Capgras – BIZARRE BEHAVIOR & CULTURE BOUND SYNDROMES

Leopoldo Fregoli

This delusion is named after the Italian actor Leopoldo Fregoli, who often changed appearances and identities during his performances. This type of delusion occurs when a person believes that a number of different people are actually one person who has the ability to change their appearance. The different people are usually familiar and are often considered to be hostile or persecutory to the Fregoli sufferer. This delusion is often thought of as a variant of Capgras Syndrome and it seems the underlying neuropathology is similar, usually involving lesions to the right hemisphere of the brain. It has been difficult however, to clearly trace the delusional misidentification directly to the organic pathology since the syndrome is so often comorbid with psychotic disorders (Mojtabai, 1994; Novakovic, Aje, & Sher, 2010).

One research study has reported that Capgras, Fregoli, and psychotic syndromes can be distinguished from one another by observing facial recognition reaction times. Patients suffering from delusional misidentification disorders had longer took longer to perform facial recognition tasks than psychotic patients, with Fregoli patients taking longer than Capgras patients. This may indicate differences in underlying pathology among psychotic, Capgras and Fregoli syndromes (Walther et al., 2010).

In addition to psychoses, Fregoli syndrome has been associated with a number of other disorders. Bruggemann and Garlip report a case of erotomania combined with Fregoli delusion in a 24 year old woman. This woman believed a colleague who was the target of her erotomania, appeared as other people. While they did not find any overt pathology they did note EEG differences in the right temporal lobe. This woman, as is typical for people with Fregoli syndrome, also suffered from psychotic symptoms such as imagining she had become pregnant by her colleague and that she was his fiancée. She was treated via psychotherapy and neuroleptic medication, which lessened her symptoms. When the patient stopped taking her medication her psychotic symptoms returned. The authors conclude that the Fregoli syndrome was secondary to paranoid schizophrenia (Brüggemann & Garlipp, 2007).

Melca et. al. (2012) describe two patients with delusional misidentification disorders (Vapgras and Fregoli syndromes) who also suffered from treatment resistant obsessive compulsive disorder (OCD). One of the two patients also was diagnosed with paranoid personality disorder while the other with pervasive developmental disorder. Both patients in the study exhibited varying amounts of insight related to their OCD. The authors speculate that there may be a relationship between OCD and delusional misidentification disorders (DMS).

Fregoli syndrome has also been associated with violent behavior. Delavenne & Garcia (2011) report on a case of a paranoid schizophrenic woman who was convinced that a boyfriend was able to appear as other people so he could follow her. This patient had an episode of violent behavior associated with her Fregoli delusion. She had topped taking her anti-psychotic medication 6 months prior to her violent outburst. Facial recognition tests and a CT scan of her brain revealed no abnormalities. Even though she was put back on anti-psychotic medication, her delusions returned after 10 days.

Fregoli syndrome has also been associated with bipolar schizoaffective disorder and Hashimoto’s thyroiditis (Ceylan et al., 2010).

Delusional Misidentification Syndrome in the form of Fregoli Delusion has also made appearances in popular culture. One of the best examples of this is a variant of Fregoli Delusion which is central to the film Being John Malkovich (Jonze, 1999). In this film there is a tunnel in a strange half floor of an office building. Travel through this tunnel allows people to experience ‘being’ the actor John Malkovich for a short time. Later in the film, John Malkovich himself discovers the existence of the tunnel and goes through it. When he emerges everyone else is a version of Malkovich, with his face and everything they say coming out as the word ‘Malkovich’.

Science fiction has been an especially fruitful ground for the emergence of modern stories related to imposters masquerading as humans. This can be seen most readily in stories about robots or androids. In many cases these stories revolve around the ‘imposters’ wanting to become human, or being indistinguishable from humans, as in the Phillip K. Dick story Do Androids Dream of Electric Sheep? (1968/1996), which was made into the movie Blade Runner (Scott, 1982), or the Isaac Asimov Robot series (1982) which has had a number of film adaptations including most recently the film I Robot (Proyas, 2004). In these modern portrayals humans are generally anxious about the imposter status of the robots and androids as well as being paranoid about their intentions. It is possible that the popularity of the imposters among us theme relates to a subconscious fear of misidentification in general.

An older instance of DMS can be found primarily in the British Isles. In times past British or Celtic babies were thought to be kidnapped by fairies and replaced by identical looking children. The replacement children, called changelings, were often sickly and exhibited abnormal behavior.

Evans (2000) describes the Irish belief in changelings that is typical of the British Isles;

Mothers and babies were thought to be especially liable to be abducted by the fairies, and protective charms were hidden in a baby’s dress or placed in the cradle. When children were taken to be baptized, too, special preparations were made and precautions taken, for example, a County Antrim clergyman reported that his parishioners would place a piece of bread and cheese in the child’s clothing.

The old custom of dressing boys in girls’ clothes, in long frocks, until they were ten or eleven years of age has been explained as a means of deceiving the fairies, who were always on the lookout for healthy young boys whom they could replace by feeble “changelings.” For the same reason it is unwise to praise a child without adding a saving “God bless him,” and young boys are still half jocularly referred to as “rogues and Tories.” The belief in “changelings” may have arisen as an explanation of the high mortality rate among baby boys as compared with girls. (p. 289)

Indeed, changeling legends may be related to high infant mortality rates in general. When an infant becomes sick and dies for no apparent reason, the human mind will seek an explanation for such a tragic event. If no logical reason can be found the human mind invents a reason that can provide meaning to the tragedy and lessen its sting. There is always a chance the original child can be returned by the fairies, or the thought the original child is being raised by the fairies and has been given special powers can be of comfort to the grieving parents.

The changeling legends have much in common with the belief in the ‘evil eye’ that has its origins in the Mediterranean regions. In this legend it is especially important to ward off the evil eye from infants who are susceptible to its negative influence. I hope to write more extensively about belief in the evil eye, as it has some unique and interesting features.

References

Asimov, I. (1982). The Complete Robot (1st ed.). Doubleday.

Brüggemann, B. R., & Garlipp, P. (2007). A special coincidence of erotomania and fregoli syndrome. Psychopathology, 40(6). http://doi.org/10.1159/000108127

Ceylan, M. F., Bulut, M., Virit, O., Selek, S., Bülbül, F., & Sava?, H. A. (2010). Hashimato tiroiditi olan eri?kin bipolar bozukluk hastasinda capgras ve fregoli sendromu birlikteli?i. Yeni Symposium: Psikiyatri, Nöroloji ve Davrani? Bilimleri Dergisi, 48(1), 69–71.

Delavenne, H., & Garcia, F. D. (2011). Fregoli syndrome associated with violent behavior. Jornal Brasileiro de Psiquiatria, 60(1), 71–72. http://doi.org/10.1590/S0047-20852011000100014

Dick, P. K. (1996). Do Androids Dream of Electric Sheep?. Del Rey.

Evans, E. E. (2000). Irish Folk Ways. Courier Dover Publications.

Jonze, S. (1999). Being John Malkovich. Comedy, Drama, Fantasy.

Melca, I., Rodrigues, C., Serra-Pinheiro, M., Pantelis, C., Velakoulis, D., Mendlowicz, M., & Fontenelle, L. (2012). Delusional Misidentification Syndromes in Obsessive–Compulsive Disorder. Psychiatric Quarterly, 1–7. http://doi.org/10.1007/s11126-012-9237-z

Mojtabai, R. (1994). Fregoli syndrome. Australian and New Zealand Journal of Psychiatry, 28(3), 458–462. http://doi.org/10.3109/00048679409075874

Novakovic, V., Aje, O., & Sher, L. (2010). A patient with the Fregoli syndrome: A case report and discussion of the relevant literature. International Journal on Disability and Human Development, 9(1), 81–83. http://doi.org/10.1515/IJDHD.2010.012

Proyas, A. (2004). I, Robot. Action, Mystery, Sci-Fi, Thriller.

Scott, R. (1982). Blade Runner. Drama, Sci-Fi, Thriller.

Walther, S., Federspiel, A., Horn, H., Wirth, M., Bianchi, P., Strik, W., & Müller, T. J. (2010). Performance during face processing differentiates schizophrenia patients with delusional misidentifications. Psychopathology, 43(2), 127–136. http://doi.org/10.1159/000277002

Delusional Misidentification Disorders: Part 1 – Capgras Syndrome

Today’s discussion turns to a group of somewhat rare syndromes that are related to the concept of misidentification and are labeled together as Delusional Misidentification Syndromes (DMS). In these syndromes someone, or something, is incorrectly identified as a person, place or thing. Thoughts and attribution of thoughts are also misidentified, in many cases to the point of being delusional. Some of these syndromes are more often than not related to organic abnormalities of the brain, or they may be a combination of organic problems with psychological issues, or in rare instances, may be purely psychological. DMS is often associated with psychoses and has only rarely been reported in non-psychotic individuals. It is nevertheless fairly rare, occurring in about 4% of patients presenting with functional psychoses (Melca et al., 2012).

Capgras Syndrome is a misidentification syndrome where a person holds a delusion or belief that an acquaintance, typically a close family member, has been replaced by an identical looking imposter. This syndrome can be transient, developing very quickly after a brain injury, or can take a chronic form where the delusion is long standing. The syndrome is named after Joseph Capgras lived 1873-1950 French psychiatrist who first described the disorder in a 1923 paper and used the term ‘illusion of doubles’ to describe a case of woman who had various doubles that had taken the place of people she knew. For some people with Capgras syndrome, even inanimate objects such as chairs and animals can be imposters. Often patients are so disturbed with seeing their doubles that they remove all mirrors from house. In some cases, if the Capgras sufferer can be convinced that one person is not an imposter, they will develop a Capgras delusion with someone else. (Sinkman, 2008).

Many patients suffering from Capgras Syndrome have already been diagnosed with schizophrenia. However, Capgras Syndrome can also be co-morbid with other mental health problems including; Alzheimer’s Disease, Cotard’s Syndrome, epilepsy, Farh’s Disease, Fregoli Syndrome, Hashimoto’s Hypothyroidism, Incubus Syndrome, Neurodegenerative Disease, Diogenes Syndrome, Parkison’s Disease (Bourget & Whitehurst, 2004; Ceylan et al., 2010; Chiu, 2009; Donnelly et al., 2008; Fischer et al., 2009; Josephs, 2007; Mishra, Prakesh, Mishra, Praharaj, & Sinha, 2009; Pande, 1981; Rodríguez, Madoz-Gúrpide, & Ustárroz, 2011; Yalin, Taş, & Güvenir, 2008). Capras has also been associated with the administration of morphine and ketamine (Bekelman & Hallenbeck, 2006; Corlett, D’Souza, & Krystal, 2010).

Since the time Capgras Syndrome was first described (and even a bit before) a number of theoretical explanations have been put forth as to its origins. As might be expected many of these theories were psychoanalytically based in the early days. De Pauw (Sinkman, 2008) has written a comprehensive account of these early conceptualizations of Capgras. In this article de Pauw notes that many of the psychoanalytic explanations are mutually incompatible. These psychoanalytic theories include; defense against unconscious homosexuality, a regression to the early stage of primary narcissism, which some writers believe was due to anxiety, and a novel resolution to the Oedipal and especially the Electra complexes. Psychodynamic explanations seemed to make sense because the people being replaced by imposters were almost always close family members. However, on closer scrutiny of the literature this argument falls apart as other people or things are often found to also be imposters, from doctors and nurses to entire buildings and other inanimate objects. In general, according to de Pauw psychoanalytic explanations tend to be “generally post hoc and teleological in nature, postulating motives that are not introspectable and defense mechanisms that cannot be observed, measured, or refuted” (p. 158). He concludes that while the presence of brain injury also does not fully explain Capgras Syndrome it may be due to a breakdown in the manner in which sensory information is brought into the brain and the way it is stored (and presumably retrieved).

Another issue in the published case literature about Capgras Syndrome is the focus on the delusion of the imposter to the exclusion of other aspects of the syndrome. Closer scrutiny often demonstrates other DMS and psychotic/schizophrenic symptoms in Capgras cases. Many patients suffer from a sort of expanded Capgras Syndrome where there are many other delusions present. Some of these delusions may be somatic in nature with the patient experiencing bizarre changes to their bodies, with their seeming strange and alien. Even the patient’s sense of self is changed and subject to delusion. These symptoms are reminiscent of schizophrenia and it is no surprise that many cases of Capgras have a co-morbid diagnosis of schizophrenia, usually of the paranoid variety. Upon closer examination it can become difficult to make a differential diagnosis between Capgras and schizophrenia in many sufferers, and the Capgras symptoms may be another aspect of the schizophrenic illness. In fact, studies have shown that misidentification symptoms occur in a large number of cases of schizophrenia, maybe even as high as 40% (Sinkman, 2008).

Modern clinicians and researchers now believe that Capgras has an organic basis, which is specifically related to cerebral dysfunction. Neuroimaging studies have shown that lesions in the right hemisphere of the brain are common among Capgras sufferers. Some studies have demonstrated bilateral damage to the hemispheres in Capgras patients (Bourget & Whitehurst, 2004). In one small study 81% of Capgras sufferers also had neurodegenerative disease, usually involving the Lewy body. As would be expected, these Capgras sufferers were older than Capgras patients without neurodegenerative disease, who were more likely to also suffer from paranoid schizophrenia, schizoaffective disorder, methamphetamine abuse, or other cerebrovascular problems. 100% of patients with Capgras and Lewy body disease experienced visual hallucinations (Josephs, 2007).

Capgras patients are prone to acts of violence, especially against people they have misidentified (Bourget & Whitehurst, 2004). Given the relation of Capgras to paranoid schizophrenia this makes sense.

There is evidence to support the idea that an emotional processing module in the brain, especially as it related to feelings of familiarity and unfamiliarity, and its connection to facial recognition is flawed in Capgras sufferers (Pacherie, 2009). This flaw in emotional processing can be demonstrated via facial recognition tasks and eye movement patterns (Brighetti, Bonifacci, Borlimi, & Ottaviani, 2007; Grignon & Trottier, 2005; Walther et al., 2010). Similar differences in audio perceptions related to working memory have also been reported for Capgras sufferers (Papageorgiou, Lykouras, Ventouras, Uzunoglu, & Christodoulou, 2002). In one dramatic case a Capgras patient had sexual relations with his wife, thinking she was a ‘double’. He had no feelings of familiarity with his wife whatsoever and essentially felt as if he were having sex with a different woman; so much so that he even changed his sexual behavior. The authors (Thomas Antérion, Convers, Desmales, Borg, & Laurent, 2008) note that this may be the only known documentation of a patient who was able to make his wife into his mistress!

As might be expected the typical treatment for Capgras Syndrome is anti-psychotic medications. However, when anti-psychotic medication is only partially or not effective the use of electroconvulsive therapy has been shown to be helpful. This is especially the case when Capras is co-morbid with Parkinson’s Disease (Chiu, 2009).

Fregoli Delusion

References:

Bekelman, D. B., & Hallenbeck, J. (2006). Capgras Syndrome Associated with Morphine Treatment. Journal of Palliative Medicine, 9(3), 810–813. doi:10.1089/jpm.2006.9.810

Bourget, D., & Whitehurst, L. (2004). Capgras Syndrome: A Review of the Neurophysiological Correlates and Presenting Clinical Features in Cases Involving Physical Violence. The Canadian Journal of Psychiatry / La Revue canadienne de psychiatrie, 49(11), 719–725.

Brighetti, G., Bonifacci, P., Borlimi, R., & Ottaviani, C. (2007). “Far from the heart far from the eye”: Evidence from the Capgras delusion. Cognitive Neuropsychiatry, 12(3), 189–197. doi:10.1080/13546800600892183

Ceylan, M. F., Bulut, M., Virit, O., Selek, S., Bülbül, F., & Savaş, H. A. (2010). Hashimato tiroiditi olan erişkin bipolar bozukluk hastasinda capgras ve fregoli sendromu birlikteliği. Yeni Symposium: psikiyatri, nöroloji ve davraniş bilimleri dergisi, 48(1), 69–71.

Chiu, N.-M. (2009). Repeated electroconvulsive therapy for a patient with Capgras syndrome and Parkinsonism. Progress in Neuro-Psychopharmacology & Biological Psychiatry, 33(6), 1084–1085. doi:10.1016/j.pnpbp.2009.06.003

Corlett, P. R., D’Souza, D. C., & Krystal, J. H. (2010). Capgras syndrome induced by ketamine in a healthy subject. Biological Psychiatry, 68(1), e1–e2. doi:10.1016/j.biopsych.2010.02.015

de Pauw, K. W. (1994). Psychodynamic approaches to the Capgras delusion: A critical historical review. Psychopathology, 27(3-5), 154–160.

Donnelly, R., Bolouri, M. S., Prashad, S. J., Coverdale, J. H., Hays, J. R., & Kahn, D. A. (2008). Comorbid Diogenes and Capgras syndromes. Journal of Psychiatric Practice, 14(5), 312–317. doi:10.1097/01.pra.0000336759.50060.5c

Fischer, C., Keeler, A., Fornazzari, L., Ringer, L., Hansen, T., & Schweizer, T. A. (2009). A rare variant of Capgras syndrome in Alzheimer’s disease. The Canadian Journal of Neurological Sciences/ Le Journal Canadien Des Sciences Neurologiques, 36(4), 509–511.

Grignon, S., & Trottier, M. (2005). Capgras Syndrome in the Modern Era: Self Misidentification on an ID Picture. The Canadian Journal of Psychiatry / La Revue canadienne de psychiatrie, 50(1), 74–75.

Josephs, K. A. (2007). Capgras syndrome and its relationship to neurodegenerative disease. Archives of Neurology, 64(12), 1762–1766.

Melca, I., Rodrigues, C., Serra-Pinheiro, M., Pantelis, C., Velakoulis, D., Mendlowicz, M., & Fontenelle, L. (2012). Delusional Misidentification Syndromes in Obsessive–Compulsive Disorder. Psychiatric Quarterly, 1–7. doi:10.1007/s11126-012-9237-z

Mishra, B. R., Prakesh, R., Mishra, B. N., Praharaj, S. K., & Sinha, V. K. (2009). Capgras syndrome associated with Fahr’s disease. The Journal of Neuropsychiatry and Clinical Neurosciences, 21(3), 354–355. doi:10.1176/appi.neuropsych.21.3.354

Pacherie, E. (2009). Perception, emotions, and delusions: The case of the Capgras delusion. In T.

Bayne & J. Fernández (Eds.), Delusion and self-deception: Affective and motivational influences on belief formation., Macquarie monographs in cognitive science (pp. 107–125). New York, NY US: Psychology Press.

Pande, A. C. (1981). Co-existence of incubus and Capgras syndromes. The British Journal of Psychiatry, 139, 469–470. doi:10.1192/bjp.139.5.469

Papageorgiou, C., Lykouras, L., Ventouras, E., Uzunoglu, N., & Christodoulou, G. N. (2002). Abnormal P300 in a case of delusional misidentification with coinciding Capgras and Fŕegoli symptoms. Progress in Neuro-Psychopharmacology & Biological Psychiatry, 26(4), 805–810. doi:10.1016/S0278-5846(01)00293-7

Rodríguez, R. H., Madoz-Gúrpide, A., & Ustárroz, J. T. (2011). Propuesta de una batería neuropsicológica para la exploración del síndrome de Capgras. Revista Española de Geriatría y Gerontología, 46(5), 275–280. doi:10.1016/j.regg.2011.06.001

Sinkman, A. (2008). The syndrome of Capgras. Psychiatry: Interpersonal and Biological Processes, 71(4), 371–378. doi:10.1521/psyc.2008.71.4.371

Thomas Antérion, C., Convers, P., Desmales, S., Borg, C., & Laurent, B. (2008). An odd manifestation of the Capgras syndrome: Loss of familiarity even with the sexual partner. Neurophysiologie Clinique/Clinical Neurophysiology, 38(3), 177–182. doi:10.1016/j.neucli.2008.04.003

Walther, S., Federspiel, A., Horn, H., Wirth, M., Bianchi, P., Strik, W., & Müller, T. J. (2010). Performance during face processing differentiates schizophrenia patients with delusional misidentifications. Psychopathology, 43(2), 127–136. doi:10.1159/000277002

Yalin, Ş., Taş, F. V., & Güvenir, T. (2008). The coexistence of Capgras, Fregoli and Cotard’s syndromes in an adolescent case. Nöropsikiyatri Arşivi/Archives of Neuropsychiatry, 45(4), 149–151.