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Sensory alien hand syndrome
  1. R PERSAUD
  1. The Maudsley Hospital, Croydon Mental Health Services, Westways Rehabilitation Unit, 49 St James’s Road, West Croydon, Surrey CR9 2RR, UK. Telephone 0044 181 700 8512; fax 0044 181 700 8504; emailrajendra{at}btinternet.com
    1. HAKAN AY,
    2. FERDINANDO S BUONANNO,
    3. DEAN A LE,
    4. WALTER J KOROSHETZ
    1. Department of Neurology, Stroke Service, Massachusetts General Hospital, Harvard Medical School, 32 Fruit Street, Boston MA 02114, USA
    2. Department of Neurology, McLean Hospital, 115 Mill Street, Belmont MA 02178–9106, USA
      1. BRUCE H PRICE
      1. Department of Neurology, Stroke Service, Massachusetts General Hospital, Harvard Medical School, 32 Fruit Street, Boston MA 02114, USA
      2. Department of Neurology, McLean Hospital, 115 Mill Street, Belmont MA 02178–9106, USA

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        The case report by Ay et al 1 of alien hand syndrome and review of the literature neglected the intriguing issue of why in every case so far reported the patient seems to be terrified of the alien limb. Not believing that you are any more in control of a limb is not likely to be a pleasant experience.

        Those with alien hand syndrome seem to jump to extremely negative conclusions concerning the intent of the limb. Typically, as in the report of Ay et al, the common belief is that the limb has deeply malevolent intentions towards the victim.

        It is this aspect of alien hand syndrome that I suggest also needs incorporating into its neurological explanations, and which provides a clue as to why our everyday experience of being in charge of our bodies, and so initiating all personal action, itself has a neurological basis. In other words, while the brain is the seat of all our actions and experiences, there is also a part of our nervous system which is responsible for our belief that we have free will over our behaviour. Patients with alien hand syndrome think that they are no longer in control of a limb because the part of the brain that gives us the sensation of control over our bodies has been damaged. When that happens, our limbs seem to act independently of us.

        Research2 conducted in the 1980s has found that the same electrical brain wave changes that characteristically precede all limb movements, occur several 100 ms before we seem to consciously decide to move a limb. If our conscious decision to act is preceded by brain changes that anticipate action, then our “decision” to choose how to behave or “freedom”, as in free will, is in fact illusory. Our choices have in a sense been decided beforehand by our brains.

        Spence3 asserts that evidence such as this, combined with phenomena such as alien hand syndrome, means that philosophers have to reconsider whether we have free will. He argues that these data suggest that our sense of agency is illusory and it follows that most of us share in common the useful delusion that we have free will. Patients with alien hand syndrome have lost this experience in relation to a particular limb. There is a sense then that those who experience the syndrome are closer to the reality of how much we are responsible for our actions than the rest of us. This is because they have lost the function of the part of the brain that normally works to make us think that we have conscious freedom of will. They develop the experience, therefore, of becoming mere remote spectators to the actions of their bodies.

        Defenders of human “free will” argue what happens before the brain itself decides to act is still unknown, and there may be a role for our own autonomy there. But even these free will guardians concede the neurological research indicates that whatever happens before the brain is roused, must occur below our conscious awareness.

        Yet in alien hand syndrome the patient thinks that the hand has hostile motivations; it is invariably the case that the patient not only thinks that the limb is “not self” but finds that the limb behaves towards the self in a destructive and aggressive manner. This could be explained by the suggestion that if we lose our conscious sense of voluntary control over our bodies, our minds have to come up with an explanation for the location of action of our movements. We decide that if ourselves are not in control, then someone or something else must be; therefore, we no longer have a sense of the limb belonging to us.

        Because to lose control over our bodies is one of the most terrifying experiences, our attempt to explain this finding occurs in the context of fear. It may be that our apprehension leads us to misinterpret innocent reflexive acts of our hands, such as scratching or rubbing, as malevolently inspired. Plus it could be that our interpretation of spiteful possession in turn inspires the hand itself, only this is beyond our conscious awareness.

        It may therefore be that we need to believe in our own free will and personal control over our acts, because if we did not, we might find the experience of our bodies acting as if we merely came along for the ride, too frightening. Also, we may no longer believe that our bodies or its relevant parts belong to us. All neurologists who have reported alien hand syndrome remark on how psychologically disturbing the symptom is for the patient. Psychiatrists would be interested in the parallels between alien hand syndrome and the “passivity phenomena” of schizophrenia, plus the fact that the two diseases may share corpus callosum pathology,4 could go some way to explaining why schizophrenic symptoms are frightening to the patient. So it seems we know that our limbs belong to us because they obey us. When they seem to stop responding to our wills, we conclude that our limbs are no longer our own, and try to fend them off. Hence it would seem that one of the prices we had to pay for conscious awareness of ourselves to evolve as a function of the brain, is the delusion that we are responsible for all our actions. If we had conscious awareness of ourselves, but no sense of free will, our bodies would feel alien to us. The philosophical importance of alien hand syndrome is that it shows emphatically via neurology that it is possible to drive a wedge between consciousness and the experience of free will. The brain had to develop the sensation of free will after developing consciousness, because being without the sensation of free will produces extremely negative emotional experiences. So the fact that every case so far reported of alien hand syndrome imputes negative intent to the alien limb might not be an incidental finding, but a core aspect of the disorder.

        References

        The authors reply:

        We appreciate Persaud’s comments regarding the alien hand syndrome, “the perceived malevolence of the affected limb towards its victim, and the question of whether with loss of the conscious sense of voluntary control over our bodies, our minds... decide that if ourselves are not in control then someone or something else must be”. We would offer that the value of our particular case is that it was due to a central deafferentation—therefore the term “sensory alien hand syndrome”. As opposed to the idea that “we know our limbs belong to us because they obey us”, we know that our limbs belong to us because they provide us with sensory input that is recognised as self. Many patients with movement disorders or paralysis lose control of their limbs but still have no difficulty in realising them as self. Indeed even in “phantom limb” there is sense of self due to central processes in the absence of a limb. Our patient, as do others with anosognosia and primary abnormalities of central sensory systems, shows perhaps that it is central sensory processes that are the key to identifying “self”. We know our limbs not because they obey us but because there is a pattern of sensory activation that accompanies our own limb movements. When this pattern never reaches specific cortical regions, then the limb is not perceived as self; called “amorphosynthesis” by Denny-Brown and Banker.1-1 Self stimulation by the centrally deafferented limb in “sensory” or “posterior” alien hand syndrome, or kinaesthetic stimuli due to movement of the limb as in the “anterior” or “motor” alien hand syndrome, is perceived as due to another person or thing without critical questioning. This raises the most interesting question of what brain region is deafferented in the anterior alien hand syndrome where the sensory processing is intact.

        It is not our clinical experience nor the conclusions based on published reports that all patients suffering with alien hand syndrome are terrified by the effected limb. In one author’s experience (BHP), two patients with alien hand syndrome and related intermanual conflict were irritated by but not terrified by their opposing limbs simultaneously vying for a cigarette or book. Another patient was amused but rather indifferent to his affected left side. The most terrifying situation we have heard is when the patient identified his affected left side as belonging to his mother in law! A patient reported by Heilman’s group1-2 with persistent alien hand syndrome referred to it as “my little sister”. Similar to our experience, they suggest that a predisposing personality type may be necessary given that most patients with collosal infarcts or tumours do not emphasise this complaint.

        Unlike our case of limited duration, the persistence of alien hand syndrome seems dependent on mesial frontal dysfunction. These patients rarely deny that the affected limb belongs to them. Instead, they understand it in terms of their “anarchic hand”. Hence, although the initial syndrome may result in disjointed and terrifying perceptions, it seems that the brain quickly re-establishes its control by presently unknown adaptive capacities. Furthermore, why it almost exclusively involves the left body side in right handed people remains unknown. Studying this syndrome in greater detail may yield additional insights into the pathophysiology of denial and misidentification.

        References

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