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A Case of the Body Snatchers Rajni Dulai, MD, and Sonya Lee Kelly, MD

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A Case of the Body Snatchers Rajni Dulai, MD, and Sonya Lee Kelly, MD Cases That Test Your Skills A case of the body snatchers Rajni Dulai, MD, and Sonya Lee Kelly, MD How would you Mrs. P believes spirits that reside within her are continually handle this case? replacing her body parts. She demands exorcism, not Visit CurrentPsychiatry.com to input your answers antipsychotics. How can she be helped? and see how your colleagues responded CASE Spirits replacing body parts Mrs. P’s symptoms are most consistent with: Mrs. P, age 63, is admitted involuntarily to our a) bipolar disorder with psychotic features b) schizophrenia inpatient unit after elopement from another ® Dowden Healthc) schizoaff Media ective disorder-bipolar type emergency room the prior day. For several d) delusional disorder weeks she had been leaving her house multiple e) organic pathology timesCopyright and wanderingFor the personal streets in the middle use only of each night. The authors’ observations Mrs. P is experiencing auditory and visual Mrs. P demonstrated symptoms consistent hallucinations of evil spirits and religious and with both mood and thought disorders. hypersexual delusions. She cannot recognize Her symptoms of pressured speech, gran- her face and believes her voice has been re- diosity, hypersexuality, and decreased need placed by another’s. She also thinks that her for sleep suggest a manic episode in bipo- face, nose, lips, voice, and abdomen are not her lar disorder. The thought disorganization, own. She believes evil spirits that reside within delusions, and hallucinations were in line her body are continuously replacing her body with psychosis. parts. She claims these spirits inhabit her left vaginal wall, deposit money there, and are sex- ually assaulting her each night. She feels that a HISTORY Failed medications constant battle between good and evil spirits Mrs. P was fi rst hospitalized at age 29 and has occurs within her body. She is very angry and had multiple inpatient admissions for mania, states she does not need medication but rather depression, and psychosis. As an outpatient, an exorcism. she was noncompliant with her medications During her admission, Mrs. P continues and regularly decompensated and required to display psychomotor agitation, pressured acute inpatient admission. speech, disorganized thought, religious and Past failed medication trials include ris- hypersexual delusions, grandiosity, and audi- peridone, risperidone long-acting injection, tory and visual hallucinations. A workup that paliperidone, ziprasidone, quetiapine, halo- included a basic metabolic panel, complete peridol, lamotrigine, and valproic acid. These blood count, thyroid tests, and abdominal/pel- trials failed because of intolerable side eff ects vic CT fi nds no medical causes for her symp- toms. Ob/Gyn is consulted, but Mrs. P refuses a Dr. Dulai is a resident and Dr. Lee Kelly is assistant training Current Psychiatry director and assistant professor, department of psychiatry, 56 August 2009 vaginal ultrasound. University of Connecticut, Farmington. For mass reproduction, content licensing and permissions contact Dowden Health Media. 56_CPSY0809 56 7/17/09 10:43:53 AM Cases That Test Your Skills Table 4 types of delusional misidentifi cation syndromes Syndrome Delusion Capgras syndrome Belief that a loved one has been replaced by an identical impostor Fregoli delusion Belief that different people are actually the same person in disguise Intermetamorphosis Belief that one has switched identities with another individual or that others believe the afflicted to be someone else Subjective doubles Belief there exists a double of oneself living a separate life Source: Reference 1 or lack of effi cacy. She takes lithium, 600 mg Breen2 argued that a face-processing every morning and 900 mg at bedtime, for defi cit alone may not account for a mirror Clinical Point mood stabilization but refuses to try antipsy- delusion; an inability to understand mirror Persons with Capgras chotics again because she feels the devil is spatial relations in refl ections also may be going to attack her through the medications. present. Similar to Capgras, in mirrored-self syndrome may misidentifi cation there may be a perceptual believe their loved The authors’ observations defi cit as well as a reasoning defi cit that al- ones have been During her initial hospitalization at age 29, lows the patient to hold on to the delusion. replaced by identical Mrs. P was diagnosed with schizophrenia. In both delusions, there is a failure of reality imposters In subsequent years she appeared more testing.3 manic, so her diagnosis was changed to schizoaffective disorder-bipolar type. How can a diagnosis of a Capgras syndrome Based on our clinical interview, we de- (or a variant) be made? cide that Mrs. P exhibits a variant of Capgras a) clinical interview syndrome, a type of delusional misidentifi - b) collateral information cation syndrome in which a person believes c) psychiatric history d) laboratory studies other people are not their true selves but e) neuroimaging have been replaced by identical imposters (Table).1 Patients will at some level recog- nize a person, but they cannot experience Capgras syndrome the familiarity that is usually felt when see- Capgras syndrome, which is also called ing that person. Mrs. P’s case was unusual Capgras delusion, is seen primarily in a because instead of believing her loved ones psychiatric context—most commonly in were imposters, she could not recognize functional or organic psychotic illnesses4— herself—her body, face, and voice were for- and secondarily in neurologic cases. In a eign to her. retrospective study of 920 inpatient psychi- We consider and rule out other misiden- atric admissions, the prevalence of Capgras tifi cation syndromes, including mirrored- syndrome was 1.3%; one-half of these pa- self misidentifi cation, a condition in which tients had schizophrenia.4 patients cannot recognize themselves (and Capgras syndrome can be triggered by sometimes others) in a mirror. Mrs. P’s in- systemic infections, thyroid dysfunction, ability to recognize herself is not limited concussion, or intoxication. It is seen with to her refl ection. She is adamant that her head injury, toxic encephalopathy, and de- hands and a part of her abdomen are not mentia.5 her own but another woman’s. She main- Joseph Capgras fi rst described this tains this delusion even when looking di- syndrome in 1923. He discovered it by Current Psychiatry rectly at herself. studying brain-injured patients who had Vol. 8, No. 8 57 57_CPSY0809 57 7/16/09 9:09:28 AM Cases That Test Your Skills Box Capgras syndrome: Recognition without emotion atients with Capgras syndrome believe and those involved in emotions and memory. Ppeople whom they know well have been In patients with neurologic damage, this replaced by identical imposters. One of the disconnect is believed to occur by: intriguing aspects of Capgras is that the • damage to the ventromedial frontal cortex, patient to some extent must recognize a which causes impairment of automatic person’s face to be able to identify the person arousal responses and as an imposter. • damage to the right frontal lobe, which A Capgras patient’s conscious ability to causes inability to evaluate beliefs and recognize a face is intact; however, the patient impairs reasoning. cannot produce the emotional response that To rationalize the strange feeling produced usually occurs when seeing a familiar face. by the inability to recognize a face, the patient Clinical Point There is a disconnect between the areas in the develops a delusion that the loved one is an brain that are responsible for facial recognition imposter. Capgras patients are Source: References 5-9 able to recognize faces but cannot prosopagnosia—the inability to recognize Breen2 reviewed 69 case reports of Cap- produce the familiar faces. Patients with prosopag- gras that had brain imaging results. Twen- emotional response nosia are not delusional and understand ty-seven had normal brain imaging, 31 had that occurs when that their inability to recognize faces is an global atrophy or bilateral brain damage, 2 impairment. Brain-injured patients with had global atrophy and a right focal lesion, seeing a familiar face prosopagnosia had an autonomic arousal and 6 had a right hemispheric lesion. Thus, (measured by galvanic skin response) with Capgras can occur in patients with normal familiar faces and thus unconscious face or abnormal brain imaging. recognition was intact.5 Young9 developed an interactionist Ellis et al6 described Capgras syndrome model of Capgras syndrome, in which a pa- as being a “reverse” of prosopagnosia. They tient’s delusional belief allows the patient felt that in patients with Capgras, the con- to explain his or her confusion and give the scious ability to recognize a face is intact, experience meaning. The experience then but the patient cannot produce an emotion- validates the belief, which makes the belief al response that usually occurs when seeing resistant to revision. a familiar face. Thus, patients can recognize a person but feel that something is “off” or Asomatognosia is a type of misiden- “wrong” and believe that the person must tifi cation syndrome in which a patient be an “imposter.” This hypothesis was sup- misidentifi es or is not aware of the condi- ported by a 1997 study of 5 patients with tion of a part of his or her body. It is seen schizophrenia who had Capgras.7 with right hemispheric brain lesions, left Hirstein et al8 showed similar fi ndings hemiplegia, left-sided sensory loss, and in a case study of a patient who developed left hemispatial neglect.10 Some clinicians Capgras after a brain injury. These research- believe that asomatognosia is a Capgras ers felt that there was a relationship between syndrome for the unrecognized body Capgras and the inability to link successive part.10 Because Mrs. P refused brain im- memories (because of the lack of emotional aging, it is unclear whether she has aso- recognition).
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