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The role of affect and
reasoning in a patient
with a delusion ofmisidentificationNora Breen , Diana Caine & Max
Coltheart
Published online: 09 Sep 2010.
To cite this article: Nora Breen , Diana Caine & Max Coltheart (2002):The role of affect and reasoning in a patient with a delusion of
misidentification, Cognitive Neuropsychiatry, 7:2, 113-137
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The role of affect and reasoning in a patient with a
delusion of misidentification
Nora Breen
Macquarie University and Royal Prince Alfred Hospital, NSW, Australia
Diana Caine
Royal Prince Alfred Hospital and University of Sydney, Australia
Max ColtheartMacquarie University, NSW, Australia
Introduction. This study investigated a patient with a delusion of misidentification(DM) resembling a Capgras delusion. Instead of the typical Capgras delusionthe
false belief that someone has been replaced by an almost identical impostorpatient MF misidentified his wife as his former business partner.
Method. Detailed investigation of MFs face processing, affective response andaffect perception, and ability to evaluate, and reject, implausible ideas was
undertaken.Results. MFs visual processing of identity, gender, and age of familiar and
unknown faces was intact but he was unable to identify the facial expressions ofanger, disgust, and fear, or to match faces across expressions. MF also showed a
reduced affective responsiveness to his environment, and impaired reasoningability.
Conclusions. We propose that MFs delusion of misidentification resulted from a
combination of affective deficits, including impairment of both affective responseand affect perception, in addition to an inability to evaluate, and reject, implausibleideas. These deficits, in combination with specific life events at the time of onset of
the delusion, may have contributed to the form and content of the delusion. Inaddition, the results raise the possibility that the processing of face identity and
facial expression are not as independent as previously proposed in models of faceprocessing.
Correspondenc e should be addressed to Nora Breen, Macquarie Centre for Cognitive Science
(MACCS), Division of Linguistics and Psychology, Macquarie University, Sydney, NSW 2109,
Australia. Email: [email protected] u
# 2002 Psychology Press Ltd
http://www.tandf.co.uk/journals/pp/13546805.html DOI:10.1080/13546800143000203
COGNITIVE NEUROPSYCHIATRY, 2002, 7 (2), 113137
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Delusions of misidentification (DM) are a group of fascinating disorders in
which there is a mistaken belief in the identity of oneself, other people, places,
or objects. Of all the different forms of DM, the Capgras delusionthe false
belief that someone, often a close relative, has been replaced by an almost
identical-looking impostorhas received both the most attention and the most
rigorous scientific investigation. Much of this work has attempted to delineate
the factors underlying the form and content of these delusions, with a particular
focus on face perception. The innovative testing of face processing in these
patients has further enabled a more sophisticated understanding of normal face
recognition (Breen, Caine, & Coltheart, 2000a; Ellis & Young, 1990).
Recent work on the Capgras delusion has revolved around Ellis and Youngs
(1990) proposal that the Capgras delusion might arise from a loss of the normal
affective (autonomic) response to familiar faces. In these circumstances, thepatient would have the conflicting experience of recognising a known face (such
as that of their spouse), but without any accompanying affective response,
leading them to conclude that the person was an impostor or double. In
confirmation of this hypothesis, two independent research groups (Ellis, Young,
Quayle, & de Pauw, 1997; Hirstein & Ramachandran, 1997) have now
documented reduced skin conductance response (SCR) to known faces in
patients with the Capgras delusion.
This absent affective accompaniment to seeing a known face was describedby Stone and Young (1997) as constituting anomalous perceptual experiences
created by a deficit to the persons perceptual system. (p. 327). Although the
concept of a perceptual anomaly successfully captured a salient aspect of the
patients experience, it also elided two potentially separable sources of distorted
or impoverished information: externally derived incoming sensory information
(visual, auditory, tactile), more usually described as perceptual, and internally
derived autonomic information with its cognitive correlates, more usually
described as affect or emotion.
We have previously reported two cases of mirrored-self misidentification
(Breen et al., 2000a, 2001), a delusion involving the false belief that your own
reflection is another real person. In these studies we clearly distinguished
between the terms perceptual and affective in order to explore the
possible contribution to the DM from both of these sources. Both cases (FE and
TH) had perceptual abnormalities that, we argued, to some extent determined
the form and content of the delusion, although the actual abnormality varieddramatically between the two casesFE had a dramatic impairment in the
perceptual processing of faces, whereas TH had an inability to interpret reflected
space, a mirror agnosia. These two cases thus also demonstrated that very
different perceptual abnormalities could give rise to very similar delusional
phenomena. In addition both FE and TH tended to judge unknown faces to be
personally familiar. As we have discussed in detail elsewhere (Breen et al.,
2001), a sense of familiarity occurs when viewing a personally known face as a
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result of activation of the corresponding face recognition unit (FRU) (Bruce &
Young, 1986), indicating that the face has been previously seen, and from
generation of the affective response corresponding to that particular person.
Whereas FEs false recognition may have resulted directly from his impaired
perceptual processing of facesdegradation in the structural encoding of faces
may have led to unfamiliar faces causing erroneous activation of the FRUs of
known peopleTHs structural encoding of faces was entirely intact. We
suggested that THs false recognition of unfamiliar faces resulted from an
inappropriately modulated affective response to all faces, and therefore an
erroneous sense of familiarity in response to a strangers face. Whereas Ellis and
Young have focused on the loss of the affective response, our work with TH
suggested that an excess of affective responsiveness equally might underlie the
formation of a misidentification delusion.When considering abnormal affective experience in patients with DM it is
important to consider two dissociable factorsones emotional response to the
environment and the ability to recognise emotional (face) expressions in others.
To distinguish between them, we propose to use the terms affect perception
and affective response. Using this terminology, affect perception refers to the
subjects ability to read emotional expressions on the faces of others. On the
other hand, the affective response refers to the subjects emotional
responsiveness to the environment.Although it has been argued that the affective response to known faces can be
relatively selectively impaired (Ellis et al., 1997), it is likely that patients with
brain damage causing a global flattening of responsiveness towards the
environment would concomitantly have a decreased autonomic response to
well-known faces. Support for this contention comes from work with patients
with bilateral ventromedial frontal lobe lesions demonstrating that in addition to
the more specific deficit in skin conductance response to familiar faces (Tranel,
Damasio, & Damasio, 1995), these patients also fail to produce the normal skin
conductance response to emotionally charged visual stimuli, such as pictures of
mutilation and social disaster (Damasio, Tranel, & Damasio, 1991). However, if
altered affective response is implicated in the formation of DM, this finding
raises the question of why the patients with ventromedial damage are not
delusional. One possibility is that the loss of affective response to familiar faces
is not crucial for the formation of the Capgras delusion. This seems unlikely in
that, although to date only six Capgras patients have been tested (Ellis et al.,1997; Hirstein & Ramachandran, 1997), the finding of reduced SCR to familiar
faces has been surprisingly consistent. Alternatively, patients with ventromedial
lesions may lack additional contributing factors necessary for the formation and
maintenance of a delusion, factors that have not yet been fully delineated.
One contributing factor to the phenomenology of a DM, in addition to
perceptual and affective abnormalities already described, is likely to be some
form of defective reasoning, although this idea has yet to be satisfactorily
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explored or explained (Breen et al., 2000b; Langdon & Coltheart, 2000; Young,
1998). Young et al. (1993) have argued that the failure of reasoning is generated
and maintained by a particular mood, but the question of whether reasoning as
such in these patients may be impaired has never been addressed. For instance,
although it is easy to imagine that an abnormal experience initially leads to a
false belief, it is difficult to imagine that one would not rapidly evaluate the
belief as false and subsequently reject it. There are many reports in the literature
of non-delusional patients with perceptual and/or affective deficits that are very
similar, if not identical, to those described in patients with DM. It would appear
that patients with DM lack insight regarding their perceptual and/or affective
deficits that might have helped them to override their false belief(s) arising from
their abnormal experience. For example, patients with prosopagnosia are unable
to recognise their own face in a mirror yet generally are not reported as havingthe delusion of mirrored-self misidentification, presumably because they are
aware that a neurological condition is preventing them from correct recognition
of faces. In contrast, it would appear that patients with DM are unable to reject a
belief on the grounds of its implausibility and inconsistency with everything else
that they know. This is highlighted by reports of patients with DM who
appreciate that others find their belief bizarre, yet strongly adhere to their
delusion and cannot be persuaded that their belief is false (Alexander, Stuss, &
Benson, 1979; Young, 1998).In our earlier work with patients with DM (Breen et al., 2000b, 2001), we
investigated the question of perceptual and affective abnormalities with respect
to face processing underlying the delusion of mirrored-self misidentification. In
the present study, we sought to investigate further the role of impaired
processing of affect, both in terms of affective response and affect perception,
and the nature of the inability to reject a belief once established, in the
production of a DM. The case study presented had a variant of the Capgras
delusion that had remained stable for 10 months prior to our investigations.
CASE STUDY
Background
At the time of testing, MF was a 68-year-old man, who had been married for
42 years, and had three adult children. He was a practising litigation attorney atthe time he suffered his head injury (four years prior to the current assessment)
and had up to that time enjoyed an extremely successful and high-profile
career, which included an 8-year partnership in a law firm with JY, a female
attorney. His only significant medical history prior to the head injury was a
short episode of left-sided weakness in 1996 that his general practitioner
attributed to a small stroke. In December 1997, MF sustained a severe head
injury when he fell an estimated 20 feet from a ladder, landing on a concrete
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driveway. On arrival at hospital his Glascow Coma Score (GCS) was initially
11, but then deteriorated. An initial CT brain scan showed bifrontal and right
temporal lobe contusions, and MF was immediately ventilated, intubated, and
put into an induced coma. A repeat CT brain scan the following day showed
massive bifrontal contusions, and posterior displacement of the ventricles. A
left frontal lobectomy was performed to alleviate intracranial pressure due to
swelling and haemorrhaging. A further left frontal lobectomy was performed
three days after his admission due to continued mass effects from swelling. He
remained comatose and on ventilation for 2 months. He had a number of
medical problems during that time including hydrocephalus (and subsequent
ventricular-peritoneal shunt insertion), atrial fibrillation, intermittent elevations
in intracranial pressure, shunt infections, pancreatitis, and staphylococcal
infection. He had a feeding gastrostomy inserted due to swallowing difficultiesand had a urinary catheter for 18 months. He suffered bilateral hearing loss
secondary to the head injury, and now wears bilateral hearing aids. He had
several neurosurgical operations over the next 2 years including insertion of a
metal grate implanted over the left frontal surgical site, and subsequent
debridement of the infected skull plate. He suffered several post head injury
seizures. A CT brain scan 2 years post injury reported chronic encephaloma-
lacic changes in the frontal lobes bilaterally, a small calcified subdural
haematoma in the left frontal region, mild cerebellar atrophy, and a lacunarinfarct within the pons (see Figure 1).
MF remained in an acute care hospital for 2 months, followed by 8 months in
a rehabilitation hospital, and then nursing home care. A neuropsychological
assessment 6 months post head injury demonstrated that he was oriented, had a
mildmoderately impaired attention span, a mild memory impairment, and
severely impaired constructional skills. With regard to language, his naming was
entirely normal, but he showed mildly impaired comprehension and impaired
repetition. His ability to make common sense judgements was normal but he had
a mild reasoning deficit. He was discharged home 1 year post injury. He was
initially wheelchair-bound, and received physiotherapy, speech therapy, and
nursing care. He made a dramatic recovery at home, and 4 years after the
operation had achieved independent mobility and was independent in activities
of daily living.
Following his head injury, MF showed a number of behavioural changes
consistent with bilateral frontal lobe damage. He had a flattened affect, althoughhe retained an appropriate, and often witty, sense of humour. His family
described his emotional responsiveness post head injury as blunted, and said that
his emotional warmth and interaction with them was somewhat reduced. He
lacked initiative but was cooperative with activities that were arranged for him.
He occasionally made insensitive comments and appeared unaware that he had
hurt peoples feelings, even when he had reduced someone to tears after an
insulting remark.
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Figure 1. CT brain scans for patient MF, 9 months post head injury. Scans show severe trauma to
the frontal lobes bilaterally, with the left side affected to a greater degree than the right. Lacunar
infarcts are present within the pons on the right side of the midline and also in the right thalamus. The
ventricular-peritonea l shunt is present within the body of the right lateral ventricle.
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The delusion
In June 1999, 18 months post head injury, MF underwent an operation to remove
his gastrostomy feeding tube, an operation that involved a general anaesthetic.
When MF woke from the anaesthetic after the operation his wife was sitting next
to his bed. He exchanged some pleasantries with her and then asked her if shehad seen his wife! From that point on, and for the next 10 months, MF believed
that his wife was JY, his former partner in the law firm. This was the only
misidentification that MF displayed. He correctly identified all of his other
relatives including his three children, his grandchildren, his mother-in-law, and
sister-in-law, and had no difficulty identifying friends and acquaintances.
Interestingly, his wifes name was Joan and his former business partners name
was Joanne. His wife is 13 years older than JY, but the two women are of similarcolouring and build. His wife has reddish-blonde, short, wavy hair whereas JYs
red hair was longer and straight. MF and his wife have three children, as do JY
and her husband. MF said that although he respected JYs ability as an attorney,
he intensely disliked her on a personal level. In the eight years that MF and JY
were law partners, they had only one social meal together.
MF did not protest about leaving the hospital with the woman he thought was
his former business partner and was reasonably happy for her to look after him
as long as she was not too affectionate towards him. Not long after thegastrostomy operation, he and his wife were in the small elevator in their multi-
storey home. His wife was unclear at this stage whether MFs delusion was
constant or intermittent and, as she felt they were getting along very well at that
moment, she leaned towards him, put her hand on his arm, and attempted to kiss
him. MF reacted angrily, backed away from her waving his cane in a menacing
way, and threatened to strike her. The following day, MF told his doctor about
the incident stating that she was all over me. When the doctor light-heartedly
responded that most men would be thrilled if their wives wanted to kiss them,
MF replied, I would be happy too if it was my wife, but it wasnt my wife, it
was JY. If my wife knew about this she would not have appreciated it! His
wife was forced to move out of their bedroom as MF refused to sleep in the same
room with her. MFs wife and children constantly tried to reason with him but
were unable to convince him that the woman living with him was his wife and
not JY. Ownership of their home was transferred to his wifes name at this time,
and MF was angry for several weeks, as he believed that JY now had control ofthe house that he and his wife owned.
Occasionally, MF asked his wife (whom he thought was JY) where his wife
was, but he never made an attempt to find her. When he was asked where his
wife was, he said that she was in the other house, a house that he described as
having exactly the same address, including street number, street, and suburb, as
the house in which he currently lived. He described the two houses as identical
except that the house he currently lived in had two storeys, whereas the house
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his wife lived in had three storeys. He identified all of the mens clothing in his
bedroom as being his own and said that all of the womens clothing was JYs
and did not belong to his wife. He said that all of his wifes clothing and her
belongings were at the other house. When MF was told by the examiner that
she found his storythat JY had taken him home from hospital and taken care
of him since the head injury, and that his wife now lived in another house that
had the same address as the one he currently lived inbizarre and extremely
hard to believe, MF agreed that it was strange, but nevertheless insisted that it
was true.
MFs indifference to constant questioning about his delusion was striking. He
was unperturbed when evidence contradicting his delusion was pointed out to
him, and when the examiner repeatedly emphasised the improbability of the
delusion. MF understood that the research the examiner was conductinginvolved investigating delusions, and he understood that the particular delusion
being investigated was his belief that the woman living with him was not his
wife. However, he repeatedly told the researchers that he did not have a
delusion, and that they should investigate the real delusionthe delusion held
by his former business partner, JY, who believed that she was his wife!
Neuropsychological testing
Neuropsychological testing was undertaken to evaluate MFs performance in a
range of cognitive domains (see Table 1). Based on his education and
employment history, MF was estimated to have a high averagesuperior intellect
prior to his head injury. Testing revealed that his current intellect was in the
average range, as assessed by measures of verbal (NART) and non-verbal
(Ravens Coloured Progressive Matrices; Raven, 1947) ability.
Attention and Intellectual Function. MFs verbal attention span was limited
and below the average range, but his visual attention span was in the average
range (WAIS-R; Wechsler, 1981). His manual speed was very slow as
demonstrated on a timed copying test (WAIS-R Digit-Symbol subtest).
MF performed in the average range on tests of language. In contrast, his
performance on a test of mental arithmetic was very impaired, and well below
the expected average range. MFs basic visuo-perceptual skills were intact as
evidenced by his intact clock drawing and copying of various pictures (includinga bicycle and 3-dimensional cube) and he was able to identify missing
components in line drawings (Picture Completion, WAIS-R). His constructional
skills were somewhat less robust (Block Design, WAIS-R).
Memory. MF demonstrated a dissociation between his verbal and non-
verbal memory function. His verbal memory for stories and word associations
was intact in the high average to superior range (WMS-R; Wechsler, 1987), as
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TABLE 1
Results of tests of cognitive ability for patient MF
Tests Patient MF
IQ NART (Estimated Full Scale IQ) 107 (Average)
Language Test of Reception of Grammar (TROG) 73/80 (91%)
WAIS-R MOANS ASS
Vocabulary 8
Mental Arithmetic 4
Similarities 9
Non-verbal skills Ravens Coloured Progressive Matrices 75%tile
Clock drawing 10/10
Copying of shapes, designs and bicycle intactCopy of 3-dimensional cube intact
REY Complex Figure TestCopy 29.5*
WAIS-R MOANS ASS
Picture Completion 13
Picture Arrangemen t 10
Block Design 8
Digit Symbol 4
Attention/ WMS-R MOANS ASS
Concentration Digit Span 5 (5 forward, 3 backward )
Visual Span 9 (7 forward, 6 backward )
Memory WMS-R MOANS ASS
Logical Memory I 14
Logical Memory II 14
Verbal Paired Associates I 12
Verbal Paired Associates II 13
Visual Reproduction I 12Visual Reproduction II 9
(Visual Reproduction II, with prompt) (12)
Rey Complex Figuredelaye d recall 8.5*
Autobiographica l Memory Interview Personal Sem Autobiograp h
Childhood 15 borderline 7 Acceptable
Early Adult Life 17 Acceptable 9 Acceptable
Recent Life 21 Acceptable 6 Acceptable
Total 53 Acceptable 22 Acceptable
Warrington Recognition Memory Test Raw Score ASS
Words 49 15
Faces 41 9
(Continued overleaf)
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was his recognition memory for words (WRMT; Warrington, 1984). In contrast,
he demonstrated a deterioration of newly acquired visual information over time.
His immediate recall of the WMS-R line drawings was in the high average
range, however his recall dropped to a low averageaverage level after a short
delay. Similarly, his delayed recall of the Rey Complex Figure was very
impoverished. In contrast to his very good recognition of words (ASS 15) on the
WRMT, he only achieved an ASS 9 on recognition memory for faces. His
autobiographical memory for childhood, early adult life, and recent life was
entirely intact (AMI). His personal semantic memory was in the borderline
range for his childhood, but was entirely intact regarding both his early adult and
recent life.
Executive function. MFs most striking deficits occurred on tests of
executive function. He was accurate, although slow, on Trails A, but made many
errors, became hopelessly confused, and eventually abandoned Trails B after
almost 5 minutes. His phonemic and category fluency were very impoverished.
He achieved the required two categories on the simple CFST, but did not
achieve a single category on the Wisconsin Card Sorting Test, a performance
TABLE 1
Continued
Tests Patient MF
Executive Function Trails A (ASS) 7
Trails B incomplete
Controlled Oral Word Association Test
Total in 3 minutes (phonemic cue) 13 ASS 3 1st percentile
Animal FluencyTotal in 1 minute 9 < 10th percentile
Colour Form Sorting Ttest 2/2 categories
Wisconsin Card Sorting Test
Numbe r of categorie s complete d 0
Errors 96 1st percentilePerseverative Errors 94 < 1st percentile
The scores reported for MF on the Wechsler Adult Intelligence ScaleRevised (WAIS-R),
Wechsler Memory ScaleRevised (WMS-R) are age-scaled scores (ASS) as reported in the Mayo
Older American Normative Studies (Malec et al., 1992; Ivnik et al., 1992a, 1996).
*within 1 sd of mean. (AMIPersonal Sem for Personal Semantic, Autobiograph Autobio-
graphical).
The scores reported for MF on Trail Making Test (TMT) and Controlled Oral Word Association
Test (COWAT) are age-scaled scores (ASS) as reported in the Mayo Older American NormativeStudies (Malec et al., 1992; Ivnik et al., 1992a; Ivnik et al., 1992b; Ivnik et al., 1996). *within 1 sd of
mean.
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that was dominated by perseverative errors. His performance on the Wisconsin
Card Sorting Test is discussed in more detailed later in the section on
Investigation of reasoning ability.
INVESTIGATION OF FACE PROCESSING
MFs face processing abilities were thoroughly investigated using a combination
of standardised and experimental tests. MFs performance on these tests was
compared to his wifes performance when appropriate (for example, recognition
of personally familiar faces) or compared to a normative sample of five males,
matched for age and educational attainment (see Appendix 1 for the normative
sample demographics). The results of MFs face processing tests are presented
in Table 2.
Experiment 1: Face matching
Face matching was assessed with the Benton Facial Recognition Test (Benton,
Hamsher, Varney, & Spreen, 1983), a difficult test where cues are limited
(matching is conducted on the basis of facial features only, as hairstyles have
been removed), the lighting is varied (often resulting in significant portions of
the faces being covered by dark shadow), and the faces are often in very
different orientations.
Results. MF performed in the normal range on this test.
Experiment 2: Identification of age of unfamiliarfaces
Ten black and white photographs of unfamiliar faces (with no other identifying
cues) were presented in a random order and the subject was asked to give anapproximate age for each of the faces.
Results. The age approximations on this test are subjective. MFs age
identifications for eight of the faces were within the range of ages reported by
the five control subjects. His age approximations for the other two faces were
very close to the age range provided by the controls (4 years and 9 years outside
the range). As eight of MFs age approximations were inside the range provided
by the control subjects, and as this measure is subjective and the control group
small, we have concluded that MFs age identification of faces is within the
normal range.
Experiment 3: Famous face identification
Identification of famous faces was assessed with an experimental test consisting
of photographs of the faces of 22 famous people and 22 matched unknown
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people. The unknown faces were matched according to gender, age, and
physical similarity. An additional 37 unknown faces, not matched to the famous
faces, were also included in the test, making a total of 59 strangers faces. Each
photograph was modified to produce black and white pictures of the face with no
other identifying cues (e.g., body parts, contextual cues). The faces were
TABLE 2
Results for the face-processing tests
MF Controls
Face Matching Facial Recognitio n Test (Benton) 47 Range 4154
Age Identification (Unfamiliar faces) Age (years) Range (years)
1 15
1 13
18 1320
12 38
35 2045
25 2535
35 4455
45 4560
70 5575
70 7084
Face Recognitio n Personally familiar (family members ) MFs wife
Identified as familiar 12/12 12/12
Named 12/12 12/12
Famous
Identified as familiar 19/22 19/22
Name/Specific semantic identification 17/22 18/22
Unfamiliar (strangers faces)
Identified as unfamiliar 56/59 56/59
Facial Affect Ekman & Friesen Facial Affect Photos (/10) Controls (n = 5)
Perception Happy 10 9.8 (sd 0.45)
Sadness 8 8.2 (sd 1.64)
Surprise 10 9.2 (sd 1.09)
Anger 7 8.2 (sd 1.30)
Disgust 7*** 9.3 (sd 0.55)
Fear 5** 8.2 (sd 1.30)
Controls (n = 5)
X sd
Matching Faces Neutral Expression 33* 38.0 (2.45)
Across Expressions Same Expressions 25*** 38.8 (1.79)
Different Expressions 23*** 37.2 (3.35)
*significant at p < .025, **significant at p < .01, ***significant at p < .0001.
The Calder et al. (1996) subset of Ekman and Friesen Pictures of Facial Affect was used.
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presented in a random order, one at a time, in the centre of a PC laptop screen.
The examiner controlled the rate of the stimuli presentation and each face
remained on the screen until the subject identified whether it was familiar or not.
If the face was identified as familiar, the subject was asked to provide a name
and/or identifying semantic information. MFs wife acted as the control subject
on this test.
Results. MF identified 19/22 of the famous faces as familiar and provided
the correct name or identifying semantic information for 17/22, a performance
no different from that of his wife. MF correctly identified 35/37 strangers faces
as unfamiliar, which was also consistent with his wifes performance on this test.
MF and his wife each incorrectly identified two strangers faces as familiar,
saying that the faces looked familiar but they did not know who they were.
Experiment 4a: Identification of personally knownfaces
MFs ability to identify personally familiar faces was examined with an
individually tailored test. Photographs of his immediate family members,
relatives, close friends, and JY, were modified to produce black and white
photographs of faces without any other cues (e.g., body parts, contextual cues),and 12 appropriate photographs were thus obtained. Each known face was
matched with an unfamiliar face of the same sex, approximate age, and physical
likeness. An additional 12 unknown faces were also included in the test, making
a total of 22 strangers faces. The faces were presented one at a time, in a
random order, on a PC laptop screen. The subject was initially asked whether
each face was familiar or not, and then to provide as much information as
possible, including the name, about the individuals whose faces they classed as
familiar. This test was administered to MFs wife who acted as the control
subject.
Results. MF correctly identified all 12/12 personally familiar faces as
familiar and provided the correct name for each, including his wife and JY. His
wife was also 100% correct on this test. MF correctly identified 21/22 strangers
faces as unfamiliar, a performance no different from that of his wife.
Experiment 4b: Identification of persons implicatedin the DM from photographs
MF was further tested on his ability to identify his wife and JY in photographs.
Colour photographs, which had been taken by MFs family members, were
presented in which his wife and JY appeared either individually in different
photographs or together in the same photograph. When MF was shown a
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photograph that included MF, his wife, and JY, he was asked to identify which
person in the photograph was sitting beside him during the testing (his wife).
Results. MF correctly identified his wife and JY in several photographs in
which they appeared individually. He made these identifications rapidly and
confidently. When shown a photograph of himself, his wife and JY together, hecorrectly named each person. When he was asked to point to the person in the
photograph who was the same person as the one sitting next to him during the
testing (his wife), he pointed to JY. The examiner asked MF several times
whether he was sure that the person he had indicated in the photograph (JY)
looked exactly the same as the woman beside him (his wife), and MF remained
adamant that they were the same person. The examiner pointed out to MF that,
in her opinion, the photograph of JY did not look like the woman sitting next to
him, but rather the photograph of his wife looked identical to the woman whowas sitting next to him. MF said that he did not agree. His reaction was
unperturbed, and he did not get agitated when confronted in this way.
Experiment 5: Identification of facial expressions(affect perception)
MFs ability to identify facial expressions was tested with Ekman and Friesens
(1976) black and white photographs of unfamiliar people expressing emotion.We used the Calder et al. (1996) subset of 60 of the Ekman and Friesen faces,
which included pictures of 10 models faces (5 women, 5 men). For each face,
there were poses corresponding to each of six emotions (happiness, sadness,
disgust, fear, anger, and surprise). The names of the six emotions were printed
on a card and this was placed in front of the subject throughout the test. The
subject was shown each of the photographs one at a time, in a random order, and
asked to decide which of the six emotion names best described the facial
expression shown. There were 60 trials (one for each of the six emotions for
each of the 10 models), leading to an accuracy score out of a possible maximum
of 10 for each of the six emotions.
Results. MFs ability to identify the facial expressions happiness, sadness,
and surprise did not differ from the controls. In contrast, MFs ability to identify
anger was only borderline and he was significantly worse than controls in his
ability to identify the facial expressions disgust and fear (see Figure 2).
Experiment 6: MFs understanding of the emotionshe was impaired at identifying
MFs difficulty in recognising some facial expressions did not appear to reflect
failure to comprehend emotional terms: he gave examples of occasions when he
would feel angry, disgusted, and afraid, and could describe circumstances in
which other people would experience the same emotions.
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Experiment 7: Matching faces across expressions
This test consisted of pairs of faces (black and white photographs from the
Ekman and Friesen series), presented side by side, so that for each trial two face
images were presented simultaneously until MF made a response. This test had
three different conditions:
1. Neutral Expression; two pictures either of the same person or of two
different people (same gender), with the same neutral expression.
2. Same Expression; two pictures either of the same person or two different
people (same gender) with the same facial expression (happy, sad, disgust, fear,
anger, or surprise).
3. Different Expression; two pictures either of the same person or two
different people (same gender) each having a different expression (happy, sad,
disgust, fear, anger, or surprise).
In each condition the subject was asked to decide if the two faces had the
same identity (that is, whether or not they were pictures of the same person)
regardless of the facial expression. The items were presented in a random order,
and the subject gave a verbal response.
Results. In contrast to his good performance on other tests of face
recognition, MF demonstrated a significant interference effect of facial
expression when making judgements about face identity. When the two faces
were expressionless (neutral expressions) he was 83% accurate in discriminating
whether the face identity was the same or different. In striking contrast, he was
almost at chance (60%) at discriminating facial identity when the faces had an
expression (see Figure 3). The interference effect was cumulative: he was 83%
Figure 2. Face expression recognition.
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correct when both faces had a neutral expression; 63% correct when the two
faces had the same expression; and only 58% (almost chance) if the two faces
had different expressions.
As MF performed in the normal range on the more difficult Benton Face
Recognition Test (indicating intact face matching on the basis of limited cues,
varied lighting, and different orientation), it was somewhat surprising that his
ability to match faces in the Neutral Expression condition of this test was not
equal to that of the controls. It should be noted that had MF achieved one more
correct match on this Neutral Expression subtest of the Matching Faces Across
Expressions test, his performance would not have been significantly different
from that of the controls. Nevertheless, his below average performance on this
subtest remains puzzling. The only difference between the two tests was in the
administration, in that the easier neutral Matching Faces Across Expressions testwas intermixed with matching of faces with various expressions. As we will
discuss later, MF was impaired at identifying facial expressions and very
impaired at discriminating between faces when the face identities were
discrepant with the facial expressions (e.g., same identities, different expres-
sions). It may be that the presentation of the neutral expression face stimuli
among faces with expressions in the experimental Matching Faces Across
Expressions test interfered with MFs ability to perform the neutral face-
matching test to the best of his ability.
INVESTIGATION OF REASONING ABILITY
MF demonstrated average level verbal reasoning and averagehigh average
level reasoning about visually presented material on standardised subtests of the
WAIS-R. This included tests of visual reasoning (Picture Completion, ASS 13),
logical sequencing of events, which included anticipating the consequence of
Figure 3. Face constancy: Matching faces across expressions.
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actions and distinguishing essential from irrelevant details (Picture Arrange-
ment, ASS 10), and conceptual reasoning (ASS 9).
Experiment 8: Affect-neutral reasoning test
The Wisconsin Card Sorting Test was administered to assess MFs reasoningability on an affect-neutral task.
Results. MF was grossly impaired on this test. He perseverated to an
incorrect category for the entire test, 128 consecutive trials. His performance
indicated impaired error monitoring and set shifting, and inability to adapt his
own performance according to external feedback.
Experiment 9: Plausible/implausible reasoning test
An experimental test of reasoning ability was devised to assess MFs ability to
evaluate information (provided in story format) that could be interpreted in two
ways, to make either a plausible or implausible conclusion. One of the stories
was specifically tailored to MFs delusion in order to investigate whether his
delusional belief (that his wife had been replaced by someone else) was a
circumscribed belief, or whether the belief was more generalised (i.e., whether
he believed that other people could have relatives replaced by impostors). Thefour stories that made up this test are presented in Appendix 2. The subjects had
unlimited time to read the story and select their response (by circling).
Results. The results are presented in Table 3. All five of the controls chose
the plausible conclusion for Story 1, and 4/5 chose the plausible conclusion for
both Story 3 and Story 4. One control subject for both Story 3 and Story 4 chose
the cant tell option, indicating that he did not feel he had enough
information to reach a conclusion. It is important to note that none of the control
subjects chose the implausible conclusion for any of the four stories. In contrast,
MF selected the cant tell option for Stories 1, 2, and 4. In addition, he chose
the implausible conclusion for the scenario that was tailored towards his own
TABLE 3
MFs performance on the experimental plausible/implausible reasoning test
MF Controls (n = 5)
Subject 1 Subject 2 Subject 3 Subject 4 Subject 5
Story 1 Cant tell No No No No No
Story 2 Cant tell No No No No No
Story 3 No Yes Yes Yes Cant tell Yes
Story 4 Cant tell No No Cant tell No No
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delusional belief, indicating that he believed that identical-looking impostors
could replace other peoples wives.
DISCUSSION
Following the work of Ellis and Young (1990) on face processing deficits in
Capgras patients, and our own positive findings in two cases of mirrored-self
misidentification, we examined in detail MFs ability to discriminate and
recognise faces. MF was able to identify both personally familiar and famous
faces, to discriminate between familiar and unfamiliar faces, and to identify the
approximate age of unfamiliar faces. Although his ability to match unfamiliar
faces was inconsistent, he was able to match unfamiliar faces with neutral
expressions on the most difficult face matching test (Facial Recognition Test,Benton 1983).
As visual face processing per se seemed to be intact, we proceeded to
investigate the possible contribution of altered affect in MF. We did this in three
ways. We interviewed his family about his affective responsiveness towards
them; we interviewed MF with respect to his understanding of emotion; and we
looked at his ability to recognise facial affect (affect perception). Although he
appeared to understand the difference between emotions, in that he was able
appropriately to describe occasions when he or others would feel differentemotions, his family reported that there was generalised blunting of emotions,
with little emotional expression, dulled responses in emotional situations, and
reduced emotional warmth towards his children and other close relatives.
As previously discussed, it is likely that MFs global dampening of affective
responsiveness to the environment encompasses a reduction in affective
response (SCR) to familiar faces, as has been documented in other patients
with ventromedial frontal lobe damage (Tranel et al., 1995). To that extent he
can be thought of as being like more typical Capgras patients. It is further
possible that MFs delusional belief that he was not living in his own home was
directly related to this reduced responsiveness to the environment. MF may have
resolved the discrepancy of living in a house that looked like his own house with
the same address as his house, but that didnt feel like his home, by
generating the belief that he was living in a house that was somehow like his real
home, but that his real home (where his wife lived) was somewhere else.
In addition to reduced affective responsiveness, MFs ability to identify facialexpressions was selectively impaired: while his identification of the facial
expressions of happiness, sadness, and surprise were normal, his ability to
recognise anger was only borderline, and he was frankly impaired at
discriminating disgust and fear. His difficulty in recognising facial expression
was not simply an exaggeration of the normal pattern: while control subjects in
this study, and in studies by Calder et al. (1996) and Ekman and Friesen (1976),
found anger and fear relatively more difficult to identify, they were easily able
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to identify the expression of disgust, which was second only to happiness (see
Appendix 3 for control data for Calder et al., 1996, Ekman & Friesen, 1976, and
our controls for this study).
We investigated whether MFs difficulty in discriminating among some facial
expressions might affect his otherwise intact face matching ability. This was
indeed the case: MFs impaired expression analysis interfered with his ability to
match faces and the interference effect was incremental. MF was best at
matching faces with neutral expressions, more impaired if both faces had the
same expression, and most impaired if the two faces had different expressions.
Thus, MFs deficit in interpreting facial expression led him to mistake
differences in expression for differences in identity, notwithstanding that he
was able to make appropriate allowances for the effects of changes in orientation
and lighting when matching faces with neutral expressions.We speculate that MFs impaired identification of some facial expressions,
and his very impaired ability to discriminate face identity when the face showed
an expression, are likely to be contributing to his misidentification of his wife as
his former business partner. Interestingly, MFs wife provided some support for
this when she was given feedback about his face processing deficits. MF had
told his wife that she could not be his wife because his wife smiled a great deal
whereas she never smiled. MFs wife reported that the observation was true in
that since his head injury she was not the happy person she used to be: she hadbeen forced to take on the role of head of the household, which included
controlling their finances and making all the decisions. This was a role that she
had never previously assumed or desired during their 42 years of marriage, and
having to do so now caused her a great deal of stress and worry.
However, other patients have been reported with either widespread problems
in the recognition of facial expressions (Etcoff, 1984) or more specific deficits in
the recognition of fear (Adolphs, Tranel, Damasio, & Damasio, 1994, 1995;
Broks et al., 1998; Calder et al., 1996), disgust (Gray et al., 1997;
Sprengelmeyer et al., 1997), or both (Sprengelmeyer et al., 1996, 1997), and
are not delusional, although matching of identity across expressions has only
rarely been tested. One non-delusional patient, DR, has been reported to have
both a specific deficit in the recognition of fear and an impaired ability to match
faces across identities, a profile very similar to that of MF (Young, Hellawell,
van de Wal, & Johnson, 1996). The degree of deficit was different, however.
While both MF and DR had significant deficits in the perception of facialexpressions, DR was only mildly impaired in her ability to match face identities
across different expressions, whereas MF was severely impaired on this task.
Why did MF believe his wife was JY, and not a stranger who looked similar
to his wife, or some other person that he knew? In addition to the physical
similarity between the two women, and their similar names (Joan and Joanne),
the nature of MFs attachment to JY may have contributed to her role in his
delusional belief. MF and his family described him as having a strong, albeit
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negatively charged, emotional relationship with JY. During the 8 years that MF
and JY ran their law firm, MF reported that he and JY had many confrontations
due to personality clashes and conflicting ethical values. Although MF respected
JY on a professional level, he said that he disliked her intensely on a personal
level. In the same way that Capgras patients typically misidentify the person to
whom they have the strongest positive or negative emotional attachment
(Young, 1998), it is probably significant that MF misidentified his wife, to
whom he had a very close positive emotional attachment, as a woman with
whom he had an intensely negative emotional relationship. Such similarities
between actual and delusional characteristics have been reported previously.
Burgess, Baxter, Rose, and Alderman (1996) reported a man (PD) who,
following a severe head injury, had the delusional belief that a fellow patient
(Jake) was a male nurse (Jamie) who had previously cared for him (in a differentinstitution), and that he was having an affair with PDs wife. Further, the wife of
one of the nurses who had cared for PD had the same name as PDs own wife
(Jane).
It is further conceivable that the content of MFs delusion, and possibly other
delusions of misidentification, may depend on specific life events occurring at
the time of the onset of the delusion. Although prior to the head injury MF had
not had contact with JY for 8 years, she regularly visited him following the head
injury and while he was in PTA. She spent a substantial amount of time with himshowing him photographs and mementos to assist his recall. MF does not have
much conscious recollection of her visits during this time. He may have stored
interlinked memories of his wife and JY during his period of PTA, memories
that were most likely patchy and somewhat confused. Following the head injury
and his recovery from PTA, MF was not delusional, and he correctly identified
both his wife and JY. It was only 18 months after the head injury that the
delusion arose, immediately following a surgical procedure that involved a
general anaesthetic. The mild disorientation and confusion due to the effects of
the general anaesthesia may have caused displacement of patchy recall of
episodes from the period of PTA, and hence contributed to the misidentification
of his wife as JY. A number of other cases have also been reported to have
developed delusions while either still in, or immediately following, a period of
PTA following a head injury (Box, Laing, & Kopelman, 1999; Burgess et al.,
1996).
We have argued here that perceptual and/or affective deficits, as well,possibly, as specific life events occurring at the time of onset of the delusion,
can contribute to the form and content of the DM, yet they cannot be the entire
explanation, as all of these occur in patients who do not develop delusional
states. Patients with a DM must also have an additional deficit in reasoning that
prevents them from evaluating, and rejecting, implausible beliefs. In this study,
we had the opportunity to examine the reasoning of our patient with a DM on an
affect-neutral taskthe Wisconsin Card Sorting Test. On this task DM
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perseverated to the incorrect category he first generated for the entire test (128
consecutive trials) despite feedback after every trial that his response was
incorrect. His reasoning was defective precisely in the sense that once he had
formed a belief (in the case of the Wisconsin Card Sorting Test, that a particular
category was the required one), he could not subsequently evaluate or change it.
This behaviour also characterised his DM: he clung tenaciously to the DM for 10
months, and no amount of evidence to the contrary could persuade him
otherwise during that time.
MFs reasoning was further tested with the experimental reasoning test. For
the story that was closest in content to his own delusional belief MF chose the
implausible conclusion; that is, he believed that an impostor had replaced the
mans wife in the vignette. MFs (implausible) response for this story was in
contrast to his cant tell response for the three other stories, suggesting thatMF may have identified with the fictitious man in Story 2, and responded to the
story scenario in the same way that he reacted to his own situation. For the three
stories that were not directly related to his own delusional belief, MF, in contrast
to controls, was not able to discard the implausible aspects of the story to come
to the more plausible conclusion. These data together indicate a more pervasive
reasoning deficit than has previously been suggested (see for example Young et
al., 1993; Stone & Young, 1997).
As demonstrated by Ellis and Young (1990) and by Breen et al. (2000a), thestudy of DM has both profited from and made a contribution to models of
normal face processing. Until recently, the dominant cognitive model of face
processing (Bruce & Young, 1986) only incorporated a role for affect in relation
to facial expression analysis. It proposed that expression analysis was
independent from, and not important to, either the recognition of familiar faces
or the processing of unfamiliar faces, both of which utilised separate, and
independent, cognitive pathways (Young et al., 1993). More recently, following
the work of Ellis and Young, and based on the findings of a double dissociation
between prosopagnosi c patients who demonstrated no overt face recognition yet
intact autonomic responses (SCR) to familiar faces, and Capgras patients, who
demonstrated intact overt face recognition but reduced or absent autonomic
responses to familiar faces, we proposed a modification to the Bruce and Young
(1986) model of face processing that included an intrinsic role for the processing
of affect in face recognition.
Although we have not yet tested whether MFs impaired facial expressionanalysis also interferes with his ability to identify famous or personally familiar
faces, a task he has no difficulty with when the faces had neutral expressions, the
data on MF raise further questions about the possible role of affect perception in
face processing. The finding that although he could efficiently discriminate
unfamiliar faces with neutral expressions, he was unable to match faces showing
expressions, suggests that facial expression analysis may not be as independent
of other aspects of face processing as previously thought.
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CONCLUSION
In conclusion, we have proposed that MF has a delusion of misidentification
resulting from a combination of affective deficits, including impairment of both
affective response and affect perception, in addition to an inability to evaluate,
and reject, implausible ideas. The nature of his underlying deficits, incombination with specific life events at the time of onset of the delusion, were
likely to have contributed to the form and content of MFs delusion of
misidentification. In addition, our work with MF raises the possibility that the
processing of face identity and facial expression are not as independent as
previously proposed in cognitive models of face processing.
Manuscript received 12 February 2001
Revised manuscript received 7 September 2001
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APPENDIX 2
The four stories from the experimental Plausible/implausible reasoning test are listed below. The
stories were presented one at a time and the subject was given as much time as he or she needed to
read the story and answer the question for each story. They were required to circle the response they
thought was correct.
Story 1Fred lay still all the time.
His wife and daughter tried to talk to him.
Fred did not respond.
Fred said that he was dead.
Do you think Fred is dead? (Please Circle)
YES NO CANT TELL
Story 2Margaret thought that people were always following her around.
She thought that the people following her around were people that she knew but that they were in
disguise.
It did not matter what time of day or night she left the house, the people would always follow her.
She said that sometimes the disguises were so good that a young woman could be disguised as a very
old stooped man with wrinkles and a bald head.
Nobody ever saw these people, even when they were with Margaret.
Margaret had contacted the police but after a long investigation they were unable to find any
evidence of people in disguise following Margaret.
Do you think people are following Margaret around? (Please Circle)
YES NO CANT TELL
Story 3
Peter and his wife had been married for 30 years and had two children.
One day Peter confronted the woman next to him in his bed and said that she was not his wife.
Peter said the woman was an impostor.
APPENDIX 1
Demographic details for control subjects and patient MF
Control subject Age Yrs education
RW 69 yrs, 2 months 16HR 67 yrs, 7 months 16
RT 70 yrs, 4 months 15
FB 69 yrs, 2 months 16
FC 69 yrs, 9 months 13
Mean 69 yrs, 1 month 15.2 years
Patient MF 68 yrs, 5 months 17 years
136 BREEN, CAINE, C OLTHEART
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His children disagreed, and said that the woman in their home was his wife and their mother.
His relatives also disagreed with him, and said that the woman was his wife.
Peter agreed that his wife and this impostor looked very similar.
He had no explanation as to where his wife was or where this impostor had come from.
He continued to live with this woman in his house.
Do you think the woman living with Peter is his wife? (Please Circle)
YES NO CANT TELL
Story 4
Jack went to town to do some shopping.
He paid for his groceries and then looked out of the shop window.
Across the street he saw his wife Mary kissing another man.
Jack rushed out onto the street but the couple were gone.
He immediately phoned Mary at home.
Mary answered the phone and denied leaving their home that day.Mary has a twin sister.
Did Jack see his wife Mary kissing another man? (Please Circle)
YES NO CANT TELL
APPENDIX 3
Face expression recognition: Control data
Ekman & Friesen
Percentage recognition
rates
Calder et al. n = 10
Mean identification
rates
Our controls n = 5
Mean identificatio n
rates
Happiness 99.10 sd 2.51 9.90 sd 0.32 9.8 sd 0.45
Disgust 93.10 sd 5.20 9.00 sd 1.25 9.3 sd 0.55
Surprise 90.70 sd 7.78 8.50 sd 1.58 9.2 sd 1.09
Fear 89.50 sd 5.91 8.60 sd 1.17 8.2 sd 1.30Sadness 89.70 sd 7.87 8.70 sd 1.34 8.2 sd 1.64
Anger 89.50 sd 11.39 7.70 sd 1.42 8.2 sd 1.30
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