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Neuropsychoanalysis: An Interdisciplinary Journal for

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Psychoanalytic Observations on the Location of

Meaning in Patients with Reduplicative Paramnesia
a

Michel Silberfeld M.D., M.Sc., F.R.C.P.

a

Assistant Professor, Department of Psychiatry, Joint Centre for Bioethics, University

of Toronto; President, Toronto Psychoanalytic Society; Coordinator, Competency Clinic,
Baycrest Centre for Geriatric Care, North York, Ontario, Canada
Published online: 09 Jan 2014.

To cite this article: Michel Silberfeld M.D., M.Sc., F.R.C.P. (2003) Psychoanalytic Observations on the Location of Meaning
in Patients with Reduplicative Paramnesia, Neuropsychoanalysis: An Interdisciplinary Journal for Psychoanalysis and the
Neurosciences, 5:2, 171-176, DOI: 10.1080/15294145.2003.10773423
To link to this article: http://dx.doi.org/10.1080/15294145.2003.10773423

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Neuro-Psychoanalysis, 2003, 5 (2)

171

Psychoanalytic Observations on the Location of Meaning

in Patients with Reduplicative Paramnesia

Downloaded by [Adelphi University] at 01:00 23 August 2014

Michel Silberfeld (Toronto)

This paper presents a clinical psychoanalytic examination of the location of meaning of the symptoms in patients with
reduplicative paramnesia. The examination is set up first by a consideration of the countertransference problemof
awareness in anotherto prepare for the views on the cases of reduplicative paramnesia. The psychoanalytic viewpoint is
then contrasted with the psychiatric and neuropsychological perspectives. These differences are used to demonstrate a
psychoanalytic standpoint in the debates about the location of meaning. Some conclusions are also drawn about the limits
of empathy, the charitable requirements for interpretation, and when interpretation is likely to be an effective intervention.

Today the programmatic benefits for psychoanalysis to heed the progress made in neuroscience are
clearer than ever. I shall take this up by providing a
psychoanalytic viewpoint on the location of meaning in reduplicative paramnesia. This will also lead
to some remarks on the role of psychoanalytic interpretation in the understanding of such patients and
the role of psychoanalytic interpretation as an intervention.
So long as psychoanalysis hopes to understand
human actions, it will always be, and must be, an
interpretive discipline. It will attempt to find out
what we have meant by what we have said. . . .
Interpretation is not subjective in a sense that
leaves truth up for grabs, or that makes it merely a
matter of one persons opinion, or that potentially
places all narratives on an equal footing. [Cavell,
1993, p. 74]

With such thoughts in mind, this paper addresses

first the countertransference problems of diagnostic
knowledge in response to a neurological patient and
then considers a psychoanalytic interpretation of the
complaints of a series of patients with reduplicative
paramnesia. These patients hold some familiar person to be a duplicatea facsimile of the real person.
I begin with the cases.

Case illustrations
Case 1: The general countertransference
problem of awareness
I made a careless mistake. Shortly after a brief
lunch, I saw a young man referred because he
was told there was no further treatment for his
pituitary tumor. His tumor was large and pressing
up into the base of the forebrain. When he came
in and sat down, I carelessly put a piece of gum in
my mouth since I hadnt had time to brush my
teeth. That was the end of the interview. He
rushed out of the room in a frenzy, running to the
cafeteria. There he emptied his wallet buying
food and eating voraciously in complete oblivion
of his surroundings. It was not possible to get him
back to my office.
It is a daunting prospect to speak to a young man
who has been told that there is no further treatment.
I was aware that the nature of his tumor indicated a
miserable terminal period and inevitable death. I
knew enough neuroanatomy to think about the immediate implications of the location of his tumor.
The ventral hypothalamic nucleus controls satiation, and the lateral hypothalamic nucleus nearby

Michel Silberfeld, M.D., M.Sc., F.R.C.P.: Assistant Professor, Department of Psychiatry, Joint Centre for Bioethics, University of Toronto;
President, Toronto Psychoanalytic Society; Coordinator, Competency Clinic, Baycrest Centre for Geriatric Care, North York, Ontario, Canada
Correspondence: Michel Silberfeld, 439 Spadina Road, Suite 305, Toronto Ontario M5P 3M6, Canada (email: competency@sympatico.ca).
My thanks to Dr. Doug Frayn and to Prof. Donald Stuss for their input into the preparation of this paper.
A version of this paper was presented at the Annual Day in Psychoanalysis, Toronto, 20 April 2001.

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172

controls food-seeking behavior (Milner 1970). Both

were compromised. I could possibly have foreseen
that the effect of my eating in front of him would
trigger an uncontrollable response.
In these circumstances, the consideration of countertransference is reasonable. Had I interpreted better, I could have overcome my countertransference
feelings to deal with this young man more effectively. I might have been able to stay with him. The
thought of his cruel demise, and the possibility of
being there with a person who was not fully aware of
implications or prognosis, seemed a lonely, daunting, and possibly unrewarding task. I had reasons (in
the form of reasons not due to loss of neural tissue)
for making myself unaware.1 They could have been
brought to my attention. I could have waited for my
gum.
In my experience, and that of others, most neurological patients do not refer themselves for psychological care.2 The chief of medical oncology
referred this patient because the oncologist was
desperate about the young mans plight. The young
man himself had not voiced any concern.3 In coming
to see a psychiatrist, he was just being compliant. If
this lack of concern were generally true, it may say
something important about the injured brains
awareness of injury to itself, regardless of the location of the injury.
We can only guess at his subjective experience
that lead him to rush out of the room to feed himself.
Because of his reported unawareness, his subjective
experience was not that the tumor is pressing on
my hypothalamus causing me to eat irrepressibly. I
feel quite certain that his subjective experience of
hunger felt natural. He likely felt very hungry and
felt recognizably compelled to eat, as we all do at
times, but irresistibly so.4 Yet, his injured brain may
not, as has been suggested, be the same as ours in
relation to awareness.
How was his experience different from ours?
Was it radically different? It is fruitful to answer
such questions by examining the relevance of an
interpretation. Had I interpreted his experience in
the light of his diagnosis, would anything have
1

This is more than a reaction, on the part of the analyst, to the dim
prospects as one may expect with cancer patients in generalthat is,
the avoidance of cancer patients where their losses are recognized. This
is a symptomatic unawareness of the losses themselves.
2
Stuss (2001, p. 10) has stated the same thing.
3
Conscious experience does not come from a passive reception of
incoming information, but involves the active construction of mental
models of the world (Stuss, 2001, pp. 1516). For Freud this was
clearly so. He saw the ability to inhibit actionpermitting information
processing leading to the development of awareness and mental structures that model the worldas modified by internal processes.
4
Freud says the following about endogenous stimuli: From these
the organism cannot withdraw as it does from external stimuli. . . .
They only cease subject to particular conditions which must be realised
in the external world (Freud, 1950 [1895], p. 297).

Michel Silberfeld

changed for him? Perhaps after he was satiated, and

possibly then capable of reflecting, an interpretation
might have been useful. But what words could have
been said and to what benefit? If indeed he did not
appreciate the source of his compulsion as stemming from his tumor, giving him a perspective on it
may have some marginal benefit in regaining selfcontrol or in the development of some compensatory strategies. Such perspective-giving is a variant
of clarification. It empowers by offering greater
understanding of the causal motives for his
behavior. However, this is not an uncovering of
unconscious motivation so much as it is information-giving. It is a biological hypothesis that postulates a bodily cause as the source of his difficulties.
This is interpreting the body to the mind.
Do we interpret the body or the mind (Cavell,
1993)? We interpret the body to the mind. People
with disabilities have losses in accordance with
their disabilities. Possibly this young man did grieve
over the loss of a subjective dimension of experience manifested by his unawareness. It is beneficial
to acknowledge and mourn losses, even if the expressions of loss and mourning are also distorted by
the disability. Even though it appears that many
brain disorders imply some disturbance of awarenessof the disorder itself, of the self, of others
there is some evidence that the adjustment to disability is ameliorated by therapeutic intervention
promoting an acceptance, leading to a relatively
better quality of life (Sinason, 1995).
Often patients like this young man are not given
the opportunity to mourn their losses. Even if no
psychological readjustment like the full mourning
of loss is possible, a therapeutic function may yet be
served by remaining present and bearing witness
(Poland, 2000). Nevertheless, generally, we do not
stay with these people. Their lack of awareness may
suit us and stimulate our desire to not be aware of
their plight.

Case 2: Reduplicative paramnesia

Because most neurological patients do not refer
themselves, my experiences with them usually begin by meeting with their relatives, most often their
partners. The partners would be grieving the illness
of their spouse. They would eventually complain
about the loss of intimacy and the confusion engendered in them by someone who externally looked
the same but now felt different. Many of the subtleties that were the product of a developed intimacy
were lost. The hunger for that lost intimacy was
profound, and this sometimes led to attempts to
restore it by developing involvements with others.
These complicated circumstances became more so

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The Location of Meaning in Patients with Reduplicative Paramnesia

when guilt about these involvements became an

additional burden for their partners, the patients.
The partners principal complaint was that their
spouse was no longer the same person. By all appearances they should be the same, but vital dimensions of subtlety and intimacy were absent. That old
familiar feeling had changed to one akin to sleeping
with a stranger. They also felt within themselves a
corresponding loss of intimacy and distancing from
their partners.
The patients complained of a classical duplication syndrome. They said that their partner was not
the same personthey looked identical to the real
partner, but actually they were someone else. The
real partner had been usurped. They retained their
appearance, and much of their behavior remained
the same, yet there was a clear presence of an
absence of a familiar being. The neurological patients themselves, in contrast to their partners, did
not complain about their subjective loss of dimensionality, but only about their partner being a duplicate and not being the original.
The striking complaints of these neurological
patients have always been viewed as entirely subjective distortions, much like a hallucination. From
my perspective, their complaints take on a wider
meaning that is easier to grasp because it matches to
some degree the experience of their partners. Yet it
is different. Is it a different expression of the same
felt loss of familiar intimacy? Or does the subjective
loss of dimensionality make it a different experience
altogether?
My claim is that both the experience itself and the
expression of it are different. There are two real
lossesone from the ravages of the illness, and the
other from the changed relationship with the partner. The duplication explanation given by the patient is not the cause of his/her experience. Also, the
patient is not seeing a double. So, where does the
choice of symptom arise?
1. For the psychiatrist, this is a delusional disorder of misidentification. The duplication is due to
holding an unshakable false belief. Patients agree
that their stated experience would not be credible
were it reported to them by someone else. The
false-belief interpretation leans on the lack of
correspondence between what the patient says and
the normative experience that mirror duplicates do
not exist. The patient is having a persistent private
experience of duplicates that imposes itself on what
would otherwise be the normal experience. This
interpretation does not say more than that the experience is not what we would naturally expect, and
that the experience is not subject to the usual constraints of what we call reality-testing. In accordance with the theory of delusions, it explains the
persistence of the patients statements but says noth-

173

ing much about their subjective experience and content.

2. For some neuroscientists (e.g., Stuss & Alexander, 1999), reduplicative paramnesia is the persistence of an affectively burnt in experience5
conjoined with an impairment of awareness. There
is the past affectively burnt-in memory (pre-illness)
and current memory (post-illness). Both memories
coexist, and the patient cannot reconcile them, due
to (usually) a right frontal-lobe deficit impairing
judgment.6 Some psychoanalysts believe that the
function of the right frontal lobe can be given a
dynamic context. Damage to this region results in a
loss of the ability to bind our fundamentally ambivalent attitudes towards the real object world, with all
its frustrations and privations, and therefore to an
inability to relate to objects in a mature and balanced way (Kaplan-Solms & Solms, 2000, pp.
197198).
Alternatively, in my view, the strength of the
burnt-in experience does not match patients current
real-time subjective experience of the other person.7 Patients do not take account of the fact that the
correspondence they are seeking with their burntin experience is actually out there. Also, the experience of the person out there is diminished by the
two losses indicated above. The subjective experience is altered by the loss of dimensionality due to
the alterations of the brain (one of the losses), and
there is a true loss of relationship.

5
This may be understood as the substrate of transference, where the
past persists into the present, mostly unaltered by experience.
6
To quote Stuss and Alexander (1999): Following James, it seems
that the existence of the two memories was based on the warmth,
intimacy, and immediacy of the two separate memories that occurred at
separate times. The persistence of the two memories is secondary to the
emotional salience and the impact of the two episodic (personal, warm,
individual) events, which in essence allows both memories to be
affectively burnt in in an individual who has impaired executive
functioning (p. 26). Freud puts it this way: If the perceptual image is
not absolutely new, it will now recall and revive a mnemic perceptual
image with which it coincides at least partly. The previous process of
thought is now repeated in connection with this mnemic image, though
to some extent without the aim which was afforded previously by the
cathected wishful idea (Freud, 1950 [1895], p. 330); While it is in a
wishful state, it newly cathects the memory of an object and then sets
the discharge in action; in that case satisfaction must fail to occur
because the object is not real but is present only as an imaginary idea
(pp. 324325); Biological experience has taught that this idea should
not be so strongly cathected that it might be confused with a perception, and that discharge must be postponed till the indications of quality
appear from the idea as proof that the idea is now real (p. 361).
7
The burnt-in experience serves as a comparator for the current
experience, as suggested by Stuss and Alexander (1999) in their
feedback system. In psychoanalysis the equivalent for the comparator
may be the internal-object representation. For me, the internal-object
representation is the object complementary part of the selfthe withinthe-skull precipitate of a relationship. For complex adaptive systems,
the cases illustrate that the feedback loop can extend beyond the skull
(Hurley, 1998).

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174

The delusion and the burnt-in recollection interpretation are aimed at the persistence of the experience. In the latter interpretation, the persistence is
due to the patients experience of a cherished
affect (Stuss & Alexander, 1999). However, the
reason for that persistence is neurologicalit is an
affectively burnt-in recollection mistakenly believed to be current. The failure to reconcile the two
memory images (pre- and post-illness) results in the
delusion of there being two objects (real and duplicate). Both the delusion and the burnt-in interpretations are meant to be subpersonal explanations for
subjective experiences. Let me extend them to be
interpretations of personal subjective experiences.
Such patients have a compelling affective
memory that interferes with the judgment of an
outside object as being the familiar object of those
feelings. This is not a disorder of perception. Furthermore, the memory is not attributed to the outside
object to which it properly belongs. The experience
is of a lack in the object to which the memory
belongs.
Both of the interpretations aimed at the persistence of the experience of duplication say little about
its content. It is on the question of content that
psychoanalysis adds a valuable additional interpretation. The content is determined by a common
(natural) experience of loss. The loss of a relationship has internal aspects (within the body of the
patient), together with a real alteration in the familiar response of the other, who cannot relate to the
changed patient in the familiar cherished way.
3. For this psychoanalyst, this is a disorder in
the experience of loss. The patients experience is
probably close to, but not the same as, that of his/her
partner. It is sufficiently close that it is within the
bounds of charity to say that the patient is reacting
in his/her own way to the same loss. The patients
own way suggests a real difference, nevertheless.
There is an incomplete awareness of what has transpired (the subjective loss of dimensionality by the
illness is unacknowledged), accompanied by a concrete explanation for the loss of relationship.
This psychoanalytic interpretation claims that the
content of the experience is determined by the normative experience of loss of love (for whatever
causes). The patient is expressing grief in an unusual way. The expression is unusual because it is
concretized, as is common with frontal-lobe alterations of the capacity for abstraction. The experience
also includes a loss of a dimension of affect,8 not
just a persistence of affective memory (of better
times). The duplication is a restorative attempt to
repair the subjective experience of loss.
8
This is also a common experience of patients with frontal-lobe
damage.

Michel Silberfeld

Why this particular choice of restoration? The

patients mind is embedded in a nonsubjective
world that gives meaning to his/her subjective experience. The patient seeks what is lost, and insists on
it. Why, then, the insistence? In part, because the
losses are not acknowledged. There is often, for a
number of reasons, a conspiracy of silence in the
surrounding community. The result is that patients
are not helped in their grieving process. Furthermore, their abnormal expressions of grief are not
recognized for what they are. Also not recognized
are the collateral losses that often occur, such as the
loss of a partner to another relationship. The psychoanalytic explanation has the advantages of being
charitable about the patients subjective experience
and of placing it within the bounds of a natural
experience known to all of us.
Denial of deficit, or denial of the implications of
deficit, in neurological patients is not subject to
psychodynamic interpretation as an intervention.
The combinations of loss of awareness and loss of
abstract capability render interpretation hollow for
these patients. They cannot accept the conventional
explanation of their experience. Furthermore, the
patients are not defended against the loss that is the
conventional reason for grief. They insist that the
conventional reason is not congruent with their experience. The patients give a reason that is not the
cause. We would be wise to accept that. At the same
time, we would be wise to accept that the loss of
their partners is a contributing cause. Without being
defended against the illness, we must accept their
experience of the loss as being in a different dimension that remains nevertheless within grasp. We can
grasp the experience of a duplicate, though not
fully. But we cannot help them with our understanding in the way that we can help their partners.
Is there any way that, with our limited grasp of
their experience, we could help the patients? Can
we make use of our limited empathy to reconstruct
their subjective experience, to account for the
changes in their processing capacity, and come up
with something beneficial? I cannot tell. The questions are useful because they put to us some limiting
case for the use of empathy and interpretation. Interpretation may overcome some limits. Perhaps these
patients have an implicit memory of what is lost. In
that case, it may be that the method of free association could be tried. There is evidence that the
method of free association is the most effective way
to recover memories that we have forgotten
(Erdelyi, 1988). This method has not been tried over
time with neurological patients, so their ability to
expand their awareness may still be untapped. The
use of free association from implicit memory could
be very interesting. It seems to me that human
progress has depended on the expansion of con-

The Location of Meaning in Patients with Reduplicative Paramnesia

sciousness to include an ever-widening range of

diverse subjective experiences (Silberfeld, 2001).

Discussion

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The location of meaning

The relationship between meaning and the subpersonal processes of the brain remains to be adequately explained. Some claim that the mind/brain
contains a model of itself and the world, so that
meanings can be held within the brain entirely in the
subpersonal realm. Others claim that, even allowing
that partial aspects of meaning can be held in subpersonal processes, meaning as a subjective experience depends on a relationship with the natural
environment. We should not confuse talk about the
mental states of a person with talk about the underlying subpersonal processes on which those personal-level mental states causally depend. . . .
Dynamic systems approaches to the mind aim to
show how cognition emerges in development from
cycles of perception, action, perception (Hurley,
1989). And, some of those cycles depend on feedback loops that extend beyond the skin into the
natural environment.
The explanation provided of patients with reduplicative paramnesia would support the role of the
natural environment in the creation and support of
meaning. Grief is a more common example. When
the feedback from the environment is lost because of
death, the brain/mind has to remodel itself.
Limits of empathy
Empathy is the stock and trade of what we, as
psychoanalysts, practice. We have to be able to
grasp the experience of our patients. This necessity
may compel us to assume that all subjective experiences are within our grasp, but a good therapist
rejects that assumption and selects a caseload consonant with his/her empathic reach. Having a good
imagination for the experiences of others can extend
empathic reach. Interpreters, like actors, can extend
their subjectivity to grasp unfamiliar circumstances
(Frayn, 1993).9 To the extent that this succeeds, we
all have to be broadly the same. We know little, and
certainly not enough, about the limits of that assumption.10 The more we know, the better we will
9
It is the analysts task to experience, organize and synthesize
aspects of his intuitive and empathic responses into some construction
initially for himself and only latterly in the way of the interpretation to
the patient (Frayn, 1993). For similar views, see Gabbard (1990).
10
The cases discussed could be a good illustration of Sterns affect
attunement (1985)a shared affect state without necessarily being a
copy of the other.

175

be at treating people. Clarifying the limits of empathy will tell us where interpretation is likely to be of
value, where it can be applied to benefit, and where
it should be avoided. Neurological patients test the
limits of our beliefs about what is within the common reach. They also challenge our beliefs about
the pervasive usefulness of interpretation.

Charity of interpretation
Subjectivity as a point of privileged access to mental contents is a basic given in psychoanalysis. Taking a radical view of this basic belief, subjectivity is
essentially private so that empathy could never fully
bridge the gap. Interpretation, on this view, is only
an imaginative construction for the purposes of
leading a person out of their solipsism. By contrast,
there is the belief that subjectivity can always be
grasped with appropriate effort. It is likely that both
views are somewhat true. Most importantly, what is
essential and ineffable about subjectivity may not be
pertinent to interpretation. What needs to be interpreted is the subjective experience of the not commonly spoken. The interpreter brings this into the
fold of shared experience, so that the patient feels
that his/her subjectivity is understood, accepted, and
now available for further therapeutic work. For the
unconscious to be made conscious, the veils supporting awareness of the unconscious have to be
lifted.
The mind is embedded in the world and not just
in the skull. Principles of charity (taking account of
the commonality of human experience), which gives
truths about the world as well as requirements of
consistencynorms of correspondence as well as
norms of patternshave a constitutive role in
relation to the contents of mental states (Hurley,
referring to Davidson, in Hurley, 1989, p. 93). Interpretable subjectivity is not unknown, or unknowable, to the community of interpreters (Cavell,
1993).
The experience of neurological patients experience is not so much prohibited as different. It may
be essentially different because the brain is altered.
The usual requirements of charity of interpretation
can only hold in part. The norms of patterns may
still hold, while the patients rules of correspondence require a more or less successful act of imagination on the part of the interpreter.

The effectiveness of interpretation

The interpretation of hidden motivation is the goal
of psychoanalytic intervention. Two forms have
been mentioned here. Making the unconscious con-

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176

scious is the prime task of psychoanalysis. Multifarious as that task may be, reasons (formerly unawareness?) for action are uncovered as causes. This
can only apply when there are reasons that are
causes of action. Sometimes reasons are not the
causes of action (as in the first clinical case). In the
latter case, interpretation offers perspectivemaking up for ignorance in the understanding of the
circumstances surrounding the actioncompensating for deficient beliefs. Both uncovering and perspective-giving are potentially empowering by
offering greater degrees of freedom to the patient.
The greater degrees of freedom are generated by the
options that come with new knowledge and increased awareness. The difference between acting
in the presence of a reason and acting for a reason
may be that in the latter case the reason is also a
cause of what is done. [It is a matter for the interpreter to provide] the right description for the purposes of causal explanation and understanding
(Hurley, 1989, pp. 9798).

Limitations of this paper

This paper treats only a very particular aspect of
psychoanalytic intervention. This aspect is not to be
equated with the entire mechanism of action of
psychoanalysis. Beneficial interventions extend beyond purely verbal interventionsthat much is well
accepted. If psychoses are understood primarily as
brain disorders, then psychoanalysis has a long history of heroic attempts to test the merits of interpersonal intervention (see, e.g, Searles, 1965). Some of
my remarks could have launched a comment on
intersubjectivity. However, that has not been my
purpose here.11 Nor was it possible for me to review
extensively the debates about the nature of the
embeddedness of the mind/brain in the natural environment.

Conclusions
My hope in writing this paper has been to show that
neuroscience and psychoanalysis do benefit each
other. I have put forward a psychoanalytic view-

11
My own view is very close to that of the early communications
engineers, such as Colin Cherry (1968), who said that there were
always three components to a communication: the two persons and the
interaction between them, treated separately as the third part.

Michel Silberfeld

point on the location of meaning in patients with

reduplicative paramnesia. Conversely, neuroscientific views can help clarify the mechanism of action
of psychoanalysis. In particular, I wanted to show
that neuroscience could contribute to psychoanalytic understanding of the appropriateness and effectiveness of interpretation.

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