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 . 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) with psychotic features b) inpatient unit after elopement from another ® Dowden Healthc) schizoaff Media ective disorder-bipolar type emergency room the prior day. For several d) 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 of evil spirits and religious and with both mood and thought disorders. hypersexual . She cannot recognize Her symptoms of pressured speech, gran- her face and believes her voice has been re- diosity, , 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 . 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 , states she does not need medication but rather , 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 , pressured acute inpatient admission. speech, disorganized thought, religious and Past failed medication trials include ris- hypersexual delusions, grandiosity, and audi- peridone, long-acting injection, tory and visual hallucinations. A workup that paliperidone, ziprasidone, , 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 director and assistant professor, department of psychiatry, 56 August 2009 vaginal ultrasound. University of Connecticut, Farmington.

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Table 4 types of delusional misidentifi cation syndromes Syndrome Capgras syndrome Belief that a loved one has been replaced by an identical impostor Belief that different people are actually the same person in disguise 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 , 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 -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 , 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

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Box Capgras syndrome: Recognition without

atients with Capgras syndrome believe and those involved in 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 , 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 —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). They hypothesized that there matognosia. was a disconnect between the temporal The main treatment of Capgras syn- cortex (where faces are recognized) and the drome is pharmacotherapy with antipsy- (which is involved in emo- chotics and cognitive-behavioral therapy Current Psychiatry 58 August 2009 tions) (Box).6-9 (CBT) to help with fi xed delusions. continued on page 65

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continued from page 58 TREATMENT Pharmacotherapy Related Resources At admission, Mrs. P was taking only lithium • Denes G. Capgras delusion. Neurol Sci. 2007;28:163-164. for mood stabilization because she refused • Coltheart M, Langdon R, McKay R. Schizophrenia and to take antipsychotics. During her stay, she monothematic delusions. Schizophr Bull. 2007;33:642-647. http://schizophreniabulletin.oxfordjournals.org/cgi/content/ reluctantly agrees to start , which full/33/3/642. is titrated up to 20 mg bid. She experiences Drug Brand Names delusions related to the Devil attacking her Fluphenazine • Prolixin Risperidone • Risperdal via the haloperidol and thus is switched Haloperidol • Haldol Risperidone long-acting Lamotrigine • Lamictal injection • Risperdal Consta to fl uphenazine, titrated up to 20 mg bid. Lithium • Eskalith, Lithobid Valproic acid • Depakote She feels that liquid fl uphenazine agrees Paliperidone • Invega Ziprasidone • Geodon Quetiapine • Seroquel with her the most, so she is stabilized and Disclosure eventually discharged with this formulation. The authors report no fi nancial relationship with any Switching to a depot formulation would have company whose products are mentioned in this article or Clinical Point improved compliance, but Mrs. P adamantly with manufacturers of competing products. Capgras syndrome resists this. As her psychotic symptoms begin to re- is treated with References solve, Mrs. P begins to feel she is getting her 1. Ellis HD, Luauté JP, Retterstøl N. Delusional misidentifi cation antipsychotics and body parts back. For example, she feels her syndromes. Psychopathology. 1994;27(3-5):117-120. 2. Breen N, Caine D, Coltheart M. Mirrored-self misidentifi cation: CBT to help with face is her own but her nose is still not hers. two cases of focal onset . Neurocase. 2001;7:239-254. fi xed delusions 3. Brédart S, Young A. Self-recognition in everyday life. Cogn During Mrs. P’s hospitalization, these bodily . 2004;9:183-197. delusions lessen and eventually clear. 4. Tamam L, Karatas G, Zeren T, et al. The prevalence of Capgras syndrome in a university hospital setting. Acta Other aspects of her psychosis and mania Neuropsychiatrica. 2003;15:290-295. also resolve. She has some residual religious 5. Barton J. Disorders of and recognition. Neurol Clin. 2003;21:521-548. delusions at discharge but feels she has her 6. Ellis H, Young AW. Accounting for delusional misidenti- body back and overall is much improved. fi cations. Br J Psychiatry. 1990;157:239-248. 7. Ellis HD, Young AW, Quayle AH, et al. Reduced autonomic Upon discharge Mrs. P is encouraged to fol- responses to faces in Capgras delusion. Proc Biol Sci. low up with a therapist for CBT, but she feels 1997;264(1384):1085-1092. 8. Hirstein W, Ramachandran V. Capgras syndrome: a novel probe she does not need therapy and wants only to for understanding the neural representation of identity and familiarity of persons. Proc Biol Sci. 1997;264(1380):437-444. speak with her priest, even after most of her 9. Young G. Capgras delusion: an interactionist model. symptoms resolve. She also declines neuro- Conscious Cogn. 2008;17:863-876. 10. Feinberg T, Keenan J. Where in the brain is the self? Conscious psychological counseling. Cogn. 2005;14:661-678.

Bottom Line

Variants of Capgras syndrome—a misidentifi cation syndrome in which a person believes other people have been replaced by identical imposters—are rare and often unrecognized. Careful, extensive dialogue is needed to help recognize and diagnose this delusion. Treatment includes pharmacotherapy with antipsychotics Current Psychiatry and cognitive-behavioral therapy. Vol. 8, No. 8 65

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