strange face in the mirror illusion

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Research Article Visual Perception during Mirror-Gazing at One’s Own Face inPatients with Depression

Giovanni B. Caputo,1 Marco Bortolomasi,2 Roberta Ferrucci,3 Mario Giacopuzzi,2

Alberto Priori,3 and Stefano Zago3

DIPSUM, Universit ̀a di Urbino, Via Saffi , Urbino, Italy Unit ̀a Operativa di Psichiatria “Villa Santa Chiara”, Via Monte Recamao , Quinto di Valpantena, Verona, Italy

Fondazione IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, Dipartimento di Scienze Neurologiche,Universit ̀a degli Studi di Milano, Via F. Sorza , Milano, Italy

Correspondence should be addressed to Giovanni B. Caputo; [email protected]

Received July ; Revised November ; Accepted November ; Published November

Academic Editor: Pietro Pietrini

Copyright © Giovanni B. Caputo et al. Tis is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

In normal observers, gazing at one’s own ace in the mirror or a ew minutes, at a low illumination level, produces the apparition o strange aces. Observers see distortions o their own aces, but they ofen see hallucinations like monsters, archetypical aces, aceso relatives and deceased, and animals. In this research, patients with depression were compared to healthy controls with respectto strange-ace apparitions. Te experiment was a -minute mirror-gazing test (MG) under low illumination. When the MGended, the experimenter assessed patients and controls with a specically designed questionnaire and interviewed them, askingthem to describe strange-ace apparitions. Apparitions o strange aces in the mirror were very reduced in depression patientscompared to healthy controls. Depression patients compared to healthy controls showed shorter duration o apparitions; minornumber o strange aces; lower sel-evaluationrating o apparition strength; lower sel-evaluation rating o provoked emotion. Tesedecreases in depression may be produced by decits o acial expression and acial recognition o emotions, which are involved inthe relationship between the patient (or the patient’s ego) and his ace image (or the patient’s bodily sel) that is reected in themirror.

1. Introduction

Strange-ace in the mirror illusions [–] are apparitional

experiences that are produced by gazing at one’s own acereected in a mirror, under low illumination. In a study set-up, under controlled laboratory conditions, healthy young adults, afer about one minute o mirror-gazing,began to perceive strange-ace apparitions []. Tese includedhuge deormations o one’s own ace (reported by % o individuals), a monstrous ace (%), an unknown person(%), an archetypal ace (%), a ace o a parent or relative(%), and an animal ace (%).

Recently, Caputo et al. [] showed that some schizo-phrenic patients perceived much more intense strange-aceapparitions than healthy individuals. In this paper, the scopeo the study was to investigate strange-ace illusions in

patients with depression. Depressive subtypes are positionedto differ unctionally by differential contributions by sero-toninergic, noradrenergic, and dopaminergic neurotransmit-

ter circuits []. Te altered cognitive and affective processingin depression has been associated with disruption o ron-totemporal and rontosubcortical networks []. Depressionis characterized by maladaptive bottom-up processes that aregenerally perpetuated by attenuated cognitive control [, ].Tereore, the main hypothesis o the present study wasthat strange-ace apparitions, in response to mirror-gazing,should be different in requency and intensity in depressedpatients with respect to healthy controls.

Human aces convey important messages, such as iden-tity, age, sex, eye gaze, and emotional expression, whichare relevant to social communication and interpersonalinteraction. In ace-to-ace interactions between the subject

Hindawi Publishing Corporatione Scientific World JournalVolume 2014, Article ID 946851, 4 pageshttp://dx.doi.org/10.1155/2014/946851

http://dx.doi.org/10.1155/2014/946851http://dx.doi.org/10.1155/2014/946851


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Te Scientic World Journal

and the other, acial expressions by the other and acialrecognition o the other’s expressions by the subject arereciprocally intertwined through mimicry and subject-othersynchronization [].

Mirror-gazing at one’s own ace is similar to an inter-personal encounter by the subject (or the subject’s ego) with

itsel (which is the subject’s bodily ace that is reected inthe mirror), as i the subject were an other [, ]. In thecase o mirror-gazing, the subject’s acial expressions arereected in the mirror and then perceived and recognized by the subject itsel. Tis dynamic sel-reection can produce,within the subject, recognition-expression or perception-action loops. Hence, mirror-gazing can involve, within thesubject, processes o mimicry, synchronization, emotionalconnectedness, and so orth, that are all implicated duringace-to-ace interactions.

In relationship to aces, patients with depression show decits both in acial recognition o emotions and in acialexpression o emotions [–]. Emotional-processing biasesoccur to sad aces presented below the level o consciousawareness in depression [, ]. Depression patients show decits in both voluntary and involuntary acial expressiono emotions []. By inuencing the salience o social stimuli,mood-congruent processing biases may contribute to dys-unction in conscious recognitions, expressions, and socialinteractions in depression [].

Tereore, a specic hypothesis, which is based on decitso acial recognition and acial expression o emotions indepression, is thatstrange-ace apparitions should be strongly reduced in patients with depression compared to healthy controls.

From the clinical viewpoint, it may be noted that nostudy has previously investigated mirror-gazing in depressedpatients. Tereore, a simple, standardized test to trigger areproducible pattern o strange-ace apparitions could helpin completing the standard psychopathological assessment o patients with depression.

2. Materials and Methods

Te study was approved by the hospital ethical committee.Te experiment was conducted in accordance with the Dec-laration o Helsinki (). All participants provided writteninormed consent beore entry to the study.

.. Participants. Our clinical sample consisted o thirteenhospitalized patients in “Villa Santa Chiara” Clinic in Verona,Italy. Tey were men and women (mean age . years;SD .) with depression. Clinicians who have many years o practice with psychiatric patients did their diagnoses accord-ing to DSM-IV-R criteria (American Medical Association,). Controls were individuals recruited rom hospitalworkers. Tey were men and women (mean age .years; SD .) who declared no history o neurological orpsychiatric impairment. Depressed and control individualswere volunteers; they were naı̈ve to the research aim.

.. Procedure. In the experiment, participants were testedin random order. Te experimenter was blind about thecondition o the participant either a patient or a controlindividual.

.. Mirror-Gazing est (MG). MG was conducted in a

darkened room, 5 m × 5 m. Te walls o the room werepainted light gray. A mirror (0.5 m × 0.5 m) was mounted ona tripod and placed in the center o the room. Te subjectswere seated at a distance o . m in ront o the mirror.Te room was lit only by a halogen light bulb ( V, W).Te bulb was mounted on a spotlight placed . m behindthe subjects so that they could not see it. Te light bulbbeam was directed toward the oor (about a distance o cmrom bulb to oor), in order to avoid direct lighting. Tisindirect illumination provided diffuselighting over the whole

room. Te ace was lit relatively uniormlyat about . cd m−2

(digital photometer Pantec LM- by Carlo Gavazzi, Milano,Italy). All the ne acial eatures could be perceived in detail;

colors were attenuated.With the subject seated in ront o the mirror, the

experimenter explained the task: “Your task is look at your ace in the mirror. You should keep staring into your eyes. Tetask will last seven minutes.” During the MG, the subjects’perceptions were qualitatively and quantitatively assessed.Te number and latency o abnormal perceptions wereevaluated by recording event-related responses to appari-tional experiences. Every time subjects had an abnormalperception, they had to press a button and their responseswere recorded and digitally stored. Te experimenter toldparticipants how to use the button using the ollowing words:“During the seven minutes while you are looking at your ace

in the mirror and staring at your eyes you may or may not notice changes in your ace. I you notice a change then pressthe button and hold it down or as long as the change lasts. I

you do not notice any changes then do not press the button.”Subjects were then asked i they understood the task, and,afer the experimenter had urther claried and explainedunclear points, the task began. Te mirror-gazing sessionlasted seven minutes.

When the -minute MG ended, the experimenterassessed patients and controls with a specically designedquestionnaireand interviewed them asking them to describeabnormal perceptions. Te interview comprised the ollow-ing question: “What did you see? ” For both patients and

controls, the experimenter transcribed the answers.Lastly, afer the interview, the participants answered our

ve-point Likert-type scale sentences: “How ofen did younotice anything strange? ”, “How ofen did it inuence youemotionally? ”, “How ofen did it seem real? ”, and “How ofendid you see another person in the mirror? ”. Responses givenwere scored on a ve-point Likert-type scale, ranging rom“never” (= ), “rarely” (= ), to “very ofen” (= ). Teexperimenter transcribed patients’ and controls’ answers tothe questionnaire.

.. Statistical Analyses. Te two groups (patients versuscontrols) were matched or gender. Instead, the age o


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participants was not adequately matched between groups,which were different in mean age ( = 1.8; = 0.08). Tere-ore, possible effects o age differences between groups wereinvestigated by including age as covariate variable in statisti-cal analyses.

For event-related responses, the mean onset o the rst

apparition was dened as the rst timethe subject pressed thebutton. Te requency o event-related responses was denedas the number o times subjects pressed the response button,averaged per minute. Te mean duration was the meantime they held the response button down. Te cumulativeduration o apparitions was dened as the sum o durationso apparitions in MG, averaged per minute (the cumulativeduration equals the algebraic product o requency and meanduration).

Te phenomenological descriptions were classied orcontent into strange-ace categories []: deormed traits, rel-atives, unknown persons, archetypal aces, animal aces, andmonstrous aces. Te number o strange aces was calculatedor each subject by counting the number o different types o strange aces described.

Between-subjects ANOVAs were run with a two-levelactor (patients versus controls). Te effect o age differencesbetween patients and controls was analyzed by inserting ageas covariate variable in ANOVAs. All data are expressed asmeans ± SEM.

3. Results and Discussion

.. Event-Related Responses. Five out o patients (%)perceived strange-ace apparitions; out o healthy con-trols (%) perceived strange-ace apparitions.

Te mean onset o the rst apparition (patients ± s versus controls ± s) did not differ signicantly betweenpatients and controls. Te mean requency o event-relatedresponses (patients . ± . versus controls . ± .) didnot differ signicantly between groups. Te mean durationo apparitions (patients . ± . s versus controls . ± . s)was lower in patients than in controls ((1, 23) = 13.9; < 0.001). Age differences between groups had statistically nonsignicant effects.

Te trade-off between requency and duration o subject’sresponses was veried using the mean cumulative durationo apparitions per minute o MG that differed signicantly between groups ((1, 23) = 4.1; = 0.05). Te mean cumu-

lative duration o apparitions was shorter in patients thanin controls (patients . ± .smin−1 versus controls . ±.smin−1). Age differences between groups had statistically nonsignicant effects.

Results o event-related responses take on more impactwhen compared with data rom schizophrenic patients [],as shown in Figure (the three groups were actually studiedin the same sessions and all participants were tested in blinddesign).

.. Phenomenological (Qualitative) Descriptions. During the-minute MG, patients perceived a lower number o strangeaces than controls(patients. ± . versus controls . ± .)

0

2

4

6

8

10

12

14

Healthy

controls

Depression

patients

Schizophrenic

patients(Caputo et al., 2012)

F : Cumulative duration o apparitions per minute o MG[smin−1].

and this difference was statistically signicant ((1, 23) = 4.4;

= 0.047). Age differences between groups had statistically nonsignicant effects.

.. Likert-ype Scale Questionnaire. Te sentence “Howofen did you notice anything strange? ” was rated to be lowerin strength o apparitions by patients than controls (Likert-type scale score o patients . ± . versus controls . ± .).Te difference between groups was statistically signicant((1, 23) = 6.6; = 0.017). Age differences between groupshad a statistically signicant effect ((1, 23) = 6.2; = 0.02).

Te sentence “How ofen did it inuence youemotionally? ”was rated as lower by patients than controls (patients . ±

. versus controls . ± .). Te difference between groupswas statistically signicant ((1, 23) = 8.4; = 0.008). Agedifferences between groups had statistically nonsignicanteffects.

Te sentence “How ofen did it seem real? ” did not differbetween patients and controls (patients . ± . versuscontrols . ± .). Te sentence “How ofen did you seeanother person in the mirror? ” did not differ between patientsand controls (patients . ± . versus controls . ± .). Agedifferences between groups had statistically nonsignicanteffects.

4. Conclusions

Our study provides rst evidence showing that mirror-gazing, at a low illumination level, produces less requentstrange-ace apparitions in depressed patients than in healthy individuals. Moreover, apparitions were usually o lowerintensity and shorter duration in depressed patients than inhealthy controls. Te hypothesis o the present study is there-ore supported by the decreased requency and duration o event-related responses, decreased number o strange aces,and lower sel-evaluation ratings o apparition strength andemotions among the patients. Instead, the age o participantsdid not inuence strange-ace apparitions.


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Te experimental nding that depression patientsreported lower ratings o the emotional content o strange-ace apparitions than healthy controls can be explained by the general dampening o emotions in depression [, , ].

Te experimental nding that patients reported ewerand less requent strange-ace apparitions than controls can

be explained by decits in emotional acial recognition andemotional acial expression and by decit in interpersonalinteractions o patients with depression [–, ].

Our phenomenological observation o typical depressedpatients’ behaviour in ront o the mirror gives the compellingimpression that patients saw their own reected aces similarto inanimate materials. Tis behaviour in depression isopposite to intense strange-ace hallucinations that can beobserved in schizophrenia []. In act, depression patientsduring mirror-gazing can be described as completely immo-bile similar to statues o death [].

Conflict of Interests

Te authors declare that there is no conict o interestsregarding the publication o this paper.

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