Case in Point She’s Not My Mother: A 24-Year-Old Man With Capgras Delusion 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 delusions in the general popu- presentation of Capgras delusion 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an individual or a group of objects; these delusions collectively This case involved a 24-year-old male people has been replaced by dou- are known as delusional misiden- veteran who had received a wide bles or imposters.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- Fregoli delusion 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 anxiety 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 psychiatry 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, paranoia, 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 bipolar disorder. 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 insomnia. 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 hallucinations. 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 suicide 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 www.fedprac.com DECEMBER 2017 • FEDERAL PRACTITIONER • 39 CAPGRAS DELUSION 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