Perceptual and Motor Skills, 1992, 75, 971-974.
AN UNUSUAL VARIANT
O Perceptual and Motor Skills 1992
OF CAPGRAS SYNDROME '
TARAK VASAVADA AND PRAKASH MASAND
Department of Psychiah.y SUN Y Health Science Center Summary.-In a 40-yr.-old man a variant of Capgras syndrome called reverse subjective doubles is described. The unusual feature of the case was the presence of a delusion that the patient had been transformed into someone else.
Delusions of misidentification have intrigued psychiatric observers ever since Capgras and Reboul-Lachaux (2) reported the case of a 53-year-old woman who believed that there existed physical but not psychologicdy identical doubles of herself, her husband, children, police, and neighbors as part of a plot to steal her inheritance. Since their first report, more than 100 cases of Capgras syndrome have been reported in the literature (1).I n 1927 Courbon and Fail (6) described a variant of Capgras syndrome in which the patient had a delusional belief that the doubles were psychologically identical but had acquired the physical characteristics of strangers. They named it Fregolis syndrome after a European actor who could change his face very easily. Courbon and Tusques (7) described the syndrome of intermetamorphosis in which the patient had a delusional belief that someone who was either a stranger or familiar to the patient was both physically and psychologically transformed into someone else. I n the original report the patient, a 49-yearold woman, believed that her husband and son had been transformed into someone else. Two other rare variants of Capgras syndrome have been described. I n the syndrome of subjective doubles the patient has a delusional belief that another person in the patient's surroundings has acquired the physical but not the psychological make-up of the patient. This syndrome may occur in conjunction with other delusions of misidentification as in the original report of Capgras and Reboul-Lachaux (2) or exclusively ( 5 ) . I n reverse subjective doubles, however, the patient believes that he has become someone else or is in the process of being transformed. We describe a case of reverse subjective doubles which occurred exclusively in a patient.
CASEREPORT Mr. A, a 40-year-old divorced white male, was hospitalized for his complaint that h s identity had been changed in the last six years. H e stated that he was not Mr. A but Mr. B and preferred to be called by that name. H e ex'Send enquiries to Prakash Masand, M.D., Department of Psychiatry, SUNY Health Science Center, 750 East Adams Street, Syracuse, NY 13210.
972
T. VASAVADA & P. MASAND
plained that the Federal Bureau of Investigation (F.B.I.) had overpowered him and implanted a microtape recorder or a computer-like device into his brain which had erased all old memories of Mr. B and replaced them with new memories about Mr. A. H e also stated that t h s powerful and sophisticated device had changed his physical appearance including fingerprints. Mr. A insisted that this type of device did exist and that, if given an opportunity, he could transform himself back to Mr. B. The patient feared that he might again be transformed into someone else. H e showed his driver's license and stated that even this had been tampered with and that someone had affixed a new photograph. When asked to describe Mr. B, he replied that the only thing he remembered was that Mr. B was an orphan and had made his fortune by working hard. H e denied that Mr. B had any family members. H e would get angry when addressed as Mr. A and would insist on being c d e d Mr. B. Mr. A had had one previous psychiatric hospitalization three months earlier. He was diagnosed as having chronic schizophrenia, paranoid type. Mr. A refused treatment and signed out against medical advice. Family history was significant for alcohol abuse by his father whom the patient described as being verbally abusive. Mr. A had lived with his parents for the last 5 years. H e had divorced his wife 12 years ago after accusing her of being unfaithful. Mr. A had a past history of alcohol consumption of about eight to ten cans of beer a day but had quit drinking ten years ago. His physical and neurological examinations were unremarkable. His mental status examination was significant for anxiety, paranoid delusions, delusions of control, and thought insertion. H e denied any hallucinations either in himself or in his double. H e was cognitively intact on gross testing. H e met DSM111-R criteria for chronic schizophrenia, paranoid type. Following his admission and prior to discharge, he refused to undergo an electroencephalogram (EEG), computerized tomography (CT) of the head, or neuropsychoIogical testing, stating that enough experiments had been performed on his brain. Routine laboratory work-up including electrolytes, liver function tests, VDRL, haematologic, and thyroid indices were within normal limits. The patient was started on molindone 20 mg. orally twice a day with improvement in his anxiety and thought disorder. One month later at the time of discharge, Mr. A stated that he did not think about being another person since he had 'enough day to day problems to thmk about.' In the above case our patient believed that he had been changed both physically (face, fingerprints, etc.) and psychologically (he could recount details of his life as Mr. A but few as Mr. B). DISCUSSION Siomopoulos and Goldsmith (12) described the case of a 34-year-old man diagnosed as 'paranoid schizophrenic' who believed that he had adopted
CAPGRAS SYNDROME
973
the identity of a political writer to whom he bore a certain physical resemblance. H e could recount details of his new life but not of his "original" self which he attributed to the excessive use of drugs. In contrast to Mr. A their patient did not object to being addressed as his transformed self. Fialkov and Robins (8) reported the case of a 43-year-old woman with vitihgo, multinodular goitre, and a history of head injury who had the delusional belief that she had been transformed by an American secret political organization into someone else. She claimed to be from Uranus originally and was waiting for a spaceship to take her back. A diagnosis of paranoid schizophrenia was made. Her blood chemistry including thyroid function tests were normal. Her skull x-ray and EEG were also within normal limits. However, their patient in contrast to ours also believed that her husband was an impostor. Signer and Benson (10) reported the case of a 29-year-old Asian student who in addition to believing that his fellow students, instructors, and parents had been replaced, also stated that another human being was being physically created within his body. His developmental milestones, physical, neurologic, and mental status examinations were unremarkable. His EEG and blood chemistry were also within normal limits. However, he had a positive purified protein derivative test (PPD) and was treated with Isoniazid 300 mgper day for six months prior to hospitalization. The diagnosis was 'brief psychosis with affective features.' H e responded to treatment with haloperidol 5 mg per day and was discharged one week later on 2 mg per day. Silva, Leong, and Luong (11) described a 27-year-old Female who believed that the left side of her body had been transformed into an angel with supernatural powers. Her delusions appeared shortly after a closed head injury in a motor vehicular accident. She showed evidence of mania and was given a diagnosis of 'organic affective disorder with mania.' Her neurological examination was within normal limits. Mikkelsen and Gutheil (9) described the case of a 44-year-old woman, Mrs. M, who in addition to believing that her husband, mother, and son had been replaced by impostors, also believed that she was not the real Mrs. M; she herself was a good loving mother while the real Mrs. M was a "no-good birch," The patient carried a diagnosis of paranoid schizophrenia. Besides our case we are aware of only the above five cases of reverse subjective doubles in English literature, although several cases of subjective doubles have been described in the British and French literature (1). As with Capgras syndrome, the most common underlying diagnosis is chronic schizophrenia particularly ~ a r a n o i dtype, although organic conditions can also be responsible (11). Most patients have more than one delusion of misidentification similar to the patient described by Capgras and Reboul-Lachaux (Z), leading some to question whether these are distinct syndromes or
974
T.VASAVADA & P. MASAND
simply variants of a single one (4). Psychodynamic explanations of Capgras syndrome have included a "paranoic disposition," derealization-depersonalization, and an intense ambivalence to the original object, including certain aspects of the self (2, 3 , 9, 13). A better nosological system for classifying delusions of misidentification would aid in studying their epidemiology, phenomenology, prognosis, and response to treatment. REFERENCES 1. BERSON,R. J. Capgras syndrome. American Journal of Psychiatry, 1983, 140, 969-978. 2. CAPGRAS, J., & REBOUL-LACHAUX, J. Illusion des sosies dans un delire systematise chronique. Bulletin de la Societk Clinique de Medicine Menfale, 1923, 2 , 6-16. 3. CHRISTODOULOU, G. N. T h e syndrome of Capgras. British Journal of Psychiatry, 1977, 130, 556-564. 4. CHRISTODOULOU, G . N. Course and prognosis of syndrome of doubles. Journal of Nervous and Mental Disease, 1978, 166, 68-72. G. N. Syndrome of subjective doubles. American Journal of Psychiatry, 5. CHRISTOOOULOU, 1978, 135, 249-251. 6. COURBON,P., & FAIL, G . Illusion d e fregoli. Bulletin de lo Socief; Clinique de Medicine Mentale, 1927, 15, 121-124. 7. COURBON, P., & TUSQUES,J. Illusion d'intermetamorphose et de charme. Annaks MedicoPsychologiques, 1932, 90, 401-405. 8. FIALKOV,M. J., & ROBINS,A. H. An unusual case of the Capgras syndrome. British Journal of Psychiatry, 1978, 132, 403-404. 9. MIKKELSEN, E . J., & GUTHELL,T. G . Communication and re&ty in the Capgras syndrome. American Iournal of Psychotherapy, 1976, 30, 136-146. 10. SIGNER,S. J., & BENSON,F. TWOcases of Capgras symptom with dysmorphic (somatic) delusions. Psychosomatics, 1987, 28, 327-328. 11. S ~ L V A A., J., LEONG,G. B., & LUONG,M. T. Split body and self: an unusual case of misidentification. Canadian Journal of Psychiatry, 1989, 34, 728-730. o s&, GOLDSMITH, J. TWOreports of the Capgras syndrome. American Jour12. S ~ o ~ o ~ o mV., no1 of Psychiatry, 1975, 132, 756. 13. TODD,J., DEWHURST,K., & WALLIS, G. The syndrome of Capgras. British Journal of Psychiatry, 1987, 139, 319-327.
Accepted September 9, 1992
AN UNUSUAL VARIANT
O Perceptual and Motor Skills 1992
OF CAPGRAS SYNDROME '
TARAK VASAVADA AND PRAKASH MASAND
Department of Psychiah.y SUN Y Health Science Center Summary.-In a 40-yr.-old man a variant of Capgras syndrome called reverse subjective doubles is described. The unusual feature of the case was the presence of a delusion that the patient had been transformed into someone else.
Delusions of misidentification have intrigued psychiatric observers ever since Capgras and Reboul-Lachaux (2) reported the case of a 53-year-old woman who believed that there existed physical but not psychologicdy identical doubles of herself, her husband, children, police, and neighbors as part of a plot to steal her inheritance. Since their first report, more than 100 cases of Capgras syndrome have been reported in the literature (1).I n 1927 Courbon and Fail (6) described a variant of Capgras syndrome in which the patient had a delusional belief that the doubles were psychologically identical but had acquired the physical characteristics of strangers. They named it Fregolis syndrome after a European actor who could change his face very easily. Courbon and Tusques (7) described the syndrome of intermetamorphosis in which the patient had a delusional belief that someone who was either a stranger or familiar to the patient was both physically and psychologically transformed into someone else. I n the original report the patient, a 49-yearold woman, believed that her husband and son had been transformed into someone else. Two other rare variants of Capgras syndrome have been described. I n the syndrome of subjective doubles the patient has a delusional belief that another person in the patient's surroundings has acquired the physical but not the psychological make-up of the patient. This syndrome may occur in conjunction with other delusions of misidentification as in the original report of Capgras and Reboul-Lachaux (2) or exclusively ( 5 ) . I n reverse subjective doubles, however, the patient believes that he has become someone else or is in the process of being transformed. We describe a case of reverse subjective doubles which occurred exclusively in a patient.
CASEREPORT Mr. A, a 40-year-old divorced white male, was hospitalized for his complaint that h s identity had been changed in the last six years. H e stated that he was not Mr. A but Mr. B and preferred to be called by that name. H e ex'Send enquiries to Prakash Masand, M.D., Department of Psychiatry, SUNY Health Science Center, 750 East Adams Street, Syracuse, NY 13210.
972
T. VASAVADA & P. MASAND
plained that the Federal Bureau of Investigation (F.B.I.) had overpowered him and implanted a microtape recorder or a computer-like device into his brain which had erased all old memories of Mr. B and replaced them with new memories about Mr. A. H e also stated that t h s powerful and sophisticated device had changed his physical appearance including fingerprints. Mr. A insisted that this type of device did exist and that, if given an opportunity, he could transform himself back to Mr. B. The patient feared that he might again be transformed into someone else. H e showed his driver's license and stated that even this had been tampered with and that someone had affixed a new photograph. When asked to describe Mr. B, he replied that the only thing he remembered was that Mr. B was an orphan and had made his fortune by working hard. H e denied that Mr. B had any family members. H e would get angry when addressed as Mr. A and would insist on being c d e d Mr. B. Mr. A had had one previous psychiatric hospitalization three months earlier. He was diagnosed as having chronic schizophrenia, paranoid type. Mr. A refused treatment and signed out against medical advice. Family history was significant for alcohol abuse by his father whom the patient described as being verbally abusive. Mr. A had lived with his parents for the last 5 years. H e had divorced his wife 12 years ago after accusing her of being unfaithful. Mr. A had a past history of alcohol consumption of about eight to ten cans of beer a day but had quit drinking ten years ago. His physical and neurological examinations were unremarkable. His mental status examination was significant for anxiety, paranoid delusions, delusions of control, and thought insertion. H e denied any hallucinations either in himself or in his double. H e was cognitively intact on gross testing. H e met DSM111-R criteria for chronic schizophrenia, paranoid type. Following his admission and prior to discharge, he refused to undergo an electroencephalogram (EEG), computerized tomography (CT) of the head, or neuropsychoIogical testing, stating that enough experiments had been performed on his brain. Routine laboratory work-up including electrolytes, liver function tests, VDRL, haematologic, and thyroid indices were within normal limits. The patient was started on molindone 20 mg. orally twice a day with improvement in his anxiety and thought disorder. One month later at the time of discharge, Mr. A stated that he did not think about being another person since he had 'enough day to day problems to thmk about.' In the above case our patient believed that he had been changed both physically (face, fingerprints, etc.) and psychologically (he could recount details of his life as Mr. A but few as Mr. B). DISCUSSION Siomopoulos and Goldsmith (12) described the case of a 34-year-old man diagnosed as 'paranoid schizophrenic' who believed that he had adopted
CAPGRAS SYNDROME
973
the identity of a political writer to whom he bore a certain physical resemblance. H e could recount details of his new life but not of his "original" self which he attributed to the excessive use of drugs. In contrast to Mr. A their patient did not object to being addressed as his transformed self. Fialkov and Robins (8) reported the case of a 43-year-old woman with vitihgo, multinodular goitre, and a history of head injury who had the delusional belief that she had been transformed by an American secret political organization into someone else. She claimed to be from Uranus originally and was waiting for a spaceship to take her back. A diagnosis of paranoid schizophrenia was made. Her blood chemistry including thyroid function tests were normal. Her skull x-ray and EEG were also within normal limits. However, their patient in contrast to ours also believed that her husband was an impostor. Signer and Benson (10) reported the case of a 29-year-old Asian student who in addition to believing that his fellow students, instructors, and parents had been replaced, also stated that another human being was being physically created within his body. His developmental milestones, physical, neurologic, and mental status examinations were unremarkable. His EEG and blood chemistry were also within normal limits. However, he had a positive purified protein derivative test (PPD) and was treated with Isoniazid 300 mgper day for six months prior to hospitalization. The diagnosis was 'brief psychosis with affective features.' H e responded to treatment with haloperidol 5 mg per day and was discharged one week later on 2 mg per day. Silva, Leong, and Luong (11) described a 27-year-old Female who believed that the left side of her body had been transformed into an angel with supernatural powers. Her delusions appeared shortly after a closed head injury in a motor vehicular accident. She showed evidence of mania and was given a diagnosis of 'organic affective disorder with mania.' Her neurological examination was within normal limits. Mikkelsen and Gutheil (9) described the case of a 44-year-old woman, Mrs. M, who in addition to believing that her husband, mother, and son had been replaced by impostors, also believed that she was not the real Mrs. M; she herself was a good loving mother while the real Mrs. M was a "no-good birch," The patient carried a diagnosis of paranoid schizophrenia. Besides our case we are aware of only the above five cases of reverse subjective doubles in English literature, although several cases of subjective doubles have been described in the British and French literature (1). As with Capgras syndrome, the most common underlying diagnosis is chronic schizophrenia particularly ~ a r a n o i dtype, although organic conditions can also be responsible (11). Most patients have more than one delusion of misidentification similar to the patient described by Capgras and Reboul-Lachaux (Z), leading some to question whether these are distinct syndromes or
974
T.VASAVADA & P. MASAND
simply variants of a single one (4). Psychodynamic explanations of Capgras syndrome have included a "paranoic disposition," derealization-depersonalization, and an intense ambivalence to the original object, including certain aspects of the self (2, 3 , 9, 13). A better nosological system for classifying delusions of misidentification would aid in studying their epidemiology, phenomenology, prognosis, and response to treatment. REFERENCES 1. BERSON,R. J. Capgras syndrome. American Journal of Psychiatry, 1983, 140, 969-978. 2. CAPGRAS, J., & REBOUL-LACHAUX, J. Illusion des sosies dans un delire systematise chronique. Bulletin de la Societk Clinique de Medicine Menfale, 1923, 2 , 6-16. 3. CHRISTODOULOU, G. N. T h e syndrome of Capgras. British Journal of Psychiatry, 1977, 130, 556-564. 4. CHRISTODOULOU, G . N. Course and prognosis of syndrome of doubles. Journal of Nervous and Mental Disease, 1978, 166, 68-72. G. N. Syndrome of subjective doubles. American Journal of Psychiatry, 5. CHRISTOOOULOU, 1978, 135, 249-251. 6. COURBON,P., & FAIL, G . Illusion d e fregoli. Bulletin de lo Socief; Clinique de Medicine Mentale, 1927, 15, 121-124. 7. COURBON, P., & TUSQUES,J. Illusion d'intermetamorphose et de charme. Annaks MedicoPsychologiques, 1932, 90, 401-405. 8. FIALKOV,M. J., & ROBINS,A. H. An unusual case of the Capgras syndrome. British Journal of Psychiatry, 1978, 132, 403-404. 9. MIKKELSEN, E . J., & GUTHELL,T. G . Communication and re&ty in the Capgras syndrome. American Iournal of Psychotherapy, 1976, 30, 136-146. 10. SIGNER,S. J., & BENSON,F. TWOcases of Capgras symptom with dysmorphic (somatic) delusions. Psychosomatics, 1987, 28, 327-328. 11. S ~ L V A A., J., LEONG,G. B., & LUONG,M. T. Split body and self: an unusual case of misidentification. Canadian Journal of Psychiatry, 1989, 34, 728-730. o s&, GOLDSMITH, J. TWOreports of the Capgras syndrome. American Jour12. S ~ o ~ o ~ o mV., no1 of Psychiatry, 1975, 132, 756. 13. TODD,J., DEWHURST,K., & WALLIS, G. The syndrome of Capgras. British Journal of Psychiatry, 1987, 139, 319-327.
Accepted September 9, 1992
