3rournal ofNeurology, Neurosurgery, and 1995;58:499-501 499

SHORT REPORT J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.58.4.499 on 1 April 1995. Downloaded from

Shared of doubles

G N Christodoulou, M M Margariti, D E Malliaras, S Alevizou

Abstract Folie a deux, on the other hand,6 is a rare This is the first report of two partners in phenomenon in which two closely associated a folie a deux situation manifesting iden- persons share the same delusions. Four sub- tical Capgras delusions. It is postulated types have been described. The most frequent that the Capgras syndrome developed as is folie imposee, in which one partner is a result of interaction between a domi- usually dominant and active and the other nant patient with primarily paranoid one is passive, submissive, and suggestible. psychopathology and a submissive one with primarily organic dysfunction. The submissive "neuro-organic" partner Case report experienced a non-delusional misidenti- The dominant partner was a 54 year old, fication that acquired a delusional com- obsessional, stubborn and touchy, but also ponent and developed into the Capgras sociable and warm widow, mother of two syndrome as a result of elaboration by children, with a family history of , the dominant paranoid partner, who who started being delusional in 1971, shortly subsequently "imposed" the Capgras after her husband's death, which she attrib- on the submissive partner. The uted to poisoning. She continued to express submissive patient, and, to a lesser similar ideas, particularly in relation to her extent the dominant patient, had evi- neighbours and her relatives. dence of organic cerebral dysfunction. The submissive partner was her daughter, a pleasant, good looking, loyal, and obedient (7 Neurol Neurosurg Psychiatry 1995;58:499-50 1) law student of 24, with limited social inter- action. She was closely associated with and dependent on her mother. She became an

Keywords: Capgras syndrome; delusions of doubles; active participant in her mother's misinterpre- http://jnnp.bmj.com/ folie a deux; organic dysfunction tative behaviour in 1988 when she started accusing her neighbours and misinterpreting Both the Capgras delusion (delusion of the behaviour of her grandmother and aunt, doubles) and folie a deux are rare conditions always in keeping with the beliefs of her and their combination is even more rare. In mother. fact, a shared Capgras delusion in the setting In 1989 she informed her mother that her of folie a deux has never been reported in the teacher in English had the ability to change medical literature. This occurrence provides her facial characteristics. Similarly, she on October 2, 2021 by guest. Protected copyright. the opportunity to study the step by step reci- reported that the characteristics of a girl at procal reinforcement of two partners (one of school kept changing ("at times her hair is them contributing her misinterpretative psy- short and at other times it is long"). She was chopathology, the other one her organicity) amused by these changes, by contrast with eventually to develop a shared Capgras delu- her mother who became very upset and made sion. Furthermore, it supports the view that her discontinue her English lessons and stop Athens University organic participation is important in the seeing the girl with the hair transformations. Departnent of Psychiatry, Eginition pathogenesis of the delusional misidentifica- Some months later, financial help was Hospital, Athens, tion syndromes. requested from the aunt but this was refused Greece The Capgras syndrome' is the delusional because of short notice. This produced G N Christodoulou negation of identity of a familiar person and further in the daughter's relation- M M Margariti aggravation D E Malliaras the conviction that this person has been ship with her aunt who complained to her S Alevizou replaced by a physically identical double. It is mother that she did not behave "like a real Correspondence to: a variant of the delusional misidentification relative". Professor G N Christodoulou, Department syndromes, the other three subtypes being the In June 1991 the mother's delusions of Psychiatry, University of syndrome of Fregoli, the syndrome of inter- became more pronounced. She accused her Athens, Eginition Hospital, 74, Vas Sofias Avenue, metamorphosis, and the syndrome of subjec- neighbours of stealing various objects and 11528 Athens, Greece. tive doubles.23 There is evidence that organic decided to sue them. The daughter, who Received 5 July 1994 factors play a major part in the pathogenesis sided with her mother, as always, was sent to and in revised form 3 October 1994 of these syndromes45 although all Capgras her aunt to ask her to appear in court as a Accepted 14 October 1994 cases cannot be explained on this basis. witness. On return, she stated that the aunt 500 Christodoulou, Margariti, Malliaras, Alevizou

appeared physically "different". The mother 108, performance 72, mean 92), which is was now convinced that her sister had been again a probable indicator of neuro-organic J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.58.4.499 on 1 April 1995. Downloaded from replaced by a different, identical looking per- dysfunction. The age graded subtest scores son and that this must have happened in were as follows: information 13, compre- 1942, during the German occupation, when hension 12, arithmetic 9, similarities 10, digit the Germans put other people in the place of span 11, vocabulary 14, digit symbols 7, her relatives. The daughter agreed. The picture completion 3, block design 7, picture mother also started expressing doubts about arrangement 5, object assembly 4. The the identity of her son. She said that "this patient had a particularly low score in the boy" has been behaving irresponsibly by stay- arithmetic subtest of the verbal scale which ing out late at night (contrary to her real son's tests immediate recall, concentration, atten- behaviour). She examined old photographs of tion, and conceptional manipulation. All her son, discovering differences and together, scores in the performance scale were low, mother and daughter, decided that the substi- particularly the picture completion subtest, tution of her son by his double must have which is a test of visual recognition. The sub- happened in 1983, when he first started "mis- scale distribution showed deterioration of the behaving". intellectual abilities of the patient, which They gradually discovered that the double could not be attributed to functional distur- was not just one person. Almost every day, a bance, as the subscales that are sensitive to different person appeared claiming to be the functional disturbance (comprehension, pic- son. They all had similarities but some facial ture arrangement) were within the normal characteristics were different. Mother and range. The Rorschach test did not show dis- daughter eventually started worrying about turbance in reality testing. A drug induced the fate of the real son. sleep EEG and an EEG after sleep depriva- At Christmas 1991 they had an open dis- tion showed abundant paroxysmal bursts of cussion with the double and asked him to slow waves, within the theta and delta range, leave the house. They also reported to the as well as spike like formations, with definite police the disappearance of the son, incrimi- left preponderance more pronounced in the nating his double. frontal-temporal area. Brain CT was normal. The patients were eventually admitted to The patients were on neuroleptic treatment hospital under a compulsory admission sec- when the psychological tests and EEGs were tion after an application by 25 neighbours carried out, but the abnormalities detected and an arson attempt on the neighbouring were qualitatively and quantitatively different apartment. from those that might be attributed to the On admission the mother expressed her influence of neuroleptics. Both patients conviction that she and her daughter had were treated with neuroleptics and carba- been admitted to hospital to be executed. She mazepine. To secure their cooperation they refused to be placed in a different ward to were originally admitted to hospital in the that of her daughter and warned the staff that same ward but after three months the daugh- she would not cooperate if her request was ter was transferred to the day hospital. not satisfied. Originally the patients refused to see any of Physical examination and routine labora- their relatives except the mother's sister, iden- tory tests were normal. Benton's visual reten- tified as a "friend", and their attitude towards http://jnnp.bmj.com/ tion test and Rey's copy of a complex figure the son was reserved and at times hostile, but test showed evidence of disturbance of visual two months after onset of treatment they retention and visual-spatial ability suggestive became more tolerant of him and agreed that of organic cerebral dysfunction. Wechsler's the mother's sister might indeed be more adult intelligence test (WAIS) showed a ver- than a mere "friend". bal IQ of 86, a performance IQ of 79, and a Shortly after separation from her mother,

mean IQ of 82. An EEG after sleep depriva- the daughter's indifference gave way to her ex- on October 2, 2021 by guest. Protected copyright. tion was normal, with the exception of rare pressed wish to resume her law studies. Both theta and delta waves, more pronounced on patients agreed to see the son but they showed the left. Brain CT was normal. no positive feelings when he visited them. The daughter was anxious on admission Six months after admission, both patients and kept close to her mother. She expressed agreed to have the son live with them. When ideas of persecution and delusions of doubles, asked who he was, the mother expressed identical in content to those of her mother. doubts about his identity but she was not Physical examination and routine laboratory as adamant as before. The daughter differen- tests were normal. Benton's visual retention tiated herself from the mother for the first test and Rey's copy of a complex figure test time by stating that he was indeed her showed pronounced disturbances of visual brother. She also "explained" that she had retention and visual-spatial ability, indicative to side with her mother because, otherwise, of organic cerebral dysfunction. More specifi- like her brother, she would have been cally, there was a difference of 3 points below thrown out of the house. On discharge, the expected score in Benton's test (form C), neither of the patients had obtained full 6 points below the expected score on form D, insight but they agreed to continue with their and a score of 13 in Rey's test (normal range medication. for the patient's age group: 18-34). The On follow up, one year after discharge, the WAIS showed a difference of 36 points patients were free from delusions and contin- between verbal and performance IQ (verbal ued their "a deux" existence. Shared delusions ofdoubles 501

Discussion appearance of the English teacher, the mother The coexistence of the Capgras syndrome reacted with increased suspicion but did not J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.58.4.499 on 1 April 1995. Downloaded from with folie a deux is very rare. To our know- develop the delusion of doubles at this stage. ledge, only two such cases have appeared in This is not solely because a maturation the medical literature, but in one of them7 the process is necessary for the manifestation of patients really manifested not the Capgras the syndrome in its fully developed form but delusion but the syndrome of subjective also because the emotional attitude of the doubles8 and in the other case, as pointed out patient towards the teacher was neutral. It by the authors themselves9 the submissive was later, in association with persons closely partner did not really maintain his mother's related to her emotionally (sister, son), that Capgras delusion. It seems therefore that the she developed the syndrome. This is in keep- case we have described is the only report of ing with previous clinical findings4 and pro- shared Capgras delusions in a folie a deux vides some support for the psychodynamic setting. This underlines the rarity of the hypotheses that consider the syndrome as a combination, which is not surprising in view solution to the problem of the patient's of the rarity of its constituents. ambivalence towards the misidentified per- The folie a deux psychopathology, in the son.3 Ambivalence, however, can function case we have described, was clearly initiated only as a precipitant and neuro-organic by the paranoid dominant partner, the factors are aetiologically more relevant. mother. Her submissive daughter resisted for It is important to note that for both our a while but eventually adopted her mother's patients there was evidence of cerebral delusions fully. Thus this case has many char- organic dysfunction, revealed by Benton's acteristics of the "folie imposee" type.'01' and Rey's tests in the case of the mother and With respect to the development of the by Benton's, Rey's, and the WAIS tests, as Capgras delusion, on the other hand, it was well as by the EEGs in the case of the daugh- the daughter who initially took the lead. It ter. This is in keeping with many relevant was she who started misidentifying first publications reviewed by one of us,4 which (English teacher). Her misidentifications, consider the syndrome of Capgras as result- however, were non-delusional. They became ing from delusional elaboration of experi- delusional under the influence of the para- ences produced by cerebral dysfunction. noid mother. The daughter adopted them and both mother and daughter elaborated on 1 Capgras J, Reboul-Lachaux J. L'illusion des sosies dans them further. un delire systematise chronique. Bulletin de la societi It is important to note that it was the part- clinique de Midecine Mentale 1923;11:6-16. 2 Christodoulou GN. The Delusional misidentication syn- ner with the neuroorganic dysfunction who dromes. Basel: Karger, 1986:VIII-IX. contributed the misidentification, and it was 3 Enoch D, Trethowan W. Uncommon psychiatric syndromes, Bristol: John Wright and Son, 1991:1-23. the patient with the paranoid component who 4 Christodoulou GN. The Delusional misidentification syn- provided the delusional elaboration of it. dromes. BrJ Psychiatry 1991;159(suppl 14):65-9. 5 Ellis HD, De Pauw KW, Christodoulou GN, Thus it was their interaction that produced Papageorgiou L, Milne AB, Joseph AB. Responses to the delusional misidentification. It is possible facial and nonfacial stimuli presented tachystoscopically in either or both visual fields by patients with the that independently, neither of them would Capgras delusion and paranoid schizophrenics. J Neurol Neurosurg Psychiatry 1993;56:215-9. have manifested the syndrome of Capgras. http://jnnp.bmj.com/ 6 Lasegue C, Falret J. La folie a deux ou folie commu- The daughter would probably have mani- niquee. Ann Mid-Psychol (Paris) 1877;18:321. fested a non-delusional misidentification, in 7 Hart J, McClure GMG. Capgras' syndrome and folie a deux involving mother and child. Br J Psychiatry keeping with her organic dysfunction, and the 1989;154:552-4. mother would have continued to express her 8 Christodoulou GN. Syndrome of subjective doubles. Am J Psychiatry 1978;135:249-51. paranoid delusions, in keeping with her para- 9 Signer SF, Ibister SR. Capgras syndrome, de noid . Clerambault's syndrome and folie a deux. Br J Psychiatry 1987;151:402-4. It is interesting to note that the mother did 10 Malliaras DE. Folie a deux. University of Athens, Athens: not elaborate on the daughter's misidentifica- Kovanis, 1969. (Thesis.) on October 2, 2021 by guest. Protected copyright. 11 Christodoulou GN. Two cases of "Folie a deux" in tions right from the beginning. When the husband and wife. Acta Psychiatrica Scandinavica 1970; daughter first reported the changes in the 46:413-9.