The Woman in the Mirror: A Reflection of a Life-Threatening Condition

Michelle E. Grady

January 05, 2021

When a 47-year-old woman with well-controlled schizophrenia attended the Smell and Taste Research Clinic in Chicago, Illinois, Justin Virk, MD, had no idea he was about to encounter one of the most unusual cases of his career.

The patient told Virk that every time she looked in the mirror, her image moved and spoke independently of her. The reflection issued commands, telling the patient what to wear and how to style her hair.

In addition, she experienced intense paranoia while driving, especially when she looked in the rear-view mirror. This paranoia, Virk told Medscape Medical News, caused his patient significant distress, and ultimately she became incapacitated.

Initially, Virk and mentor Alan Hirsch, MD, suspected Fregoli syndrome, a condition in which patients experience hallucinations of themselves immediately in front of them. However, an autoscopic hallucination that only manifests in the mirror "has never been described before," said Virk.

The patient's context-specific hallucinations suggested a dysfunctional visual network for visual perception or recognition. Virk and Hirsch hypothesized that she may have a neurologic condition involving the parietal or occipital lobes.

They conducted a full neurologic exam as well as neuroimaging ― both of which yielded abnormal findings.

"Her Mini–Mental State Exam was a borderline failure. She couldn’t recall four out of four objects without reinforcement and would only recall two out of four with reinforcement," said Virk.

Her visual acuity was 20/40 in both eyes without glasses, she had bilateral ptosis in both eyes, and her reflexes had gone from +2 in her upper and lower extremities to 0 in a matter of just a few weeks, he added.

Blood testing revealed abnormalities, including low chloride and high protein levels and low-folate red blood cells. Results of urinalysis were also abnormal. Through neuroimaging, the clinicians discovered a stage IV glioblastoma.

Interestingly, the tumor was in the brain's frontal lobe, not in the occipital or parietal regions, which would explain the hallucinations.

"If it were in those regions, then we could understand the hallucinations easily, because it would affect the visual pathways," said Virk.

The clinicians then thought that because the tumor was located in the frontal region, it might be inducing secondary dysfunction in other parts of the brain ― a mechanism known as diaschisis.

"Our theory was that since the tumor was somewhere else in the brain, it could be that it induced secondary dysfunction to other parts of the brain," said Virk.

Because this case was so rare and there was so little available literature to guide them, the clinicians tried adjusting the patient's antipsychotic medication, but it had no impact.

"Though we of course referred her to an oncologist, we also made these adjustments and monitored her for improvement or deterioration. We saw neither. We also wondered whether we should give her antiseizure medication, because she had a space-occupying lesion in the brain. This was another huge challenge, but because we had so little to go on, we stuck to what we knew rather than experimenting on the patient," he said.

The patient's neurosurgeon determined that the tumor was inoperable and recommended chemotherapy. However, despite treatment, the malignancy remained, and the autoscopic hallucinations continued to occur.

"Her prognosis is poor, given the nature of this malignancy, and we are continuing her treatment with antipsychotics, as well as chemotherapy for her cancer," said Virk.

Virk notes that this was one of the most unusual cases of delusional misidentification syndrome he and Hirsch have ever encountered.

"We don’t have much information on these syndromes," he said, adding that he believes they are more common than the evidence base suggests. Virk suspects that many patients do not disclose these syndromes to their physicians, which highlights the importance of building strong doctor/patient relationships.

"If we had more people to research and write about such cases, it would definitely provide us with more treatment options, because right now we are limited to antipsychotics, which is a huge challenge for us," he said.

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