The Syndrome of Capgras

Abstract

The delusional belief that a close relative has been replaced by a look-alike impostor was named the Capgras delusion in honor of Joseph Capgras, who described the first case. Capgras's original patient, Mme M., had a complex mental illness with various symptoms in addition to the delusion of substitution. The focus in the literature has always been on her eponymous delusion, ignoring the rest of her condition. However, studying the substitution delusion in isolation from the rest of her illness has led to inadequate conclusions. It is necessary to understand the delusion within the broad context of her illness. Toward that goal, her mental illness is described here in detail. A particular pattern of delusions and illness is identified. This same pattern is noted in other cases of Capgras in the literature. Three new cases are reported here, each with the same overall pattern of illness that Mme M. had. This pattern is labeled the Syndrome of Capgras. A hypothesis is offered to explain the Capgras delusion within the context of this illness. [PUBLICATION ABSTRACT]

Headnote

The delusional belief that a close relative has been replaced by a look-alike impostor was named the Capgras delusion in honor of Joseph Capgras, who described the first case. Capgras's original patient, Mme M., had a complex mental illness with various symptoms in addition to the delusion of substitution. The focus in the literature has always been on her eponymous delusion, ignoring the rest of her condition. However, studying the substitution delusion in isolation from the rest of her illness has led to inadequate conclusions. It is necessary to understand the delusion within the broad context of her illness. Toward that goal, her mental illness is described here in detail. A particular pattern of delusions and illness is identified. This same pattern is noted in other cases of Capgras in the literature. Three new cases are reported here, each with the same overall pattern of illness that Mme M. had. This pattern is labeled the Syndrome of Capgras. A hypothesis is offered to explain the Capgras delusion within the context of this illness.

In 1923 Capgras and Reboul-Lachaux reported the case of a woman who had the delusion that close family members were replaced by look-alike impostors. Several years later, as other patients were observed with similar symptoms, the condition was named the Capgras Syndrome in his honor. Over the years it became apparent that it was not a unique syndrome. Rather, it was a delusion that was part of an underlying mental illness, often schizophrenia but other conditions as well, such as mood disorders or brain diseases, particularly Alzheimer's Disease.

In the decade following Capgras's original paper, two additional but rarer syndromes involving false identity and substitution of one person for another were described, the Fregoli Syndrome and the Syndrome of Intermetamorphosis. In the Fregoli Syndrome, the patient holds the belief that a persecutor takes on the appearance of various people at different times, like an actor dressing for a role. In the Intermetamorphosis Syndrome a person is transformed into another person, becoming a different individual. In 1978, the delusion of subjective doubles was described, in which the patient believes that a copy of herself exists elsewhere. Five years later, it was reported that the Capgras delusion and the delusion of subjective doubles frequently occur together as they did in the original 1923 case (Berson 1983; Sinkman 1983). More recently, this whole group of delusions has been labeled the Delusional Misidentity Syndromes (DMS). Since then, numerous case reports have appeared in which patients have delusions of identity that are variants of the original named syndromes or are new types of misidentity delusions (Mojtabai 1998). At this point, with the ever growing expansion of the DMS, it is worthwhile to turn back to the original case report from 1923 to see if any new light can be shed on these misidentity delusions.

In reviewing the original case described by Capgras, it becomes apparent that the patient had significant clinical findings in addition to the delusion that her close family members were replaced by impostors. In order to clarify these factors, a summary of the original case report is presented (Capgras Sc Reboul-Lachaux, 1923).

Mme M. was a 53-year-old married woman with a 10-year course of psychosis. She had been hospitalized for the preceding five years, ever since she went to the police and made bizarre statements, complaining that a large number of children were imprisoned in the basement of her house as well as all over Paris. She asked the police to free the children. The central feature of the patient's illness was a very elaborate delusional system with two main themes: 1) She had been substituted at birth and was not really herself but an heiress to a great fortune; and 2) There was an elaborate plot against her that involved thefts and poisonings as well as substituting one person for another and making people disappear. The substitution of duplicates involved all members of her family including herself, as well as many others in her environment. Many thousands of people were replaced, and these imposters tormented her. Aside from being excited when first hospitalized and being very talkative when complaining about her delusions, the patient was calm and isolated, completely idle and not aggressive. Her thought patterns were disorganized. She was hallucinatory. She noticed changes in her own appearance that were not there. She also noted minor changes in other people's appearances which convinced her that these people were not who they claimed to be.

In summary, the delusion of substitution of her family members was a small but striking part of a severe mental illness that was marked by numerous delusions. These included the delusions that 1) her identity was changed and that she had a double; 2) numerous impostors were present, not just her close relatives; 3) she was persecuted in various ways; and 4) there were changes in her body and appearance.

There are other cases in the literature that are similar to Mme M. 's They are cases of very ill schizophrenics with paranoia, multiple misidentity delusions including the Capgras delusion, and somatic delusions that are often quite bizarre (Fialkov Sc Robins, 1978; Koritar Sc Steiner, 1988; McLaughlin & Sims, 1984; Mulholland Sc O'Hara 1999; O'Reilly Sc Malhotra, 1987; Voros, Tenyi, Simon, & Trixler, 2003). There are many case reports of patients with the Capgras delusion with some but not all of these additional clinical findings. For example, there are patients who have somatic delusions along with the Capgras delusion (Kourany and Williams 1984; Signer and Benson 1987). Also, it is well known that several misidentity delusions can be present together in the same patient (particularly the Capgras and subjective doubles delusions). Clearly, there is a group of patients with severe schizophrenia who are like Mme M., the original Capgras patient. They show various aspects of her illness, not just the delusion of substitution limited to a close relative. One could say that they have the broader syndrome of Capgras, not the narrower delusion of Capgras.

I have encountered several patients with this expanded Capgras syndrome and present the clinical findings of three.

CASE PRESENTATIONS

Diane

Diane was a 28-year-old single woman who was seen for an evaluation at a day hospital program in preparation for discharge from a psychiatric hospital. This was her third psychiatric admission in the past five years. Always shy and reclusive, Diane first became psychotic at age 23. Following an examination by her physician, she began to worry that the doctor had damaged her internally and that she might never be able to become pregnant. Subsequently, she developed erotomanie delusions about a customer at a fast-food restaurant where she worked on a summer job while in college. She began to believe that he was following her around and that he was changing his appearance from day to day, looking different each time. As she became increasingly preoccupied with him, she could not function and her condition deteriorated. She withdrew from college, became hostile, suspicious, and withdrawn, and began acting bizarrely. She was also increasingly preoccupied by the belief that her physician had changed her body and re-arranged her internal organs, such as moving her esophagus in front of her larynx. She was finally hospitalized when she threatened to cut off her foot because of the delusion that the foot was being tampered with at night. In the hospital it was noted that she had a formal thought disorder and auditory hallucinations.

The patient's condition improved with neuroleptic treatment but deteriorated after discharge because she refused medication. When she was admitted eight months later, she presented with delusions that a man was making exact copies of people - "screens" and that there were two screens of her, one evil and one good. The diagnosis was schizophrenia with Capgras delusion. She was disheveled and had a bald spot on her scalp from self-mutilation. Her affect was blunted, and she was guarded and suspicious with a severe thought disorder. She had the delusion that a doctor was actively manipulating her feet, spine, and hips and that her internal organs had been damaged.

After discharge, she remained ill for the next two years, refusing medication. She remained at home, reclusive and odd, disorganized, unable to function, and delusional. She was finally readmitted after a two-week course of increasing agitation and disruption of her home. When seen by us after a few weeks in the hospital, she had an odd appearance and manner, a formal thought disorder, and numerous bizarre delusions, including the belief that her father was an impostor the impostor was shorter than her real father. In addition, she felt that "every person has a twin in the world. You are someone else every day." She believed that she had a twin. In addition she stated, "I could look like anyone; it's remarkable." Other delusions of misidentity were present; for example, many people changed into looking like her friend Kenny. She said, also "The real Donald Imus [radio personality] is a psychiatrist," and later told me that "Boy George was made up to look like you." There were delusions of persecution involving a group of tormentors who used radios ("they took everyone's memories"), as well as a doctor who secretly operated on her, making bizarre changes to her body. The doctor came to her in the middle of the night and manipulated her bones, changing her into someone else. In another operation done in her home, a ten-foot-long piece of intestine was removed from her body. Other delusions included the belief that people's appearances were changed by lifting up the jaw and using collagen; bodies were manipulated by using strings; there was a sex party that was on TV and made into a movie; she was pregnant; she was married in the middle of the night.

Peter

Peter was a 62-year-old single man who came to the emergency room seeking admission for anxiety. He was admitted because he was unable to care for himself and was quite confused, with a multiplicity of bizarre delusions and a marked disturbance of his thought patterns. He had been sick with paranoid schizophrenia since age 21, was unable to work, and had been on disability for many years. There had been numerous psychiatric admissions, some prolonged, with a steady downhill course in his condition over the last five years, partially the result of medication non-compliance. When admitted, he was malodorous, and he showed an odd manner, a severe formal thought disorder with neologisms, loose associations approaching word salad, and auditory hallucinations. Peter was preoccupied with numbers. Various delusions were present. These were variable and fragmented but with several themes: he was persecuted by a neighbor (Robert), and controlled and influenced by God. There were changes in his body, and people's identities were changed. Everyone had a twin or "robot." Most often he would say that the robots were in heaven, but sometimes the people in this world were robots. His doctors were robots. At other times, he stated that the doctors were disguised as patients. Robert came in three forms: black, brown, and white. He stated, "The boys are drones and the girls are clones." He often spoke of his own "twin" or "copy" in heaven, "Pete." God would speak to him through Pete's voice. At other times, he said that he was a robot, once "a robot with a purple light in his chest." The man in the photo on the front page of the newspaper was his twin. Regarding his twin in heaven, Peter stated, "God changes the shape of the head, the identity. No one knows why. The difference is inside the back of the ankle. The amount of glue needed to tape the robot together. I'm not only Sampson; I'm Moses." The patient's main somatic delusion was that he had cancer in various parts of his body. In addition, he had such ideas as, "God takes the steel and puts it through my stomach, adds chemicals; it turns back to oxygen." He also believed that figures in heaven "set up an alarm in my head. Trigger it once a day . . . send a pain into my stomach." Neuropsychological testing showed mild cognitive impairment that was attributed to his severe psychosis. The patient was treated with various neuroleptics without success and finally had a mild positive response to clozapine. After many months in the hospital, he was transferred to a long-term care facility.

Charles

Charles was a 48-year-old man with a long history of chronic mental illness with numerous psychiatric admissions who was disabled and receiving a pension for schizophrenia. He was brought to the hospital on an emergency basis for a medical evaluation after reporting to the staff of his residence that he had accidentally swallowed glass. In fact, this was a delusion. He believed that there was an "aggregate support" in his back that had been blown to pieces and bits of glass were coming out of his penis. Afterwards he claimed that there was a gold and plastic form, the shape of his torso, in his back. It had been placed there by the president of Japan. He had various other delusions, including that his parents were replaced by look-alike doubles and that the medications given to him at the residence were incorrect; they had been switched, as had the food. The staff and the other residents were impostors. He claimed various identities at different times, including an admiral in the Navy, the marine commandant, a fighter pilot, and a government spy on a secret mission. He believed that the police employ wet suits made in Germany that can "look like anyone." When first admitted, he was withdrawn and odd with loose associations, a severe formal thought disorder, and inappropriate affect. After several weeks on medication, his condition improved somewhat.

DISCUSSION

These severely ill chronic schizophrenic patients had the Capgras delusion of substitution of close family members as well as the four other delusions that were present in Mme M: 1) her identity was changed and/ or she had a double; 2) numerous impostors were present, not just her close relatives; 3) she was persecuted in various ways; and 4) there were changes in her body and appearance. These patients clearly meet the criteria for this expanded syndrome of Capgras. They provide additional evidence that this syndrome is a distinct clinical entity.

Further exploration of these cases will give us a better understanding of this syndrome.

(1) The patients had a variety of misidentity delusions, not just the Capgras delusion. For instance, at the onset of Diane's illness five years earlier, she also had the Fregoli delusion that her imagined lover was taking on various disguises. These delusions evolved, disappeared, and changed over time. At times, they were fragmented and distorted by loose associations. What was most striking was the multiplicity of misidentity delusions not the Capgras delusion. At times, the Capgras delusion appeared in modified form. For instance, Peter had the Capgras delusion that his doctor and others had been replaced by duplicates, but this was fleeting, and instead he would just say they were "robots." He did not point out the non-existent small differences that Capgras patients often do, and he only rarely mentioned the act of replacement. (2) In these cases the Capgras delusion occured within the context of severe schizophrenia marked by profound disturbances in functioning and by multiple delusions. The Capgras delusion was one of many delusions. It was not the focus of the illness nor did it stand out from the other delusions. It was part of the process of schizophrenia, not apart from it. (3) The patients graphically described the very bizarre way in which they experienced their bodies and changes made to their bodies by external forces. Their physical bodies and even their whole selves had become odd and alien to them-such as Peter calling himself a robot. Each patient's sense of self had become disrupted and delusional. The somatic delusions and the delusion of subjective doubles both seemed to be manifestations of the same process, that is, the fragmentation and breakdown of a stable mental representation of the self and its replacement with delusional constructs. This identity diffusion and loss of ego boundaries, traditionally understood as hallmarks of schizophrenia (Andreasen, 1999; Frith, 1992; Hemsley, 2005; Pamas & Handrest 2003), were dramatically evidenced in these severely ill schizophrenics.

Over the years, various theories have been proposed to explain the Capgras delusion, ranging from neurological approaches to psychodynamic ones. Trying to apply these theories to explain these new cases and the expanded syndrome of Capgras is problematic, as described below.

The most widely held explanation for the Capgras delusion is that there is a brain lesion that interferes with the patient's ability to sense a familiarity toward the significant other, while the ability to identify that person is intact. Also widely promulgated is the psychodynamic theory that posits that the delusion is a way in which the patient deals with the ambivalent emotions that he feels toward the close family member who is duplicated. The patient denies he is angry at the close relative and instead claims that the anger he feels is being expressed at an impostor. He feels only love towards the missing original relative.

These theories explain a single delusional impostor, one that is a close relative of the patient. There is no attempt to explain how numerous delusional impostors develop, some of whom involve people who are relatively unknown to the patient. Nor do they explain the delusion of subjective doubles or the somatic delusions. These theories are explanations for the Capgras delusion taken out of the context of the patient's overall illness. They address only the delusion of replacement of a close relative and ignore the patient's other similar delusions. For the kind of patient described here and for Mme M. these theories are inadequate. A better explanation is needed.

A possible explanation is offered here. These various delusions are understood as the manifestations of a single underlying process, the breakdown of the patient's ability to evoke and use appropriate mental representations of people, including both self and others, that occurs in schizophrenia. The delusions are the patient's attempt to describe and rationalize the bizarre subjective experience of mental fragmentation, unreality, and disorganization (Maher, 1988). No attempt is made here to explain how each separate delusion develops. Rather, the focus is on the process that underlies all of the delusions, the loss of ego boundaries. This approach satisfies the rule of parsimony. In contrast to this approach is the pattern in the literature to identify and catalogue new DMS variants and give them each separate names and explanations. Similarities between delusions are ignored, and the focus is on minor differences. A case in point is the recent description of "clonal pluralization of the self," a new type of DMS variant that is almost identical to, yet slightly different from, the Capgras delusion (Ranjan, Chandra, Gupta, Sc Prabhu, 2007; Voros, Tenyi, Simon, Sc Trixler, 2003)). Ranjan's case report of this condition focuses on the newly described delusion and ignores the fact that the patient also had various other misidentity delusions (including the Fregoli and Intermetamorphosis delusions) as well as somatic and persecution delusions. The case is extremely similar to Mme M. 's and the patients reported here, meeting all the criteria outlined above for the Syndrome of Capgras. Yet, Ranjan and his coauthors, by focusing on clonal pleuralization and excluding from consideration the rest of the patient's symptoms, missed the forest for the trees.

The hypothesis presented here is that in a patient with schizophrenia a misidentity delusion can develop as part of the process of schizophrenia. Rather than being a unique feature occurring in rare cases, it is fundamental to the illness. In support of this is the fact that misidentity delusions are more common in schizophrenia than is usually appreciated. For instance, Cutting stated that in his series of schizophrenics "no less than 40% have some form of delusional misidentification" (Cutting, 1994). Other studies have shown a high frequency as well, although not to the same degree (Dohn & Crews, 1968; Kirov, Jones, & Lewis, 1994; Mojtabai, 1998).

This hypothesis is an attempt to explain the development of the delusion of substitution in patients with schizophrenia. What about the process leading to this delusion in patients with other kinds of mental illnesses? It seems to be very different. The Capgras delusion appears to be a final common pathway with many different roads converging to get there, akin to what happens in endstage renal disease. In support of this is the observation that in these non-schizophrenic patients the form of the Capgras delusion is often very different from the way it presents in the kind of patient described here. For instance, in many patients with organic brain disease, the patient does not display any paranoid, angry or suspicious feelings towards the impostor.

The defect in brain functioning that causes these Capgras patients with schizophrenia to be unable to evoke appropriate mental representations of self and others is unknown. However, some hints can be found in the work of Goldman-Rakic who identified and described the problem in mental representations that occurs in schizophrenia. She showed how this problem was a result of deficits in frontal lobe functioning (Goldman-Rakic 1994). If her findings can be extended to include the kind of problems in mental representations described here, then a question is raised. Are the misidentity delusions in these patients a result of pathology in the frontal lobes? There is in fact evidence of impairment in the frontal lobes in DMS patients. Alteration in neuropsychological functioning in the frontal lobes has been demonstrated (Papgeorgiou, Ventouras, Lykouras, Uzunoglu, & Christodoulou, 2003). Also, bilateral atrophy of frontal and temporal lobes on neuroimaging has been shown (Joseph, O'Leary, Sc Wheeler, 1990). Carrying this speculation one step further leads to the idea that the loss of ego boundaries in schizophrenia is a result of frontal lobe pathology. In support of this is the evidence for a predominant role of the right prefrontal cortex in providing for self-awareness (Keenan, Wheeler, Sc Ewers 2003).

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