Rosamond's husband finally covered up all the shiny surfaces in their house to prevent her outbursts, but he was afraid she would hurt herself in an effort to attack the "other woman." And there was no way he could cover every reflective surface -- the plate glass of store windows, or the rearview mirror of the car. Joseph and Rosamond, whose real names are not being used, are two of a rare group of patients whose mental illnesses involve the parts of the brain that allow us to know we are who we think we are. Their strange disorders also demonstrate that it's not enough for us to recognize ourselves in a mirror -- we have to feel emotionally attached to our image before we think it is our own reflection.

The technical name for Joseph's and Rosamond's delusion is "mirror self-misidentification." It is the most striking of the Capgras delusions, in which someone recognizes an object but feels no connection with it. The syndrome, named for French psychiatrist Jean Marie Joseph Capgras, is unusual, but still probably afflicts thousands of people in the United States at any given moment, said one expert, Dr. Todd Feinberg, associate professor of neurology and psychiatry at the Albert Einstein College of Medicine in New York.

Joseph's psychiatrist, Dr. Matcheri Keshavan, clinical director at the Pittsburgh Center for the Neuroscience of Mental Disorders, said the delusion can also involve another person in the patient's life. "The main illusion [Capgras] patients have is that a dear one is an impostor, or not their real self." Keshavan explained the underpinnings of the delusion this way:

"We all have representations of the external world inside us, and that includes identities of other people and our own identities. Along with these representations of other people and ourselves, the emotional tone that goes with such memories is also linked, so when we remember our mothers or friends we remember them with the emotions that go with them.

"But what if there is a dysfunction in parts of the brain that link emotions with our memories? When that happens, the brain at the subconscious level is puzzled and looks for an alternative explanation of why that person feels different."

And suddenly, the person in the mirror becomes someone else, because when the deluded person cannot feel the emotions she normally has toward that person, that is the explanation that makes the most sense.

An impostor poodle

Not all Capgras delusions are focused on people. Sometimes, patients think there is something wrong with their pets or objects they own -- and in those cases, the same sense of emotional dissociation may be at work. In "Phantoms in the Brain," Dr. V.S. Ramachandran, director of the Center for Brain and Cognition at the University of California, San Diego, wrote about one Capgras patient who thought his poodle has been replaced by an identical but different dog. Keshavan said he has a patient now who, every morning, believes that his running shoes and other items have been replaced by identical fakes during the night.

And Feinberg described a patient who thought the same thing had happened with the dishes and towels in her kitchen. Keshavan said that when people have an emotional reaction to someone they know, they sweat slightly, making the skin more conductive. That can be measured as a galvanic skin response. But when Capgras patients see certain familiar faces, their galvanic response does not increase, he said.

Feinberg, who wrote a book about identification disorders called "Altered Egos," said he believes there is more to understanding Capgras than just the emotional disconnection with a familiar person or object, however. Take Rosamond, his patient who thought her own image was another woman. She didn't have a problem identifying anyone but herself. She properly identified her husband and the things around her, he said. And the emotional disconnection theory doesn't completely explain why Rosamond reacted as strongly as she did to her image. "Why would she scream and yell and become so emotionally upset?" he asked.

One possible reason, Feinberg said, is that people with Capgras already have ambivalent or strained feelings toward the person they misidentify -- including themselves. One common example, he noted, is an aging mother who has problems with a daughter who is taking care of her, and then begins to believe that the daughter is an impostor. As bizarre as these cases seem, both Keshavan and Feinberg said that they are only more extreme versions of experiences we all go through in everyday life. Keshavan noted, for instance, that often we think someone we know well has become "a different person" when in fact our own feelings about the person or life in general that have changed. "If we are feeling depressed or angry we might view that person in another light and we might think that person has changed, when in fact they are the same, but our feelings have changed."

Like deja vu?

And Feinberg said most of us have times when we "dissociate" from objects or events. The familiar feelings of deja vu, when a new experience feels as though it has happened before, or jamais vu, in which a familiar experience feels brand new, are both examples of that. "Who hasn't had a situation where you buy a new pair of shoes and you look at the old pair of shoes and you just can't believe you were wearing those shoes for the last six months. They look all ragged and in disrepair. But the fact is, the shoes haven't changed -- you've changed in your sense of relatedness to those shoes."

And in dreams we often have Capgras-like delusions, he added. We may meet two versions of a person we know in a dream. Or we may be in our room or our office, but it looks nothing like our actual room or office. Keshavan said that about a third of patients who suffer from Capgras delusions have either epilepsy of the temporal lobes or malformed lobes. The temporal lobes are the parts of the brain on the sides of the head above the ears. And Feinberg said that there tends to be more pathology in the right hemisphere of the brain, which is the side that "is dominant for self and self-other relationships."

Is the delusion curable?

In both Joseph's and Rosamond's cases, it was -- but in different ways. Joseph was eventually diagnosed as having schizophrenia, Keshavan said. When he was prescribed the antipsychotic clozapine, his delusion went away. Rosamond was cured because Feinberg tried a novel therapy on her. "Rosamond's husband casually mentioned that she didn't see [the other woman] when she looked in the mirror of her makeup compact," said Feinberg.

That gave him a brainstorm -- why not try to have her look at images of herself in increasingly larger mirrors? "I went around the office -- we had other mirrors of different sizes -- and went out and bought a series of mirrors," he said. "I was ultimately able to convince her that an image of slightly larger size was her."

Eventually, Rosamond recognized that her reflection in a full-sized mirror was indeed herself. "I was quite surprised that it worked, but it did," Feinberg said. What lessons do Joseph's and Rosamond's experiences hold for us? One conclusion, Feinberg said, is that our identities are not as rigid and fixed as we might imagine. "Although we tend to think of ourselves as having fixed structures -- we know where our body begins and ends and we have a sense of who we are in the world -- in actuality," he said, "our identity is in a constant state of transformation and is always changing."

Read more: http://old.post-gazette.com/pg/03266/224822.stm#ixzz4nb1oe1xU

Source:https://www.post-gazette.com/news/health/2003/09/23/Victims-of-Capgras-syndrome-often-cannot-recognize-their-own-image/stories/200309230038

That’s Not My Child: A Case of Capgras Syndrome

Mary, aged 40 years, was referred for psychiatric evaluation out of concern that a mental health diagnosis was interfering with her ability to appropriately and safely care for her child. The patient had stated on numerous occasions that her 9-year-old daughter, Sarah, had been placed in the custody of Child Protective Services and replaced by an imposter. Mary also reported that she had given birth to twins but that the hospital record only documented the birth of Sarah. On occasion, she had shown up at her daughter’s school, refusing to pick her up, screaming, “Give me my real daughter; I know what you’ve done.”

Despite reassurance from multiple health care providers and relatives, Mary continued to express concern that her daughter was not, in fact, her own. Furthermore, she related several episodes in which her daughter was “whisked away before I could talk to her” while going about her daily business. For example, Mary related that a car driven by an unknown person, with Sarah in the passenger seat, passed by her while she was running errands but sped away once she was noticed.

Following Mary’s initial evaluation, a delusional disorder—Capgras syndrome—was diagnosed.1 The results of this evaluation indicated that Mary’s condition was indeed a delusion, because it was a fixed false belief that persisted over time. Attempts to redirect or foster the development of insight were in vain. Given the patient’s suspiciousness regarding her daughter’s true identity, social services questioned Mary’s ability to parent effectively.

Although medication was prescribed (risperidone 2 mg by mouth at bedtime), Mary responded poorly, and her delusion persisted. Her medication was subsequently titrated to a total dose of 4 mg/d, also with poor response. Mary’s adherence with the prescribed medication regimen was questioned, but the intervals between prescription refills and pill counts failed to suggest that she was nonadherent.

After 2 months of regular follow-ups and medication management, she continued to display poor insight into the nature of her illness. She refused to entertain the possibility that Sarah was truly hers or the possibility that her thought processes were distorted.

At that time, the Department of Social Services sought guardianship of her daughter until Mary could be deemed fit to parent. Following the hearing, her daughter was placed into the custody of the Department of Social Services. In response, her daughter replied, “I love my mother except for when she doesn’t believe I’m me. . . .” During visitations supervised by Social Services, Mary refused to talk with her daughter, maintaining that she was not Sarah and that the real Sarah had been hidden away from her.

Discussion

Mary was believed to be suffering from a specific delusion identified as Capgras syndrome. This condition was first described by Joseph Capgras and Reboul-Lachaux in 1923 and was later named for Joseph Capgras. The syndrome describes a delusion (or fixed false belief) in which the affected individual believes that another person, generally a family member or close acquaintance, has been replaced by a look-alike imposter. It is important to note that Capgras syndrome is not a DSM-IV-TR diagnosis, but it is most often found as part of another underlying disorder, such as schizophrenia or dementia of the Alzheimer type.

The specific cause of Capgras syndrome has been hypothesized from neuropsychological and psychodynamic views. Current neurological studies have focused on similarities between Capgras syndrome and prosopagnosia, a neurological disorder in which damage to the right ventromedial occipitotemporal areas in the brain causes impairments in the ability to recognize faces.2 Some psychodynamic approaches have looked at ambivalence and hostility the delusional person may have toward the imposter, either directly or indirectly as the cause of the delusion. Severe anger toward the imposter can lead to the use of splitting as a defense mechanism. In this way, the patient can preserve some of his love for the close acquaintance while still expressing anger by saying that he loves the true person and is only mad at this “new faker.”

A case has been described in which a mother believed her adult daughter had been replaced with a look-alike imposter. On delving into the patient’s history, it was found that the patient had to leave a very serious relationship with a man she loved because she was pregnant with another man’s child. The baby eventually grew into the adult daughter who the patient believed had been replaced. The patient’s resentment for having to leave her lover when she was pregnant was believed to be the psychodynamic source for the current delusion.3

With Capgras syndrome, the family member who is believed to have been replaced is most often a spouse, parent, or sibling. For unknown reasons, the “replaced” family member is rarely the child of the delusional person and even more rarely is the child younger than 20 years.3 Although violence aimed at any person is a significant threat, violence aimed at children is particularly worrisome. Mary’s case is unique because the increased potential for violence in her relationship with her daughter needs to be taken into consideration when assessing the patient’s ability to be a safe and effective parent.

Although violence can be seen in all psychiatric disorders, there is a higher incidence of severe violence in patients with delusional disorders.4 In patients with Capgras syndrome, the violence is often directed at the imposter or, in some cases, the people the patient believes replaced the loved one with the imposter.

Bourget and Whitehurst5 found several demographic features that increase the likelihood of violence in persons with Capgras syndrome. Specifically, if the imposter lives with the patient or if the delusional person is male, has a persistent and long-term delusion, or has a history of violence or substance abuse, the risk of violence is increased. The sources of violence can be frustration or fear of the imposter, but it can also be cultural.

Silva and colleagues6 found that some folklore and regional legends suggest that if a child is thought to have been replaced by another person or even by a demon, battering and being physically aggressive toward the imposter might bring the “real” child back. One Swedish fairy tale recounts the story of a woman who believed her child was an imposter. In the story, she is advised to put her baby into a hot oven; when she does this, her “true” child is returned.6 This is a severe case that is not necessarily the norm for patients with misidentification delusions; however, it is evidence that violence in delusional persons can happen.

When the patient believes that his or her child has been replaced and when violence is a possibility, the termination of parental rights and the removal of the child from the patient’s care must be considered. The clinician should consult his local state statutes and laws to determine the rationales and processes for termination of parental rights specific to the case and area. Generally, a local court must find that removing parental rights would be in the best interest of the child. Furthermore, this decision must be based on evidence of abandonment or neglect of the child or a risk of serious physical, mental, or emotional injury to the child while in the custody of the parent. Minimal effort by the parent to support the child, prevent neglect, and avoid being an unfit parent, and to remove risks of injury (physical, mental, or emotional) to the child are also grounds for termination of parental rights.

The dangers a delusional parent poses to his children are significant and must be taken seriously. In Mary’s case, the court system granted temporary guardianship of her daughter to Social Services, because she was seen as unfit to parent. Some insight into the psychosocial stress leading to the development of this disorder would provide an area to begin psychotherapeutic treatment, but her history failed to reveal any acute stressors. Unfortunately, treatment with pharmacotherapy alone was minimally effective, underlining the fact that 50% or fewer patients with a delusional disorder improve.6 Given the very real risks associated with this case, Sarah was placed into a safe environment until her mother responds to treatment, if ever.

April 29, 2011 | Schizophrenia, Cultural Psychiatry

By Jeremy Matuszak, MD and Matthew Parra, MD

References

1. Sinkman A. The syndrome of Capgras. Psychiatry. 2008;71:371-378.

2. Talley BJ, Michels L. Two patients who think their family members have been replaced by “imposters.” Psychiatr Ann. 2009;39:247-253.

3.Fishbain DA, Schiffman J. The daughter as the principal “double” in Capgras’ syndrome: psychodynamic correlates. Am J Psychother. 1986;40:607-611.

4. Sadock BJ, Sadock VA. Kaplan and Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. Philadelphia: Lippincott Williams & Wilkins; 2003:511-520.

5. Bourget D, Whitehurst L. Capgras syndrome: a review of the neurophysiological correlates and presenting clinical features in cases involving physical violence. Can J Psychiatry. 2004;49:719-725.

6. Silva JA, Sharma KK, Leong GB, Weinstock R. Dangerousness of the delusional misidentification of children. J Forensic Sci. 1992;37:830-838.