Tuesday, December 18, 2012

Delusional Misidentification Disorders: Part 1 - Capgras Syndrome

Delusional Misidentification Disorders: Part 1 - Capgras Syndrome

Today's discussion turns to a group of somewhat rare syndromes that are related to the concept of misidentification and are labeled together as Delusional Misidentification Syndromes (DMS). In these syndromes someone, or something, is incorrectly identified as a person, place or thing. Thoughts and attribution of thoughts are also misidentified, in many cases to the point of being delusional. Some of these syndromes are more often than not related to organic abnormalities of the brain, or they may be a combination of organic problems with psychological issues, or in rare instances, may be purely psychological. DMS is often associated with psychoses and has only rarely been reported in non-psychotic individuals. It is nevertheless fairly rare, occurring in about 4% of patients presenting with functional psychoses (Melca et al., 2012).

Capgras Syndrome is a misidentification syndrome where a person holds a delusion or belief that an acquaintance, typically a close family member, has been replaced by an identical looking imposter. This syndrome can be transient, developing very quickly after a brain injury, or can take a chronic form where the delusion is long standing. The syndrome is named after Joseph Capgras lived 1873-1950 French psychiatrist who first described the disorder in a 1923 paper and used the term ‘illusion of doubles’ to describe a case of woman who had various doubles that had taken the place of people she knew. For some people with Capgras syndrome, even inanimate objects such as chairs and animals can be imposters. Often patients are so disturbed with seeing their doubles that they remove all mirrors from house. In some cases, if the Capgras sufferer can be convinced that one person is not an imposter, they will develop a Capgras delusion with someone else. (Sinkman, 2008).

Many patients suffering from Capgras Syndrome have already been diagnosed with schizophrenia. However, Capgras Syndrome can also be co-morbid with other mental health problems including; Alzheimer’s Disease, Cotard’s Syndrome, epilepsy, Farh’s Disease, Fregoli Syndrome, Hashimoto’s Hypothyroidism, Incubus Syndrome, Neurodegenerative Disease, Diogenes Syndrome, Parkison’s Disease (Bourget & Whitehurst, 2004; Ceylan et al., 2010; Chiu, 2009; Donnelly et al., 2008; Fischer et al., 2009; Josephs, 2007; Mishra, Prakesh, Mishra, Praharaj, & Sinha, 2009; Pande, 1981; Rodríguez, Madoz-Gúrpide, & Ustárroz, 2011; Yalin, Taş, & Güvenir, 2008). Capras has also been associated with the administration of morphine and ketamine (Bekelman & Hallenbeck, 2006; Corlett, D’Souza, & Krystal, 2010).

Since the time Capgras Syndrome was first described (and even a bit before) a number of theoretical explanations have been put forth as to its origins. As might be expected many of these theories were psychoanalytically based in the early days. De Pauw (Sinkman, 2008) has written a comprehensive account of these early conceptualizations of Capgras. In this article de Pauw notes that many of the psychoanalytic explanations are mutually incompatible. These psychoanalytic theories include; defense against unconscious homosexuality, a regression to the early stage of primary narcissism, which some writers believe was due to anxiety, and a novel resolution to the Oedipal and especially the Electra complexes. Psychodynamic explanations seemed to make sense because the people being replaced by imposters were almost always close family members. However, on closer scrutiny of the literature this argument falls apart as other people or things are often found to also be imposters, from doctors and nurses to entire buildings and other inanimate objects. In general, according to de Pauw psychoanalytic explanations tend to be “generally post hoc and teleological in nature, postulating motives that are not introspectable and defense mechanisms that cannot be observed, measured, or refuted” (p. 158). He concludes that while the presence of brain injury also does not fully explain Capgras Syndrome it may be due to a breakdown in the manner in which sensory information is brought into the brain and the way it is stored (and presumably retrieved).

Another issue in the published case literature about Capgras Syndrome is the focus on the delusion of the imposter to the exclusion of other aspects of the syndrome. Closer scrutiny often demonstrates other DMS and psychotic/schizophrenic symptoms in Capgras cases. Many patients suffer from a sort of expanded Capgras Syndrome where there are many other delusions present. Some of these delusions may be somatic in nature with the patient experiencing bizarre changes to their bodies, with their seeming strange and alien. Even the patient’s sense of self is changed and subject to delusion. These symptoms are reminiscent of schizophrenia and it is no surprise that many cases of Capgras have a co-morbid diagnosis of schizophrenia, usually of the paranoid variety. Upon closer examination it can become difficult to make a differential diagnosis between Capgras and schizophrenia in many sufferers, and the Capgras symptoms may be another aspect of the schizophrenic illness. In fact, studies have shown that misidentification symptoms occur in a large number of cases of schizophrenia, maybe even as high as 40% (Sinkman, 2008).

Modern clinicians and researchers now believe that Capgras has an organic basis, which is specifically related to cerebral dysfunction. Neuroimaging studies have shown that lesions in the right hemisphere of the brain are common among Capgras sufferers. Some studies have demonstrated bilateral damage to the hemispheres in Capgras patients (Bourget & Whitehurst, 2004). In one small study 81% of Capgras sufferers also had neurodegenerative disease, usually involving the Lewy body. As would be expected, these Capgras sufferers were older than Capgras patients without neurodegenerative disease, who were more likely to also suffer from paranoid schizophrenia, schizoaffective disorder, methamphetamine abuse, or other cerebrovascular problems. 100% of patients with Capgras and Lewy body disease experienced visual hallucinations (Josephs, 2007).

Capgras patients are prone to acts of violence, especially against people they have misidentified (Bourget & Whitehurst, 2004). Given the relation of Capgras to paranoid schizophrenia this makes sense.

There is evidence to support the idea that an emotional processing module in the brain, especially as it related to feelings of familiarity and unfamiliarity, and its connection to facial recognition is flawed in Capgras sufferers (Pacherie, 2009). This flaw in emotional processing can be demonstrated via facial recognition tasks and eye movement patterns (Brighetti, Bonifacci, Borlimi, & Ottaviani, 2007; Grignon & Trottier, 2005; Walther et al., 2010). Similar differences in audio perceptions related to working memory have also been reported for Capgras sufferers (Papageorgiou, Lykouras, Ventouras, Uzunoglu, & Christodoulou, 2002). In one dramatic case a Capgras patient had sexual relations with his wife, thinking she was a ‘double’. He had no feelings of familiarity with his wife whatsoever and essentially felt as if he were having sex with a different woman; so much so that he even changed his sexual behavior. The authors (Thomas Antérion, Convers, Desmales, Borg, & Laurent, 2008) note that this may be the only known documentation of a patient who was able to make his wife into his mistress!

As might be expected the typical treatment for Capgras Syndrome is anti-psychotic medications. However, when anti-psychotic medication is only partially or not effective the use of electroconvulsive therapy has been shown to be helpful. This is especially the case when Capras is co-morbid with Parkinson’s Disease (Chiu, 2009).

[Next - Fregoli Delusion]


Bekelman, D. B., & Hallenbeck, J. (2006). Capgras Syndrome Associated with Morphine Treatment. Journal of Palliative Medicine, 9(3), 810–813. doi:10.1089/jpm.2006.9.810

Bourget, D., & Whitehurst, L. (2004). Capgras Syndrome: A Review of the Neurophysiological Correlates and Presenting Clinical Features in Cases Involving Physical Violence. The Canadian Journal of Psychiatry / La Revue canadienne de psychiatrie, 49(11), 719–725.

Brighetti, G., Bonifacci, P., Borlimi, R., & Ottaviani, C. (2007). “Far from the heart far from the eye”: Evidence from the Capgras delusion. Cognitive Neuropsychiatry, 12(3), 189–197. doi:10.1080/13546800600892183

Ceylan, M. F., Bulut, M., Virit, O., Selek, S., Bülbül, F., & Savaş, H. A. (2010). Hashimato tiroiditi olan erişkin bipolar bozukluk hastasinda capgras ve fregoli sendromu birlikteliği. Yeni Symposium: psikiyatri, nöroloji ve davraniş bilimleri dergisi, 48(1), 69–71.

Chiu, N.-M. (2009). Repeated electroconvulsive therapy for a patient with Capgras syndrome and Parkinsonism. Progress in Neuro-Psychopharmacology & Biological Psychiatry, 33(6), 1084–1085. doi:10.1016/j.pnpbp.2009.06.003

Corlett, P. R., D’Souza, D. C., & Krystal, J. H. (2010). Capgras syndrome induced by ketamine in a healthy subject. Biological Psychiatry, 68(1), e1–e2. doi:10.1016/j.biopsych.2010.02.015

de Pauw, K. W. (1994). Psychodynamic approaches to the Capgras delusion: A critical historical review. Psychopathology, 27(3-5), 154–160.

Donnelly, R., Bolouri, M. S., Prashad, S. J., Coverdale, J. H., Hays, J. R., & Kahn, D. A. (2008). Comorbid Diogenes and Capgras syndromes. Journal of Psychiatric Practice, 14(5), 312–317. doi:10.1097/01.pra.0000336759.50060.5c

Fischer, C., Keeler, A., Fornazzari, L., Ringer, L., Hansen, T., & Schweizer, T. A. (2009). A rare variant of Capgras syndrome in Alzheimer’s disease. The Canadian Journal of Neurological Sciences/ Le Journal Canadien Des Sciences Neurologiques, 36(4), 509–511.

Grignon, S., & Trottier, M. (2005). Capgras Syndrome in the Modern Era: Self Misidentification on an ID Picture. The Canadian Journal of Psychiatry / La Revue canadienne de psychiatrie, 50(1), 74–75.

Josephs, K. A. (2007). Capgras syndrome and its relationship to neurodegenerative disease. Archives of Neurology, 64(12), 1762–1766.

Melca, I., Rodrigues, C., Serra-Pinheiro, M., Pantelis, C., Velakoulis, D., Mendlowicz, M., & Fontenelle, L. (2012). Delusional Misidentification Syndromes in Obsessive–Compulsive Disorder. Psychiatric Quarterly, 1–7. doi:10.1007/s11126-012-9237-z

Mishra, B. R., Prakesh, R., Mishra, B. N., Praharaj, S. K., & Sinha, V. K. (2009). Capgras syndrome associated with Fahr’s disease. The Journal of Neuropsychiatry and Clinical Neurosciences, 21(3), 354–355. doi:10.1176/appi.neuropsych.21.3.354

Pacherie, E. (2009). Perception, emotions, and delusions: The case of the Capgras delusion. In T. 

Bayne & J. Fernández (Eds.), Delusion and self-deception: Affective and motivational influences on belief formation., Macquarie monographs in cognitive science (pp. 107–125). New York, NY US: Psychology Press.

Pande, A. C. (1981). Co-existence of incubus and Capgras syndromes. The British Journal of Psychiatry, 139, 469–470. doi:10.1192/bjp.139.5.469

Papageorgiou, C., Lykouras, L., Ventouras, E., Uzunoglu, N., & Christodoulou, G. N. (2002). Abnormal P300 in a case of delusional misidentification with coinciding Capgras and Fŕegoli symptoms. Progress in Neuro-Psychopharmacology & Biological Psychiatry, 26(4), 805–810. doi:10.1016/S0278-5846(01)00293-7

Rodríguez, R. H., Madoz-Gúrpide, A., & Ustárroz, J. T. (2011). Propuesta de una batería neuropsicológica para la exploración del síndrome de Capgras. Revista Española de Geriatría y Gerontología, 46(5), 275–280. doi:10.1016/j.regg.2011.06.001

Sinkman, A. (2008). The syndrome of Capgras. Psychiatry: Interpersonal and Biological Processes, 71(4), 371–378. doi:10.1521/psyc.2008.71.4.371

Thomas Antérion, C., Convers, P., Desmales, S., Borg, C., & Laurent, B. (2008). An odd manifestation of the Capgras syndrome: Loss of familiarity even with the sexual partner. Neurophysiologie Clinique/Clinical Neurophysiology, 38(3), 177–182. doi:10.1016/j.neucli.2008.04.003

Walther, S., Federspiel, A., Horn, H., Wirth, M., Bianchi, P., Strik, W., & Müller, T. J. (2010). Performance during face processing differentiates schizophrenia patients with delusional misidentifications. Psychopathology, 43(2), 127–136. doi:10.1159/000277002

Yalin, Ş., Taş, F. V., & Güvenir, T. (2008). The coexistence of Capgras, Fregoli and Cotard’s syndromes in an adolescent case. Nöropsikiyatri Arşivi/Archives of Neuropsychiatry, 45(4), 149–151.

Thursday, September 29, 2011

Worries of a child conceived by a sperm donor

Children conceived by a sperm donor are worried that they will have an intimate relationship with an unknown, blood relative.
(http://www.familyscholars.org/assets/Donor_15findings.pdf) According to Elizabeth Marquardt, Norval D. Glenn and Karen Clark, half-46%-of donor offspring... agree. "When I'm romantically attracted to someone I have worried that we cold be unknowingly related."
Realistic fear? Consider that there is some evidence that biologically similar adults are more sexually attracted to one another, especially when reared apart and this phenomena is termed
Genetic Sexual Attraction. Just ask Phil Bailey and his grandmother, Pearl Carter or Patrick and Susan Stubing, a married couple with two children. By all outward appearances they are a normal family living in Germany with one important exception: Patrick and Susan are siblings. (http://www.bizarrebehaviors.com/2009/09/genetic-sexual-attraction-an.html) So it seems that their increased worry is justified.

Wednesday, September 28, 2011

Zombies - Part 3

Recently I ran across some articles that got me thinking of 'zombification' in the animal Kingdom. A really great summary by Mo Constandi on his blog Neurophilosophy (Costandi, 2006) as well as an article by Evans, Elliot, & Hughes (2011) describe brain altering fungi – usually from the genus Cordyceps. This entomopathogen (something that causes disease in insects) infects ants when its spores attach to the outside of the insect. The spores then germinate growing into the interior of the ant’s body through the spiracles (i.e. respiratory holes in the exoskeleton) or its trachea (or throat). The fungus then sends mycelia, which are filament-like roots, into the body of the ant where it feeds on any soft tissue while avoiding any organs necessary for the ant’s survival. Eventually, the mycelia grow into the ant’s nervous system where they release chemicals that affect its brain. This causes the ant to change its behavior. Typically, the ant will then climb up a plant to an exposed location where it will then clamp on to a leaf. At this point the fungus will then consume the ant from the inside out and produce spores. These fruiting bodies (i.e. the ‘mushroom’ part of the fungus) will then sprout from the ant’s head and body. The fungus will then release spores from the fruiting body and exposed location of the ant will allow these spores to spread via the air and hence to other ants. 

Ant with Cordyceps Fruiting Body Growing from its Brain
Such a relationship between parasites and insects is not unusual and there are many other examples in the animal kingdom. For instance a similar example involves crickets that are infected by nemotodes (roundworms) that cause them to jump into water facilitating the nematode lifecycle (Thomas et al., 2003). Lewis (1974) describes the life cycle of Leucochloridium helminthes (worms), which infect terrestrial mollusks (snails). The worms infect the snails and form broodsacs in the snail’s tentacles. The tentacles become striated, swell, and pulsate mimicking something like a maggot – a favorite food for birds. The worm also changes the snail’s behavior so that it moves to an exposed place. Birds are attracted to the maggot-like tentacles and bite them off the snails. The worm larvae are then excreted by the bird ready to infect another snail. The snails do not necessarily die, the tentacles can regenerate, and more broodsacs can be formed.* Other snails infected with helminthes may instead be castrated by the broodsac that form inside the snail. 

Snail with Leucochloridium Infection
The phenomena of parasites changing the behavior of a host are not limited to insects and mollusks. There is evidence that infection by the intracellular protozoa Toxoplasma gondii changes the behavior of rats. Rather than showing aversion to cats the rats no longer act as if the cats are no longer predators and in some instances are attracted to them. This of course results in the infected rats being eaten and the cats facilitating the life cycle of the parasite through harboring the protozoa and then excreting it in their feces.

T. gondii is infectious to all mammals and will infect the human nervous system in particular. Pregnant women infected with T. gondii can pass it on to their unborn children causing serious problems such as cerebral palsy, mental retardation, and even death. This is why pregnant women should not change the kitty litter! 

Generally infection with T. gondii is asymptomatic in the initial stages though it has been linked to psychotic symptoms in humans, especially those who have compromised immune systems. Late stage T. gondii infection has been linked to personality changes, a decrease in intelligence, psychomotor performance degradation, certain types of brain tumors, and schizophrenia. A paper by Webster et. al. (2006) clearly outlines the evidence for the association of T. gondii infection and schizophrenia. The authors hypothesize that anti psychotic medications such as haloperidol may work in part because they have anti – T. gondii properties. In fact, the authors found that haloperidol and valproic acid were as effective in controlling T. gondii infection in rats as standard anti – T. gondii medications. The authors conclude that their findings could “lead to improved prognosis and potentially new medication combinations and therapeutic modalities for the treatment of both toxoplasmosis and severe psychiatric disorders” (p. 1029). Seen from this light it is possible that schizophrenia associated with T. gondii infection could be seen as a form of ‘zombie-ism’ – one that could be treated by eradicating the protozoa,  which is also be a potentially new way of dealing with psychosis!
Of course humans suffer from other types of nervous system infections that could potentially affect behavior. For example one of the most common and oldest known infection of the brain is caused by Taenia solium otherwise known as the tapeworm. T. solium usually enters the body when a person eats undercooked pork that carries the eggs of the tapeworm. These hatch in the intestines and live in this ‘food rich’ environment. But sometimes T. solium makes its way into the bloodstream where it can travel to the muscles, eyes, or brain. 

Live Tapeworm being Removed from a Human Brain
In 2008 Fox news reported on a woman in Arizona who had a live tapeworm in her brain (“It’s Not a Tumor - Doctors Find Worm In Woman’s Brain Instead,” 2008). She had reported numbness in her arm and blurred vision and doctors suspected a tumor. Indeed something showed up on a MRI scan and the woman was scheduled for surgery. During the operation for an expected tumor the woman’s surgeon found the live worm and removed it.** Interestingly, this woman was lucky because once the worm was removed her neurological symptoms resolved. Worse problems may arise if the worm dies while in the brain. When this happens an inflammatory immune action is provoked and a cyst is formed around the worm. This can cause headaches, encephalitis, seizures, and in some cases zombie-like mental confusion as well loss of coordination and balance. While single cyst-caused lesions are less problematic, people who have multiple or calcified lesions may have permanent neurological issues (Singhi, 2011). T. solium infection highlights the importance of fully cooking food like pork as well as the necessity for good hygiene among those who handle food.

Neurocysticercosis - Tapeworm Cysts in the Brain
The infections cited above, whether deliberately part of an organism’s life cycle (as with Cordyceps or Leucochloridium) or accidental (as with T. gondii or T. solium), cause damage to the brain.  There are of course other pathogens such as viruses that can also infect the brain. These infections result in encephalitis, which is an inflammatory response causing swelling and irritation that are potentially life threatening. Encephalitis is most often caused by a virus and usually results in mild flu-like symptoms. However, encephalitis is unpredictable. Severe cases can be deadly or cause permanent brain damage, having at least the potential to create a zombie-like state. Some pathogens, like viruses in the Herpes simplex (HSV) group can cause severe encephalitis.

Three of the HSV types (HSV-1, HSV-2, and Varicella zoster) can infect the human nervous system. HSV-1 (commonly known as oral herpes) is the most common cause of viral encephalitis that can be life threatening. HSV-1 has a preference for infecting the frontal cortices, which can produce a number of neurological problems, including language and memory impairment as well as epilepsy. Psychological issues such as personality and behavioral abnormalities, including disinhibition and increased aggression can also occur (Arciniegas & Anderson, 2004). HSV-2 (the type responsible for genital herpes) infection can also produce encephalitis that causes neuropsychological symptoms. While HSV-2 seems to have a preference for infecting the meninges (tissues around the brain), it can also affect the brain, brainstem, cranial nerves, nerve roots, and spinal cord, as well. This can result in cranial nerve damage (neuropathy), weakening (hemiparesis) or loss of sensation (hemisensory loss) on one side of the body, and altered levels of consciousness. Typical herpes skin lesions may accompany neurological infection (Berger, Houff, & Fathallah-Shaykh, 2008). It seems plausible that people suffering from untreated neurological HSV 1 & 2 encephalitis could look and behave like zombies.

Heinrich Kluver
Paul Bucy

Another serious possible consequence of HSV encephalitis is Kluver-Bucy Syndrome (KBS) (Begum, Nayek, & Khuntdar, 2006; Cohen, Park, Kim, & Pillai, 2010; D Ku & Sang Yoon, 2011; Duggal, Jain, Sinha, & Nizamie, 2000; Gabison-Hermann, Pelletier, Taleb, & Bouleau, 2009; Yilmaz et al., 2008). Heinrich Kluver was a German émigré experimental neuropsychologist at the University of Chicago. He served as a German soldier from World War I and was wounded. A trip to the base hospital spared him from defending against the final Allied assault and perhaps saved his life. Those who didn’t know him well found him diffident and somewhat perfectionistic – almost a cliché of German scientists from this era. His friends however know him as a warm and thoughtful scientist. Kluver studied eidetic imagery, which led him to study hallucinations induced through mescaline. Reportedly Kluver used himself as a guinea pig with regard to the effects of mescaline and an overdose supposedly left him seriously ill for a time. After studying the effects of mescaline on monkeys he began experiments with neurosurgeon Paul Bucy on the effect of removing the temporal lobes of the brain in their primate subjects. The loss of the temporal lobes produced a syndrome that was named after the two researchers. (Hunt, 1980). 

Kluver-Bucy Syndrome (KSB) results in marked behavioral changes which include hyperorality (putting things in the mouth), hypoermetamorphosis (a fixation of attention to something in the environment – usually related to orality), hypersexuality, and a supposed passive ‘tameness’ (Klüver & Bucy, 1937, 1938, 1939). The last quality has been construed as a lack of aggression in that caged monkeys with KBS were more placid and easily approached. However, in a later experiment by Kling where the monkeys were allowed to roam freely after the operation, it was noted that the animals did not act tame and were not easily approached, but instead became socially isolated (Glick & Roose, 1993).

In humans KBS results in behavioral changes similar to those in monkeys. These changes, however, are more elaborate and include amnesia, Attention-Deficit/Hyperactivity Disorder, confusion, aggression and frustrated rage, pica (eating non-edible things including corprophagia), dysphasia (impairment in speech and comprehension of speech), emotional blunting and lability, hypermetamorphosis, hyperorality (which in one case involved continual spitting), hypersexuality, impulsivity, passivity, visual agnosia (inability to make sense of what is seen), etc. (Begum et al., 2006; Berger et al., 2008; Cohen et al., 2010; D Ku & Sang Yoon, 2011; Duggal et al., 2000; Gabison-Hermann et al., 2009; Greenwood, Bhalla, Gordon, & Roberts, 1983; Lilly, Cummings, Benson, & Frankel, 1983; Yilmaz et al., 2008). There can be a number of causes of KSB in humans (besides encephalitis) and damage to the temporal lobes may vary to a great degree (Lilly et al., 1983). Interestingly the studies of KSB in humans often report some form of aggression. Clearly many of the aspects of KSB listed above could be seen as indicative of a form of ‘zombie-ism’.

I am familiar with KSB from my psychological practice at a large state mental hospital. When I worked in a skilled nursing ward I had a patient (who I will call) John who demonstrated many aspects of KSB in humans.

John's life was a tragedy. At age five he was playing in his driveway behind his parent's car. His father, rushing off to work, failed to notice the little boy and backed the car up, driving over the boy’s head. John survived but suffered severe brain injury on one side to his temporal and frontal lobes. He became developmentally delayed (what used to be called 'retarded') and his behavior became unruly and violent. John's behavior became so bad his parents couldn't handle him at home and he was committed to a state mental institution. When I began to work with John he was 30 years old and had grown up in the mental hospital. This was not a good place to grow up. In John's case being an unruly violent child in the company of other unruly violent children meant constant fights and injuries. When John became a teenager he got in an especially bad fight that resulted in his head being repeatedly smashed against a concrete floor by an older, much stronger patient. This patient had no idea of what he was doing and kept hitting John's head against the floor until John almost died.

John suffered further traumatic brain injury from this incident, this time to the temporal and frontal lobes on the other side. Whereas after the first injury John could talk and reason to some degree, after second he could not. His demeanor was that of being in a awakened vegetative state. John also suffered damage to his motor cortex and was paralyzed from the waist down. More interestingly though (and the point of this story) is that the damage to John's frontal lobes resulted in KBS. In essence, John became an eating machine. Without consciousness John would spend every waking second trying to eat something, whatever came within his grasp. He would constantly pick at his clothes until he could rip off chunks and eat them. John's physician showed me an old X-ray of John's stomach which was filled with cloth, a couple of forks, toys, anything he could fit in his mouth. 

X-Ray of the Stomach of a Person With Pica Behavior
John would also try and eat people. When you came close to John he would reach out, grab you, and try to get a bite. Because of this insatiable appetite for anything he could get his hands on, John spent his days dressed in rip-stop clothing, with his arms tied down in restraints. This drive to eat had no conscious motivation to it, and John exhibited no consciousness at all - eating was the whole of John's being. John exhibited hypermetamorphosis in that once he locked on to something in the environment he would focus obsessively on trying to eat it. John was not usually aggressive, except if he were kept from something he wanted to eat. Then he would become frustrated and somewhat enraged. Had John able to walk, he would certainly have attacked people and tried to eat them. He had in essence become a zombie.

For me, the case of John and others like him brings up the real possibility of zombie-ism. The one saving grace in this nightmare scenario is that fully mobile and unrestrained, John-like zombies would soon eat themselves to death. They could not keep ingesting inedible objects without serious consequences. Unless John-like zombies somehow developed a taste for living creatures, the rest of us wouldn't have much to worry about and after a few days of unrestrained eating they would either be debilitated or dead. All enterprising survivors would have to do would be to hole up somewhere and wait out the ‘zombacolypse’.

Yet the case of John and others like him give hard evidence that an infectious agent or trauma can cause injury to the brain leading to zombie-like behavior changes. This scenario is far-fetched perhaps, but not impossible. Harvard psychiatrist Steven Schlozman elaborates on this idea in his book The Zombie Autopsies: Secret Notebooks from the Apocalypse (Schlozman, 2011). In this fictional account an infectious agent has caused a pandemic. The infection itself is man-made comprising a virus that delivers prion disease to the brain, selectively destroying its higher centers. The virus/prion combination (and a third infectious agent the protagonists try to identify) also infect the body, leaving just enough function to allow the zombie to move and eat. I would suggest that in real life such an elaborate mechanism is not necessary. There are plenty of prospects in the world at large that have the potential to be 'zombifying' agents. A small mutation in one of the herpes viruses or T. gondii, a tapeworm variant, a fungus that jumps from insects to humans, or some combination thereof could do the trick. Given these infectious agents our obsession with zombies starts to makes sense. Perhaps in the back of our minds we realize there is the possibility of a real zombie outbreak, that there is something to be afraid of?


* There is a wonderful video of these snails online at www.youtube.com/watch?v=EWB_COSUXMw
** Video of the worm being removed can be found here: http://media2.foxnews.com/112008/worm_tumor_700.wmv


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Berger, J. R., Houff, S., & Fathallah-Shaykh, H. M. (Ed. . (2008). Neurological complications of herpes simplex virus type 2 infection. Archives of Neurology, 65(5), 596-600. doi:10.1001/archneur.65.5.596

Cohen, M. J., Park, Y. D., Kim, H., & Pillai, J. J. (2010). Long-term neuropsychological follow-up of a child with Klüver–Bucy syndrome. Epilepsy & Behavior, 19(4), 643-646. doi:10.1016/j.yebeh.2010.09.003

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Duggal, H. S., Jain, R., Sinha, V. K., & Nizamie, S. H. (2000). Post-encephalitic Kluver-Bucy syndrome. Indian Journal of Pediatrics, 67(1), 74-76.

Evans, H. C., Elliot, S. L., & Hughes, D. P. (2011). Hidden diversity behind the zombie-ant fungus Ophiocordyceps unilateralis: four new species described from carpenter ants in Minas Gerais, Brazil. PloS One, 6(3), e17024. doi:10.1371/journal.pone.0017024

Gabison-Hermann, D., Pelletier, A., Taleb, M., & Bouleau, J.-H. (2009). [The case of temporal lobes dysfunction in atypical psychiatric episodes]. L’Encéphale, 35(5), 491-495. doi:10.1016/j.encep.2008.06.013

Glick, R. A., & Roose, S. P. (1993). Rage, power, and aggression. Yale University Press.

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Klüver, H., & Bucy, P. C. (1937). “Psychic blindness” and other symptoms following bilateral temporal lobectomy in Rhesus monkeys. American Journal of Physiology, 119, 352-353.

Klüver, H., & Bucy, P. C. (1938). An analysis of certain effects of bilateral temporal lobectomy in the rhesus monkey, with special reference to “psychic blindness.” Journal of Psychology: Interdisciplinary and Applied, 5, 33-54.

Klüver, H., & Bucy, P. C. (1939). Preliminary analysis of functions of the temporal lobes in monkeys. Archives of Neurology & Psychiatry (Chicago), 42, 979-1000.

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Lilly, R., Cummings, J. L., Benson, D. F., & Frankel, M. (1983). The human Klüver-Bucy syndrome. Neurology, 33(9), 1141-1145.

Schlozman, S. C. (2011). The Zombie Autopsies: Secret Notebooks from the Apocalypse. Grand Central Publishing.

Singhi, P. (2011). Neurocysticercosis. Therapeutic Advances in Neurological Disorders, 4(2), 67-81. doi:10.1177/1756285610395654

Thomas, F., Ulitsky, P., Augier, R., Dusticier, N., Samuel, D., Strambi, C., Biron, D. ., et al. (2003). Biochemical and histological changes in the brain of the cricket Nemobius sylvestris infected by the manipulative parasite Paragordius tricuspidatus (Nematomorpha). International Journal for Parasitology, 33, 435-443.

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Yilmaz, C., Cemek, F., Güven, A. S., Caksen, H., Ata?, B., & Tuncer, O. (2008). A child with incomplete Kluver-Bucy syndrome developed during acute encephalitis. The Journal of Emergency Medicine, 35(2), 210-211. doi:10.1016/j.jemermed.2007.05.051

Tuesday, June 14, 2011

Zombies - Part 2

In order to understand zombies it is important to know their origins. Here I would like to trace our conception of zombies back to Haiti and Africa, explain the 'original' zombie types, look at how these zombies come into being, and how they are used. I will conclude with a discussion on the psychology of zombies.

The word zombie is African in origin, though it does not have a simple etymological lineage. There are a number of Africa terms that may be related to of the modern word zombie. These include fumbi, which is the Yoruba word for spirit; mvumbi, which in the Congo can refer to either a cataleptic person or the invisible spirit of a person; ndzumbi, the Gabon word for corpse; nsumbi the Congo word for devil; nvumbi the Angolan term for a body without a soul; nzambi the Congo word for the spirit of a dead person and the Bantu word for the creator and/or serpent God; zan bii a term used in the Ghana-Togo-Benin areas of Africa to refer to a nighttime bogeyman used to scare children; and zumbi, a word used in the Congo and in Angola to refer to someone raised from the dead (Ackermann & Gauthier, 1991, p. 468) 

The Complete Idiot's Guide to Voodoo states that a zombie is an individual whose soul has been captured by a sorcerer (Turlington, 2002). However, zombies may be of two types - a soul without a body or a body without a soul. The former is relatively easy to obtain, while the latter requires extraordinary skill on the part of the sorcerer. This delineation of zombies into two types is related to the African belief that humans have two types of souls or spirits. In Haiti these are known as  the Gros Bon Ange (good big angel) and the Ti Bon Ange (little good angel). Depending on whom you talk to, one or both of these souls can be captured through sorcery. The soul itself may then become a zombie. Called a zombi astral or zombie of the spirit (I will refer to it as a spirit zombie), it is held by a sorcerer who can then transform the soul into various forms to carry out his or her bidding, for both good and evil. Conversely, one or both of these souls can be removed from a person, turning them into a soulless body that is under the power of its sorcerer master. In either case, a zombie can be considered to be someone who has problems with their soul(s). Typically, western writers have reported mostly on soulless body type zombies, which are called zombi cadavre or zombi corps cadavre which can be translated into a zombie of the flesh (I will call it a flesh zombie from here on out), Nevertheless, interviews with Haitian sorcerers indicate that spirit zombies are quite common. (Ackermann & Gauthier, 1991).

There are various ways to create zombies. Spirit zombies can be obtained simply by capturing the soul(s) of a person via magic. This is relatively easy and does not require great skill. Flesh zombies require much greater skill to obtain and may require the use of animal and plant based drugs and poisons in addition to magic. It also may require murder, though some zombies are the result of a soul stolen from a living person. In most cases however, zombie creation requires access to a dead body, regardless of whether the body is freshly murdered or not.

The use of drugs to induce a flesh zombie is controversial (Davis, 1988b; Hines, 2008). Davis (1985) was one of the first people to argue that a zombie state could be induced using a mixture of certain animal and plant based substances. However, he was not able to obtain so-called zombie powders that would have produced the 'zombification' depicted in the movie The Serpent and the Rainbow, which was based on Davis' book. However, if we are willing to stretch the point it is possible to come up with a list of useful ingredients for flesh zombie creation:

Tetrodotoxin (derived from a number of different types of Puffer Fish) - which causes paralysis, reduces oxygen consumption, and leaves a person fully conscious, Because this toxin does not cross the blood-brain barrier it can induce a profound paralysis while leaving a person fully conscious (Davis, 1985, 1988a). Psychologically this creates a profound sense of helplessness and loss of control.

Datura Stramonium (Jimson Weed also known as 'Zombi Cucumber')- Hallucinations, schizophregenic (i.e. induces symptoms of psychosis and dissociation), and possibly brain damage. Also thought to reduce or eliminate a person's willpower (Davis, 1985).

Zombia Antillarum (Zombi Palm) - The oil produced from the seeds is thought to be able to activate the senses and wake up the zombified person. The leaves of this plant are also thought to prevent being spied on by zombies (Taylor & Timyan, 2004).

Care must be taken to use right dosage of these toxins as too much will kill the victim. In popular renditions of the creation of zombies the toxins are either ingested by breathing in a powder or by having it come into contact with a cut. After the toxin takes effect the victim is typically interred in a coffin and buried alive. The person being turned into a flesh zombie is fully conscious during the burial and feels profound fear, anxiety, and loss of control. The potential flesh zombie then remains buried and the poison eventually wears off freeing them victim to struggle in their grave. At some point the zombie's master digs up the victim who is now supposedly compliant and without the will to resist.

The last part of the flesh zombie creation is the most controversial since once the poison wears off there is no reason the person should be compliant. None of the substances listed above, or listed by Davis in his publications, would induce a permanent lethargic-compliant state. Perhaps the zombie has to constantly be drugged, or is brainwashed? Some writers, notably Hines (2008) find this idea far-fetched. A more realistic explanation might be that a lack of oxygen in the coffin during burial could cause some degree of brain damage, perhaps to the frontal lobes. This would explain the blunted affect and lack of volition typical of zombies. It may be that the creation of a flesh zombie produces something akin to a person with a lobotomy.

It also may be true that what I am calling flesh zombies are nothing more than mentally ill people. Certainly some types of psychoses include the lack of volition, lethargy, compliance, and shuffling gait seen in flesh zombies. As Ackermann & Gauthier (1991) state, zombies might be based on the:

Observation of imbeciles, or certain mentally ill people, especially catatonic schizophrenes, demented or amnesic, who wandered off and were sighted later. In countries where illness and premature death are commonly attributed to magic, it would be logical to explain the vagrant mentally ill as resurrected dead without a soul. This would be a purely popular belief; sorcerers could have contributed nothing but rumor. (p. 490)

These authors go on to say that this idea is reinforced by the high incidence of psychosis among the homeless.

Regardless of the type of zombie created, they are useful to the person controlling them. Spirit zombies can be used for varied purposes ranging from helping with homework to inflicting disease. Flesh zombies can be used as domestic servants, manual laborers, limited skill workers, as well as bodyguards and assassins (Ackermann & Gauthier, 1991; Davis, 1988).

In essence, zombies make perfect slaves. In fact, aspects of the zombification process echo the forced diaspora of slaves from Africa. It is not too much of a reach to see the similarities between being conscious in a coffin and being in the hold of a slave ship. Both experiences include a complete loss of control as well extreme fright and claustrophobia. Both experiences are also easily fatal, or in the best case scenario result in lifelong degrading servitude.

There is more than just irony in the fact that slaves, and later former slaves, would want to create slaves for themselves. Psychoanalysts would call this a classic case of repetition compulsion. In other words, by repeating the process of slavery, the slaves seek mastery over their situation. This also represents the related phenomena of identification with the aggressor, where someone who is abused by another will take on the aggressive character of the abuser as a defense against their lack of self-worth. That people who were forcibly taken from their homes, subject to torture, horrible living conditions, and forced into long-term servitude would develop these psychological coping mechanisms makes sense. When you are under the total control of another, you can regain a sense of control over yourself by controlling someone else weaker and more vulnerable. Given that in many parts of the world people are still extremely vulnerable and struggling to gain control over their lives, it shouldn't be a surprise that zombies are in our thoughts**.

*In any case the film "The Serpent and the Rainbow" is well worth watching for it's depiction of the creation of a zombie with plenty of cinematic flair. Interestingly enough, Davis, absolutely hated the film even though he made quite a bit of money on it. In contrast the Voudun priest Max Beauvoir, who acted in the film loved the movie and it's portrayal of Voudun, so go figure (Craven, 1988; Marsh, 2010).

**Please consider making a donation for Haitian relief at jphro.org

Ackermann, HW., & Gauthier, J. (1991). The Ways and Nature of the Zombi. The Journal of American Folklore, 104(414), pp-466-494.

Craven, W. (1988).  The Serpent and the Rainbow. Universal Pictures.

Davis, W. (1985). The serpent and the rainbow. New York, NY Simon & Schuster.

Davis, W. (1988a). Passage of darkness: The ethnobiology of the Hatian zombie. Chapel Hill, NC: University of North Carolina Press.

Davis, W. (1988b). Zombification. Science, 240(4860), pp. 1715-1716.

Hines, T. (2008). Zombies and Tetrodotoxin. Skeptical Inquirer; (32)3, pp. 60-62.

Marsh, S. (2010). Interview with Hamilton Morris, filmmaker behind NZAMBI: documentary on Haitian zombie phenomenon. Downloaded from boingboing.net/2010/11/08/interview-with-hamil.html, 6-15-11

Taylor, FB., & Timyan, JC. (2004). Notes on Zombia Antillarum. Economic Botany, 58(2), pp-179-183.

Turlington, SR. (2002). The complete idiot's guide to Voodoo. Indianapolis, IN: Alpha Books.

Sunday, June 12, 2011

Are Anthony Weiner's Penis Pictures Bizarre

With all of the hullabaloo about the twittering of Anthony Weiner (http://www.huffingtonpost.com/2011/06/12/anthony-weiner-photos-resign_n_875534.html), We asked ourselves, “Why weren’t we writing a blog about his escapades?” Sure, he for the past three years, sent twitters of himself in various states of dress and undress to women who because of their interest in his political prowess, thought they would like to see his package.  Not a particularly glaring oversight considering the acts of other politicians, (Schwarzenegger, Vitter, Ensign) and sports figures (Favre, Woods). Why didn’t he cease and desist after marrying Huma Abedin or when he discovered that he would have a child and become a father? Now his wife has to decide if he has been unfaithful with his sexting (http://www.timeslive.co.za/lifestyle/article1114177.ece/Is-sexting-the-new-age-version-of-infidelity). He even continued his sexting after Andrew Breitbart and others told him they were on his tail and let him know what they found.  This must be a pervasive, well-established behavior, but very understandable to us experts in human behavior but strange to most others. How might we make sense of this?

The father of psychoanalysis and the greatest influence in personality theory (Schultz & Schultz, 2005), Sigmund Freud, asserted that boys love their mothers from about age 4, the phallic stage of child development.  The boy overtly expresses his love for his mother and fantasizes about realizing his love for her.  He competes with his father for his mother’s love. The son knows the father has a special relationship with his mother, which causes him to feel jealous of and then angry with his father. Freud wrote, “I have found love of the mother and jealousy of the father in my own case, too.” (Freud, 1954,p.223)  The son expects that the father will attack him by cutting off his penis, the source of the boy’s sexual maternal interests and this becomes, what Freud called, castration anxiety. This anxiety is worsened when the son is punished by the father for masturbating or even for the desire to masturbate.  How can the son get rid of such an unpleasant emotional state?  He identifies with the father and seeks to behave like him and can redirect his sexual longing for his mother with acceptable forms of expression of affection, such as bringing his mother flowers or helping her with household chores.  By discovering acceptable expressions of love for his mother, the son resolves his Oedipal Complex, seeks work that symbolizes his male virility, and remains proud of his penis.

For Freud, girls had a greater developmental challenge when they realized that they did not have a penis. They would feel inferior and blame their mother, which could become hate. Freud wrote that “girls feel deeply their lack of a sexual organ that is equal in value to the male one: they regard themselves on that account as inferior and this envy for the penis is the origin of a whole number of characteristic feminine reactions” (Freud, 1925, p212).  Freud identified these feelings of little girls as penis envy.

So little boys, four and five years old, will masturbate in front of others, because of the pride they have for their penis and their wanting to let the world know they are just like their Dads. They are usually punished for such acts and with maturation, they discover socially acceptable ways to satisfy their passionate needs.  When a mature adult behaves like a five year old, a follower of Freud would conclude that he has not sufficiently resolved his Oedipal Complex and therapy is pursued to accomplish what nature has failed to achieve.

There are other theories that are useful to understand why men would want to send women pictures of their penis or shots of them undressed sporting the results of their workout.  Gorillas will flex their muscular bodies, beat their chests, and show off in front of the female. However, female Gorillas usually start the ritual by touching their lips or sitting on the male’s lap. With power and social status comes an increased risk of men seeking mates outside of their monogamous relationship (Knox, Vail-Smith, and Zusman, 2008) and women are soliciting men by sexting, and if Mr. Weiner had googled, he could have read rules for sexting men (http://www.askmen.com/dating/dating_advice_400/477_sexting-etiquette.html).

So what are women to do? Karen Horney was so incensed by Freud’s postulating woman’s penis envy that she defected from his psychoanalytic doctrine and found her own school of psychoanalysis. Horney considered Freud’s view that women envied the penis as demeaning and asserted that men feel inferior because they cannot bear children and consequently, suffer from womb envy. Is not the tremendous strength in men of the impulse to creative work in every field precisely due to their feeling of playing a relatively small part in the creation of living beings, which constantly impels them to an overcompensation in achievement?" Horney explained.(http://psychology.about.com/od/profilesofmajorthinkers/p/bio_karenhorney.htm)

             Kristen Schaal, the Women’s Issue Correspondent for The Daily Show with Jon Stewart (http://www.thedailyshow.com/), perhaps most accurately summarized Anthony Weiner’s goal for his therapy. There is an “age old misconception; that women want more information about your penis and that seeing it will make you more attractive. Men need to realize their penis has far more power over them than it has over us.” 

Best wishes to Anthony Weiner as he pursues his treatment.


Freud, S. (1925) An autobiographical study. In Standard Edition (Vol. 20). London: Hogarth Press.

Freud, S. (1954). The origins of psychoanalysis:Letters to Wilhelm Fleiss, drafts and notes:     1887-1902. M. Bonaparte, A. Freud, & E. Kris (Eds.). New York: Basic Books.

Horney, K. (1939). New ways in psychoanalysis. New York, Norton.

Knox, D., Vail-Smith,K,., and Zusman, M. (2008). Men are dogs’: Is the sterotype justified? Data on the cheating college male. College Student Journal, Vol 42(4), Dec, 2008. Pp. 1015-1022.

Schultz, Duane P., & Schultz, Sydney Ellen, Theories of Personality, 8th.ed.,Thomson Wadsworth, 2005.

Friday, May 20, 2011

Vampires Exist?

Franck and Emilie Dayan wrote about porphyrins (Porphyrins:One Ring in the Colors of Life) in the American Scientist (May-June,Vol. 29) in which they brought together science and myth to explain the existence of Vampires. They even referenced a “vampire plant” so named by Crispin Taylor of the American Society of Plant Biologists because it has a phenotype similar to photosensitive patients afflicted with porphyria. They shed light on the legend of Dracula when they described Vlad III, born in 1431, the Prince of Wallachia, who was Knight of the Order of the Dragon (a Hungarian religious order organized to protect the interests of Catholicism and the Holy Roman Empire) as a very authoritarian ruler known for his cruelty to his foes. He chose Easter Sunday, 1459, to arrest and impale many of his nobles who had rebelled and killed his father and his brother. The Dayan’s note that his preferred method of punishment earned him the nickname, Tepes, which means the impaler. His methods of torture included skinning, decapitation, hacking, strangulation, hanging, boiling, and burning. Noses, ears and sexual organs were cut off. 20,000 to 40,000 European civilians were killed, most of whom were impaled. Tepes created a “Forest of the Impaled” described by Sultan Mehmed who, in 1462, encountered 20,000 rotting cadavers of Turkish captives when he entered the capital of Wallachia. While not known for drinking the blood of his enemies, his thirst for vengeance served as a model for the villain, Dracula. The Dayan’s pointed out that while most cultures describe mythical creatures that feed on the blood of the living, it wasn’t until Bram Stoker, an Irish writer, was introduced to Vlad Tepes in 1890 by professor Armin Vambery, that the term vampire became popular. Remember that Tepes was a Knight of the Order of the Dragon and “Dragon” is pronounced “Dracul” in Romanian and Dracula means son of Dracul.

What does this have to do with porphyria?  Porphyrin is a molecule that binds to metal ions which have many different biological functions that are necessary to sustain essential activities in all organisms. Genetically based increases in porphyrin in places of the body in which they shouldn’t be, can cause light-dependent swelling and itching of the skin, mental disorders that can include muscle numbness, pain, and vomiting. While the Dayans make it clear that there is no evidence that Tepes suffered from porphyria, they do assert that David Dolphin, a prolific Canadian chemist who wrote seven volumes on porphyrins, identified that porphyria victims suffer from sensitivity to light as well as withered fingers and lips and “gums may tighten to reveal fanglike teeth with reddish hues due to elevated porphyrin levels.” (Dolphin, 12978-1979).  The Dayans properly asserted that, “it is important to remember that patients afflicted with porphyria are by no means vampires…No one suffering from porphyria deserves a rendezvous with Buffy the vampire slayer.” We agree.


Boulton, J. (2000). The Knights of the Crown: The Monarchiacal Orders of Knighthood in Later Medieval Europe 1325-1520. Suffolk, UK: Boydell Press

Dayan, Franck E.. and Dayan, Emilie A., Porphyrins: One Ring in the Colors of LifeAmerican Scientist, May-June 2011, Vol.99, (3),p.236

Dolphin, D. (1978-1979), The Prophyrins. Volumes 1-7. New York, Academic Press

Dolphin, D. (1985) Werewolves and vampires, Annual Meeting of American Assoication for the Advancement of Sciences

Poblete-Gutierrez, P., Wiederholt, H.F., Merk and J. Frank, (2006). The prophyrins:clinical presentation, diagnosis and treatment. European Journal of Dermatology, 16(230).

Taylor, C.B., (1998), Vampire Plants? Plant Cell, 10(1071.

Tuesday, May 17, 2011

Genetic Sexual Attraction Revisited

Genetic Sexual Attraction Revisited
We have written about men who get turned on watching high heeled women step on worms (crush videos), about men who prefer a “relationship” with a realistic looking female doll to the live, breathing person, but the topic that has elicited the greatest reader reaction has been genetic sexual attraction, otherwise known as the Westermarck Effect. (http://www.geneticsexualattraction.com/, http://sixtyminutes.ninemsn.com.au/stories/peteroverton/441583/forbidden-love)  Remember Patrick and Susan Stubing who live in Germany with their two children and have a normal family except that they are brother and sister. Patrick was adopted as a baby and did not meet Susan, towards whom he had an immediate attraction until he was 23 years old. (http://news.bbc.co.uk/2/hi/europe/6424937.stm)  What brought this to mind was a documentary entitled “Donor Unknown” from Metfilm and Redbird directed by Jerry Rothwell that recently screened at the Tribeca Film Festival (http://www.donorunknown.com/). It is the story of a child from donor 150 who searches for and meets her father and discovers that she has more than a dozen half-siblings. Providing four donations per week is "an acceptable practice from a medical standpoint," said Dr. Peter Schlegel, chairman of urology and professor of reproductive medicine at the Weill Medical College of Cornell University in New York, but …the American Society for Reproductive Medicine now recommends that the number of children from an individual donor in a geographical area not exceed 10…This limits the risk of a brother and sister meeting and marrying without realizing they are related…There have been surprise meetings of siblings that sparked fears of accidental incest. In South Australia, one man's sperm was reportedly used to produce 29 children, most of whom came to live in the city of Adelaide (population 1.2 million). With more than 1 million children of donors alive today, a documented case of accidental incest would seem to be inevitable,” Schlegel says.(http://www.latimes.com/health/la-he-unreal-donor-unknown-20110516,0,5927086.column) 
Given what we know about Genetic Sexual Attraction accidental incest is not as much an accident as once thought and more predictable as a consequence of the Westermarck Effect.


Gonyos, Barbara. I'm his mother, he's not my son.

Phillips, M. (2009). High On Arrival New York, NY: Simon Spotlight Entertainment.

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Walter, A., & Buyske, S. (2003). The Westermarck Effect and early childhood co-socialization. British Journal of Developmental Psychology, 21, 353-365.

Weisfeld, G.E., Czilli, T., Phillips, K.A., Gall, J.A., & Lichtman, C.A. (2003). Possible olfaction-based mechanisms in human kin recognition and inbreeding avoidance. Journal of Experimental Child Psychology, 85(3), 279-295.

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