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Palm minimization: An unusual case of Alien Hand Syndrome

In a previous blog I briefly overviewed Alien Hand Syndrome. Since writing that blog I came across an interesting case of alien hand syndrome published in a 2000 issue of the American Journal of Physical Medicine and Rehabilitation by Dr. B. Hai and Dr. I. Odderson. They reported an unusual case in which their patient had a right hemispheric stroke and subsequently experienced what the authors described as embarrassing manifestations of Alien Hand Syndrome in the form of involuntary masturbation. The case involved a 73-year old man who was brought into a hospital emergency ward by his wife because of a sudden loss of movement in the left-hand side of his body (including a slight droop on the left-hand side of his face), slurred speech and poor balance. Furthermore, he could stand if helped but was unable to walk unaided. The man had obviously had a stroke but four days later he started to experience involuntary movements of his left arm and claimed his left hand “has a mind of his own”. The paper reported that:

“He developed a tonic grasp reflex with inability to release. He also had a tendency to reach and grasp onto objects with the left hand, such as the telephone cord or the remote control for the television, and was unable to release despite verbal commands. He would persistently grab his comb or fix the collar of his shirt. He also demonstrated difficulty performing bimanual activities, such as eating

Most worryingly, the man’s wife expressed extreme concern when her husband’s left hand would expose his genitals and start to masturbate in public. The involuntary masturbation happened on numerous occasions when talking with the nurses and doctors in the hospital, and only ever occurred with his left hand (even though the man was right-handed). The man denied that he had any history of “excessive self-stimulation, sexual dysfunction, or exhibitionism. While in hospital, the man was dismayed and frustrated that he was unable to stop his left hand stimulating his genitals in front of other people. The authors reported that:

“A clinical impression of [Alien Hand Syndrome] was made, and magnetic resonance imaging of the brain showed an acute infarct [dead tissue] in the medial right frontal lobe [of his brain] in the anterior cerebral artery distribution involving the right anterior cingulate gyrus and the corpus callosum. After [three weeks] of acute inpatient rehabilitation, the patient was able to walk with a standard walker and negotiate stairs with rails with contact guard assist. He also began to use his left hand for bimanual activities. He was subsequently discharged to home with his family”.

After a month of treatment, the man was able to walk again unassisted but his left hand was still not under his own control (and telling the medical staff that his hand “still has a mind of his own and won’t turn things loose”). However, the good news was that the involuntary masturbation in public subsided and eventually ceased. The authors of the paper claim this is a very rare case because their patient displayed “an unusual and disturbing manifestation of uncontrolled involuntary genital fondling with the nondominant, apraxic hand and with mirroring hand movements during eating”. The authors also noted that the involuntary movements of the man’s left hand never occurred while they were carrying out medical tests and suggested that their findings indicate “the possibility of the presence of a dexterous ‘alien’ mode of control that can be distinguished from a more clumsy and slow ‘voluntary’ mode of control”. Although there is no known treatment for AHS, as I noted in my previous blog on the topic, the symptoms can be minimized and managed to some extent by keeping the affected hand occupied and involved in a task (e.g., by giving it an object to hold in its grasp). This would seem to explain why the man never masturbated while undergoing medical tests (i.e., his hands were being occupied). The authors also noted that:

“So far, at least two types of [Alien Hand Syndrome] have been described. The callosal type, as seen in our patient (lesion involving the corpus callosum with or without frontal damage), is characterized by frequent intermanual conflict and apraxia of the affected limb. The frontal type (lesion involving the left mediofrontal and callosal) is associated with dominant hand grasp reflex, compulsive movements (such as groping), restraining actions, and compulsive manipulation of tool [Feinberg, Schindler & Flanagan, 1992]”.

As I noted in my previous blog on AHS, research indicates that AHS sufferers often personify the alien hand and may believe the hand is ‘possessed’ by some other spirit or alien life form. Their hands may even appear to act in opposition to each other (such as when AHS sufferers who are also cigarette smokers put a cigarette in their mouth to set it alight, only for the alien hand to pull it out and throw the cigarette away). Such behaviour is an example of ‘intermanual conflict’ and has been given the name ‘diagnostic ideomotor apraxia’.

A number of published papers have reported that involuntary masturbation can be associated with other conditions. For instance, it has been associated with temporal lobe epilepsy. Dr. M. Cherian reported the case of excessive masturbation in a young girl in a 1997 issue of the European Journal of Pediatrics. However, until the publication of this case of AHS, it had not ever been associated with having a stroke. Dr. Hai and Dr. Odderson conclude:

Although [Alien Hand Syndrome] is a rare phenomenon, this condition should be considered in patients who present with a feeling of alienation of one or both upper limbs accompanied by complex purposeful involuntary movement. It must be differentiated from limb neglect and anosognosia, which present with dissociation from the limb as perceived object (i.e., where the limb is not perceived as a part of the “self”), but without involuntary movement and without dissociation from control over purposeful complex action of the affected limb (i.e., where the actions of the limb are perceived as self-generated). Further studies are required to elucidate a definite anatomical explanation that can lead to accurate diagnosis, specific treatment, and rehabilitation of these patients”

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK 

Further reading

Biran, I. & Chatterjee, A. (2004). Alien Hand Syndrome. Archives of Neurology, 61, 292-294.

Cherian, M.P. (1997). Excessive masturbation in a young girl: A rare presentation of temporal lobe epilepsy. European Journal of Pediatrics, 156, 249.

Doody, R.S. & Jankovic, J. (1992). The alien hand and related signs. Journal of Neurology, Neurosurgery and Psychiatry, 55, 806-810.

Feinberg, T.E., Schindler, R.J. & Flanagan, N.G. (1992). Two alien hand syndromes. Neurology, 42, 19-24.

Hai, B.G.O., & Odderson, I.R. (2000). Involuntary masturbation as a manifestation of stroke-related alien hand syndrome. American Journal of Physical Medicine & Rehabilitation, 79, 395-398.

Jacome, D.E. & Risko, M.S. (1983). Absence status manifested by compulsive masturbation. Archives of Neurology, 40, 523-524.

Scepkowski, L.A. & Cronin-Golomb, A. (2003). The alien hand: Cases, categorizations, and anatomical correlates. Behavioral and Cognitive Neuroscience Reviews, 2, 261-277.

A pining for dining: A brief overview of Gourmand Syndrome

In 2005, an article in the May 8th issue of the New York Times magazine reported the case of an unnamed European political journalist who had a stroke that caused some damage to the right frontal lobe in his brain. The journalist made a full recovery but experienced an unexpected side effect – he developed an unusual passion for gourmet food (that he didn’t have prior to his stroke).  He capitalized on his strange new behaviour and became a food columnist. Similarly, a 2011 article in the Huffington Post reported the story of Kevin Pearce, a snowboarder who sustained right hemispheric brain damage following an accident that nearly killed him. Waking up from a coma he developed a craving for basil pesto (something that he never did prior to his accident). Both of these cases are examples of a rare disorder that has been named Gourmand Syndrome, a strange behaviour first written about (clinically and academically) in the mid-1990s. Gourmand Syndrome basically comprises individuals becoming totally preoccupied and obsessed with food and ‘fine dining’.

This rare (and benign) condition only seems to occur in people who have sustained brain injuries involving the right frontal lobe and was first described (and named) by neuropsychologist Dr. Marianne Regard and neurologist Dr. Theodor Landis in a 1997 issue of the journal Neurology (one of only two empirical papers on the topic). The authors noted that hyper-orality is part of other conditions such as the Kluver-Bucy syndrome that occurs in patients with bilateral mesial temporal lesions (and which I examined in a previous blog).

Regard and Landid described the cases of two individuals who both had partial damage to the right anterior cerebral hemisphere of the brain. The first case was the political journalist briefly mentioned at the start of this article. He became totally preoccupied with gourmet food and continued after he had been discharged from hospital. The second case that Regard and Landis wrote about was a businessman who (following a stroke) also developed a passion for gourmet food. However, his preoccupation with gourmet food was part of a wider disturbance of impulse control as he also made repeated sexual advances towards the female nursing staff at the hospital he was in. (Interestingly, a later 2003 study by Regard and Landis on 21 pathological gamblers – and published in the journal Cognitive and Behavioral Neuropsychology – reported that 38% of them [n=8] were reported to have Gourmand Syndrome, again suggesting that these impulsive behaviours are highly inter-linked).

Having named this type of behaviour as Gourmand Sydrome, Regard and Landis then conducted a prospective study examining the frequency and the clinical and anatomical correlates of the syndrome. Over a three-year period, and using a self-constructed checklist, they carried out 723 neuropsychological examinations of patients with known (or strongly suspected) cerebral lesions. The specific criteria for Gourmand syndrome were: (i) the presence of a significant change in a person’s eating habits (i.e. preoccupation with the preparation and eating of fine-quality food), (ii) the onset of which was associated with a single cerebral lesion in the absence of other medical or social conditions, and (iii) previous eating disorders; or other neurological or psychiatric illness. A total of 36 people fulfilled the criteria for Gourmand Syndrome (5%).

Of those identified fulfilling the three criteria, 94% of them (n=34) appeared to have right hemisphere damage in the brain (in particular, the right anterior part of the brain involving basal ganglia, cortical areas, and limbic structures). Most of the individuals’ symptoms were caused by tumours (although there were other causes including focal seizures, head trauma [with focal concussion], haemorrhage, and cerebrovascular accidents). The authors concluded that:

“Most patients with the ‘gourmand syndrome’ had clinical and anatomical evidence of a unilateral right-sided lesion, mainly involving anterior cortico-limbicregions. The strong clinical-anatomical correlation suggests that gourmand eating can represent a neurological sign of diagnostic value. The eating behavior does not correspond to any known category of eating disorders. At most, it could be classified as a benign, non-disabling form of hyperphagia, but with a specific preference for fine food”

A later case study of Gourmand Syndrome by Dr. Mary Kurian and her Swiss colleagues was published in the journal Epilepsy and Behavior. They reported the case of a 10-year-old boy with epilepsy (and who had hemispheric brain damage (i.e., “right temporoparietal hemorrhagic lesion”). As with previous adult cases, he developed Gourmand Syndrome and experienced a significant change in his eating habits, or as the authors put it, an “abnormal preoccupation with the preparation and eating of fine-quality food…without any previous history of eating disorders or psychiatric illness”. More specifically, the boy’s parent’s noticed that he began to avoid eating at fast-food restaurants and would only eat or cook the finest foods. The authors argued that their case study confirmed previous observations relating to the importance of the right cerebral hemisphere in disturbed eating habits, not just in Gourmand Syndrome but eating disorders such as anorexia and obesity.

Both of the published empirical papers noted that Gourmand Syndrome includes an obsessive component along with other behavioural consequences typically associated with addiction (e.g., cravings, preoccupation, salience, etc.). They also notes that one-third of the 36 patients identified in their prospective study had symptoms of mania (e.g., aggression, diminished impulse control, disinhibition, affective lability). In recent a review of Gourmand Syndrome by trainee psychiatrist Alexandros Chatziagorakis in the Neuropsychiatry News concluded that:

“Owing to the rarity of further articles and reports of Gourmand syndrome, its diagnostic significance is yet to be proven. It would be worth using Regard [and] Landis checklist during neuropsychological assessment of neurological patients to establish its frequency and its clinical and anatomical correlates. At the same time, it would be worth performing a psychiatric assessment to determine whether Gourmand syndrome presents in the context of an already defined psychiatric syndrome such as mania. This will tell us whether Gourmand syndrome has indeed a diagnostic value as a neurological or even neuropsychiatric sign”.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Chatziagorakis, A. (2012). Gourmand Syndrome. Neuropsychiatry News, 5 (Spring), 23-24.

Holt, T. (2005). Of two minds. New York Times (Magazine), May 8. Located at: http://www.communicationcache.com/uploads/1/0/8/8/10887248/the_way_we_live_now_-_of_two_minds.pdf

Huffington Post (2011). The Gourmand Syndrome: Brain Damage Can Trigger Food Obsession, Huffington Post, October 9. Located at: http://www.huffingtonpost.com/2011/07/11/the-gourmand-syndrome-food-obsession_n_894629.html

Kurian, M., Schmitt-Mechelke, T., Korff, C., Delavelle, J., Landis, T. & Seeck, M. (2008). “Gourmand syndrome” in a child with pharmacoresistant epilepsy. Epilepsy and Behavior, 13, 413-415.

Regard, M., Knoch, D., Gütling, E. & Landis, T (2003). Brain damage and addictive behavior: A neuropsychological and electroencephalogram investigation with pathologic gamblers. Cognitive and Behavioral Psychology, 16, 47-53.

Regard, M. & Landis, T (1997). ‘Gourmand syndrome’: Eating passion associated with right anterior lesions. Neurology, 48, 1185-1190.

Uher, R. & Treasure, J. (2005). Brain lesions and eating disorders. Journal of Neurology, Neurosurgery and Psychiatry, 76, 852–7.

Palm offensive: A beginner’s guide to alien hand syndrome

Some of you reading this blog may have seen Stanley Kubrick’s 1964 film Dr. Strangelove in which he titular character played by Peter Sellers suffers from alien hand syndrome (AHS), and where his hand clutches his own throat and (at other times) carries out a Nazi salute. Far from being fictional, AHS is one of the strangest neurological disorders and is where an individual’s hand appears to have a mind of its own and acts autonomously (and where the person feels as though their hand doesn’t belong to them and may be seen as ‘disobedient’ – even though they can feel a normal sensation in the ‘alien’ hand). In a 2004 literature review of AHS by Dr. I. Biran and Dr. A. Chatterjee in the Archives of Neurology, the authors note that:

“This syndrome is characterized by a limb that seems to perform meaningful acts without being guided by the intention of the patient. Patients find themselves unable to stop the alien limb from reaching and grabbing objects, and they may be unable to release these grasped objects without using their other hand to pry open their fingers. These patients frequently express astonishment and frustration at the errant limb. They experience it as being controlled by an external agent and often refer to it in the third person”.

AHS was first identified in 1908 by German Dr. K. Goldstein, but was not clearly defined until 1972 by French neurologists Dr. S. Brion and Dr. C.P. Jedynak. However, according to a 2000 editorial in the Journal of Neurology, Neurosurgery and Psychiatry by Dr. Gary Goldberg, the term ‘alien hand syndrome’ was coined by Joseph Bogen to describe a curious wayward behaviour occasionally seen during recovery from certain types of brain surgery. Dr. Goldberg writes that “such patients would react with surprise, concern, and perplexity at the capacity of their non-dominant hand to perform purposeful acts over which they felt no control”.

Cases of AHS have been reported among patients who have had the left and right brain hemispheres separated through surgery (as has been the case in very severe cases of epilepsy where the corpus callosum that connects the two hemispheres is cut). AHS may also occur due to other types of brain surgery as well as some types of infections and strokes. According to an online article on AHS by Charles Bryant, there have only been around “four dozen reported cases” of alien hand syndrome (confirmed by a more scientific paper in the journal Behavioral and Cognitive Neuroscience Reviews, by Dr. Lisa Scepkowski and Dr. Alice Cronin-Golomb who said there are “no more than 50 published cases”).

AHS sufferers typically display sensory deficits as a consequence of dissociating themselves from the actions of their hand. The Wikipedia entry on AHS notes that:

“Alien behaviour [in the hand] can be distinguished from reflexive behaviour in that the former is flexibly purposive while the latter is obligatory. Sometimes the sufferer will not be aware of what the alien hand is doing until it is brought to his or her attention, or until the hand does something that draws their attention to its behaviour”

A 1992 paper by Dr. R.S. Doody and Dr. J. Jankovic on “the alien hand and related signs” in the Journal of Neurology, Neurosurgery and Psychiatry said there were four classic hallmarks of AHS. These were: (i) a feeling of foreignness of the limb, (ii) failure to recognize ownership of it when visual clues are removed, (iii) autonomous motor activities that are perceived as involuntary and are different from other identifiable movement disorders, and (iv) personification of the affected body part.

Research does indeed indicate that AHS sufferers often personify the alien hand and may believe the hand is ‘possessed’ by some other spirit or alien life form. Their hands may even appear to act in opposition to each other (such as when AHS sufferers who are also cigarette smokers put a cigarette in their mouth to set it alight, only for the alien hand to pull it out and throw the cigarette away). Such behaviour is an example of ‘intermanual conflict’ and has been given the name ‘diagnostic ideomotor apraxia’. This type of AHS behaviour is typically caused by damage to the corpus callosum where an injury to a right-handed person would typically give rise to purposeful movements of the left hand.

However, other variants of AHS exist including those who have suffered frontal lobe brain damage (that tend to trigger purposive reaching and grasping movements), and those who have suffered parietal and occipital lobe damage (that tend to trigger hand withdrawal and/or levitation movements away from tactile stimuli). It has also been reported that more complex hand movements (e.g., unbuttoning clothes) are more associated with strokes, brain tumours, and aneurysms. The Wikipedia entry on AHS claims that the common emerging factor in AHS is that “the primary motor cortex controlling hand movement is isolated from premotor cortex influences but remains generally intact in its ability to execute movements of the hand”. Having said that, Dr. Scepkowski and Dr. Cronin-Golomb in their Behavioral and Cognitive Neuroscience Reviews paper assert that:

“The lack of uniformity in reported assessment methods (behavioural tests, neuroimaging) in published cases contributes to the difficulty in establishing clear subtypes of alien-hand phenomena”

Unfortunately, there is no known treatment for AHS although the symptoms can be minimized and managed to some extent by keeping the affected hand occupied and involved in a task (e.g., by giving it an object to hold in its grasp). Some research on case studies note that particular learned tasks can in some cases restore voluntary control to the alien hand. Charles Bryant’s online article on AHS concludes that “regardless of how few cases of alien hand syndrome exist, or how little we know about its cause, the mystery and intrigue of the condition will no doubt continue to inspire writers and filmmakers to explore its horrific and comedic potential”. For the same reasons, I hope it inspires further empirical research.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Biran, I. & Chatterjee, A. (2004).Alien Hand Syndrome. Archives of Neurology, 61, 292-294.

Brion, S. & Jedynak, C.P. (1972). Troubles du transfert interhemisphérique (callosal disconnection). A propos de trois observations de tumeurs du corps calleux. Le signe de la main étrangère. Revue Neurol, 126, 257- 266.

Bundick, T. & Spinella, M. (2000). Subjective experience, involuntary movement, and posterior alien hand syndrome. Journal of Neurology, Neurosurgery and Psychiatry, 68, 83-85.

Carrilho, P.E.M., Caramelli, P. Cardoso, F. Barbosa, E.R., Buchpiguel, C. & Nitrini, R. (2001). Involuntary hand levitation associated with parietal damage. Another alien hand syndrome. Arquivos Neuro-Psiquiatria, 59 (3-A), 521-525.

Doody, R.S. & Jankovic, J. (1992). The alien hand and related signs. Journal of Neurology, Neurosurgery and Psychiatry, 55, 806-810.

Goldberg, G. (2000). When aliens invade: multiple mechanisms for dissociation between will and action. Journal of Neurology, Neurosurgery and Psychiatry, 68, 7.

Goldberg, G. & Bloom, K.K. (1990). The alien hand sign. Localization, lateralization and recovery. American Journal of Physical and Medical Rehabilitation, 69, 228-238.

Goldstein, K. (1908). Zur lebre der motorischen apraxia. Z Physiol Neurol, 11, 169-187.

Heilman KM, Valenstein E Bogen JE (1993) The callosal syndromes. in Clinical neuropsychology. eds Heilman KM, Valenstein E (Oxford University Press, New York), 3rd ed. pp 337–407.

Scepkowski, L.A. & Cronin-Golomb, A. (2003). The alien hand: Cases, categorizations, and anatomical correlates. Behavioral and Cognitive Neuroscience Reviews, 2, 261-277.

Wikipedia (2012). Alien hand syndrome. Located at: http://en.wikipedia.org/wiki/Alien_hand_syndrome