Unilateral autoscopic phenomena as a lateralizing sign in focal epilepsy Robert Hoepner a , Kirsten Labudda a, b , Matthias Hoppe a , Martin Schoendienst a , Reinhard Schulz a , Maria Tomka-Hoffmeister a , Friedrich G. Woermann a , Alois Ebner a , Christian G. Bien a , Christian Brandt a, ⁎ a Bethel Epilepsy Centre, Mara Hospital, Bielefeld, Germany b Department of Psychology, University of Bielefeld, Germany abstract article info Article history: Received 12 December 2011 Revised 17 January 2012 Accepted 21 January 2012 Available online 27 February 2012 Keywords: Autoscopy Heautoscopy Out-of-body experience Lateralizing sign Epilepsy Near death experience Positive autoscopic phenomena – autoscopy, heautoscopy and out-of-body experience – may occur in a va- riety of diseases and also in physiological conditions. They are a rare but probably underreported phenome- non in focal epilepsies. Here, we investigate whether ictal lateralized autoscopic phenomena give lateralizing information about the underlying epileptic focus. We present the cases of seven patients from our center who experienced ictal lateralized autoscopic phenomena and analyzed their focus lateralization and localization of the underlying brain lesion. In addition, we reviewed seven cases published in German and English language literature. In the total group of 14 patients with ictal lateralized autoscopic phenomena, 12 (85.7%) of them had a well-defined epileptic focus contralateral to the side of the autoscopic appearance. Therefore, the data point to an association between ictal lateralized autoscopy and contralateral epileptic focus. © 2012 Elsevier Inc. All rights reserved. 1. Introduction Autoscopic phenomena can be subdivided into six different sub- types: feeling of a presence, negative heautoscopy, inner heautoscopy [1], autoscopy, heautoscopy, and out-of-body experience [2–4]. Feel- ing of a presence describes the perception of another individual's presence, which cannot be seen by the affected person. Negative heautoscopy is described by Anzelotti et al. as a disturbed visual perception of one's own body, e.g., a patient not being able to per- ceive his own mirror image [1]. In contrast to negative heautoscopy, inner heautoscopy describes the visual perception of one's own inter- nal organs — for example, visualizing one's own heartbeat [1]. Posi- tive autoscopic phenomena such as autoscopy, heautoscopy and out-of-body experience denote a visual misperception of one's own body as the main feature. The autoscopic phenomenon is composed of an intracorporeal perspective, an autoscopic hallucination and no disembodiment (e.g., one's own mirror image). In contrast, subjects having an out-of-body experience take up an extracorporeal perspec- tive, feel disembodied and experience an autoscopic illusion or expe- rience their own physical body from an extracorporeal perspective. Heautoscopy is located somewhere between autoscopy and out-of- body experience. The main feature of this autoscopic phenomenon describes the alternation of perceiving the own body image in extra- corporeal space from the inner-body perspective and perceiving the own physical body from the perspective of the extracorporeal double. Therefore, the extent of disembodiment differs between both condi- tions, and people going through heautoscopy experience both the autoscopic hallucination of one's own double and an autoscopic illu- sion, in terms of seeing oneself from an extracorporeal perspective [2–4]. This heautoscopic condition may be excruciating. Therefore, suicide as a consequence is described by Francesca et al. and Brugger et al. in order to end this rotating perspective and to unite with the own body again [1,5]. In general, autoscopic phenomena occur most commonly in near death experience [6]. Fifty percent of those who survived a near death crisis experienced autoscopic phenomena dur- ing their close brush with death [6]. On the other hand, patients with epilepsy having ictal autoscopic phenomena may associate these with near death crisis and therefore, often experience the fear of dying during their autoscopic seizures [7]. Beyond near death experience, single autoscopic events can also be found in the healthy population with a prevalence of 10% [2,8]. In healthy subjects, fear, fatigue [6,9] and self-dissatisfaction with their own body seem to be predisposing for non-ictal autoscopic phe- nomena [10]. Furthermore, they may also occur in dreams [6] and during deep grief [11]. Recently, some authors describe autoscopic phenomena occurring during pseudohallucinations in the anopic part of the visual field. Here, retinal non-epileptic release phenomena are discussed as causative [12]. Autoscopic phenomena can also be found in different internal, psychiatric and neurological disorders [13–15], e.g., migraine, meningitis, encephalitis, stroke, traumatic brain injury, cerebral neoplasm [4,18] and neurodegenerative disor- ders [19]. However, Denning et al. found in a group of autoscopic Epilepsy & Behavior 23 (2012) 360–363 ⁎ Corresponding author at: Bethel Epilepsy Centre, Mara Hospital, Maraweg 17-21, 33617 Bielefeld, Germany. Fax: + 49 521 772 78809. E-mail address: christian.brandt@mara.de (C. Brandt). 1525-5050/$ – see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.yebeh.2012.01.010 Contents lists available at SciVerse ScienceDirect Epilepsy & Behavior journal homepage: www.elsevier.com/locate/yebeh