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Home , Capgras delusion, Fregoli delusion, SCAN

Case in Point She’s Not My Mother: A 24-Year-Old Man With Capgras

Tejas Chhaya, DO

This uncommon delusion is associated with varied psychiatric, medical, iatrogenic, and neurologic conditions and may be difficult to fully resolve.

any patients admitted to such in the general popu- presentation of in- inpatient psychiatric hos- lation has not been fully studied, a volves the spouse of the patient, who pitals present with de- psychiatric hospital in Turkey found believes that an imposter of the same Mlusions; however, the a 1.3% prevalence (1.8% women and sex as their spouse has taken over his Capgras delusion is a rare type that 0.9% men) in 920 admissions over or her body. Rarer delusions are those often appears as a sequela of certain 5 years.4 in which a person misidentifies him medical and neurologic conditions.1 The Capgras delusion is one of or herself as the imposter.3,5,6 The Capgras delusion is a condi- many delusions related to the mis- tion in which a person believes that identification of people, places, or CASE PRESENTATION either an individual or a group of objects; these delusions collectively This case involved a 24-year-old male people has been replaced by dou- are known as delusional misiden- veteran who had received a wide bles or imposters. tification syndrome (DMS).5,6 The range of mental health diagnoses in In 1923, French psychiatrist Jo- involves the be- the past, including major depressive seph Capgras first described the delu- lief that several different people are disorder (MDD) with psychotic fea- sion. He and Jean Reboul-Lachaux the same person in disguise. Inter- tures, generalized disorder, coauthored a paper on a 53-year-old metamorphosis is the belief that an cannabis use disorder, adjustment woman. The patient was a paranoid individual has been transformed in- disorder, and borderline personal- megalomaniac who “transformed ev- ternally and externally to another ity disorder. He also had a medical eryone in her entourage, even those person. Subjective doubles is the history related to a motor vehicle closest to her, such as her husband belief that a doppelganger of the accident with subsequent intestinal and daughter, into various and nu- afflicted person exists, living and rupture and colostomy placement merous doubles.”2 She believed she functioning independently in the that had occurred a year and a half was famous, wealthy, and of royal world. Reduplicative paramnesia prior to presentation. He had no his- lineage. Although 3 of her children is the belief that a person, place, or tory of brain trauma. had died, she believed that they were object has been duplicated. A rarer The patient voluntarily presented abducted, and that her only surviv- example of DMS is the Cotard de- to the hospital for increased suicidal ing child was replaced by a look- lusion, which is the belief that the thoughts and was admitted volun- alike.2,3 Although the prevalence of patient himself or herself is dead, tarily for stabilization and self-harm putrefying, exsanguinating, or lack- prevention. He stated that “I feel ev- Dr. Chhaya is a PG-2 resident in the ing internal organs. erything is unreal. I feel suicidal and Department of Psychiatry at the University of Cali- fornia, San Francisco Fresno Center for Medical The most common of the DMS is guilt” and endorsed a plan to either Education and Research. the Capgras delusion. One common walk into traffic or shoot himself in

38 • FEDERAL PRACTITIONER • DECEMBER 2017 www.fedprac.com the head due to increasingly distress- substance use counseling to curtail etine were not restarted. Aripiprazole ing thoughts and memories. Accord- his marijuana use. He was prescribed 15 mg daily was prescribed for his ing to the patient, he had reported a combination of duloxetine and delusions, , and visual hal- to the police that he raped his ex- risperidone as an outpatient, which lucinations. The patient also received girlfriend a year previously, although he was taking with intermittent a prescription for hydroxyzine 50 mg she denied the claim to the police. adherence. every 6 hours as needed for anxiety. The patient further disclosed that Regarding substance use, the pa- Because of the nature of his de- he did not believe his mother was tient admitted to using marijuana lusions, comorbid medical and real. “Last year my sister told me it regularly in the past but quit com- neurologic conditions were con- was not 2016, but it was 2022,” he pletely 1 month prior and denied sidered. Neurology consultation said. “She told me that I have hurt any other drug use or alcohol use. recommended a noncontrast head my mother with a padlock—that He reported a family history of a sis- computer tomography (CT) scan you could no longer identify her ter who was undergoing treatment and an electroencephalogram (EEG). face. I don’t remember having done for . In his social Laboratory workup included HIV this. I have lived with her since history, the patient disclosed that he antibody, thyroid panel, chemistry that time, so I don’t think it’s really was raised by both parents and de- panel, complete blood count, hepa- [my mother].” He believed that his scribed a good childhood with a life titis B serum antigen, urine drug mother was replaced by “government absent of abuse in any form. He was screen, hepatitis C virus, and rapid employees” who were sent to elicit single with no children. Although plasma reagin. All laboratory results confessions for his behavior while in he was unemployed, he lived off the were benign and unremarkable, and the military. He expressed guilt over funds from an insurance settlement the urine drug screen was negative. several actions he had performed from his motor vehicle accident. The noncontrast CT revealed no while in military service, such as He was living in a trailer with his acute findings, and the EEG revealed punching a wall during boot camp, brother and mother. He also denied no recorded epileptiform abnormali- stealing “soak-up” pads, and napping having access to firearms. ties or seizures. during work hours. His mother was The patient was overweight, Throughout his hospital course, contacted by a staff psychiatrist in the neatly groomed, had good eye con- the patient remained cooperative inpatient unit and denied that any as- tact, and was calm and cooperative. with treatment. Three days into the sault had taken place. He seemed anxious as evidenced by hospitalization, he stated that he The patient’s psychiatric review of his continuous shaking of his feet; al- believed the entire family had been systems was positive for visual hal- though speech was normal in rate and replaced by imposters. He began to lucinations (specifically “blurs” next tone. He reported his mood as “de- distrust members of his family and to his bed in the morning that disap- pressed and anxious” with congruent was reticent to communicate with peared as he tried to touch them), and tearful affect. His thought process them when they attempted to con- depressed mood, anxiety, hope- was concrete, although his thought tact him. He also experienced frag- lessness, and . Pertinent content contained delusions, suicidal mented sleep during his hospital negatives of the review of systems in- ideation, and paranoia. He denied stay, and trazodone 50 mg at bedtime cluded a denial of manic symptoms any homicidal thoughts or thoughts was added. and auditory . For ad- of harming others. He did not pres- After aripiprazole was increased ditional details of his past psychiat- ent with any auditory or visual hal- to 20 mg daily on hospital day 2 and ric history, the patient admitted that lucinations. Insight and judgment then to 30 mg daily on hospital day his motor vehicle accident, intestinal were poor. The mental status exami- 3 due to the patient’s delusions, he rupture, and colostomy were the re- nation revealed no notable deficits in began to doubt the validity of his sult of his 1 attempt a year cognition. beliefs. After showing gradual im- and a half prior after a verbal dispute The patient’s differential diagnosis provement over 6 days, the patient with the same ex-girlfriend that he included schizophreniform disorder, reported that he no longer believed believed he had raped. After under- exacerbation of MDD with psychotic that those memories were real. His going extensive medical and surgical features, and the psychotic compo- sleep, depressed mood, anxiety, and treatment, he began seeing an outpa- nent of cannabis use disorder. His paranoia had markedly improved to- tient psychiatrist as well as attending outpatient risperidone and dulox- ward the end of the hospitalization

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and suicidal ideation/intent resolved. emotional recognition, and impaired all cases has not been consistently The patient was discharged home to self-correction due to executive dys- demonstrated in the current litera- his mother and brother after 6 days function. ture.5,7,9,10 Patients with the Capgras of hospitalization with aripiprazole Methamphetamine also has been delusion are challenging to treat, 30 mg daily and trazodone 50 mg at implicated in a small number of cases because their delusions have been bedtime. of Capgras; the proposed mechanism shown to be refractory to antipsy- involves dopaminergic neuronal im- chotic therapy. However, antipsy- DISCUSSION pairment/loss.1,2 Additionally, Cap- chotics are currently the mainstay The Capgras delusion can pres- gras delusions have been described of treatment. Some case studies ent in several different contexts. A in cases of patients treated with an- have shown efficacy with pimozide, psychiatric differential diagnosis timalarial medications, such as chlo- tricyclic , and mir- includes disorders in the schizophre- roquine.8 Younger patients with the tazapine.6,9 nia spectrum (brief psychotic disor- Capgras delusion were more likely One case study in 2014 in India der, schizophreniform disorder, and to have purely psychiatric comor- of a 45-year-old woman who be- ), schizoaffective dis- bidities—such as schizophrenia, lieved her husband and son were order, , and sub- substance-induced , or replaced by imposters out to kill stance-induced psychotic disorder. In —as opposed her, showed a 40% to 50% reduc- addition to psychiatric disorders, the to underlying medical conditions.1 In tion of paranoia, irritability, and Capgras delusion has been shown to the case presented here, the Capgras suspicious scanning behaviors with occur in several medical conditions, delusion was thought to be due to a a combination of risperidone and which include stroke, central nervous disorder in the schizophrenia spec- trihexyphenidyl. Despite the im- system tumors, subarachnoid hemor- trum, specifically schizophreniform provements, the woman continued rhage, vitamin B12 deficiency, hepatic disorder. to have delusions.7 encephalopathy, , Because an increasing amount A notable feature associated with hyperparathyroidism, , and of evidence indicates that the Cap- those experiencing the Capgras delu- .1,2,4,7 gras delusion is associated with cer- sion is the increased risk of violent A 2007 retrospective study by tain medical conditions, a workup behaviors, often because of suspi- Josephs examined 47 patients di- should be performed to rule out ciousness and paranoia. A 2004 re- agnosed with the Capgras delusion underlying medical etiology. Of view suggested the risk of violence from several tertiary care centers. Of note, no official guidelines for the and homicidality is much higher in those patients, 38 (81%) had a neu- workup have been produced for male patients compared with that rodegenerative disease, most com- the Capgras delusion. However, of female patients with the Capgras monly Lewy body dementia (LBD).1 the workup may include brain im- delusion.9 This is despite evidence In his review of the Josephs study, aging, such as magnetic resonance suggesting that the prevalence of the Devinsky proposed that the loss of imaging and/or CT scan to rule out Capgras delusion seems to be greater striatal D2 receptors in LBD may be mass lesions, vascular malforma- in women.6,9 Moreover, patients often implicated in the manifestation of tions, stroke, or neuro-infectious demonstrated social withdrawal Capgras delusions.2 The data sug- processes; laboratory tests, such as and self-isolation prior to violent gest multiple brain regions may be vitamin B12, liver panel, HIV, rapid acts. The victims often were fam- involved, including the frontal lobes, plasma reagin, hepatitis B and C ily members or those who live with right , right parietal viruses, parathyroid hormone lev- the patient, which is consistent with lobe, parahippocampus, and amyg- els, urine drug screen, and thyroid the evidence that those most famil- dala.1,2 Most patients in the Josephs panel can be ordered to rule out iar to patients are more likely to be study demonstrated global atrophy other medical causes.1,2,6,7,9 misidentified.1,2,7,9,10 on imaging studies. One hypothesis Consultations with internal A 1989 case series that examined is that it is the disconnection of the medicine and neurology depart- 8 cases of the Capgras delusion listed to other brain regions ments may be beneficial. Although the following violent behaviors: that may be implicated.1,2,4 This re- treatment of the underlying condi- shot and killed father, pointed knife sults in intact recognition of facial tion may lead to an improvement at mother, held knife to mother’s features of familiar people, impaired in the symptoms, full remission in throat, punched parents, threatened

40 • FEDERAL PRACTITIONER • DECEMBER 2017 www.fedprac.com Capgras Delusion

to stab husband with scissors, non- sistent with the literature, which sug- reflect those of Federal Practitioner, specifically threatened physical harm gests that those with the delusions at Frontline Medical Communications to family, injured mother with axe, younger ages may have a psychiatric Inc., the U.S. Government, or any of its and threatened to stab son with etiology. agencies. This article may discuss un- knife and burn him. Seven of the Although this patient was respon- labeled or investigational use of certain 8 patients lived with the misidenti- sive to aripiprazole, the Capgras de- drugs. Please review the complete pre- fied persons, and 5 of the 8 patients lusion has been known to be resistant scribing information for specific drugs were treatment resistant. The study to therapy. It is worth or drug combinations—including indi- posited that chronicity of the delu- considering a medical and neuro- cations, contraindications, warnings, sion, content of the delusion, and logic workup with the addition of and adverse effects—before administer- accessibility of misidentified persons a psychiatry referral. Further, while ing pharmacologic therapy to patients. seemed to increase the risk of violent the patient in the presented case had behaviors. These authors went on to the delusion that he had assaulted REFERENCES suggest that despite the appearance his mother, whom he misidentified 1. Josephs KA. The Capgras delusion and its relation- ship to neurodegenerative disease. Arch Neurol. of stability, patients may react vio- as an imposter, the patient did not 2007;64(12):1762-1766. lently to minute changes.10 Overall demonstrate any hostility and denied 2. Devinsky O. Behavioral neurology. The neurol- ogy of the Capgras delusion. Rev Neurol Dis. literature seems to suggest the im- thoughts of harming her. However, 2008;5(2):97-100. portance of performing a violence given the increased risk of violence 3. Sadock BJ, Sadock VA. Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. and homicidality assessment with in patients with the Capgras delu- 10th ed. Philadelphia, PA: Wolters Kluwer; 2007. special attention to assessment for sion, a homicidality and violence 4. Tamam L, Karatas G, Zeren T, Ozpyraz N. The prevalence of Capgras syndrome in a uni- themes of hostility toward misidenti- assessment should be performed. versity hospital setting. Acta Neuropsychiatr. fied individuals.9,10 While further recommendations are 2003;15(5):290-295. 5. Klein CA, Hirchan S. The masks of identities: who’s outside the scope of this article, the who? Delusional misidentification syndromes. J CONCLUSION provider should be cognizant of local Am Acad Psychiatry Law. 2014;42(3):369-378. 6. Atta K. Forlenza N, Gujski M, Hashmi S, Isaac The Capgras delusion is an uncom- duty-to-warn and duty-to-protect G. Delusional misidentification syndromes: sepa- mon symptom associated with varied laws regarding potentially homicidal rate disorders or unusual presentations of exist- ● ing DSM-IV categories? Psychiatry (Edgemont). psychiatric, medical, iatrogenic, and patients. 2006;3(9):56-61. neurologic conditions. Treatment of 7. Sathe H, Karia S, De Sousa A, Shah N. Capgras syndrome: a case report. Paripex Indian J Res. underlying medical conditions may Author disclosures 2014;3(8):134-135. improve or resolve the delusions. The author reports no actual or poten- 8. Bhatia MS, Singhal PK, Agrawal P, Malik SC. Cap- gras’ syndrome in chloroquine induced psychosis. However, in this case, the patient tial conflicts of interest with regard to Indian J Psychiatry. 1988;30(3):311-313. did not seem to have any underly- this article. 9. Bourget D, Whitehurst L. Capgras syndrome: a re- view of the neurophysiological correlates and pre- ing medical conditions, and it was senting clinical features in cases involving physical thought that he may have been ex- Disclaimer violence. Can J Psychiatry. 2004;49(11):719-725. 10. Silva JA, Leong GB, Weinstock R, Boyer CL. Cap- periencing a prodrome within the The opinions expressed herein are those gras syndrome and dangerousness. Bull Am Acad schizophrenia spectrum. This is con- of the author and do not necessarily Psychiatry Law. 1989;17(1):5-14.

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