the continuous flow of stimuli he is confronted with. Hence, the world around him is chaotic and incomprehensible, and he is an observer, whose only function is to react to situations he does not understand. In consequence he has no means to form his self-awareness. Only his core self, acting at the limbic, unconscious level is intact. This is reflected in his emotional reactions to any attempt to make him realize who he really was, as well as reactions to music he formerly liked. In a way, there is a regression to a former state of consciousness, which may also explain why he has stopped smoking and drinking: after all, these are not the activities of the boy he believes himself to be.

Acting on the limbic level explains also his inability to control his emotions and his inappropriate social behaviors. But most disastrous is the fact that he has lost his identity, since he has no elements to rely upon. Hence, he tends to cling to the self of others, borrowing their identities at least for the period he is able to remember.

Additional problems are created by frontal lobe dysfunction, which makes it difficult – if not impossible – for PA to assemble the disparate pieces of his foggy world.