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Delusional Misidentification Syndromes

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Delusional Misidentification Syndromes ANALYSIS AND COMMENTARY The Masks of Identities: Who’s Who? Delusional Misidentification Syndromes Carolina A. Klein, MD, and Soniya Hirachan, MD Delusional misidentification syndromes (DMSs) are complex psychotic phenomena that may be present in a variety of ways within the context of several neurological and psychiatric disorders. Since the first case of Capgras syndrome was described in 1923, various other syndromes have been identified, including Fregoli syndrome, intermetamorphosis, subjective doubles, reduplicative paramnesia, mirrored self, delusional companions, and clonal pluralization of the self. In this article, we review each of the different syndromes in definition and presentation, as well as the field’s attempts at classifying them. We then describe their role in forensic psychiatry, particularly in regard to their potential as a marker of a particular subpopulation or of illness severity and their consideration in risk assessments of violence. A review of the literature was conducted for this purpose, and, although it was extended to include publications from over four decades, it revealed a paucity of research on DMSs. J Am Acad Psychiatry Law 42:369–78, 2014 Without wearing any mask we are conscious of, we have a drome of subjective doubles, mirrored self, delu- special face for each friend.—Oliver Wendell Holmes sional companions, and clonal pluralization of the Few concepts in psychiatry can be as confusing as the self. Misidentification syndromes show a great de- delusional misidentification syndromes (DMSs). gree of overlap and do not represent distinctive syn- One goal in psychiatry is to achieve a better under- dromes, nor can they be regarded as an expression of standing of the self: who it is, how it is organized, and a particular disorder. Evidence suggests that one type of misidentification delusion may evolve into an- how it develops and reacts to others. DMSs intro- 1 duce a multiplicity of aspects into this understanding other type. However, these syndromes merit dis- of identities and relationships, adding to its inherent tinct identification and therapeutic approaches be- cause of their possible underlying disorders and their multifaceted complexity. They are fascinating be- 2 cause they are disruptions in what we consider the potential for dangerous behavior. Furthermore, for normal integrity of the self, and for forensic experts, forensic experts, they may be instrumental in assess- interesting for how they help us understand entan- ments of risk and criminal responsibility. glements between mental health and unlawful In this article, we review the available literature behavior. regarding these syndromes. We also analyze DMSs Delusional misidentification syndromes are rare and the forensic population, seeking any correlations psychopathologic phenomena that may occur within between diagnosis of DMSs and other key concepts the context of schizophrenia or affective or organic such as dangerousness or legal underpinnings. Fi- illnesses. They include Capgras syndrome, Fregoli nally, we attempt to describe guidelines for the clin- syndrome, intermetamorphosis syndrome, syn- ical management of these patients, or for the incor- poration of this psychopathology into forensic Dr. Klein is Associate Program Director, Forensic Psychiatry Fellow- assessments. ship, Georgetown University Hospital, Washington D.C., and Chief Medical Officer, The Maia Institute, Alexandria, VA. Dr. Hirachan is Forensic Psychiatry Fellow, Western Psychiatric Institute and Clinic, Definitions and Classifications University of Pittsburgh Medical Center, Pittsburgh, PA. Address cor- respondence to: Carolina A. Klein, MD, 2050 Ballenger Avenue, Suite DMSs all carry a common classic theme of one 200, Alexandria, VA 22314. E-mail: [email protected]. person being an exact likeness of another: the sosie or Disclosures of financial or other potential conflicts of interest: None. double. They can be distinguished as hypoidentifica- Volume 42, Number 3, 2014 369 Delusional Misidentification Syndromes tions (Capgras syndrome) and hyperidentifications Leopoldo Fregoli, an entertainer from the late (the other syndromes).3 Different terminologies and 19th century, perfected a style of performance classifications have led to confusion in the past. known as protean or quick-change. He could switch Roessner4 presented a classification that included costumes and characters during his stage shows so two categories: one in which the object of the delu- rapidly that it was thought that several other Fregolis sion is physically altered (or replaced) in the patient’s must have existed for his act to be possible. Fregoli mind, and a second in which the object is doubled, syndrome is the delusional belief that one or more rather than replaced or transformed. Another pro- familiar persons, usually persecutors following the posed classification system using developmental and patient, repeatedly change their appearances (i.e., the regressive understanding has also been proposed,5 in same person assumes numerous different disguises). which DMSs are divided into two main subgroups: Intermetamorphosis is a misidentification syn- relational misidentifications (misidentification of drome in which an individual has the erroneous be- human relationships) and identical misidentifica- lief that familiar persons have exchanged identities. tions (misidentifications of identity itself, which in- In the syndrome of subjective doubles, patients be- cludes Capgras and Fregoli). Identical misidentifica- lieve that there are other persons who look like them, tions are further subdivided into divided-identity but that they have different traits and live different type, unionized-identity type, and transformed- lives. This situation has been commonly depicted in identity type. This typologic approach allows for de- movies, such as The Sixth Day,9 where Arnold velopmental understanding and the application of Schwarzenegger’s character is cloned without his regressive theories. Signer6 proposed an extension of knowledge or consent, and in TV shows, such as reverse types of misidentification syndromes, distin- Battlestar Galactica10 and Star Trek,11 where clones guished by alteration of the self rather than of others. represent the main rivals to the shows’ heroes. Mir- Beyond definitions, the phenomena have sparked rored-self misidentification involves the mispercep- human interest throughout time, as reflected in sto- tion that one’s reflection in the mirror is a stranger. ries and myths about doppelgangers, imposters, and Individuals affected with the syndrome of delusional clones. Some of these artistic examples emphasize the companions believe nonliving objects possess con- importance to human psychology of the identifica- sciousness, can think independently, and feel emo- tion of self and others and the potential ramifications tion. The movie Night at the Museum12 features ob- of wrongful identification. We briefly review the jects exhibited at a museum that appear alive to the concepts and psychopathology and offer a few illus- protagonist. Clonal pluralization of the self differs trative examples. from the syndrome of subjective doubles, in that the Capgras syndrome was first described in 1923 by patient believes that there are multiple copies of him- psychiatrists Joseph Capgras and Jean Reboul- self who are physically and psychologically similar to Lachaux. It is the most prevalent of the delusional themselves. As an example, Ranjan and colleagues13 misidentification syndromes and is described as a dis- reported a patient with schizophrenia who thought order in which a person holds a delusion that an that there were triplicate copies of herself and others. identical-looking impostor has replaced a friend, Further extensions of these core DMSs have also spouse, parent, or other close family member. One been described. Somatoparaphrenia is a subtype of can imagine this syndrome in the performance by asomatosognosia, in which patients also display de- Donald Sutherland in the movie, Invasion of the Body lusional misidentification and confabulation. It also Snatchers,7 a remake of the original 1956 science fic- involves orbitofrontal dysfunction, which distin- tion film in which humans are replaced by emotion- guishes it from asomatosognosia.14 Reduplicative less alien clones. Reverse Capgras syndrome refers to paramnesia is the belief that a place or location has the psychological change of the self as opposed to been duplicated or relocated. This is the scenario in others. A study8 found that, of 30 subjects with this the movie The Truman Show,15 where the protago- syndrome, most of the new identities were famous nist finds that his world is actually a reality TV show figures or others who were admired by the affected set. Similarly, the concept of the physical world as an person. Most of the individuals also experienced a illusion has been depicted in Vanilla Sky,16 The Thir- sudden belief or realization of having a new identity teenth Floor,17 and The Matrix.18 Other extensions of or of having rediscovered a pre-existing one. DMS have been postulated to include lycanthropy,19 370 The Journal of the American Academy of Psychiatry and the Law Klein and Hirachan Ekbom syndrome, delusional hermaphroditism,20 familiar stimuli; on the other, the preserved left delusion of sexual transformation,21 and the anti- hemisphere areas exert a positive effect from release christ delusion.22 DMSs have even been docu- or overactivity, providing a narrator from the
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