Monday, January 01, 2001

No One in My Mirror

Altered Egos: How the Brain Creates the Self

By: Andrew Derrington, Ph.D., and Amanda Parker, Ph.D.

In this short book Todd Feinberg attacks a big question with a promising approach and produces a surprising result. 

The question is the toughest in neuroscience, and arguably the most exciting in human scientific endeavor. Feinberg states it clearly: “We need to know how the brain, which is composed of billions of individual neurons, creates the single and unified entity we call the self.” He starts with two questions to be answered on the way: “What is the self?” and “Where is the self located in the brain?” 

Feinberg’s approach, taken with the intelligent layman in mind, is “softly, softly,” no tedious, mystifying, philosophical hair-splitting here, no intimidating neurological details. We sit in Feinberg’s consulting room (he is a psychiatric neurologist at the Beth Israel Medical Center in New York) and meet his most unusual patients. In the first seven chapters we witness their idiosyncrasies of mental state emerging in conversations with him. We see their brain scans. We are led gently toward Feinberg’s answer to the big question, an answer he refines in the final three chapters, which address theoretical matters. 

Feinberg begins examining the nature of the self by considering John. John arrives in the consulting room, sent by his wife. He seems normal, but terrible chemical burns have stripped much of the skin from his hands. Despite their shocking state, he offers to shake hands with Fein-berg. John seems unaffected by the damage. 

John’s condition is called pain asymbolia, in his case associated with a large area of damage to the frontal and parietal lobes in the brain’s right hemisphere and a smaller area of damage in the left frontal lobe. Loss of these brain areas has left John indifferent to painful sensations and careless about physical harm. John’s rare neurological condition leads Feinberg to a provocative question: What are the boundaries of the person, of self? Are they flexible? He explores the questions through studies of patients whose conditions challenge these boundaries. 

Patients introduced in the second chapter, on deconstructing the self, present several conditions. “Neglect,” generally the result of right hemisphere damage, causes patients to ignore everything that happens or exists in the space to their left. This gives rise to many problems in their daily lives, which can be exacerbated by asomatognosia. This usually accompanies neglect rather than appearing on its own. Patients with asomatognosia refuse to recognize some part of their bodies—usually an arm or leg—as belonging to them. Sonya, one of these patients, consistently answers the question, “Whose hand is this?” with “Not mine.” Her rejection of the limb is complete; she is unmoved by arguments or evidence advanced by her physician. 

The final condition in this chapter, anosognosia, is a resolute belief by the patient that nothing is wrong. Two patients believe they are moving paralyzed limbs, even when they can see the limb does not move. A third denies her blindness, describing her surroundings erroneously but in great detail. 

Feinberg draws an interesting conclusion from this: Although brain damage causes some fragmentation of their sense of self, the patients strive to maintain an integrated sense of self and make sense of the experience. This often involves developing what seem to be bizarre inventions. The patient Lizzy calls her arm “Pet Rock.” She has an overwhelming conviction that it is not part of her body. 


The proposal that patients strive to maintain an integrated self leads naturally to discussion of a group of patients with Capgras and Fregoli syndromes. The brain region damaged here usually includes parts of the frontal lobes. Because both conditions involve changes in feelings of personal relatedness that patients have with people they know well, Capgras and Fregoli patients are relevant to understanding the self and its boundaries. 

In Capgras syndrome, the feeling of relatedness to a person or possession based on past experiences is no longer there. The patient feels alienated, a change in relatedness that can be devastating when the rejected person is a spouse or child. Feinberg compares this change in interpersonal relatedness with the change in relatedness to the body in asomatognosia. In Capgras syndrome, the patient’s loss of relatedness involves a person or possession; in asomatognosia it is directed towards a part of the patient’s own body. 

In contrast to how Capgras and asomatognosic patients abruptly lose the ability to recognize parts of their bodies or members of their families as related to them, in Fregoli syndrome the patient develops an intense feeling of relatedness to an unrelated person. Feinberg apparently never had a patient, or at least a cooperative patient, with Fregoli syndrome; he uses three cases from the annals of neurology to illustrate this condition. All three patients felt strangers were people they knew well. One, a well-known neurologist, Dr. Max Levin, made a similar mistake with a place—the hospital room where he was treated—rather than a person. Levin formed the delusion that the hospital room was in a hospital annex near his home rather than in the main hospital, which he knew to be several miles away. 

Feinberg uses Capgras and Fregoli patients to make connections between brain structure and the structure of self. That the feeling of relatedness can be attached or detached so readily from people and places, Feinberg argues, suggests there are links between discrete brain regions in the right hemisphere. Damaging those links in some way affects feelings of relatedness in both types of patients. But Feinberg’s arguments on this point are vague; he does not try to back them with specific information about the kinds of damage that cause different manifestations of the syndromes. 


Knowing who you are, having a clear impression of yourself as an individual, has several components. In addition to feeling related to yourself and your family, you are anchored to your personal identity by memories of yourself in situations you have experienced. In amnesic patients, whose disorder affects memories from before the onset of their illness (retrograde amnesia), this anchor is weakened. Patients lose personal memories for parts of their lives. 

In a chapter titled “Mything Persons,” Feinberg explains that some patients with retrograde amnesia, whose brain damage includes parts of the frontal lobes, exhibit a condition called confabulation. He describes four patients who create fictitious narratives about the missing periods in their lives, weaving real and invented people and events together. Patients who confabulate usually seem unaware that they are inventing. When challenged about their inventions in a way that forces them to acknowledge inconsistencies, they become agitated. 

Feinberg argues that the confabulating patient strives to create an alternative reality to rebuild an integrated self:

The narrative may involve real or fictitious places or persons; it may be rather commonplace, but it is often quite fantastic in nature. It often involves the patient’s neurological problems, but it may also be about any traumatic event or circumstance of a personal nature. These confabulations can be likened to a personal myth, a story about the self in disguised form. 

Feinberg sees a clue in how the confabulations of different patients share common themes: trauma, denial of illness, and invented phantom children. He suggests these common themes reveal the patients’ feelings about themselves and their medical condition. The impetus for confabulation underlies all the endless stories composed of random elements from the patient’s long-term memory; it is an impetus to reweave the fabric of self.


The next group of patients Feinberg considers has problems identifying themselves and others. This impairment is neither a simple failure to recognize everyday objects or a more specific problem seen in some neurological patients who can no longer identify faces (prosopagnosia); it is much more selective. Two of these unusual patients have a Capgras syndrome that renders them unable to identify themselves in a mirror. 

In the same chapter, Feinberg seems to spoil his argument that the self has flexible boundaries by including a far less convincing example. Florence has an imagined presence in her home, a woman she believes is having an affair with her husband.

Although Feinberg uses this to propose that the mind can create representations of hidden emotions, giving them a life of their own, he does not distinguish between Florence’s delusional state and states of dementia common in Alzheimer’s patients and many other groups. It is not clear that Florence advances our understanding of how the brain creates the self. 


A recurring theme of Altered Egos is that a crucial role of the self is to integrate information processed in disparate brain areas. In his last and least cohesive chapter about patients, Feinberg grapples with three groups that might shed light on how the brain could weld into a unified experience of self the myriad emotions, memories, and actions that impinge on it at any one time. The three groups are patients in whom the main connections between the left and right hemispheres of the brain have been cut, so that the two hemispheres operate independently, alien-hand patients, and two patients, Sonia and Seymour. 

Using these groups to advance his argument that the self will find a way to remain whole in the most challenging circumstances, Feinberg completely fails to convince—partly because he fails to produce a consistent evaluation of the evidence. For example, he spends time on alien-hand patients, who have one hand that acts involuntarily—often contradicting the expressed wishes of the patient, who may find himself simultaneously trying to dress with one hand and undress with the other—but draws no conclusion from this apparent failure to integrate. Instead, he goes on to consider split-brain patients. Of them he concludes, almost without telling anything about them, that “one of the most striking features of split-brain patients is the degree to which they act, feel and experience themselves as completely intact.” 

At this point, Feinberg cuts quickly to his consultations with Sonia and Seymour, who are remarkable for performing reasonably well despite missing a great deal of brain tissue. Sonia has hydrocephalus, a condition in which the brain’s ventricles are enlarged during development, causing the cortex to distend and become ribbon-like. Despite this, Sonia has led a normal life into her 30s; her symptoms are mild. The second patient, Seymour, has no memory of a lobotomy he had decades ago; it is discovered during a magnetic resonance imaging (MRI) scan. He too has led a normal life, with the feeling of an integrated self, despite severe challenges to his brain structure. 


In his last three chapters, Feinberg looks at the many regions of the brain involved in producing the feeling of an integrated self, and how they cooperate to create the sense of being one conscious, behaving person. This phenomenon has challenged philosophers for centuries and neuroscientists for decades. Feinberg touches on arguments from both perspectives, but because the self and consciousness are intimately bound up, he soon falls prey to problems of definition that tax scientists and philosophers addressing consciousness. 

Feinberg first considers a traditional proposal for brain organization, the hierarchy. This model proposes that sensory regions connect to increasingly complex brain regions until the highest or most controlling region is reached. Unfortunately, this leads to an infinite regress, or what has been called the “homunculus,” the positing of a “little person” as the explanation of our unified self, but still with no explanation of this person’s unity. 

Feinberg suggests the homunculus problem can be solved by appealing to the phenomenon of emergence. The doctrine of emergence he adopts from philosophy and biological theory rests on the idea of hierarchies. Feinberg proposes three aspects of emergence theory relevant to the quest to understand the self: 

  1. Novelty—each level of the hierarchy can produce novel elements by combining the outputs of the levels below.
  2. Constraint—higher levels impose control over lower ones.
  3. Nonreducibility—the sum is more than the individual parts. 

Based on this, Feinberg suggests the proper model for relating mind and brain is a nested hierarchy in which all neurons involved in processing a sensory input work interdependently but on numerous levels. All lower-order and higher-order, more cognitive processing contributes to conscious perception. 

Feinberg fails to explain, however, how different components of the nested hierarchy are integrated. If the hierarchy has no ultimate top, what and where is the unifying force that makes decisions? Feinberg concludes that meaning constrains and “pulls together” the hierarchy to enable us to make decisions. This asserts that higher levels of meaning govern lower ones. Deficits in levels of this behavior hierarchy can be seen in patients with some forms of aphasia, who may not be able to produce words when asked to, but can produce words—for example, expletives—when in a heightened mood. Feinberg further proposes that the unified feeling of self is the result of the brain’s construction of a nested hierarchy of meaning and purpose. Thus the self filters input to construct useful interpretations of the world and produce purposeful behavior, which again are seen as nested possible actions. 

In the end, no clear view of the self emerges from this book. Feinberg seems to support split-brain theorist Roger Sperry’s idea of the mind as immaterial but the pinnacle of a hierarchy that controls the brain. Feinberg’s proposal of a nested hierarchy as an alternative to a rigid hierarchy does not advance us much.

Another disappointment is that the three questions we started with do not seem to be much closer to an answer in the final chapter than early in the book. At present, “What is the self?” can be answered only tentatively by neuroscience, but examples of patients with disturbances in their boundaries of self are a valuable perspective on it. Feinberg’s second question, “Where is the self located in the brain?” is both too ambitious and a question neurology’s methods are poorly equipped to address. Patients almost invariably have large, ragged regions of brain damage. Localization even of straightforward functions is difficult. Answering philosophical questions is impossible. The final question, “How does the brain produce a unified self?” is answered with the concept of a nested hierarchy but how the disparate components are unified remains far from clear. 

Unfortunately, the ultimate surprise of Altered Egos is that, despite the intriguing topic and accessibility of Feinberg’s approach, the end result is tedious. In part, this is because the book fails in the task it sets itself, but its style is at least as much to blame. You might think that to be a fly on the wall of Feinberg’s consulting room would be riveting. Sadly, it is not. His conversations with patients are leaden. Rosamond’s insistence that the face she sees in the mirror is that of a hostile stranger may be arresting, but her rambling conversation with Feinberg is tedious in the extreme. Adding the details of her husband’s concern and her family history to the account of her consultation does not save it. It is a mercy that Feinberg was able to cure Rosamond quickly by persuading her to look at herself in a small mirror, sparing us further neurological details of her case. 

The bottom line is that promising raw material and an interesting question do not necessarily make a good book; you still need a good writer. Unfortunately, Feinberg has a long way to go in that regard. The thought that keeps recurring as one reads this book is, “Oliver Sacks does this sort of thing so much better.”



From Altered Egos: How the Brain Creates the Self by Todd Feinberg. © 2000 by Oxford University Press. Reprinted by permission of Oxford University Press. 


A semi-retired gentleman from a middle-class Italian neighborhood in Queens, Richard B., brings his wife to my office. Richard and his wife, Rosamond, have been married for more than thirty years and have successfully raised two children together. Just recently she has begun to exhibit an odd behavior that worries her husband and their two grown-up children: Whenever Rosamond sees her reflection, she is convinced that a strange woman is following her. When she asks the woman to identify herself, she refuses to talk, so Rosamond—first verbally, then physically—attacks her reflection. Richard cannot let her stay alone in the bathroom because she attacks the mirror on the medicine cabinet. At night, she cannot pass the living room window without ranting and raving at the woman who is apparently outside looking in. She yells, “You tramp! Go on home!... Leave us alone!” 

The woman appears in the windows of parked cars and in storefronts along the streets of their neighborhood. In broad daylight, Rosamond screams and wildly flails her arms at her. While Rosamond’s family is quite embarrassed by her behavior, they are also afraid that she will harm herself. 

Richard’s account of his wife’s behavior is at first quite surprising to me, since Rosamond’s outward appearance is somewhat grandmotherly, prim, and proper. She adjusts the buttons on her cardigan sweater, firmly clasps her leather purse against her stomach, and brushes the lint off her pant legs while meekly answering my questions. She is obviously unaware of the wild behaviors that her husband reports to me. 

During the course of my interview, Rosamond sat quietly listening while her husband described her symptoms; she didn’t appear particularly agitated. I had a mirror hidden behind my back, anticipating her visit, and I presented it to her, so she could observe her own reflection. She looked at it for about ten seconds, then she stood up and down and raised her eyebrows and became quite angry and disturbed. 

Rosamond: Did you hear the story? Eh? Did you hear it? Now you get out ... get home where you belong. You don’t belong here ... you don’t live here! Out! [Waving her hand.]

Her entire demeanor changed. Her face became almost contorted in agitation. 

Feinberg: Who is that?
Rosamond: [Screaming] That’s her, that’s her! Yeah, that’s her ... sure that’s her! She has no
name ... I never heard her name ... never, never! I never! She never told me her name. No, no ...
you can’t go in the house! No, you can’t go in the house! She never let me know, had a lot of
problems with her.

She eventually became so agitated that I had to take the mirror away from her to calm her down. She sat hunched over, rubbing her knees back and forth. 

Rosamond: I’m gonna kill her ... so mad at her.

Her husband became concerned that Rosamond was going to stand in front the mirror with a knife and actually stab herself, so I needed to treat her immediately before she injured herself or her husband. The husband reported that the misidentification occurred in any reflective surface, from glass in store windows to car mirrors. She did not, however, misidentify her reflection in the mirror of her cosmetic compact. It occurred to me that perhaps its small size made it less likely for the symptom to occur. So I first instructed her to take out the compact and asked her to identify her image, which she did correctly. Using a series of mirrors of increasing size, I was able to convince her as the reflection got larger, despite her initial protestations, that they represented her OWN reflection. I repeated this process over several days until her husband reported that the behavior had vanished.

About Cerebrum

Bill Glovin, editor
Carolyn Asbury, Ph.D., consultant

Scientific Advisory Board
Joseph T. Coyle, M.D., Harvard Medical School
Kay Redfield Jamison, Ph.D., The Johns Hopkins University School of Medicine
Pierre J. Magistretti, M.D., Ph.D., University of Lausanne Medical School and Hospital
Helen Mayberg, M.D., Icahn School of Medicine at Mount Sinai 
Bruce S. McEwen, Ph.D., The Rockefeller University
Donald Price, M.D., The Johns Hopkins University School of Medicine
Charles Zorumski, M.D., Washington University School of Medicine

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