|Year : 2021 | Volume
| Issue : 2 | Page : 283-286
“They're not my children” – A case series of capgras syndrome in depression, a rare occurrence, and a missed diagnosis
Akansha Bhardwaj, Jagriti Yadav, Priti Singh, Rajiv Gupta
Department of Psychiatry, Institute of Mental Health, Pt. B. D. Sharma University of Health Sciences, Rohtak, Haryana, India
|Date of Submission||20-May-2021|
|Date of Decision||31-May-2021|
|Date of Acceptance||01-Jun-2021|
|Date of Web Publication||29-Dec-2021|
Dr. Jagriti Yadav
H.No-1195/24 Jagdish Colony, Rohtak - 124 001, Haryana
Source of Support: None, Conflict of Interest: None
Capgras syndrome is a psychopathological phenomenon which is defined under the broad category of “Delusional misidentification syndromes.” It is seen in a wide range of psychiatric and neurological disorders. In the psychiatric literature, Capgras syndrome is most commonly seen in association with schizophreniform psychosis. Here, we report the two cases of severe depressive disorder with psychotic symptoms presenting as Capgras syndrome, leading to significant socio-occupational and biological dysfunction. The case series highlights the need for the early identification of depressive symptoms and timely intervention in patients presenting with Capgras syndrome as it carries high risk of harm to self and others.
Keywords: Biopsychosocial formulation, Capgras syndrome, delusional misidentification syndrome, neuropsychiatry interface, severe depressive disorder
|How to cite this article:|
Bhardwaj A, Yadav J, Singh P, Gupta R. “They're not my children” – A case series of capgras syndrome in depression, a rare occurrence, and a missed diagnosis. Arch Med Health Sci 2021;9:283-6
|How to cite this URL:|
Bhardwaj A, Yadav J, Singh P, Gupta R. “They're not my children” – A case series of capgras syndrome in depression, a rare occurrence, and a missed diagnosis. Arch Med Health Sci [serial online] 2021 [cited 2022 Jul 5];9:283-6. Available from: https://www.amhsjournal.org/text.asp?2021/9/2/283/333995
| Introduction|| |
Delusional misidentification syndromes are psychopathologic phenomena in which a patient consistently misidentifies persons, objects, places, or events. Christodoulou described delusional misidentification syndromes as Capgras syndrome, Fregoli syndrome, syndrome of intermetamorphosis, and syndrome of subjective doubles; most common form being the Capgras syndrome. The patient with Capgras syndrome believes that a person closely related to him has been replaced by an exact double. Even though the patient does not disregard the misidentified person's extreme resemblance to the familiar person, he believes that they are in fact, different.
Multiple neurocognitive and psychodynamic basis has been proposed for Capgras syndrome. The neurocognitive hypothesis emphasizes on right hemisphere dysfunction, focal structural cerebral abnormalities, and face recognition process abnormalities. The important neurological causes of Capgras syndrome include cerebral-vascular disorders, closed head trauma, neoplasms, Alzheimer's disease,, dementia with Lewy bodies,, multiple sclerosis, Parkinson's disease, semantic dementia, epilepsy,, frontal meningioma, and posterior cortical atrophy. The proposed psychodynamic theories are ambivalence theory, regression theory, and depersonalization theory. In two large systematic reviews,, the most common functional cause of Capgras syndrome identified was paranoid schizophrenia, whereas only 5%–10% of the cases were reported in depression or manic depressive psychoses. However, due to the lack of consensus in diagnostic criteria, there might be underestimation of the problem statement in patients with affective disorders.
We report the two cases of severe depressive disorder with psychotic symptoms, presenting with a delusional belief of replacement of children with an impostor. In both the cases, the development of Capgras delusion was associated with worsening of the depressive disorder warranting in-patient management.
| Case Series|| |
A 55-year-old male, a farmer by occupation, presented with 4 months illness characterized by withdrawn behavior, decreased social interaction, crying spells, decreased food intake, decreased sleep, decreased self-care, and loss of weight as a result of the untimely demise of his wife. The family members considered the symptoms to be a normal grief reaction and did not feel necessity to seek help. The patient acutely developed marked fearfulness after 3.5 months of demise of his wife and started saying his family members “you all have sold the land, how will I repay the debt now, they will kill me now.” The patient also started identifying his own son as a perpetrator who was sent by the people from whom he had borrowed money for the treatment of his wife. The patient would refuse to be with his son in the same room and frequently shouted at him to leave the house. Despite the pleas and re-assurance by his son and other family members, the patient did not believe that he was really his son and not a perpetrator. The patient also called the police and asked them to bring his real son back and arrest the person who was staying in his house by taking his son's appearance and mannerism. The patient's sleep duration significantly reduced by this time. The patient would eat minimal amount of food because of unwarranted suspicion. The patient remained highly distressed throughout day and night. One day in the absence of family members, the patient tried to hang himself to a tree in his farm but was saved by a passer-by following which he was bought to the medicine emergency department of our institute. The patient was referred to the psychiatry services for further management after physical stabilization. The patient had no significant past history of medical or surgical illness. There was no contributory family history or substance use history.
The detailed general physical and systemic examinations were within the normal limits. The hematological and biochemical parameters were also within the normal limits. On mental status examination, the patient had a vacant stare for most of the time and was not maintaining eye-to-eye-contact. The rate, tone, and volume of speech of the patient were reduced. His reaction time in response to questions asked was increased, and the affect was objectively dysphoric. There was constant preoccupation that his son has been abducted and the impostor staying in his house would kill the patient. The patient was unable to explain when and how this occurred. The patient had depressive cognitions and expressed ideas of self-harm due to which he was promptly admitted in the in-patient unit. After detailed neuro-cognitive assessment, organic basis for the present symptoms was ruled out.
The patient was subsequently diagnosed with severe depression with psychotic symptoms, presenting as Capgras syndrome. The patient was administered Capsule Fluoxetine 20 mg and Tablet Olanzapine 5 mg. Capsule Fluoxetine was gradually increased to 60 mg and Tablet Olanzapine was also increased to 10 mg over the next 4 weeks. There was the resolution of psychotic symptoms and the patient was discharged on the combination of fluoxetine 60 mg and olanzapine 10 mg. However, the patient had partial insight during discharge and was planned for appropriate psychological intervention on follow-up as outpatient on the weekly basis.
A 33-year-old Hindu married female, postgraduate, homemaker, presented with an illness insidious in onset and continuous in course, characterized by the symptoms of decreased sleep, low mood, decreased energy, and decreased social interaction for the last 1 year and suspiciousness for the last 8 months. The patient was apparently asymptomatic 1 year back when she was living with her in-laws. Thereafter, they mutually agreed to shift to a different floor in the same house. The patient on separation from her in-laws became apprehensive as to how she alone would manage household along with her 7- and 9-year-old two kids. The patient started having reduced sleep duration, low mood with occasional crying spells, and lethargy for most of the time of the day. On sharing her difficulties with her husband, the patient's husband consoled her, saying “it is all just an initial adjustment problem which would be resolved.” The patient gradually reduced interactions with family members and would remain alone throughout the day. The patient's husband observed her condition and approached the patient's mother to take her home for a couple of days for some positive change. During the stay of the patient at her mother's home, her condition remained the same. The patient when returned to her matrimonial house after 4 weeks gradually started having suspiciousness against her husband that he had cheated her. The patient also started saying that her children had been replaced with someone else. The patient was questioned how was it possible, “the children looked different,” replied the patient. “Earlier they did not like “kadi” (an Indian cuisine) but now they were enjoying it,” said the patient further. The patient did not look like an affectionate mother. Although her family members tried to convince her several times that her husband was faithful and these were her children, but the patient was not convinced. The patient would remain distressed at her husband's house. She could not do the household chores or take care of her children. The patient had ingested around ten tablets of painkillers in her room 1 week before her admission to the hospital, when her husband was at work and the children were playing outside. Coincidentally, her mother-in-law came there and saw the patient unconscious and rushed her to the hospital. The patient regained consciousness after conservative management. However, the patient did not regret her act of self-harm. The patient still asserted that her husband was not loyal to her and her children had also been replaced. The patient was then brought to psychiatry outpatient department and was promptly admitted in view of risk of self-harm.
There was no contributory past history or family history of any psychiatric illness. Mental status examination revealed decreased psychomotor activity and increased reaction time. The rate, tone, and volume of speech were decreased. The effects of the patient were depressed, restricted in range, reactive, communicable, and congruent. The patient's thought content was suggestive of delusional misidentification, ideas of infidelity, death wishes, ideas of hopelessness, and ideas of helplessness. Higher mental functions were intact and insight was Grade 1/5. General physical examination, systemic examination, and routine laboratory tests were within normal limits. The neurocognitive assessment did not indicate any deficit.
The patient scored 19 on Hamilton Depression Rating Scale. Based on history and clinical assessment, the patient was diagnosed with “Severe depressive disorder with psychotic symptoms.” During the in-patient stay, the patient was started on Tab sertraline 50 mg, Tab olanzapine 10 mg, and Tab clonazepam 0.5 mg. Tab sertraline was gradually increased to 100 mg and Tab clonazepam was tapered off over 2 weeks. After stabilization of acute symptoms, psychological interventions in the form of cognitive behavior therapy were started for the patient. The condition of the patient improved within 5 weeks. She scored 10 on Hamilton Depression Rating Scale toward the end of 5 weeks and was subsequently discharged. There was remission of symptoms with continued medication adherence and return to the baseline level of function.
| Discussion|| |
Severe depression with psychotic symptoms is a disorder which carries a high risk of recurrence and mortality. It comprises approximately 28% of all the depressive patients, with higher proportion among older adults. It has been observed that the patients with psychotic depression are more likely to attempt suicide and have poorer response to treatment than those with nonpsychotic depression., This results in a significant poorer outcome in psychotic depression.,
In depressive disorder, the psychotic experiences can be explained on the basis of pathological mood state and altered psychomotor activity. The common delusional beliefs encountered in patients with severe depressive disorder include Ideas of sin, poverty or imminent danger, which arise from four basic insecurities of humans, namely moral worth, financial status, health, and relationships. The psychodynamic interpretation for the presented cases could possibly be patients' maladaptive coping with the ambivalent emotions toward the close family members; denying anger at the loved one and instead claiming that the anger is being expressed at the imposter. Therefore, the hostility is expressed without the development of guilt. However, the close association of Capgras syndrome with paranoid spectrum and dementia often leads to decreased attention of clinicians toward the neurotic spectrum.
We believe that: (1) the reported cases of Capgras syndrome appear to be lower in association with depressive disorder (2) Capgras syndrome in patients with depressive disorder warrants more attention due to potential worsening of depressive symptoms if not adequately treated. The majority of patients with Capgras syndrome may be treated in the background of neurological or psychotic disorders, instead of depressive disorder (3) Capgras syndrome provides a window into common etiologies for delusional and psychotic symptoms across neuropsychiatric presentations. (4) Diagnostic guidelines for Capgras syndrome should be framed due to its etiological overlap.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Cipriani G, Vedovello M, Ulivi M, Lucetti C, Di Fiorino A, Nuti A. Delusional misidentification syndromes and dementia: A border zone between neurology and psychiatry. Am J Alzheimers Dis Other Demen 2013;28:671-8.
Christodoulou GN. The syndrome of Capgras. Br J Psychiatry 1977;130:556-64.
Albonico A, Barton J. Progress in perceptual research: The case of prosopagnosia. F1000Res 2019;8:765.
Doran JM. The Capgras syndrome: Neurological/neuropsychological perspectives. Neuropsychology 1990;4:29-42.
Kaufman KR, Newman NB, Dawood A. Capgras delusion with violent behavior in Alzheimer dementia: Case analysis with literature review. Ann Clin Psychiatry 2014;26:187-91.
Feinberg TE, Roane DM. Delusional misidentification. Psychiatr Clin N Am 2005;28:665-83.
Thaipisuttikul P, Lobach I, Zweig Y, Gurnani A, Galvin JE. Capgras syndrome in dementia with lewy bodies. Int Psychogeriatr 2013;25:843-9.
Sharma A, Garuba M, Egbert M. Capgras syndrome in a patient with multiple sclerosis: A case report. Prim Care Companion J Clin Psychiatry 2009;11:274.
Moro A, Munhoz RP, Moscovich M, Arruda WO, Teive HA. Delusional misidentification syndrome and other unusual delusions in advanced Parkinson's disease. Parkinsonism Relat Disord 2013;19:751-4.
Harciarek M, Kertesz A. The prevalence of misidentification syndromes in neurodegenerative diseases. Alzheimer Dis Assoc Disord 2008;22:163-9.
Kim E. A post-ictal variant of Capgras' syndrome in a patient with a frontal meningioma. A case report. Psychosomatics 1991;32:448-51.
Schroeter ML, Albrecht F, Ballarini T, Leuthold D, Legler A, Hartwig S, et al.
Capgras delusion in posterior cortical atrophy - A quantitative multimodal imaging single case study. Front Aging Neurosci 2020;12:133.
Berson RJ. Capgras' syndrome. Am J Psychiatry 1983;140:969-78.
Pandis C, Agrawal N, Poole N. Capgras' delusion: A systematic review of 255 published cases. Psychopathology 2019;52:161-73.
Lykouras L, Gournellis R. Psychotic (delusional) major depression: New vistas. Curr Psychiatry Rev 2009; 5:1-28.
Jääskeläinen E, Juola T, Korpela H, Lehtiniemi H, Nietola M, Korkeila J, et al.
Epidemiology of psychotic depression - Systematic review and meta-analysis. Psychol Med 2018;48:905-18.
Gournellis R, Tournikioti K, Touloumi G, Thomadakis C, Michalopoulou PG, Christodoulou C, et al.
Psychotic (delusional) depression and suicidal attempts: A systematic review and meta-analysis. Acta Psychiatr Scand 2018;137:18-29.
Gaudiano BA, Beevers CG, Miller IW. Differential response to combined treatment in patients with psychotic versus nonpsychotic major depression. J Nerv Ment Dis 2005;193:625-8.
Flint AJ, Rifat SL. Two-year outcome of psychotic depression in late life. Am J Psychiatry 1998;155:178-83.
Maj M, Pirozzi R, MaglianoL, Fiorillo A, Bartoli L. Phenomenology and prognostic significance of delusions in major depressive disorder: A 10-year prospective follow-up study. J Clin Psychiatry 2007;68:1411-7.
Saddock BJ, Sadock VA, Ruiz P. Kaplan & Sadock's Comprehensive Textbook of Psychiatry. 10th
ed. China: Wolters Kluwer; 2017.
World Health Organization. The International Classiﬁcation of Diseases. 10th
ed. (ICD-10). Geneva: WHO; 1992.
Casey P, Kelly B. Fish's Clinical Psychopathology Signs and Symptoms in Psychiatry. 3rd ed. Cambridge: Royal College of Psychiatrists: Gaskell; 2007.