Psychiatric Factors Associated with Dangerous Misidentification Delusions J. Arturo Silva, MD, Gregory B. Leong, MD, Robert Weinstock, MD, and Rochelle L. Klein, MBA The delusional misidentification syndromes are characterized by misidentifica- tion delusions of others or of the self. Aggressive ideas or behaviors often ac- company these delusions. The relationship between delusional misidentification and dangerousness remains for the most part poorly understood. In the present article, we compare a group of dangerous individuals suffering from dangerous misidentification delusions with a group of dangerous individuals suffering from other types of delusions. Individuals with dangerous misidentification delusions were more likely to experience grandiose ideation, thought disorder, generalized hostility, excitement, general psychopathology, and a previous history of vio- lence than dangerous delusional individuals with no delusional misidentification. The group with dangerous delusional misidentification syndromes was less likely to attack others with weapons than were the dangerous delusional group with no delusional misidentification. Although there has been relatively little viduals rarely act upon their delusions.' empirical work in defining the relation- This makes sense clinically, as even in the ship between delusions and behavior, a extreme cases of chronically delusional hypothesis commonly held by the psychi- and so-called high-risk assaultive persons atric professional community is that indi- housed in secure hospital settings, actual- ized physical violence is a low-base-rate phenomenon occurring in only a small Dr. Silva is associate professor of psychiatry, University percentage of the patients7 total hospital- of Texas Health Science Center at San Antonio, and staff psychiatrist, Audie L. Murphy Memorial Veterans Hos- ization time. However, studies have been pital, San Antonio, TX. Dr. Leong and Dr. Weinstock conducted examining the converse- are associate clinical professors of psychiatry, Univer- sity of California, Los Angeles, and staff psychiatrists, whether delusional beliefs have been as- West LQS Angeles Veterans Affairs Medical Center, Los sociated with abnormal behavior, espe- Angeles, CA. Ms. KIein is a doctoral candidate, Gradu- ate School of Management, University of California, cially criminal or dangerous behavior^.^ Iwine. This is a revised version of a paper presented at In this manner, the hypothesis that delu- the 24th Annual Meeting of the American Academy of Psychiatry and the Law, San Antonio, TX, October sional thinking has a significant role in 21-24, 1993. Address correspondence to: J. Arturo the commission of criminal behaviors or Silva, MD, Audie L. Murphy Veterans Hospital, 7400 Merton Minter Blvd, San Antonio, TX 78284. acts of violence has credence. Bull Am Acad Psychiatry Law, Vol. 23, No. 1, 1995 53 Silva et a/. Recently there has been a significant lusion of inauthenticity regarding the attempt to examine the relationship be- identity of others or the self." For exam- tween delusions and action." These ple, in the most common delusional studies used both patient and informant misidentification syndrome, Capgras syn- reports to arrive at their findings and drome, the affected person questions the showed that actions associated with ab- identity of others, and as a result of this normal beliefs were more common than experience the person usually postulates previously suggested.' They also found the existence of doubles or imposters. 11,12 that there was no association between the Delusional misidentification can also delusional thinking and acting on the occur in reference to the person's own delusion when an informant provided in- self. These cases are also known as "re- formation, but that when the patients verse" delusional misidentification syn- themselves were queried, their actions dromes.13 were associated with delusional content The study of misidentification delu- and with dysphoric or anxious feelings sions provides a potential interactive associated with their delusions.~owever model between delusions and resultant these studies did not address in depth the dangerous behaviors. There are several more specific issue about the possible reasons for this. First, each misidentifica- linkage between delusions and aggressive tion syndrome presents with a different behavior. Therefore, considerable further constellation of features that may repre- exploration remains to be done before this sent potential modifiers regarding degrees relationship can be more fully under- of associated dangerousness. These fea- stood. tures include such factors as paranoia, In his review of acting on delusions, grandiosity, affective symptomatology, ~uchanan~covered the different types of and emotional proximity to the delusion- delusions, including persecutory, jealous, ally misidentified object. Second, recent grandiose, passivity, ill health or bodily progress in the classification of delusional change, erotomanic, Capgras, guilt, reli- misidentification syndromes facilitates gious, and sexual. In this article, we focus the collection of relevant psychopath- on misidentification delusions. These ology into a more cohesive system delusions encompass more than one cate- and thereby encourages more systemic gory of delusional thinking, particularly studY.''' 13' l4 Third, advances in neu- persecutory, grandiose, and somatic. They ropsychiatric research indicate that also have been cited as an example of po- right (nondominant) brain abnormali- tentially "dangerous" delusions by De- ties,15' l6 including face misrecognition Pauw and ~zulecka.~In the past five years and other forms of topographical recogni- these dangerous delusions have received tion defi~its,'~-'%a~be associated with significant forensic attention in the anglo- delusional misidentification phenomena. phonic medical literat~re.~~' Therefore, misidentification delusions The delusional misidentification syn- offer a unique opportunity to develop an dromes are chiefly characterized by a de- integrated model of psychosis in which 54 Bull Am Acad Psychiatry Law, Vol. 23, No. 1, 1995 Misidentification Delusions phenomenologic, biological, and forensic tact. The use of weapons by the attacker aspects are rele~ant.~OSucha model could was also recorded. shed light on the mechanisms of the gene- All subjects were rated for misidentifi- sis of dangerous delusions and the resul- cation delusions. Although we have so far tant dangerous behaviors. used the term "misidentification delu- In this article, we report a study of 25 sions," controversy remains as to whether subjects who suffered from aggressive these delusions in fact comprise a sepa- delusional misidentification syndromes. rate syndrome. We will use hereafter the This group is compared with a group of term "delusional misidentification syn- 25 aggressive delusional subjects who drome" interchangeably with "misidenti- harbored no delusional misidentification. fication delusions," because much of the Factors that may predispose delusional world's literature uses the term syndrome; misidentification individuals to become for example, "Capgras syndrome" instead hostile are explored. A case is presented of "Capgras delusion." The following def- in order to highlight the main issues intro- initions were used for delusional misiden- duced by dangerous delusional misidenti- tification of others: the Capgras delusion fication. occurs when an individual believes that there has been a radical change in the psy- chological, but not physical, appearance Methods of another; 24, 25 the FrCgoli delusion The data were collected over a five- occurs when an individual believes in a year period on 25 subjects suffering from radical change in the physical, but not nonmisidentification delusions (NMD) psychological, identity of another; 10, 26, 27 and 25 subjects suffering from misidenti- the intermetamorphosis delusion occurs fication delusions (MD). Information on when a person believes in radical changes demographics, dangerousness, phenome- in both the physical and psychological nology, and diagnosis was collected via identities of another. lo' 28> 2') Definitions review of records. Psychiatric diagnosis for delusional misidentification of the self were made in accordance with DSM-III- include the following: the "subjective7' R rite ria.^' The subjects were routinely Capgras delusion occurs when the delu- rated, using the Brief Psychiatric Rating sional person believes that physical repli- Scale (BPRS),~~,23 by the first author, cas of him/herself exist although these who had been previously calibrated on the replicas have different psychological scale. Criteria for dangerousness con- identities (minds) from that of the per- sisted of either serious verbal aggression son's original identity;7' 30 the "reverse" or physical aggression. Serious verbal ag- Capgras delusion occurs when an individ- gression was defined as oral threats to ual believes that hislher own psychologi- harm another that had led to the subject's cal, but not physical, identity has radically civil or criminal confinement. Physical changed; "', l3 and the "reverse" intermeta- aggression or violence was defined as any morphosis delusion occurs when the delu- attack that culminated with bodily con- sional person believes that helshe has Bull Am Acad Psychiatry Law, Vol. 23, No. 1, 1995 55 Silva et a/. undergone fundamental changes in both other whites, and one Native American. physical and psychological identities.''' 31 The MD group