Capgrasā syndrome is an uncommon, colourful syndrome in which the patient believes that a person, usually closely related to him, has been replaced by an exact double.
Historical
The condition was first described in 1923 by Capgras and Reboul-Lachaux, who used the term lāillusion des sosies, the illusion of doubles. The case they presented was that of a woman with a chronic paranoid psychosis who complained that ādoublesā had replaced various persons in her environment.
The term āillusion of doublesā is a misnomer as the central pathology is a delusional belief and not a disorder of perception; a more accurate term is the ādelusion of doubles.ā (Sosie is a French word meaning ādoubleā and is derived from Plautusā play Amphitryon in which the god Mercury assumes the appearance of Sosie, the servant of Amphitryon, and thus becomes his double.)
In 1924, Capgras and Carette described a second case in a woman diagnosed as suffering from schizophrenia. She was a solitary woman of low intelligence who expressed ideas of reference and delusions of persecution. Since childhood she had exhibited a striking attachment to her father and hostility towards her mother. She always improved in hospital but quickly relapsed on returning home. Later she developed ideas of incest and the delusion of doubles. She accused her parents, who visited her in hospital, of being ādoublesā and of taking her parentsā place.
Capgrasā syndrome is the best known and most frequently occurring example of the delusional misidentification syndromes, which can be classified as follows:
- Capgrasā syndrome ā described above.
- Illusion of FrĆ©goli ā described by Courbon and Fail in 1927; the patient identifies his supposed persecutors in several persons ā in the doctor, the nurses, the attendants, a neighbour, and a postman, the persecutor being accused of changing faces, as did the famous European actor FrĆ©goli on the stage.
- Illusion of intermetamorphosis ā described by Courbon and Tusques (1932); the patient believes that persons in his environment change with one another, i.e. A becomes B, B becomes C, C becomes A, and so on.
- Syndromes of subjective doubles (doubles of the self ) ā described by Christodoulou (1978); the patient believes that other people have transformed into his own self. This particular condition is further subdivided into three subtypes: 1. Capgras type, in which unseen doubles are active in the patientās environment (this was included in the Capgrasā-Lachaux original 1923 description but never emphasised). 2. Autoscopic type, where the patient sees doubles of himself āprojectedā onto other people or objects (Raschka, 1981). 3. Reverse type, where the patient believes himself to be an impostor or in the process of being replaced (Simopoulos and Goldsmith, 1975).
- Reduplicative paramnesia ā patients believe that a physical location has been duplicated. This term was introduced by Pick (1903) in reference to a hospitalised 67-year-old woman who, following a neurological illness, fever, diarrhoea and vomiting, came to believe that the entire hospital had been replicated at a new, second location at the instigation of her doctor. There exist three subtypes, which may occur singly or together (Politis and Loane, 2012) ā 1. Place reduplication, as in Pickās description, two identically appearing places coexist in geographically distinct locations. 2. Chimeric assimilation, whereby two places become assimilated into one. 3. Extravagant spatial localisation, in which the patient believes that his location is different from its actual location. Reduplicative paramnesia is often associated with neurological lesions, particularly affecting the right cerebral hemisphere (Fƶrstl et al., 1991; Devinsky, 2009).
Jacques Vie (1930) termed Capgrasā syndrome the āillusion of negative doublesā and the illusion of FrĆ©goli as the āillusion of positive doubles.ā In the former there is a perception of non-existent differences resulting in a negation of identities, whereas in the latter there is an affirmation of imaginary resemblances. Similarly Christodoulou (1976; 1977) regarded the syndrome of Capgras as a hypoidentification and the other types, including FrĆ©goli, as hyperidentification. Other variants of delusional misidentification syndromes have been described ( Joseph, 1986).
In contradistinction to British psychiatrists, considerable attention was initially given to Capgrasā syndrome by French and German practitioners. However, since the 1970s the balance has been redressed, and increasing numbers of case reports have been appearing in the English-language literature.
Other case reports soon followed the Capgras-Lachaux original description. For example, Larrive and Jasiensky (1931) described a woman with an unsystematised persecutory psychosis. She developed a delusion that her poorly endowed lover had a rich, aristocratic, handsome and potent double. Other cases include those of Halberstadt (1923), Dupouy and Montassut (1924), Bouvier (1926), Brochado (1936), LĆ©vy-Valensi (1939) and Vie (1944).
In 1933 and 1944, Coleman wrote extensively on the phenomenon of misidentification and non-recognition which included a comprehensive description of Capgrasā syndrome. He admitted that the case he described was not an entirely satisfactory example, because it did not concern the double of a person but letters written by an individual. The woman, aged 50 years, who was diagnosed as suffering from involutional melancholia with feelings of guilt and hopelessness and expressed feelings of depersonalisation, then developed an illusion of doubles in the form that she refused to recognise the letters of her daughter. She insisted that they were facsimiles written by someone else.
Such fragmentary forms of the Capgrasā phenomenon are rare. Another example occurred in an intelligent university student, aged 22 years, who, while suffering from an acute attack of schizophrenia, was subsequently able to give a striking account of her primary delusional state and wrote, āI walked on until I came to a steep bank aligned with trees and a small stream at the bottom. I sat down and had a cigarette. ā¦ I threw the empty packet into the stream then I examined my watch. I did not think it was mine, but a clever copy that the police had made so I threw it into the stream as well.ā
It is significant that all reports up until 1936 concerned women only. Then Murray (1936) reported the first example of the syndrome in a man. He was young, single, apparently homosexual and was diagnosed as suffering from schizophrenia. When his parents visited him in hospital, he insisted that they were not his real parents but doubles. Stern and MacNaughton (1945) described two new cases with special reference to the Rorschach findings. Todd (1957) and then Todd and Dewhurst (1955) described seven further cases: five associated with schizophrenia and allied illnesses and two associated with affective psychosis. They emphasised the role of depersonalisation in the psychopathology (Dewhurst, 1954).
Wagner (1966) presented a diagnostic case study of a young girl with a delusional system which he regarded as a variant of Capgrasā syndrome. The patient, a young unmarried woman who had recently been jilted by a medical student, experienced great annoyance with acquaintances who would relate that they had met a married couple whose descriptions matched that of the estranged couple in all essential details. Wagner acknowledged that the case differed from Capgrasā syndrome in that the experience was indirect; but one of the doubles was of the patient herself and that there were two doubles. Disertori and Piazza (1967) presented a case occurring in a woman and related it to the āAlcmene complexā or the ācomplex of innocent adultery.ā
Since 1970, an increasing number of cases of the Capgrasā delusion and the illusion of FrĆ©goli have been reported, often with an emphasis on co-existing overt organic brain disease. The list of organic disorders is now very long and includes drug intoxication and withdrawal, infection and encephalitis, endocrine disorders, epilepsy, serious and minor head injury, brain tumours, delirium, Alzheimerās disease, vascular dementia, multiple myeloma, Lewy body disease, lithium toxicity and migraine. More recently many of the reported cases have included the results of electrophysiological, neuroimaging and neuropsychological studies, and great interest has been aroused concerning a possible neurobiological basis for all of the misidentification syndromes.
The Capgrasā phenomenon has also been described in fictional literature. For example, Dostoevsky gives a striking description of the phenomenon in his novel The Possessed. The psychopathic Marya Timofyevna has been secretly married to Stavrogin, but at a social function in their hometown he fails to acknowledge her, drawing her aside saying, āOnly think you are a girl, and that though I am your devoted friend, I am an outsider not your husband, nor your father, nor your betrothed.ā When Stavrogin visits her a few days later, Marya, refusing to recognise him, laughs in his face. She speaks the words quoted at the head of this chapter and then accuses him of murdering her prince, stating, āWhen I saw your mean face after I had fallen down ā¦ it was like a worm crawling into my heart. It is not he, I thought, not he! My falcon would never have been ashamed of me a fashionable lady ā¦ tell me, you impostor, have you much bite? Did you need to be bribed to consent?ā
Also, in Lord David Cecilās biography of Cowper, The Stricken Deer (Cecil, 1943), there is an example of the Capgrasā phenomenon. It is clear that Cowper suffered from an affective psychosis with paranoid features. The Reverend Newton had been a close friend and confidant for many years. About one of the later depressive phases, Cecil writes, āHe still believed he was damned. So little hold he had on reality that years after this he could never be sure if the Newton he saw was the real Newton or some phantom masquerading in his shape.ā
