Capgras (Delusion) Syndrome

The Capgras delusion (or Capgras syndrome) (/kpr/, US dict: kpgr)

[1]
is a disorder in
which a person holds a delusion that a friend, spouse, parent, or other close family member
has been replaced by an identical-looking impostor. The Capgras delusion is classified as
a delusional misidentification syndrome, a class of delusional beliefs that involves the
misidentification of people, places, or objects (usually not in conjunction).
[2]
It can occur
in acute, transient, or chronic forms. Cases in which patients hold the belief that time has been
"warped" or "substituted" have also been reported.
[3]

The delusion most commonly occurs in patients diagnosed with paranoid schizophrenia, but
has also been seen in patients suffering from brain injury
[4]
and dementia.
[5]
It presents often in
individuals with a neurodegenerative disease, particularly at an older age.
[6]
It has also been
reported as occurring in association with diabetes, hypothyroidism and migraine attacks.
[7]
In
one isolated case, the Capgras delusion was temporarily induced in a healthy subject by the
drug ketamine.
[8]
It occurs more frequently in females, with a female:male ratio of 3:2.
[9]

The information gathered from studying people with Capgras delusion has theoretical
implications for understanding face perception and neuroanatomy in both healthy and
unhealthy individuals
Causes[edit]
It is generally agreed that the Capgras delusion has a more complex and organic basis, and
can be better understood by examining neuroanatomical damage associated with the
syndrome.
[17]

Some of the first clues to the possible causes of the Capgras delusion were suggested by the
study of brain-injured patients who had developed prosopagnosia. In this condition, patients
are unable to recognize faces consciously, despite being able to recognize other types of
visual objects. However, a 1984 study by Bauer showed that even though conscious face
recognition was impaired, patients with the condition showed autonomic arousal (measured by
a galvanic skin response measure) to familiar faces,
[18]
suggesting that there are two
pathways to face recognitionone conscious and one unconscious.
In a 1990 paper published in the British Journal of Psychiatry, psychologists Hadyn Ellis and
Andy Young hypothesized that patients with Capgras delusion may have a "mirror image" of
prosopagnosia, in that their conscious ability to recognize faces was intact, but they might
have damage to the system that produces the automatic emotional arousal to familiar
faces.
[19]
This might lead to the experience of recognizing someone while feeling something
was not "quite right" about them. In 1997, Hadyn Ellis and his colleagues published a study of

five patients with Capgras delusion (all diagnosed with schizophrenia) and confirmed that
although they could consciously recognize the faces, they did not show the normal automatic
emotional arousal response.
[20]
The same low level of autonomic response was shown in the
presence of strangers. Young (2008) has theorized that this means that patients suffering
from the disease experience a "loss" of familiarity, not a "lack" of it.
[21]

William Hirstein and Vilayanur S. Ramachandran reported similar findings in a paper
published on a single case of a patient with Capgras delusion after brain
injury.
[22]
Ramachandran portrayed this case in his book Phantoms in the Brain,
[23]
and gave a
talk about it at TED 2007.
[24]
Since the patient was capable of feeling emotions and
recognizing faces, but could not feel emotions when recognizing familiar faces,
Ramachandran hypothesizes that the origin of Capgras syndrome is a disconnection between
the temporalcortex, where faces are usually recognized (see temporal lobe), and the limbic
system, involved in emotions. More specifically, he emphasizes the disconnection between
theamygdala and the inferotemporal cortex.
[4]

In 2010 William Hirstein revised this theory to explain why a person suffering from Capgras
syndrome would have the particular reaction of not recognizing a familiar person.
[25]
[1]Hirstein
explained the theory as follows
[26]
[2]
"...my current hypothesis on Capgras, which is a more specific version of the earlier position I
took in the 1997 article with V. S. Ramachandran. According to my current approach, we
represent the people we know well with hybrid representations containing two parts. One part
represents them externally: how they look, sound, etc. The other part represents them
internally: their personalities, beliefs, characteristic emotions, preferences, etc. Capgras
syndrome occurs when the internal portion of the representation is damaged or inaccessible.
This produces the impression of someone who looks right on the outside, but seems different
on the inside, i.e., an impostor. This gives a much more specific explanation that fits well with
what the patients actually say. It corrects a problem with the earlier hypothesis in that there
are many possible responses to the lack of an emotion upon seeing someone."
Furthermore, Ramachandran suggests a relationship between the Capgras syndrome and a
more general difficulty in linking successive episodic memories because of the crucial role
emotion plays in creating memories. Since the patient could not put together memories and
feelings, he believed objects in a photograph were new on every viewing, even though they
normally should have evoked feelings (e.g., a person close to him, a familiar object, or even
himself).
[27]
Others like Merrin and Silberfarb (1976)
[12]
have also proposed links between the
Capgras syndrome and deficits in aspects of memory. They suggest that an important and
familiar person (the usual subject of the delusion) has many layers of visual, auditory, tactile,
and experiential memories associated with them, so the Capgras delusion can be understood
as a failure of object constancy at a high perceptual level.
Most likely, more than an impairment of the automatic emotional arousal response is
necessary to form Capgras delusion, as the same pattern has been reported in patients
showing no signs of delusions.
[28]
Ellis and colleagues suggested that a second factor explains
why this unusual experience is transformed into a delusional belief; this second factor is
thought to be an impairment in reasoning, although no definitive impairment has been found to
explain all cases.
[29]
Many have argued for the inclusion of the role of patient phenomenology
in explanatory models of the Capgras syndrome in order to better understand the mechanisms
that enable the creation and maintenance of delusional beliefs.
[30][31]

Capgras syndrome has also been linked to reduplicative paramnesia, another delusional
misidentification syndrome. Since these two syndromes are highly associated, it has been
proposed that they affect similar areas of the brain and therefore have similar neurological
implications. Reduplicative paramnesia is understood to affect the frontal lobe and thus it is
believed that Capgras syndrome is also associated with the frontal lobe.
[32]
Even if the
damage is not directly to the frontal lobe, an interruption of signals between other lobes and
the frontal lobe could result in Capgras syndrome


Capgras Syndrome, named for its discoverer, the French psychiatrist Jean Marie Joseph Capgras. The
person's primary delusion is that a close relative or friend has been replaced by an impostor, an exact
double, despite recognition of familiarity in appearance and behavior. The patient may also see himself as
his own double. Also know as Delusional misidentification, illusion of doubles, illusion of negative
doubles, misidentification syndrome, nonrecognition syndrome, phantom double syndrome, subjective
doubles syndrome.
Delusions are false beliefs, sometimes with bizarre content, that are held with strong conviction even in
the presence of contrary evidence. For persons suffering from Capgras Syndrome they typically believe
they exist in a world of impersonators. This feeling in a delusional world of doubles can be so alarming
that it drives the Capgras sufferer to psychotic behavior. The syndrome typically has the following
characteristics:
The person is convinced that one or several persons known by the sufferer have been replaced by a
double, an identical looking imposter.
The patient sees true and double persons.
It can may extend to animals and objects.

The person is conscious of the abnormality of these perceptions. There is no hallucination.
The double is usually a key figure for the person at the time of onset of symptoms. If married, always
the husband or wife accordingly.
Associated Features:
Cerebral lesions caused by head injury, which are often located in the posterior area of the right
hemisphere, where face recognition is performed.
Schizophrenic diseased conditions (paranoid-hallucinatory schizophrenia), but also in affective and
organic-psychic disturbances.
Affects both sexes, but prevalent in women.
Differential Diagnosis:

Some disorders have similar symptoms. The clinician, therefore, in his diagnostic attempt, has to
differentiate against the following disorders which need to be ruled out to establish a precise diagnosis.
Schizophrenia
Alzheimer's Disease
Huntington's Disease
Multiple Sclerosis
Traumatic Brain Injury
Substance-Induced Delusional Disorders - hallucinogens and alcohol
Mood Disorders with Delusions - manic and depressive types
Dementia
Cause:
It has been reported that the Capgras Syndrome and related substitution delusions, that 35% have an
organic etiology. Some researchers believe that Capgras' syndrome can be blamed on a relatively simple
failure of normal recognition processes following brain damage from a stroke, drug overdose, or some
other cause. This disorder can also follow after accidents that cause damage to the right side of the brain.
Therefore, controversies exist about the etiology of Capgras Syndrome, some researchers explain it with
organic factors, others with psychodynamic factors, or a combination of the two,
Treatment:

Individual therapy may be best suited to treat the persons delusions. Persistence is needed in
establishing a therapeutic empathy without validating the persons delusional system or overtly
confronting the system. Cognitive techniques that include reality testing and reframing can be
used. Antipsychotics and other drugs have been used with some success.
Counseling and Psychotherapy [ See Therapy Section ]:
Cognitive-Behavioural therapy, for treating delusions that is based on persistent gentle discussions about
evidence for the belief, might help overcome the problem the person has with believing this substitution al
delusion against the available evidence.
Pharmacotherapy [ See Psychopharmacology Section ] :
A reasonable pharmacological treatment approach for the person with delusional disorder is a standard
trial of an antipsychotic or SSRI at starting doses commonly used to treat psychotic or mood disorders.
Antipsychotics (typical and atypical)
Pimozide
Risperidone
Clozapine
Capgras syndrome is what's known as a delusional misidentification. It's the opposite of dj vu.
People with Capgras syndrome think that their spouse, family members or even their pets have been
replaced with doubles. Imagine how disconcerting it would be to have someone who looks like a lovedone
sit down with you and know intimate details about your life, even though you're sure that this person is a
trickster.
Capgras syndrome used to be considered very rare, but medical professionals are beginning to think that
perhaps it isn't so rare after all. The more doctors that know about it, the more people they find who have
it. Capgras was first described by two French doctors, Joseph Capgras, for whom the syndrome is
named, and Jean Reboul-Lachaux. Their patient, Madame M., was convinced that her family and
neighbors had all been replaced by lookalikes. She said she'd had 80 husbands -- one imposter would
simply leave to make room for a new one.
Capgras syndrome isn't the same thing as face blindness, or prosopagnosia. People with prosopagnosia
can see a face for the hundredth time and still not know who it is. You can walk right by your best friend
and not recognize her even when she says hello (For a more in-depth look at face blindness, check out
"Can face blindness explain why that person at work never says hi to me?"). People with prosopagnosia,
however, show changes in their skin conductance when shown a picture of someone they know. Part of
their brain recognizes this person emotionally, even if consciously they don't know who it is.
People with Capgras syndrome can perceive faces, and recognize that they look familiar, but they don't
connect that face with the actual feeling of familiarity. That woman looks like your wife, but you don't feel
that she really is your wife. You don't have the feelings you should have when you look at this person with
your wife's face. Their skin conductance stays the same as it would if they were looking at a total
stranger. It's a problem of disconnection. So what's going on?

DELUSIONS VS. HALLUCINATIONS
Delusions are different from hallucinations. A hallucination is something that affects your senses - you
see or hear or smell things that aren't real. Delusions just have to do with a person's thoughts -- a
delusional person has some thoughts and beliefs that aren't true.

The Capgras Delusion You Are Not My Wife!


Imagine the horror of learning that your brother is in a coma as the result of a car crash. Now
imagine the relief when he emerges from that coma; a relief that is soon shattered by your brothers
reaction to your presence. He thinks you, his sister, are an imposter. You look and sound just like his
sister, but you are not she. This bizarre scenario is the lynch-pin for the plot of Richard Powers
National Book Award-winning novel, The Echo Maker published in 2006. The booka wonderful
readis fictional, but the neuropsychological disorder at its core is a real disorder. It is called the
Capgras Delusion, and although rare, it has been described in many people with psychiatric or
neurological disorders. The victim, often following a traumatichead injury or suffering from conditions
such as Alzheimers Disease, believes that familiar people, or sometimes even their pet dog or their
own home are imposters. In the case of traumatic brain injury, the patient may have no other
significant cognitive problems yet believes firmly that his wife, or his mother, or his pet poodle, or his
house are imposters, and no amount of discussion about the improbability of this occurring will
convince him otherwise. Sometimes the imposter delusion will begin with the person closest to him
and then gradually extend to other members of his family until he believes his whole family are
imposters.
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PsychoanalyticalFreudiantheories about the cause of this delusion are no longer given
credibility, but there have been a number of neuropsychological theories proposed to explain it. In
common with most of these is the idea that when we see a familiar face and recognize it, the visual
pathways in the temporal lobe of the brain are activated, and this activates a separate pathway,
probably involving the amygdala, causing an emotional response to that familiar face. People who
suffer from the Capgras Delusion have, as a result of their brain damage, lost the connection
between the visual face recognition area in the right temporal lobe and the area of the brain that
provides the emotional response to that face. Thus, when they see their wifes face, they recognize it
but they dont have the warm feeling that goes along with it. They dont experience that feeling of
familiarity. Thus, they form the belief that this cant be their wife although she looks and acts exactly
like her, and even knows everything his wife knew about their relationship. She must therefore be an
imposter. Common sense may tell the patient that this is implausible, but that feeling of familiarity is
so essential that its absence is sufficient to make him think that this imposter is determined to trick
him into thinking she is his wife by purposely finding out everything about his wife in order to pretend
to be her. When the patient also believes his house is not his house but another one exactly like it
and in exactly the same location, it is an extension of the same visual recognition problem; the
house is recognized but the connection with the emotional response is missing, and as a result the
patient has no feeling of familiarity. When he thinks his dog has been replaced by an imposter,
perhaps he tells himself it is not the dog who is intentionally trying to fool him, but the woman who is
pretending to be his wife who has also swapped his dog for another look-alike! Of course while this
is so strange it is amusing when read about in the abstract, for families of a person with Capgras
Delusion it is traumatic. For the patient himself, to believe he is being cared for by an imposter and
not his wife, and an ill-intentioned one at that, must be terrifying.
Ramachandran described a patient with Capras Delusion who thought his father was an imposter
when he saw him, but when his father phoned him he knew it was his father. This is consistent with
the Capgras Delusion being a disorder of the visual recognition system. The visual sense is the
dominant sense in humans, so when the patient was talking with his father face-to-face, the visual
sense that told him he was an imposter was much stronger than the auditory sense that told him this
was his father. Watch this YouTube video clip where Ramachandran interviews and tests a person
with Capgras Delusion.