Monthly Archives: October 2009

Delusional Misidentification Syndromes

Whenever I’m doing research on the Internet it seems that I constantly get sidetracked into hidden corners and nooks and crannies and stumble across some really unusual stuff. A case in point would be the Delusional Misidentification Syndromes, an odd and thankfully rare group of psychiatric problems. The term Delusional Misidentification Syndrome is a catch all for a number of psychiatric problems that share a delusional belief that some person, object, or place has been changed or altered in some unusual way. There appears to be four main variants of this syndrome along with a few other minor types that may be related. They are each wild and unusual in their own right.

I should point out that in the field of psychiatry there is always arguments over what things should be called and which patients fit into which categories. That’s simply due to the subjective and inexact nature of psychiatry. It’s not like math and chemistry but rather is very interpretive. So much is in the eye of the beholder. Many of these syndromes overlap or contain similar features. For this reason there will always be arguments as to which ones are real and distinct and which ones are simply unusual manifestations of another.

The Capgras Syndrome: In this disorder the victim believes that a spouse, relative, or friend has been replaced by an identical appearing imposter. Uncle Joe is not Uncle Joe but rather is some stand in that has been inserted into Uncle Joe’s place.

This syndrome was first described by French psychiatrist Joseph Capgras in 1923 after he treated a woman who complained that many of the people she knew had been replaced by identical doubles. It seems to occur most often in those with schizophrenia or some previous brain injury.

The Fregoli Syndrome: This is the belief by the victim that many of the people he meets during his daily life are actually the same person over and over again just wearing a different disguise. So the teller at his bank, the young lady that steams up his cappuccino at his local Starbucks, the person sitting next to him for three wasteful hours at the DMV, and the guy behind him in line at the ZZ Top concert are all the same person. The fact that they are each different in size, age, sex, and ethnicity doesn’t seem to click. The belief that they are really all the same person holds firm.

The syndrome is named after the Italian actor Leopoldo Fregoli who was famous quick change artist. It was first documented in 1927 in a report that dealt with a young woman who believed she was being stalked by two actors she often saw at the theater. She felt that many of the people she knew were actually these actors in disguise. Who knows, maybe she was right.

Intermetamorphosis: The victim of this syndrome believes that the people around them, though their appearance remains unaltered, have swapped identities with each other. Sort of like Bob is Bill and Bill is Bob yet Bob still looks like Bob and Bill still looks like Bill. This could get confusing. How can you keep everyone straight without a scorecard?

I’m not sure how common this syndrome is but I have many times in my career seen victims of Alzheimer’s disease and other forms of dementia misidentify family and friends. An elderly man might think his daughter is his deceased wife or his third-grade schoolteacher or almost anyone else. This is simply a manifestation of the dementia and probably not a true case of Intermetamorphosis. Many of you may have seen this in your own families. It can be a difficult problem.

Subjective Doubles: (Also called the Subjective Capgras Syndrome) Here the victim believes that he has been duplicated and that his duplicate is going about another life independently. The old doppelgänger deal. I remember reading a case many years ago where a guy stated that he did not commit the robbery but rather his duplicate did. Though this would be a lame alibi, if I remember correctly, this guy turned out to have schizophrenia and did not remember the robbery but was absolutely certain that his doppelgänger had pulled it off.

There are a few other syndromes that many believe should not be included in the Delusional Misidentification family of syndromes but they share some common characteristics that are worth mentioning because they are very interesting entities.

Mirrored Self-Misidentification Syndrome: This one is just what you would expect from its name. The sufferer believes that his own reflection in a mirror is actually someone else. You mean that guy in the mirror when I shaved this morning wasn’t me? Who the hell is that guy? How did he get into my house? You see, this can be a fairly distressing syndrome.

Reduplicative Paramnesia: This is the erroneous belief that a familiar person, place, or object has been duplicated. A spouse is not the true spouse but rather an identical copy. Or the hospital where the patient finds himself is not the same one he was originally admitted to, but rather an identical hospital in an entirely different location.

Syndrome of Delusional Companions: This is the belief that an object is actually a living, breathing entity. Your car can think and talk, your golf clubs have personalities, or the stuffed cat sitting on the sofa is a real cat.

Clonal Pluralization of Self: In this situation the victim believes that he has been copied multiple times and that these identical beings are all going about their lives without his control. Don’t you often wish this was true? Maybe get one of these guys to run your errands or even go to work for you? I think this one is a keeper.

Cotard’s Syndrome: This is the belief that some of the victim’s organs or body parts are missing. They might believe that their heart no longer exists, or that their internal organs have somehow melted or evaporated. Some victims also believe that they no longer exist and are unable to feel anything. This syndrome is often associated with schizophrenia and/or bipolar disorder.

The brain is a wonderful organ and it does so many incredible things. It is also capable of the oddest constructions and we understand its workings not even a little bit.


Sodium Azide: Cyanide’s Distant Cousin

Writers are constantly looking for cool poisons. I would suspect that about half the questions I receive from writers deal with poisons, usually looking for one that is cool, odd, or difficult to trace. Sodium azide is one of those.

Writers often look to the real world for story ideas. A recent case at a Harvard lab is one that might be useful. Unfortunate for those who became ill, but useful in the world of fiction. It seems that six Harvard medical researchers drank some coffee that was contaminated with sodium azide. All became ill with symptoms that range from dizziness to loss of consciousness. Fortunately none of them died. The question that always arises in such workplace exposures is whether this was accidental or intentional. Apparently an investigation is ongoing.

In the fictional world, my friend Kathleen Antrim used sodium azide in a clever way to off a US senator in her excellent book Capital Offense.

Sodium azide is an odorless white solid that easily dissolves in water or other liquids. When dissolved, it releases a pungent-odored toxic gas and inhalation of this gas can lead to poisoning. It can also be ingested and has the unusual property of rapidly absorbing across the skin. Simply touching the compound or having the liquid it is dissolved in splashed on you could lead to poisoning. This means lab workers who use this compound must be very careful but for fiction writers it offers a world of potential plot events.

Sodium Azide is often discussed in the same sentence with cyanide. Even though they are distinctly separate chemicals, they have many properties in common. They can enter the body by ingestion, inhalation, or through the skin. Both interfere with the ability of the cells within the body to use oxygen and it is this interruption that leads to rapid death. The symptoms of exposure to either of these compounds are similar and might include: chest pain, shortness of breath, dizziness, headache, rapid heartbeat, nausea and vomiting, a low blood pressure with shock, loss of consciousness, sometimes seizures, and death.

Writers are often looking for toxins that mimic a heart attack and, like cyanide, sodium azide fits the bill. The victim would develop chest pain, shortness of breath, become weak and dizzy, collapse, and die. Exactly as would happen in a major heart attack that resulted in sudden death. Since neither cyanide nor sodium azide show up on a routine drug screen, the medical examiner must have a suspicion that such a chemical was involved before he would go to the time and expense of testing for it. With cyanide the medical examiner might notice the bright red color of the blood, the skin, and the internal organs of the victim, a coloration that is due to a chemical reaction between the cyanide and the hemoglobin found within the red blood cells. Sodium azide has no such reaction and so the bright red color is not present. Your sleuth will need some other reason to persuade the ME to do the testing, but that’s what storytelling is all about.

CDC Article

Northeastern University Article


Guru On Hot Seat: Sweat Lodges and Heat Stroke

James A. Ray is still a Spiritual Warrior… for anything new to live something first must die. What needs to die in you so that new life can emerge?

This was a Twitter tweet apparently posted by self-help guru James Ray. I guess what needed to die were a few kidneys, hearts, brains, and people. And now for his incredibly dangerous “Sweat Lodge” sessions, Mr. Ray might just find himself facing murder charges.

On October 8th, James Ray oversaw a retreat at the Angel Valley Retreat Center in Sedona, Arizona, where approximately 60 people gathered for a session of self-examination, meditation, and other activities orchestrated by the guru. Unfortunately one of these activities was spending a couple of hours in an enclosed 415 square-foot Sweat Lodge. The homemade structure consisted of a wooden frame covered with blankets and tarps and measured 53 inches in the center and 30 inches around the outer edges. Cozy just isn’t the right word.

AZ Sweat Lodge

So we’re talking 60 people packed into a short, squatty 2-car garage with no windows or doors in mid-afternoon in Arizona for two hours. It is reported that a flap was opened briefly every 15 minutes or so to drag in some fresh air, but after two hours in such an arrangement, as would be expected, the temperature within the packed lodge became dangerously elevated.

To make matters worse, the participants apparently fasted for 36 hours before having breakfast on that day, which suggests that many were likely at least somewhat dehydrated before entering the lodge at 3 p.m. A single meal will not make up for a day and half of fasting. It’s worth noting that the participants, who ranged in age from 30 to 60 or so, paid around $10,000 to attend the retreat.

It was two hours later that the first victim collapsed and at the end of the day nearly 2 dozen people were hospitalized and two people had died. A third victim died of multiple organ failure a week later. Others suffered kidney damage.

Sweat lodges have been around for a very long time and were used by many early American Indian tribes as part of their religious and cleansing ceremonies. Apparently they had enough experience and common sense not to spend too long in the lodge. Native tribes were well schooled in observing the environment and conforming their behavior to survive the weather, predatory animals, and other things that mother nature threw at them. It was a harsh existence but common sense and passed-on knowledge and tradition allowed them to survive and prosper. Not so much of either in this case.

Have you noticed those little signs hanging in the sauna or steam room at your local health club? You know, the ones that say not to spend more than 15 minutes and to keep yourself well hydrated? I guess James Ray didn’t get the message.

The situation these people found themselves in is very similar to a sauna or perhaps being abandoned in the desert. The result is what we in medicine call a heat injury. These come in various degrees of severity but the two most important are heat prostration and heat stroke. These are simply the same disease with one being further along a deadly pathway than the other.

When the body is exposed to heat, such as someone running a marathon or someone abandon in an Arizona desert, the body works to lower its core temperature, mainly through sweating. The evaporation of sweat from the skin draws heat from the body and lowers the core temperature. We’ve all experienced this natural phenomenon. But, as the body loses water, the blood volume contracts, and the blood flow to the skin is reduced. This is simply the body saving its most important parts. Under stress such as this, as the blood volume declines, blood is shunted toward vital organs such as the heart, lungs, and brain and away from the skin, a less vital organ.

But this decrease in blood flow to the skin has some very dangerous effects. The skin is the body’s natural radiator and as blood flow through it diminishes, it no longer works properly, is no longer able to dissipate the heat that is collecting within the body, and the core temperature begins to rise. The heart and the brain begin to malfunction. The kidneys, which now are receiving much less blood flow, began to fail. The electrolytes — things like sodium and potassium — within the blood began rising, and sometimes falling, to abnormal levels which will then interfere with the function of many things within the body, the most important being the electrical system of the heart. This will ultimately lead to cardiovascular collapse and death.

But even if this doesn’t happen the brain can become severely damaged from the elevated body temperature. Any time the body temperature rises above 104°F the brain is not happy. Once it rises to 106 or 107°, brain damage is likely if not certain.

When a marathon runner or football player collapses, heat injury is often involved. Sports such as these, when performed in excessively hot weather, can cause heat prostration, heat stroke, and death. This is what happened in the sweat lodge in Arizona. And in children left in cars while mom has a couple of drinks. And the vans left abandoned in the desert packed with illegal immigrants. And the trains that ran to Buchenwald and Bergen-Belsen.

How do these heat injuries occur? What distinguishes heat prostration from heat stroke? As the body temperature begins to rise, from either exercise, environmental exposure, or both, the body will begin to produce more sweat in an attempt to lower the body temperature. This process will continue for as long as it possible. But as the body begins to lose water and the blood volume begins to contract, the blood is shunted away from the skin, the radiator no longer works properly, and the body temperature begins to rise. The victim will then simply sweat more, which only makes things worse.  It is at this point that the body will begin to malfunction. The victim will become weak and dizzy, maybe confused and disoriented, and maybe develop muscle weakness and cramps. Physical activity is no longer possible. This is heat prostration. The treatment is to move to the shade, drink plenty of liquids, pour water over your body and have someone fan you with a towel or whatever is available, and rest. This is often all that is necessary to avoid serious injury.

But, if the activity is continued, or if the individual is not able to leave the hot environment, the temperature within the body will continue to rise. When the core temperature reaches 106-107 brain injury begins. One of the first areas involved is near the base of the brain in what we call the hypothalamus. This is where the temperature regulation center resides and when it begins to malfunction, several very bad things happen. Sweating ceases and, with the radiator now shut off, the body core temperature rises even further. The victim, who typically is already experiencing most of the above symptoms, will now collapse and become unconscious. There can even be seizures and death can follow very quickly. This is called heat stroke and is a true medical emergency.

Someone suffering from heat stroke must undergo the cooling things that I described above except that, since the victim is unconscious and can’t take fluids by mouth, the severe dehydration can’t be corrected in the field. Transportation to the hospital should be immediate. Once there, intravenous fluids in very large amounts are given and the victim might be placed in an ice bath — basically a tub filled with ice water–since rapidly lowering the body temperature is critical to survival. But even if these measures are undertaken, the victim might still die or be left with permanent brain injury.

So you can see that these people, who trusted the guru, were placed into a very dangerous situation, apparently without proper monitoring, without proper knowledge of what was going on, and without proper medical care being available. At least everything that I have read on this case so far seems to point in that direction.

Interestingly, it seems that back in 2005, during a similar sweat lodge session, 911 was called after someone passed out.

Will James Ray be charged with a criminal act? Was this tragedy an accident or was it something else? Maybe negligent homicide? We’ll wait and see.

CBS News



Fingerprints and the Forensic World (Part 3)

In 1858, Argentine police officer and scientist Juan Vucetich was born in present-day Croatia (then part of the Habsburg empire). He came to Buenos Aires in 1884. He was apparently a music, languages, and mathematics prodigy.


In 1888, he joined the provincial police in La Plata, where he studied anthropometry, but soon became convinced that anthropometry was flawed, resulting in mistaken identities and the imprisonment of innocent people. He turned his attention to the budding science of fingerprinting.

Vucetich developed a method of classifying fingerprints into four different types, a system that is still the basis for the one used in Argentina today. The biggest test of his fingerprinting system came in 1892, when it was used to resolve a murder, a first in the history of criminology.

On June 29, 1892, in the city of Necochea, Francisca Rojas killed her six- and four-year-old children by slitting their throats. She then superficially stabbed herself and said she was also a victim of the attack. She accused neighbor Ramón Velázquez. She apparently did so because she blamed Velázquez for telling her husband of her infidelity. Velázquez denied having killed the children.

Buenos Aires provincial police chief Guillermo J. Nuñes sent police officer Eduardo M. Álvarez, a colleague of Vucetich and well-versed in his fingerprinting techniques, to investigate the crime. At the crime scene, Álvarez found a bloody fingerprint on the door and showed that it came from the mother and not from Velazquez. Rojas was tried and convicted.

Rojas Fingerprints

Vucetich’s methods attracted great attention throughout the field of criminology and his system quickly spread. Fingerprinting had arrived and it soon became the preferred method for individual identification.


Electronic Noses: Sniffing Out Corpses


Finding the body is critical.


How are bodies located?







Dogs play an important in corpse location.



But the days of these detective dogs just might be numbered.


Many of these devices are simply small portable gas chromatographs, which can separate and identify many chemicals and in some cases determine the amounts of each. Newer studies are looking into using the new technology of microfluidics and LOCAD– Lab On A Chip. These are a spinoff of current research going on at NASA’s Marshall Space Flight Center in Alabama and other areas around the country.



Fingerprints and the Forensic World (Part 2)

Anthropometry and Bertillonage

Anthropometry (anthrop means human; metry means to measure) is defined as the study of human body measurements for use in anthropological classification and comparison. Simply put, it is the making of body measurements in order to compare individuals with each other.

In 1882, using anthropometry, French police officer Alphonse Bertillon developed the first truly organized system for identifying individuals. Believing that the size of the human skeleton did not change after about age 20 and that each person’s measurements were unique, he created a system of body measurements that became known as bertillonage. According to Bertillon, the odds of two people having the same “bertillonage measurements” were 286 million to one.


This belief led Bertillon to state that all people could be distinguished from one another by key measurements, such as overall height, seated height from head to seat, length and width of the head, right ear length, left little finger length, and width of the cheeks among others.

His greatest triumph came in February, 1883, when he measured a thief who said his name was Dupont and compared his profile to those of known criminals. He found that Dupont’s measurements matched a man who had been arrested in 1882 under the name of Martin. Under questioning, the thief finally admitted that he was both Martin and Dupont, but that his real name was neither Martin nor Dupont.


For many years, this system was accepted by many jurisdictions, but by the dawn of the 20th century cracks began to appear. The measurements were inexact and subject to variation, depending upon who made them. Also, since the measurements in two people who were of the same size, weight, and body type varied by fractions of a centimeter, flaws quickly appeared and the system was soon discontinued.

Its death knell tolled with two famous cases:

The Will West Case:

Though landmark in its importance, this case was an odd comical coincidence. On May 1, 1903, Will West came to Leavenworth Penitentiary in Kansas. The records clerk apparently thought that the man looked familiar, but the new inmate denied ever having been in the prison before. As part of his intake examination, anthropometry was performed and officials were surprised to find that Will’s measurements exactly matched those of William West, another inmate at Leavenworth. The two men even looked eerily similar.

They were brought together into the same room, but each stated that they were neither brothers nor related in anyway. Fingerprints were then used to distinguish between the two Wills after which Leavenworth dumped anthropometry and switched to a fingerprint-based system for identifying prisoners. New York’s Sing Sing Prison followed a month later.

Was the similarity between Will and William West simply a bizarre coincidence? Not really. A report in The Journal of Police Science and Administration in 1980 revealed that the two were actually identical twins. They possessed many fingerprint similarities, nearly identical ear configurations (unusual in any circumstance except with identical twins), and each of the men wrote letters to the same brother, same five sisters, and same Uncle George. So, even though the brothers denied it, it seemed that they were related after all.

Bertillon reluctantly agreed to add fingerprints to his bertillonage profile. However, he only added those of the right hand, which proved to be a huge mistake.

The Mona Lisa Theft:

On August 21, 1911, the Mona Lisa was stolen from the Louvre Museum in Paris. The thief left a clear thumbprint on the glass that protected Da Vinci’s masterpiece. To assist investigators, Alphonse Bertillon added his profiles to the investigation. Unfortunately, he had no classification system to streamline the search through his thousands of data cards, resulting in he and his assistants spending several months digging through his files. They found no matches. Two years later, the police apprehended Vicenzo Perugia and his prints matched the one found at the crime scene.


It turned out that Perigia’s prints were among those in Bertillon’s files all the time. Why no match? The print found at the scene was from Perugia’s left thumb, while Bertillon’s files only contained that of the right. This unmasked yet another flaw in Bertillon’s anthropometric system and led to it falling into disfavor as a means for identification.


On This Day in History: Edgar Allan Poe


The Tell-Tale Heart by Edgar Allan Poe


Maybe it’s because I’m a cardiologist, but this short story has always been special to me. As is old Edgar, a master storyteller if there ever was one.
On this date in 1849, at the very young age of 40, the world lost the true father of the mystery novel. God bless thee, Edgar.

Poe Museum


1 Comment

Posted by on October 7, 2009 in On This Day, Writing


Redheads Are a Pain

Redheads are trouble. Redheads are a pain. Redheads have stirred things up for centuries. Who are these redheads? People like Napoleon, Gen. George Armstrong Custer, Lucille Ball, Thomas Jefferson, Richard the Lionheart, and even the current British royal family’s redhead Prince Harry.

Ball, Lucille copy

But let’s be fair, it’s not really their fault. It’s a genetic deal. It seems that one of the things that distinguish redheads from the rest of us is that they have a lower pain threshold. They seem to feel pain more severely and make greater attempts to avoid painful situations.

A recent study reported in the Journal of the American Dental Association (JADA) evaluated resistance to local anesthetics and level of anxiety in people with red hair versus non-redheads. They found that redheads experienced more anxiety and fear of dental procedures and tended to avoid them more often than others. Other studies have shown that redheads may require as much as a 20% increase in both local and general anesthesia and in pain treatment than do non-redhead.

So what is the deal with redheads?

The problem seems to be related to a gene that produces a substance called melanocortin-1 receptor (MC1R). The MC1R gene belongs to a family of receptors that include pain receptors in the brain and a mutation in this gene apparently alters the person’s sensitivity to pain. Though this mutation can occur in non-redheads, it is more common in redheads. Normally the MC1R gene produces melanin but if the mutation occurs it produces a substance called pheomelanin, which in turn causes the individual to have red hair, fair skin, and a lower pain threshold.

So the next time the redhead in your family or circle of friends gets his or her “Irish Up,” it might be that they are suffering discomfort. Or maybe redheads are simply fiery and feisty by nature.

The Pain of Being a Redhead

NIH Article on Anesthetic Requirements

NIH Article on Thermal Sensitivity


Posted by on October 4, 2009 in Medical Issues


Fingerprints and the Forensic World (Part 1)

The History of Fingerprinting

The evolution of fingerprints as a method of identification was a long, slow journey of nearly 3000 years. The milestones in this process include:

Prehistory: Early pot makers “signed” their works with an impressed finger or thumbprint, which identified the work as their own.

1000 BC: The Chinese used fingerprints to “sign” legal documents and criminal confessions. It is unclear whether this was a ceremonial practice or a true method of personal identity

Ca. 1000: Quintilian, a Roman attorney, exonerated a blind man accused of murdering his own mother by showing that a bloody palm print found at the scene had been placed by someone else in an attempt to frame the unfortunate man.

1685: Marcello Malpighi, professor of anatomy at the University of Bologne, was the first to recognize fingerprint patterns when he wrote of the “varying ridges and patterns” he saw on human fingertips. He was the first to use the terms “loops” and “whorls” in describing these patterns.

12-2 Tented archzz copy

1823: Johannes Purkinje of Breslau University devised the first system for classifying fingerprints. He listed nine basic patterns and laid down rules for their individual classification. These rules and patterns are the basis for today’s classification systems.

1858: To prevent fraud in contracts and pension distributions, Sir William Herschel, an English civil servant stationed in Bengal, India, required that the natives sign contracts with a hand imprint. He is perhaps the first European to recognize the individuality of such prints. He also kept a record of his own prints and showed that they did not change over a 50-year period, a discovery that was of paramount importance to the development of fingerprints as a forensic tool.

1880: Henry Faulds, a physician and surgeon at Taukiji Hospital in Tokyo, Japan, wrote that fingerprinting could be used for personal identification and suggested that it might be useful for identifying criminals. He also recognized that latent (invisible) prints could be exposed by dusting them with powder and used this method to exonerate a man accused of thievery. The man was arrested and his prints were checked against one the thief had left on a window, but they didn’t match. Days later the real thief was found, his prints matched, and he confessed.

1883: Even Mark Twain understood the discriminatory power of fingerprints and used the technique in his books, Life on the Mississippi and Puddin’ Head Wilson.

1892: Sir Francis Galton published his classic textbook, Finger Prints, the first book on the subject. He described three patterns within the prints that he called loops, arches, and whorls. More importantly, he gave convincing evidence that no two prints were identical.

1892: Juan Vucetich, a police official in La Plata, Argentina became convinced that fingerprints could be used to identify criminals and devised a classification system that is still in use in most of South America. He published a book on the subject in 1894.

1892: Argentina became the first country to use of fingerprints to solve a crime. On June 18, 1892, the illegitimate children of Francesca Rojas were murdered and she accused a man named Velasquez. Alvarez, a police investigator who trained under Juan Vucetich, discovered that Rojas had a lover who had previously stated that he would marry her if she did not have children. A bloody fingerprint found at the scene matched Rojas’ right thumb and she confessed.

1897: Herman Welcker compared his own prints taken in 1897 with ones he had taken 41 years earlier in 1856 and found they were unchanged, thus supporting the findings of William Herschel.

1899: Sir Edward Henry devised a classification system based on five types of prints. His system is the basis for those used in Britain and America today.

1901: Edward Richard Henry was appointed head of Scotland Yard and adopted a fingerprint identification system in place of anthropometry.

1902: Burglar Harry Jackson became the first person in England to be convicted by fingerprint evidence when he left his thumbprint at the scene of his crime.

1903: The New York State Prison system instituted the first systematic use of fingerprints for criminal identification in the United States.

1910: Thomas Jennings became the first United States citizen convicted of a crime by use of fingerprints. Tried for murder in Chicago, Jennings was convicted and the verdict was upheld on appeal, making his case a landmark in the use of fingerprint evidence in court.

Near the end of the 19th century, fingerprints weren’t the only identification method being studied. The field of anthropometry vied with fingerprints to become the standard method for identification. Until an odd and landmark confrontation between the two methods settled the issue. I’ll discuss that in Part 2 of this three-part series.

Howdunnit 200X267 copy


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