Reduplicative paramnesia: a review

Delusional belief about location ("reduplicative paramnesia")

INTRODUCTION

People admitted to hospital as inpatients following head injury or stroke sometimes form the delusional belief that they are located somewhere else-often, near or in their home. This delusion was first described by Pick, who named it "reduplicative paramnesia"; we argue instead for the term "location delusion".

METHODS

We carried out a literature search and identified 112 cases of location delusion published since Pick's original 1903 case.

RESULTS

We found that, in this cohort of patients, the belief about being located elsewhere than the hospital is elaborated into more specific delusional beliefs about just where the patient is located (e.g., beliefs that involve mislocation of the hospital). We identified eight specific location beliefs and offered a two-factor motivational explanation of these eight forms of location delusion. The patient wishes to be somewhere more congenial, that wish becomes a hypothesis (as occurs in normal belief formation), and then, because these patients have impaired ability to evaluate hypotheses, the hypothesis is accepted and maintained as a (delusional) belief.

CONCLUSION

Our previous papers on the two-factor theory of delusional belief focussed on fully neuropsychological delusions. Here we propose that this theory can also explain delusions generated by motivational influences.

Everything in its right place: a case report of reduplicative paramnesia with therapeutic and theoretical considerations

Introductions: Reduplicative paramnesia (RP) is a rare and poorly understood phenomenon in which a person believes the place they are in has been replicated and exists in two places at once. There is minimal extant theoretical work addressing possible cognitive mechanisms subtending RP.Method: We present a new case of RP and discuss the therapeutic and theoretical implications of this case for the management and understanding of this phenomenon. Using the hypothetico-deductive approach to a neuropsychological case, we examine the phenomenon in the light of one and two-factor approaches to understanding the genesis of delusions.Results: The individual discussed in this case showed some evidence of relatively efficient incorporation of new evidence (belief updating) despite concurrently maintaining a delusional belief system.Conclusion: This case raises novel challenges for the two-factor account of neurological delusions.

The neuropsychology and neuroanatomy of reduplicative paramnesia

Reduplicative paramnesia refers to the delusional belief that there are identical places in different locations. In this case-control study we investigated the clinical, phenomenological, neuropsychological and neuroanatomical data of eleven patients with reduplicative paramnesia and compared them against a control group of eleven patients with severe spatial disorientation without signs of reduplicative paramnesia. We show that most patients with reduplicative paramnesia report that a current place is reduplicated and/or relocated to an other familiar place. Patients with reduplicative paramnesia show a higher prevalence of deficits in the executive functions compared to the control patients, while mnestic and visuo-spatial deficits were both frequent in patients with reduplicative paramnesia and the control group. Patients with reduplicative paramnesia mostly suffer from right hemispheric lesions with a maximal overlap in the dorsolateral prefrontal cortex. Using lesion network mapping we show that lesions causing reduplicative paramnesia are connected to bilateral anterior insula and the right cingulate cortex. We argue that patients with reduplicative paramnesia fail to integrate the actual context with visuo-spatial memories and personal relevant emotional information due to a disruption of the neural network within the anterior temporal lobe, the cingulate cortex and the anterior insula. Also patients with reduplicative paramnesia are not able to resolve this conflict due to the lesion of the dorsolateral prefrontal cortex and executive dysfunction.

Clinical presentation and neural correlates of stroke-associated spatial delusions

BACKGROUND AND PURPOSE

Incongruent beliefs about self-localization in space markedly disturb patients' behavior. Spatial delusions, or reduplicative paramnesias, are characterized by a firm conviction of place reduplication, transformation, or mislocation. Evidence suggests they are frequent after right hemisphere lesions, but comprehensive information about their clinical features is lacking.

METHODS

We prospectively screened 504 acute right-hemisphere stroke patients for the presence of spatial delusions. Their behavioral and clinical features were systematically assessed. Then, we analyzed the correlation of their duration with the magnitude of structural disruption of belief-associated functional networks. Finally, we described the syndrome subtypes and evaluated whether the clinical categorization would be predicted by the structural disruption of familiarity-associated functional networks using an unsupervised k-means clustering algorithm.

RESULTS

Sixty patients with spatial delusions were identified and fully characterized. Most (93%) localized the misidentified places closer to home than the hospital. The median time duration was 3 days (interquartile range = 1-7 days), and it was moderately correlated with the magnitude of structural-functional decoupling of belief-associated functional networks (r = 0.39, p = 0.02; beta coefficient regressing for lesion volume = 3.18, p = 0.04). Each clinical subtype had characteristic response patterns, which were reported, and representative examples were provided. Clustering based on structural disruption of familiarity- and unfamiliarity-associated functional networks poorly matched the clinical categorization (lesion: Rand index = 0.47; structural disconnection: Rand index = 0.51).

CONCLUSIONS

The systematic characterization of the peculiar clinical features of stroke-associated spatial delusions may improve the syndrome diagnosis and clinical approaches. The novel evidence about their neural correlates fosters the clarification of the pathophysiology of delusional misidentifications.

Syndrome of subjective doubles as a rare presentation of a first-episode psychosis

In this paper, we report the case of a man in his 30s with a first-episode psychosis, characterised by a subtype of delusional misidentification syndrome in which the delusion of doubles is exclusively of the patient's own self. This subdivision can be termed 'syndrome of doubles of the self' or 'syndrome of subjective doubles'. Additionally, an examination of the patient's mental state showed paranoid delusions. After being evaluated in the emergency department, the patient was hospitalised, and medicated with antipsychotic drugs. One week later, he was discharged with total remission of psychotic symptoms. This is a rare and curious presentation of a psychotic episode, with very few similar cases described to date.

Reduplicative paramnesia as an atypical form of presentation of a Heidenhain variant of Creutzfeldt-Jakob disease: A case report

A previously healthy woman began to present recurrent episodes of reduplicative paramnesia within her home and later structured visual hallucinations. The case was initially oriented as an incipient vascular dementia. Detailed anamnesis and neuropsychological examination suggested a rapidly progressive pattern of neuropsychological deficits mostly attributable to parieto-occipital disturbances with some component of fronto-temporal involvement. Subsequently, cerebellar symptoms were added. Although the initial imaging studies were inconclusive, the MRI performed during follow-up showed a series of findings compatible with a prion disease. Based on the neuropsychological and clinical features and the imaging pattern, the diagnosis of Heidenhain Variant of Creutzfeldt-Jakob disease was established. This is the first report of a Heidenhain Variant of Creutzfeldt-Jakob disease presenting as a reduplicative paramnesia as the first manifestation of this disease.

Mapping delusions of space onto a structural disconnectome that decouples familiarity and place networks

Interpretation of space is an important determinant of human behaviour. Delusions of space, or reduplicative paramnesias, are a particularly disturbing form of spatial disorientation characterized by the patients' strong belief of place reduplication, transformation or mislocation. Their occurrence following focal brain damage provides a unique opportunity to unveil the structural-functional basis of space misinterpretations. First, we identified reports of lesion-associated reduplicative paramnesias with brain images available through a systematic review of the literature (n = 24). Each lesion was matched with 4 stroke controls and the sample was randomly split in an exploratory (n = 60) and in a validation (n = 60) dataset. Second, we used 178 7T tractographies to compute structural disconnectome maps and analysed lesion topography and disconnection patterns. Delusions of space were significantly associated with structural disconnection of right ventrolateral prefrontal and right temporal regions, and this finding was replicated in the validation sample. Third, we performed a functional meta-analysis of syndrome-related terms. We demonstrated that the structural disconnectomes of delusions of space were spatially correlated with the functional meta-analytic maps of familiarity and place, and replicated the previous evidence that the lesion topography maps are spatially correlated with belief-related functional networks. No association was found with control terms. These results reveal that structural disconnection putatively mediates functional changes associated with reduplicative paramnesias and provide a possible neural basis for the content specificity for places that characterizes these delusional beliefs.

Unravelling the Neural Basis of Spatial Delusions After Stroke

OBJECTIVE

Knowing explicitly where we are is an interpretation of our spatial representations. Reduplicative paramnesia is a disrupting syndrome in which patients present a firm belief of spatial mislocation. Here, we studied the largest sample of patients with delusional misidentifications of space (ie, reduplicative paramnesia) after stroke to shed light on their neurobiology.

METHODS

In a prospective, cumulative, case-control study, we screened 400 patients with acute right-hemispheric stroke. We included 64 cases and 233 controls. First, lesions were delimited and normalized. Then, we computed structural and functional disconnection maps using methods of lesion-track and network-mapping. The maps were compared, controlling for confounders. Second, we built a multivariate logistic model, including clinical, behavioral, and neuroimaging data. Finally, we performed a nested cross-validation of the model with a support-vector machine analysis.

RESULTS

The most frequent misidentification subtype was confabulatory mislocation (56%), followed by place reduplication (19%), and chimeric assimilation (13%). Our results indicate that structural disconnection is the strongest predictor of the syndrome and included 2 distinct streams, connecting right fronto-thalamic and right occipitotemporal structures. In the multivariate model, the independent predictors of reduplicative paramnesia were the structural disconnection map, lesion sparing of right dorsal fronto-parietal regions, age, and anosognosia. Good discrimination accuracy was demonstrated (area under the curve = 0.80 [0.75-0.85]).

INTERPRETATION

Our results localize the anatomic circuits that may have a role in the abnormal spatial-emotional binding and in the defective updating of spatial representations underlying reduplicative paramnesia. This novel data may contribute to better understand the pathophysiology of delusional syndromes after stroke. ANN NEUROL 2021;89:1181-1194.

Reduplicative paramnesia for places: A comprehensive review of the literature and a new case report

Reduplicative paramnesia for places (i.e., the delusional belief that a place has been duplicated or exists in two different locations) is a rare disorder observed in neurological patients. We review the existing literature on the topic, highlighting commonalities and differences among the 51 cases published since the first report in 1903. Our results highlight the combination of multiple factors in the pathogenesis of this monothematic spatial delusion. From a neurological perspective, a crucial role is played by damage to the right frontal and temporal lobe. Deficits of non-verbal memory and executive functions, along with topographical disorientation, appear to be the most common (but, not systematic) cognitive impairments. The clinical picture of the disorder is further complicated by often overlooked psychological and motivational factors. Consequently, the precise neuro-cognitive substrate of this disorder is yet to be described in detail. We stress the need for a more detailed and systematic approach exploiting neurological, neuroimaging, neuropsychological and psychopathological methods. To guide future investigations, we provide clinical- and research-oriented recommendations. Finally, we illustrate the interplay of all above-mentioned factors with a new case report.

Delusional misidentification in Parkinson's disease: report of two cases and a review

Syndromes of delusional misidentification consist of disordered familiarity and have been reported in diverse diagnoses, including Parkinson's disease. Although the most common delusional misidentification is Capgras syndrome, in which the sufferer believes a familiar person has been replaced by an identical imposter, other forms have been also described. The pathogenesis of delusions of misidentification appears to require dysfunction of or connection to a left cerebral cortical area involved in recognition of familiarity, and also right frontal cortex serving belief evaluation. Two cases of Parkinson's disease with an unusual delusional misidentification, intermetamorphosis, are presented, along with their improvement with pimavanserin, a novel atypical antipsychotic medication.

An unusual delusion of duplication in a patient affected by Dementia with Lewy bodies

Background

Dementia with Lewy bodies (DLB) is the second most frequent diagnosis of progressive degenerative dementia in older people. Delusions are common features in DLB and, among them, Capgras syndrome represents the most frequent disturbance, characterized by the recurrent and transient belief that a familiar person, often a close family member or caregiver, has been replaced by an identical-looking imposter. However, other delusional conditions near to misidentification syndromes can occur in DLB patients and may represent a major psychiatric disorder, although rarely studied systematically.

Case presentation

We reported on a female patient affected by DLB who presented with an unusual delusion of duplication. Referring to the female professional caregiver engaged by her relatives for her care, the patient constantly described the presence of two different female persons, with a disorder framed in the context of a delusion of duplication.

A brain 99Tc-hexamethylpropyleneamineoxime SPECT was performed showing moderate hypoperfusion in both occipital lobes, and associated with marked decreased perfusion in parieto-fronto-temporal lobes bilaterally.

Conclusions

An occipital hypoperfusion was identified, although in association with a marked global decrease of perfusion in the remaining lobes. The role of posterior lobes is certainly important in all misidentification syndromes where a natural dissociation between recognition and identification is present. Moreover, the concomitant presence of severe attentional and executive deficits evocative for a frontal syndrome and the marked global decrease of perfusion in the remaining lobes at the SPECT scan also suggest a possible dysfunction in an abnormal connectivity between anterior and posterior areas.

Electronic supplementary material

The online version of this article (doi:10.1186/s12883-017-0842-1) contains supplementary material, which is available to authorized users.

A Case of Reduplicative Paramnesia for Home

We present the case of a high-functioning 88-year-old woman who suddenly developed the persistent and disturbing belief that her home of 40 years was not genuine, but rather an accurate replica. Her episode was probably caused by a small stroke that left her with this single extremely specific deficit. We describe the patient in detail and link to a video interview of her 3 months after the onset of the delusion, eloquently describing her experience. We summarize some of the many reports and discussions of our patient's delusion, reduplicative paramnesia, as well as other delusional misidentification syndromes.

Some Unusual Neuropsychological Syndromes: Somatoparaphrenia, Akinetopsia, Reduplicative Paramnesia, Autotopagnosia

Some unusual neuropsychological syndromes are rarely reported in the neuropsychological literature. This paper presents a review of four of these unusual clinical syndromes: (1) somatoparaphrenia (delusional belief in which a patient states that the limb contralateral to a brain pathology, does not belong to him/her); (2) akinetopsia (cortical syndrome in which patient losses the ability to perceive visual motion); (3) reduplicative paramnesia (believe that a familiar place, person, object, or body part has been duplicated); and (4) autotopagnosia (disturbance of body schema involving the loss of ability to localize, recognize, or identify the specific parts of one's body). It is concluded that regardless of their rarity, it is fundamental to take them into consideration in order to understand how the brain organizes cognition; their understanding is also crucial in the clinical analysis of patients with brain pathologies.

Capgras syndrome associated with limbic encephalitis in a patient with diffuse large B-cell lymphoma

We report the case of a patient with insidious onset and slowly progressive cognitive impairment, behavioral symptoms, temporal lobe seizures and delusional thoughts typical of delusional misidentification syndromes. Clinical presentation along with extensive diagnostic work-up revealed limbic encephalitis secondary to diffuse large B-cell lymphoma. The patient underwent immunotherapy with high-dose corticosteroid but no significant improvement was observed. No specific treatment for lymphoma was performed because the patient died of septic shock following a nosocomial respiratory infection. Delusional misidentification syndromes are an unusual and unique form of cognitive impairment in which a patient consistently misidentifies persons, places, objects, or events. Capgras syndrome is the most common subtype of this disorder, being defined by the recurrent and transient belief that someone close has been substituted by an imposter. These entities are generally associated with neurodegenerative diseases and psychiatric disturbances. Rare reports of associations between misidentification syndromes and autoimmune diseases such as multiple sclerosis have been published, but no papers address a correlation with limbic encephalitis or lymphoma.

Dissecting the uncinate fasciculus: disorders, controversies and a hypothesis

The uncinate fasciculus is a bidirectional, long-range white matter tract that connects lateral orbitofrontal cortex and Brodmann area 10 with the anterior temporal lobes. Although abnormalities in the uncinate fasciculus have been associated with several psychiatric disorders and previous studies suggest it plays a putative role in episodic memory, language and social emotional processing, its exact function is not well understood. In this review we summarize what is currently known about the anatomy of the uncinate, we review its role in psychiatric and neurological illnesses, and we evaluate evidence related to its putative functions. We propose that an overarching role of the uncinate fasciculus is to allow temporal lobe-based mnemonic associations (e.g. an individual's name + face + voice) to modify behaviour through interactions with the lateral orbitofrontal cortex, which provides valence-based biasing of decisions. The bidirectionality of the uncinate fasciculus information flow allows orbital frontal cortex-based reward and punishment history to rapidly modulate temporal lobe-based mnemonic representations. According to this view, disruption of the uncinate may cause problems in the expression of memory to guide decisions and in the acquisition of certain types of learning and memory. Moreover, uncinate perturbation should cause problems that extend beyond memory to include social-emotional problems owing to people and objects being stripped of personal value and emotional history and lacking in higher-level motivational value.