The Stranger in the Mirror Phenomenon

Are you caring for a loved one with dementia? You don't have to figure this out all on your own. Welcome to Truth, Lies Alzheimer's, the show that helps you reimagine a new relationship with your loved one, a relationship a little more free of stress and anxiety. Join host Lisa Skinner and her 30+ years of experience as she guides you on a new path to a better relationship with those you care for. Here's Lisa.

Welcome once again to the Truth, Lies 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 mindingdementia.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 Doones. You gotta try these, Nancy overheard her Harold saying to the mirror Harold one night. The next morning, she found two smashed up Lorna Doone cookies on the floor beneath the mirror. He'd 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 was an 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 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 as 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 visuospatial 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 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 prosopagnosia, 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, visuospatial 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 misattribution 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 themself, 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 themself and assumed it was a stranger watching them. Symptoms in 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 misreads 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 cognition 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 statements. 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 clutter-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, lighting, 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 healthcare 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." collection, 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 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 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, that was one of my 8 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 mindingdementia.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. Listen to another episode. Have a great rest of your week. Be happy, stay healthy, and I will see you again next time.

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