Second edition

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sertraline (Mendhekar and Duggal 2005), or antipsychotics
(Carrol et al. 2001); should an antipsychotic be
chosen, a second-generation agent, such as risperidone or
quetiapine, may be considered. Hypersexuality has also
been reduced by treatment with leuprolide (Ott 1995). As
noted in one of the examples above, hyperorality may be
lethal and appropriate precautions must be taken.
4.13 ALIEN HAND SIGN
The alien hand sign represents one of the most remarkable
phenomena seen in neuropsychiatric practice, or for that
matter, in the practice of medicine at large. Here, one of
the patient’s hands, almost always the left one, begins to act
as if it had an independent will of its own, often engaging
in complex activity that thwarts what the patient is
attempting to do with the right hand.
This sign was first described by the German physician
Kurt Goldstein in 1908; Akelaitis, in 1941, described it in
patients who had been subjected to corpus callosotomy for
epilepsy, and named it ‘diagonistic dyspraxia’. The current
name, ‘alien hand sign’, is derived from a French paper by
Brion and Jedynak (1972), who termed it ‘le signe de la
main étrangère’: although the authors translated this as the
‘strange hand’ sign (which is indeed a more faithful translation
from the French), English-speaking authors have
universally favored translating it as ‘alien hand sign’.
Another synonym, seen infrequently, is ‘anarchic hand’
(Della Sala 1994).
Clinical features
The alien hand sign is said to be present when one of the
patient’s hands (almost, as noted above, always the left one)
spontaneously and autonomously acts in a way that is at
definite cross-purposes to what the patient is intending to
do with the right hand (Bogen 1985a). This ‘intermanual
conflict’, as it has been termed, is not merely a matter of a
clumsy or apraxic left hand ‘getting in the way’, or of reflexive
groping or grasping by the left hand, but rather of the
appearance of complex and seemingly purposeful activity
of the left hand, activity that is at definite cross-purposes
with the patient’s consciously experienced will and intent.
Patients may be astonished to see the left hand acting independently
and outside their control, and may comment
that it is as if the left hand had ‘a mind of its own’.
Some examples of the alien hand sign will serve to flesh
out this definition. The complexity of the behavior engaged
in by the alien hand ranges from relatively simple activities,
such as buttoning or unbuttoning, to very complex behaviors,
even to the point of ‘murderous’ behavior. Examples
of relatively simple alien hand behavior include the case of
a patient, who, after an infarction of the corpus callosum,
found that after he buttoned ‘a shirt with the right hand the
left hand would proceed to unbutton it and if pulling a cup
4.13 Alien hand sign 129
of coffee toward him with the right hand the left hand
would push it away’ (Gottlieb et al. 1992). Similarly, subsequent
to a corpus callosotomy, ‘one patient was seen buttoning
up his shirt with one hand while the other hand was
following along behind it undoing the buttons’ (Bogen
1985b). Akelaitis (1945) noted that one of his patients, also
after a corpus callosotomy, ‘would be putting on her clothes
with her right hand and pulling them off with her left hand,
opening a door or drawer with the right hand and simultaneously
pushing it shut with the left hand’.
More complex behavior is illustrated in the case of a
patient who, after suffering an infarction of the corpus callosum,
‘told the story of herself frying a steak, turning it
over in the frying pan with her right hand and, immediately
after, finding herself turning it over once again with
her left hand’ (Barbizet et al. 1974; Degos et al. 1987).
Another patient, after suffering an infarction of the anterior
portion of the corpus callosum and adjacent medial
aspects of both frontal lobes, found, ‘while playing checkers
on one occasion, [that] the left hand made a move that
he did not wish to make, and he corrected the move with
the right hand; however, the left hand, to the patient’s frustration,
repeated the false move’ (Banks et al. 1989).
Finally, there are examples of a ‘murderous’ alien hand.
The first reported case of the alien hand sign, described by
Kurt Goldstein (1908), was just such an example: the
patient was a 57-year-old female with a callosal infarction
whose ‘left hand attempted to choke [her] ... and this hand
had to be pulled away. Furthermore the left hand did other
unpleasant acts, such as tearing the bedclothes off the bed’
(Geschwind 1981). The patient herself ‘complained, “Es
muss wohl ein boser Geist in der Hand sein” [There must
be a devil in my hand]’ (Hanakita and Nishi 1991). In
another case, a patient who had suffered a callosal infarction
treated her left arm ‘as an alien presence with hostile
motivations . . . she complained that the arm moved on its
own and that it struck her and tried to choke her . . . often
the hand reached for the neckline of her gown, pinched her
right arm or leg, or knocked her glasses off’ (Levine and
Rinn 1986). Finally, there is the case of a patient who had
suffered a callosal infarction (Geschwind et al. 1995) who
‘awoke several times with her left hand choking her, and
while she was awake her left hand would unbutton her
gown, crush cups on her tray, and fight with the right hand
while she was using the phone’.
Patients’ reactions to the presence of the alien hand
vary. One patient commented that ‘my hands don’t agree
with each other’ (Degos et al. 1987), and another, that her
hand ‘disobeyed her’ (Goldenberg et al. 1985), whereas a
third felt ‘as if someone “from the moon” were controlling
her hand’ (Geschwind et al. 1995). Patients also adopt different
strategies to control the alien hand: one, ‘to keep her
left hand from doing mischief, . . . would subdue it with
her right hand’ (Geschwind et al. 1995); another found the
behavior ‘so astonishing and uncontrollable that he occasionally
hit his left [hand] . . . with the right one’
(Leiguarda et al. 1989). Another patient, ‘encouraged to