The Stranger in the Mirror Phenomenon

Welcome once again to the truth lies and

Alzheimer's television show. I'm Lisa Skinner, your host, and I

have, as promised, another new episode planned for you all.

Today, I am going to be talking about a very unusual phenomenon

that happens to people, some people who live with dementia.

It's called the stranger in the mirror. Now, some of you may

have actually witnessed it, but may not have been aware that it

is a real thing. So before we dive in, I just wanted to remind

everybody that we do have updated resources and

information being uploaded continuously on the website. You

can find us at minding dementia.com so when a person

with Alzheimer's or related dementia display hallucinations,

they may see, hear, smell and even taste or feel something

that isn't there. Some hallucinations may be

frightening, while others may involve ordinary visions of

people, situations or objects from the past. Now, according to

the Alzheimer's Association, hallucinations are false

perceptions of objects or events involving their senses. These

false perceptions are caused by changes within the brain that

result from Alzheimer's disease, usually in the latter stages of

the disease. So the people may see the face of a former friend

in a curtain, or may see insects crawling on his or her hand. In

other cases, a person may hear someone talking and may even

engage in conversation with that imagined person, like you're

going to hear in this true story that I'm about to tell you,

called stranger in the mirror. Okay? Harold had been diagnosed

with Alzheimer's disease, and he lived with his wife, Nancy, who

was his primary caregiver. One day, Nancy was sitting in the

living room watching TV, and she noticed Harold ambling down the

hallway. He paused as he passed the hallway mirror, nodded at

his reflection and continued into the living room, where

Nancy was watching TV. Who's that guy? He asked Nancy Well,

she replied, What guy that older guy in the hallway? Nancy looked

down the hallway and saw the mirror. Oh, that's Harold. She

said. Oh, said, Harold shrugging his shoulders as he headed into

the kitchen. Then over the next several months, Nancy watched

Harold's relationship with his new friend, Harold blossom. She

overheard them discussing a variety of subjects, including

sports, aviation and her Harold's favorite kind of

cookie. Lorna dunes, you gotta try these. Nancy overheard her

Harold saying to the mirror? Harold one night, the next

morning, she found two smashed up Lorna dune cookies on the

floor beneath the mirror. He had actually tried to give them,

give the mirror Harold the cookies. On another day, Harold

came dashing into the living room and demanded to know where

his reading glasses were. I didn't take your glasses. Nancy

said, without even looking up from the TV, moments later, she

heard Harold's voice from the hallway. You didn't take my

glasses, did you, buddy? Nah. He said to the mirror, you're not

that kind of guy. I think you're my friend. Well, a few days

later, Nancy caught her husband looking at his feet in the full

length mirror in the hallway. He turned to her and he said,

Harold and I must be getting really close. Apparently, I gave

him my shoes. Nancy mentioned her husband's imaginary friend

at a support group that she attended regularly, and she

learned that Harold's behavior wasn't. Actual thing. It was a

common phenomenon that is called stranger in the mirror. She

joked to the group that Harold's new friend wasn't the stranger,

it was her husband that she no longer recognized as Alzheimer's

disease progresses, she learned the short term, memory

diminishes, and the person with dementia believes that they are

a younger version of themselves. They're going backwards in their

timeline. When he looked in the mirror and saw his reflection

and saw an older man, he didn't believe that that could possibly

be him, so the group's recommendation was that she

cover up the mirror or remove it altogether, or to continue to

join his reality like she had been doing by continuing To go

along with his story, Nancy went home that evening and covered up

the mirror, and then her Harold said, well, Mirror, mirror.

Harold must have found a new place to hang out, said Harold,

and then he never mentioned his name again. So this phenomenon

commonly referred to a stranger in the mirror does occur when

people with dementia misrecognize their own

reflection as a stranger or an unfamiliar person. This

experience intersects with several dementia related

cognitive and perceptual changes, including Visio spatial

deficits, also with preserved recent memory, contrasted with

impaired semantic or logical knowledge and with fluctuating

awareness. Now, as we know, dementia is a broad syndrome

characterized by progressive cognitive decline that

interferes with daily life. Therefore, within the

constellation of symptoms that we see, individuals may

experience disturbances in self perception and social

recognition. Some people with dementia even report seeing

themselves in mirrors as strangers, which can be

distressing for both the person living with dementia and also

their caregivers and family members, while not as widely

discussed as memory loss or language impairment. Mirror

recognition phenomena are clinically relevant because they

reflect the underlying neural changes and can influence

behavior, safety and emotional well being. So what exactly is

the stranger in the mirror phenomenon. It refers to a

misrecognition of one's own reflection, wherein the person

perceives the person in the mirror as being somebody else,

other than themselves. It may manifest as confusion, fear,

concern, or scripted phrases like, who is that person? Just

like Harold asked Nancy or that man is not me. There are several

variations in how people may not recognize themselves. Full

misrecognition is when the person believes the reflection

is a separate individual, like Harold did. Partial

misrecognition is when the reflection is identified but

described as being unfamiliar,

an unfamiliar version of themselves, a common response is

that they may display fear or anxiety elicited by seeing that

mirror image, sometimes accompanied by attempts to Avoid

the mirror. Contextual triggers include mirrors in certain

contexts, like bathrooms, hallways, elevators or times,

different times of the day, evening, during the sundowning

periods, may provoke the phenomenon, so distinguishing

from the stranger in the mirror phenomenon, there are also

conditions called prosopaganosia, which is face

blindness. And what happens there is a person will have

difficulty recognizing familiar faces, which can complicate

mirror recognition, but is not identical. To misidentifying

one's own reflection. They could also be having an illusion or

confabulation, meaning misinterpretations of sensory

input or fabricated memories mirror misrecognition can co

occur with these they may be experiencing delirium, which is

defined as acute, fluctuating confusion. Mirror misrecognition

can appear during delirium, but is often chronic in dementia.

Possible causes for why this occurs? First of all, due to

neurocognitive factors, physiospatial and perceptual

processing deficits, dementia, particularly Alzheimer's disease

and Lewy body dementia, can impair visual processing and

facial recognition pathways, contributing ambiguous visual

input from a reflection self awareness and metacognition,

decline is another factor, and that's the ability to attribute

thoughts and identity to the self may be deteriorating, or

may have deteriorated, weakening the sense of self and leading to

mis attribution of the reflection another one memory

and semantic or logical knowledge disruption, impairment

of logical memory can undermine stable self knowledge, making it

harder to recognize one's own image as me being themselves.

Executive dysfunction, which is difficulties with attention

monitoring and updating self related information may also be

contributing to the misidentification. Then there's

sensory integration and environment. There's mirror

ambiguity, which means reflections are dynamic,

reversible images that require integration of multiple sensory

cues in dementia, the integration process can be

faulty, leading to misperception. For some

individuals, the reflection may appear unsettling, triggering

fear based responses that reinforce avoidance or

misinterpretation. Now, I have heard over the decades many

stories of caregivers who have led the person they're caring

for into a bathroom, and then all of a sudden, and they pass

by a mirror on the way to the shower, and all of a sudden,

they just flat out refuse to take that shower. And

caregivers, unless they know about Stranger in the mirror,

can't, for the life of them, figure out, okay, what just

happened? Well, the person with dementia saw the reflection in

the mirror, did not recognize it as being themselves, and

thought, literally thought there was a stranger in the bathroom

with them who was going to watch them take their clothes off and

get into the shower, and they absolutely refused. So this is

one benefit to knowing about Stranger in the mirror, because

if that happens to you, you may realize that it's because your

person saw the reflection in the mirror and didn't recognize

themselves and assumed it was a stranger watching them. Symptoms

and dementia can vary by time of day. We call that sundowning or

arousal level influencing the likelihood and intensity of

having the misrecognition, and it definitely has an impact on

daily life. As I mentioned, it can cause distress or fear when

encountering the mirror, can lead to avoidance, withdraw or

or anxiety and agitation, repetitive questioning or

attempts to change the mirror image can occur. I've heard of

people who have actually hit the mirror out of fear because they

thought a stranger had intruded into their home. Now potential

safety concerns, if the person misinterprets their surroundings

or misread social cues during interactions, are a realistic

concern. So how do you distinguish from other symptoms?

It is. Not uncommon for this phenomenon to co occur with

other visual disturbances or delusions. So careful assessment

is needed to differentiate normal aging, mild cognitive

impairment, delirium and progressive dementia

progression. So what caregivers can do when this occurs. Here

are some immediate response strategies for you always remain

calm and reassuring, approach your person gently from the

front, avoid confrontation and acknowledge their emotions, for

example, I can see that you're that that reflection is very

confusing for you, but I'm here with you. Avoid arguing the

reality of the mirror image, arguing can only increase

distress and agitation. You can try offering a distraction or a

redirection, engage in a comforting activity or change

their environment. For example, dim the mirror, cover the mirror

briefly with a towel or a blanket, take them into a

different room, and then you always, always want to consider

their safety first, if fear or agitation leads to unsafe

behaviors like pacing or attempts to flee, provide A safe

calm space and consider supervision. There's also

environmental modifications to think about and consider

utilizing, like mirror management, so temporarily

removing or obscuring mirrors in areas where misrecognition is

frequent, using frosted or slightly tinted mirrors that can

reduce clarity, staging and orientation. You can label rooms

with simple signs and provide gentle environmental cues to

reduce the person's confusion about where they are. Consider

lighting adjustments by providing adequate steady

lighting to minimize Stark reflections and shadows that can

increase misperception. Here are some effective communication

techniques you can try use simple, clear statement avoid

negation, which can create more confusion instead of saying

that's not you try saying, Oh, that's a reflection, but I'm

here with you. Validate their feelings. I understand that this

is scary. Slow pacing. Give time for processing. Do not rush the

conversation.

Here are some behavioral and psychological consideration.

Monitor for what triggers these behaviors, the time of day,

specific environments, recent events that may precipitate the

phenomenon, screen for comorbid conditions like anxiety,

depression, visual impairment or delirium, which can worsen

perceptual disturbances. Consider medical review. If the

event is new. You've been caring for this person for a while, and

you've never seen this happen before, or increasingly

frequent, evaluate for reversible factors, such as

maybe they now have some vision impairment problems, or they

have an infection, maybe they're not adapting to a medication

that was recently prescribed, or there's some metabolic issue

going on there. So there are therapeutic and supportive

interventions available. Some examples are occupational

therapy, and they can provide strategies to cope with

perceptual disturbances and help adapt to daily routines. There's

psychological support, counseling or therapy for the

caregiver to manage stress and prevent burnout. And of course,

there's Dementia Care, training, education or communication

techniques and environmental strategies. And then finally,

other things to consider. Safety planning, assess fall risk. If

the person reacts suddenly to the mirror, it might catch them

off balance, ensure close. Or free spaces to reduce confusion,

plan for times of day when misrecognition is more likely,

and adjust their activities accordingly. Respect for

autonomy and dignity is critical, even when

misrecognition occurs, the person's subjective experience

and feelings should be acknowledged and honored. Use

non stigmatizing language, use Person Centered language, and

avoid labeling or belittling phrases related to the

misperception now, cultural beliefs can play a role about

mirrors and self image. Cultural norms may influence how

individuals interpret mirror reflections and how their family

members or even caregivers respond. So here are some

practical tools for caregivers and clinicians stay calm and non

confrontational, acknowledge their emotions, avoid arguing

about reality, assess their safety, remove immediate threats

and provide a safe space. Modify the environment the mirror. Use

lightning, lighting as needed, redirect attention to comforting

activities, document what you believe to have triggered this

reaction, the frequency and outcomes for medical teams

review their medications and medical status with the health

care providers. Use simple, short phrases and a gentle tone,

correcting the person or asserting that is you validate

again. I can see you're upset by this reflection, and I'm here

with you again. Redirect by offering a preferred activity or

a distraction. And then finally, environmental checklist. Are

mirrors present in high traffic rooms? Is lighting even and not

creating a glare? Are reflective surfaces covered or softened in

the areas of concern? Is there a consistent daily routine to

reduce their confusion. So in conclusion, the stranger in the

mirror phenomenon is a niche but meaningful expression of the

broader cognitive cognitive and perceptual changes seen in

dementia. It reflects disruptions in self perception,

visuospatial processing and emotional regulation. And while

not everyone with dementia will experience this phenomenon when

it occurs, it can be distressed. Distressing for both the person

and their caregiver. A compassionate, patient centered

approach that emphasizes safety, environmental adjustments,

effective communication and caregiver support is always

essential. So that's what I have for you today. I hope you found

that really interesting, and it is a real thing. As a matter of

fact, the story of Harold, I was one of my eight family members

that had Alzheimer's disease. That was my dad's twin brother,

and his name actually was Harold. So my aunt Nancy told me

that story years ago, and I thought it was so cute. But in

other cases, it can represent safety issues and danger to

people. This particular story was just really sweet and cute,

so that'll do it for today's episode of the truth lies in

Alzheimer's. I'm Lisa Skinner, your host, and don't forget

about visiting minding dementia.com. And look for those

updated resources and information that we provide for

you on a regular basis. I'll be back next week with another

brand new episode for you, and thanks again for joining me

today. I really appreciate you spending part of your day with

me today, and every other day that you come and listen to

another episode, have a great rest of your week. Be happy,

stay healthy and I will see you again next time bye, bye.