D isentangling the A lien and A narchic H and

Disentangling the Alien and Anarchic HandD isentangling the A lien and A narch ic H and
C lelia M a rche tti
``S . M augeri’ ’ F oundation, R ehab ilita tion Institu te o f V eruno , Ita ly
S ergio D ella S ala
U niversity o f A berdeen , U K
``A na rch ic hand’ ’ is the te rm by w hich w e propo se to iden tify com p lex goa l-
direc ted m ovem en ts o f a hand , w h ich a re pe rfo rm ed aga ins t the patien t’ s w ill, and
that canno t b e volun tar ily inh ib ited . T h is phenom enon shou ld be d ifferen tia ted
from the fee ling o f nonbelong ing o f a hand, know n in the lite ra ture since the repo rt
of B rion and Jed inak (1972) , to w h ich th e term ``a lien hand ’ ’ sh ou ld be re ta ined.
A na rch ic hand, w hich is linked w ith an te r io r les ion s o f the corpus ca llo su m and the
su pp lem en ta ry m oto r a rea contra la tera l to the w ayw ard hand, sh ou ld be conceived
as s ``f ron ta l’ ’ sign. A lien hand , w h ich has been repo rted a fter po ster io r les ion s of
the co rpus ca llo su m , p robab ly enc ro ach ing upon the pa rie ta l co rtex , shou ld be
thought o f a s a pa rtia l h em iso m a tognos ia , th at is, a un ila te ral ``loss o f the
know ledge o r sen se o f one’ s ow n body and bod ily cond ition ’ ’ (B eaum on t,
K enealy, & R ogers , 1996 , p . 108 ) . T his d istin ction w ill ease th e desc rip tion and the
in te rp retation o f new case s o f alien and ana rch ic hand and w ill avo id so m e o f the
con fu sion cu rren tly p re sen t in the fie ld .
SOME ORDER IN THE ANARCHY
Alien han d is one of the m ost in trigu ing phenom ena in neuro logy . Its
in terp re ta tion is still debated , and som e of the d isagreem ent is due to b lurred
definitions of the sym ptom . C lin ica l p ictu res quite d iffe ren t from one ano ther,
caused by lesions to d ifferent reg ions of the bra in and due to d iffe ren t
ae tio log ies, a re subsum ed under the labe l o f ``a lien hand ’ ’ .
The term , w hich underlines the ``a lien ’ ’ characteristics of the sym ptom , dates
back to B rion and Jedynak (1972), w ho defined ``main eÂtrangeÁ re ’ ’ (fo reign
C or resp on den ce an d re q ue s t fo r re prin ts sh ou ld be sen t to P ro f es so r S e rg io D e lla Sa la,
D ep a rtm en t o f P sy cho log y , U n iv e rsi ty of A be rd een , A B 2 4 2U B A b e rd ee n , S co tla nd ; e -m a il :
se rg io @ ab erd een .ac .uk .
W e th an k G eorg e W a tso n w h o in t rod uced u s to L e Fan u ’ s n ov e ls . T h is p ape r d ra w s ex ten sive ly
from p re v iou s co llab o ra tive w o rk w i th H an s Sp inn le r.
Ó 1 9 98 Psych o log y P re ss L td
C O G N IT IV E N E U R O PS Y C H IA T R Y , 19 98 , 3 (3 ), 19 1±2 07
hand , o r strange hand, as the au thors them se lves transla ted the sign in the
E ng lish abstrac t o f the ir paper) as the failu re to recogn ise the ow nership of one ’ s
left lim b , w hen this is held by the right ou t of v isua l con trol. T hey reported the
sign of the m ain eÂtrangeÁ re in four pa tien ts: three affec ted by a tum our in the
posterior part o f the corpus callosum (CC ) and the four th presen ting a left
posterior paracallosal ang iom a 1
(see F ig. 1 ).
T he pa tien ts reported by Brion and Jedynak (1972 , p. 262 , 1974) d id not
p resen t w ith any invo lun tary m ovem ent: they fe lt the ir left hand as a fore ign
body w hich they failed to reco gn ise. T heir desc rip tion of the sym ptom is
com pelling :
L e pa tient qui se tient se s m a ins l’ u n e dan s l’ autre derrieÂre le do s, ne reconna õÁ t pa s
l ’ appa rten ance de la m ain gauche . . . le d eÂfic it n e po rte pas su r la reconnaissance
tac tile de la m a in, m a is sur la re conna issance de so n appa rtenance .
(Tran sla tion : T he pa tient w ho holds h is h and s one w ith in th e oth er b ehind his back
does no t recogn ise the lef t hand as h is ow n . . . T he s ign does no t con sist in th e lack
o f tac tile recogn ition o f the hand as su ch , bu t in the lack o f re cogn ition o f the hand
a s one ’ s own .)
1 A rte ro v eno us m a lfo rm at ion con s is ting of a tan g le of d ila ted v es se ls .
FIG. 1. R edra w in g of o n e o f the sk e tch es re p ort ed b y B r io n an d Jed yn ak (19 72 ) in th e ir
p os tm o rtem stu dy of fo ur p a tie n ts sh ow ing al ien h an d . It a p pea rs c le a r tha t the an g iom a en c ro ac h e s
u po n the p o ste rio r p a rt o f th e corp us c a llo sum , inv ad ing th e su rrou n d ing pa rie ta l co rtex .
192 MARCHETTI AND DELLA SALA
There fo re , the sign of the a lien hand , as the au thors acknow ledged , can be
considered a circum scribed hem isom atognosia , possib ly due to the invo lvem ent
of the parie tal co rtex as w ell as to the lesion of the C C.
C linical p ic tures sim ilar to those observed by B rion and Jedynak have been
reported in pa tien ts a ffec ted by d iffe ren t diseases. For exam ple , V en tu ra,
Goldm an , and H ildebrand (1995) desc ribed the fee ling of nonbe long ing of her
le ft a rm in a p a t ien t w i th a righ t cap su lo th a lam ic h aem orrh ag e w ith
m esencefa lic ex tension, and recen tly K aufer, M endez, M ische l, Verity , &
Benson (1996) repor ted the case of a m an presen ting fea tures o f a d iffuse
dysm yelina ting d isease show ing left a lien arm .
In 1979, B ogen , d iscussing the seque lae of ca llosa l lesions, translated Brion
and Jedynak ’ s sign as ``a lien hand’ ’ . 2
H ow ever, in his definition , he added the
term ``ac tive m otor m isbehav iour’ ’ to the experience of nonbe long ing of the
pa tien ts’ left ``a lien’ ’ hand . Bogen (1985 , p . 313) la ter desc ribed alien hand as
an autonom ous hand w hich ``behaves in a way w hich the patien t finds fore ign ,
alien , o r a t least uncooperative ’ ’ . G oldberg , M ayer, and T oglia (1981) gave to
the term ``a lien hand’ ’ ye t another m ean ing. In their defin ition, the fee ling of no t
be long ing of the hand , and the pa tients’ lack of recogn ition of the ir hand ,
assum ed by Brion and Jedinak to be the key fea ture of alien hand , was no t
m en tioned . O n the con trary , the presence of au tonom ous, w ayw ard m ovem ents
tha t the ``a lien ’ ’ hand perfo rm ed against the pa tien t’ s w ill w as du ly stressed .
They reported (1981 , p. 685) the case of two pa tien ts w ith infarc tion invo lving
the ante rio r portion of the CC and the left m ed ial fronta l co rtex , and refe rred to
the presence of com plex and co-ordina ted m ovem ents ``that appeared to be
dissocia ted from consc ious vo lition ’ ’ . Bo th patien ts com plained tha t the ir hand
had a w ill of its ow n, bu t never denied tha t the bizarre hand was their own. A
sim ilar case , pa tien t H M , had been reported as early as 1908 by G oldstein , w ho
nam ed the phenom enon Spontanbew engungenÐ spontaneous m ovem ents (see
F ig . 2 ), and in terpre ted it as the effec t o f the lesion of the gyrus fo rn ica tus
(curren tly c ingu late gyrus) of the hem isphere contra latera l to the patho log ica l
hand .
From our d iscussion, it is c lea r that the tw o signs have on ly the nam e in
com m on. The abrup t m odifica tion of the defin ition of alien hand , the m ean ing of
which w as lost in transla tion, is partly reponsib le fo r the taxonom ic confusion.
In turn , th is term ino logical tang le underm ined the possib ility o f p rovid ing a
sound in terp reta tion of eithe r o f these tw o phenom ena . W e suggest lim iting the
term ``a lien hand ’ ’ , w h ich w ell desc ribes the feeling of the hand no t being
recogn ised as one ’ s ow n, to the partia l hem iso m atogno sia reported by B rion and
Jedynak . W e propose instead the term ``anarchic hand’ ’ (D e lla Sa la, M ache tti,
& Spinn le r, 1991 , 1994) fo r the phenom enon firstly desc ribed by Goldste in
2 In a re c en t te lev is io n in te rv iew (A .A h u jia : D isco v er y C h ann e l, 1 9 97 ), B og en ack no w led ged th at
th is cho ice w as u nfo rtu n at e .
ANARCHIC HAND 193
(G oldste in , 1908 , 1909 ; see D ella Sala e t a l., 1994 for a histor ical review ), and
recen tly resta ted by Bogen (1985) and by G oldberg et a l. (1981). T h is te rm
em phasises be tter the apparen t se lf-governm ent o f the hand w hich acts at c ross
purposes to the w ill of the patien t, who , however, pe rce ive it as part o f his/he r
ow n body .
It a lso occurs to us tha t in m any instances the term ``a lien hand ’ ’ has been
used as a m isnom er to iden tify c lin ica l signs tha t have little in com m on w ith
e ither o f the tw o phenom ena as defined in the foregoing . For instance , alien
hand has been used to describe invo lun tary m ovem ents show n by pa tients
su ffering from corticobasa l degenera tion 3
(G ibb , Lu thert, & M arsden, 1989;
D oody & Jankov ic, 1992 ; R inne, L ee , Thom son , & M arsden , 1994) or o ther
FIG. 2. G o ld ste in ’ s (1 90 9 ) co ron a l ou tl in e o f th e p o stm ort em stu dy of th e br ain of the p a tie n t H M ,
w h ose an a rc h ic h and h e re po rted a yea r be fo re . T h e so ften ing (H erd ) en c roach e s u po n th e righ t
m ed ia l fro n tal a re a and in clud e s the an te rio r p a rt o f the corp u s c a llo sum . In h is p ape r, G o ld ste in
l ink ed th e le sion o f the rig h t c ing u la te g yru s (i .e . gy ru s fo rn ica tus ) to th e le ft a n a rc h ic h an d s ig n
sh ow n b y H M .
3 S low ly p rog re ssive bra in d ise as e cha ra c te ri sed b y ap ra x ia , b a lan ce p rob lem s, m y clon u s,
o cu lom o to r d iso rd er s, a k in e tic -r ig id syn d rom e , v isu oco ns truc tiv e de fi c its , a n d a tend ency of th e
p a tie n ts ’ a rm s and h an d s to lev i ta te an d o f the ir fin ge rs to w and e r like ten tac le s (G ib b , L u th e rt, &
M ar sd en , 19 89 ).
194 MARCHETTI AND DELLA SALA
degenerative d iseases like A lzheim er’ s dem entia (Ba ll e t al., 1993). The
pa tholog ica l hand of these pa tien ts is seen to w ander invo lunta rily and to
perform purpose less m ovem ents. O f ten , the arm lev itates spon taneously ,
som etim es w ith tentacula r m ovem ents o f the fingers. Furtherm ore , add ing to
the chaos of defin itions and term ino logy , M agnan i, M azzucchi, Pole tti, Scoditti,
and Parm a, (1987) m isinte rpre ted as alien hand , a grasp ing reac tion 4
shown by a
pa tien t w ith a stroke in the left m ed iofronta l reg ion . In fact, their patien t R V
never showed unw anted purposefu l actions, bu t on ly pursu it m ovem ents
fo llow ing ob jec ts in space , end ing w ith a final grip , w hich he had d ifficu lty in
re leasing. M oreover, Lev ine and R inn (1986) ca lled a lien hand the defic it show n
by a pa tien t affected by optic ataxia (the fa ilu re to reach or grasp an ob jec t in
sigh t) w ho w as unab le to exert vo lunta ry con trol on uncoordina ted m ovem ents
fo llow ing an in farc tion in the te rrito ry of the righ t poste rio r ce rebra l arte ry . A ll
these la tte r signs are d ifferen t from eithe r alien or anarch ic hand , and should be
kep t separa te in the taxonom ies of invo lunta ry m ovem ents.
The m isuse of the te rm alien hand as a m isnom er is even m ore ev ident in the
popu lar science press and in the m edia. For instance O liver Sacks in a recen t
pub lica tion ca lls ``alien ’ ’ a phan tom lim b (1995, p . 149); and in a television
docum entary (The M ind Trave ller , B BC 2, 31 O ctober 1996) he described as a
typ ica l alien hand the invo lun tary m ovem ents show ed by a patien t a ffec ted by
the Park inson-dem entia-m otorneuron d isease com plex of Guam (see R eed and
Brody, 1975).
M oreo ver, o ther signs, sim ilar to anarch ic hand , bu t due to d iffe ren t lesions,
are reported in the lite ratu re. A m ong these it is worth m ention ing the
in term anua l conflic t (B ogen , 1985 ; T anaka , Y osh ida , K aw ahata, H ash im oto,
& O bayash i, 1996) often repor ted in sp lit-b ra in patien ts, and first observed by
Akelaitis (1944), w ho labe lled it ``d iagon istic dysparx ia ’ ’ , and in terp re ted it as a
psych ia tric m an ifesta tion accom pan ied by ``sch izo id pattern on the Rorschach
test’ ’ , o r a lte rnative ly as a varien t o f the ep ilep tic fits b rough t on as a resu lt o f
surgery. T h is phenom enon consists of co-ordinated com plex actions perfo rm ed…