Sautter1991 Capgras syndrome

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Neuropsychology Copyright 1991 by the Educational Publishing Foundation1991, Vol. 5, No. 3, 139-150 0894-4105/91/S3.00

A Neuropsychological Profileof Capgras Syndrome

SCOTT W. SAUTTERDivision of Behavioral MedicineWestern State HospitalStaunton, VirginiaDepartment of Behavioral Medicine and PsychiatryUniversity of Virginia School of MedicineLEONARD BRISCOEKAY FARKASDepartm ent of Behavioral M edicine and PsychiatryUniversity of Virginia School of Medicine

Abstract: The neuropsychological profile of a' woman with the delusion ofmisidentification characteristic of Capgras syndrome is presented. Capgras syn-drome can develop from both psychodynam ic a nd neuropathological etiologies.The available empirical data in the literature support a hypothesis ofbifrontaland temporal cerebral dysfunction and a need fo r careful differential diagnosisto rule out prosopagnosia and confusional states. The results of this specific casesuggest greater impairment in anterior right-hemisphere-mediated functions.These findings are discussed in the context of clinical neuropsycho logical assess-ment and treatment issues, and additional questions regarding use of the termsyndrome are raised.Keywords: Capgras syndrome, neuropathology, psychodynamic therapy, neu-ropsychology.

The delusion of misidentification has fascinated clin icians since its original descrip-tion in the psychiatric literature almost seven decades ago (Capgras & Reboul-Lachaux, 1923). Psychodynam ic interpretations of this phen om enon were richlydescribed in colorful terms; however, recent advances in the clinical behavioralneurosciences have helped to elucidate a possible neuropathological etiology. Inthis article, we present a neuropsychological profile of Capgras syndrome. Bothpsychodynamic and neuropathological interpretations are described in the litera-ture review, and the results of this particular case support evidence of anteriorright-hemisphere-mediated dysfunction. Further questions are raised about com-peting explanations and use of the term syndrome.Most of the literature we reviewed provided case presentations with psycho-dynamic interpretations invo lving "ego splitting an d projection in defense of

Address correspondence to Scott W. Sautter, Behavioral and Neuropsychiatric Center,1745 Camelot Drive, Suite 200, Virginia Beach, Virginia 23454.139


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14 0 Scott W . Sauter el al.overwhelming erotic or aggressive impulses directed at a parental figure or intensiveambivalent feelings directed toward a significant other, such as a spouse or sibling"(Sullivan, Cavenor, M altbie, & Silverstein, 1978, p. 275). The delusion arises in analtered effective state toward others with intolerable ambivalent feelings that areneutralized through imaginal existence of doubles (O'Reilly & Malhatra, 1987).Berson (1983) reviewed 133 cases in the English-language literature and reportedthat the syndrome is most commonly seen in paranoid schizophrenics; although18 of these cases had neuropathological involvement, he suggested that brainpathology could no t account for the selectivity of the delusion. Berson (1983)offered criteria for inclusion that required psychosis, paranoia, pathological splittingof a significant other, and changes in the crucial interpersonal relationship. Thereis a great deal of heterogeneity in the literature, im plyin g a need to ex am ine bothpsychopathological and neuropathological evidence in a careful differential diag-nosis (Bienenfield & Brott, 1989).Others have described Capgras syndrome as a disorder that occurs in womenonly (Vogel, 1974), that involves family systems dynamics (Moskowitz, 1975), orthat is associated with reduced platelet monoamine oxidase activity (Sullivan etal., 1978), drug toxicity (Daniel, Swallows, & Wolff, 1987), hypothyroidism (Fish-bain, 1989; Madakasira & Hall, 1981), or head traum a (Weston & Whitlock, 1971).In a group comparison study, Joseph, O'Leary, an d Wheeler (1990) examined 12Capgras syndrome patients with matched controls and assessed computed tomo-graphies (CTs) in a single blind paradigm; the results showed that Capgras syndrom epatients had significantly greater bilateral frontal and temporal atrophy. A briefreview of the literature that has been published since Berson's article is presentedin Table 1.For the purpose of this article, Capgras syndrome is defined as occurring in apsychotic state with paranoid features, manifested by a delusion of misidentificationof a significant other, an d having greater anterior than posterior neuropsychologicaldysfunction in the absence of gross visuoperceptual distortions, such as prosopag-nosia or acute confusiona l states. The present case met the above criteria (as wellas Berson's 198 3) but raised additional com peting hypotheses that w ere not easilyruled out.

Case HistoryMs. C. is a 45-year-old, right-handed, divorced White woman with 11 years ofeducation and an episodic work history of unskilled jobs. She had a number ofpsychiatric hospitalizations dating back to 1979 for psychotic symptomatology,including paranoid delusions, depression, and noncompliance with medicationregimens. She had been diagnosed with schizophrenia and treated with Xanax andMellaril. W hen admitted to our facility on an involuntary, men tally ill status, sheexhibited marked paranoid delusions and reported that she felt someone had takenthe place of her real father and that this person was out to kill her. Three weeksprior to this hospitalization, M s. C. had been discharged from a psychiatric facilityin New Orleans with the diagnosis of undifferentiated schizophrenia. After dis-charge, she traveled to Florida to meet her father for a return trip to Virginia,during which they decided to take a vacation at a state park. Upon returning froman evening walk in the park, the patient reportedly found a man in her roomclaiming to be her father. She stated that this man was not her real father, but an


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Capgras Syndrome 14 1imposter, and became very angry and agitated. The park rangers were called tosubdue her and take her to a local emergency room, where she complained oftactile hallucinations and thought broadcasting. She also reported that she felt shemay have done something to her real father and that this imposter wanted to killher. Although Ms. C. has no history of neuropathology in her medical records, herlong history of alcohol abuse and numerous motor vehicle accidents suggestedotherwise. In one accident, she lost consciousness and was hospitalized for 5 days.The duration of unconsciousness and probable posttraumatic amnesia was notreported. Although she had been charged with driving while under the influenceearlier in that year, Ms. C. denied using alcohol or other drugs since that charge.At admission, Ms. C.'s speech was quiet with decreased intonation and rate.Her thought processes showed looseness of associations and tangentia lity. Shedenied any suicidal or homicidal ideation. Her judgm ent w as poor, and insight wasabsent. She was well dressed, groomed, and appeared slightly younger than herchronological age of 45 years. At admission, she scored 20/30 on the Mini-MentalState Examination (MMSE; Folstein, Folstein, & McHugh, 1975), the next day,she scored 27/30. She remained reserved and suspicious and was quite guardedwhen talking about her "father." She complained of decreased sleep and increasedfeelings of guilt but not of anhedonia, change in energy, or decreased appetite. Ms.C. was given the diagnosis of paranoid schizophrenia, chronic, with acute exacer-bation, and was placed on a regimen of 100 mg of Thorazine twice a day forattenuation of psychotic symptoms. After a brief hospital stay of 3 weeks and acourse of neuroleptics, her psychotic symptoms dissipated, and she was dischargedto her local community.

Neuropsychological ProfileMs. C. was referred for neuropsychological evaluation for the purpose of providinga differential diagnosis and documenting suspected brain-behavior dysfunctionresulting from multiple motor vehicle accidents an d alcohol abuse. During theevaluation, Ms. C. was initially suspicious about being tested. However, after thetype of procedures that would be given were explained to her, she relaxed. As aresult, she was pleasant and cooperative but remained guarded. She denied auditoryhallucinations but frequently smiled and laughed out loud at inappropriate times.Ms. C. did not report that her father was an imposter during the testing, althoughshe appeared perplexed when confronted about this. An electroencephalographwas within normal limits, and no further neuroradiological studies were pursued.Neuropsychological impressions were consistent with greater anterior right-hemisphere-mediated dysfunction of mild to moderate cognitive impairment,particularly for tasksof memory and abstract reasoning. Right- and left-hemisphere-mediated functions with respect to normative data are presented as z scores inFigure 1 . A breakdown of various neuropsychological functions (also z scores) arepresented in Figure 2. Relatively greater impairmen t can be seen in right-hemi-sphere-mediated functions (Figure 1 ) , as well as more anterior functions (Figure2). Standard scores were computed by subtracting the mean of each test from theraw score and dividing the result by the test's standard deviation as found in thenormative literature (Benton & Hamsher, 1976; Bornstein, 1984; Delis, Kramer,Kaplan, & Ober, 1987; Fromm-Auch & Yeudall, 1983; Golden, 1978; Halstead &text continues on p. 148


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Capgras Syndrome 145

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Figure 1. Ms. C's left-hemisphere- versus right-hemisphere-mediated cognitive functioning,presented as z scores (WAIS-R = Wechsler Adult Intelligence Scale-Revised; VIQ = verbalIQ; PIQ = performance IQ; WMS = Wechsler Memory Scale; Hooper = Hooper VisualOrganization Test).


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Figure 2. Ms. C's individual test results, presented as z scores, grouped by neuropsycholog-ical function (DH = dominant hand; NDH = nondominant hand; REC = recognition;Hooper = Hooper Visual Organization Test; WAIS-R = Wechsler Adult Intelligence Scale-Revised; PIQ = performance IQ; VIQ = verbal IQ; CVLT = California Verbal LearningTest; WMS = Wechsler Memory Scale; W = word; C = color, C-W = color and word;WCST = Wisconsin Card Sort Test; RESP = response).


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Capgras Syndrome 14 7

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Figure 3. Ms. C's Minnesota Multiphasic Inventory (MMPI) profile (L = Lie scale; F =Frequency scale; K = Correction scale; 1 = Hypochondriasis scale; 2 = Depression scale;3 = Hysteria scale; 4 = Psychopathic Deviate scale; 5 = Masculinity-Femininity scale;6 = Paranoia scale; 7 = Psychasthenia scale; 8 = Schizophrenia scale; 9 = Hypomania scale;0 = Social Introversion scale).


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14 8 Scott W . Sauter et al.Wepman, 1978; Heaton, 1981; Hooper, 1985; Loring, M artin, M eador, & Lee,1990; Wechsler, 1945, 1981; Yeudall, 1987).Ms. C's language skills were seen as a relative strength, as were her attempts toincrease interpersonal contact. Interestingly, the personality assessment depicted aprofile uncharacteristic of paranoid schizophrenia; Ms. C.'s profile may best bedescribed as a resolving episodic psychotic depression (see Minnesota MultiphasicInventory profile in Figure 3). Ms. C.'s apparent need for nurturance and attemptsto increase interpersonal contact were viewed as a positive prognostic sign forfurther gains in adaptive competency, as long as she complies with outpatientfollow-up (e.g., to the ex tent tha t she takes medication as prescribed, abstains fromalcohol, and receives supportive therapy). As her psychiatric symptomatologyclears, a return to work will become important for continued recovery.

DiscussionThe results of this case presentation of Capgras syndrome support the literature indescribing the neuropathological aspects of this syndrome, as well as Berson's(1983) criteria for Capgras syndrome. The use of the term syndrome may bemisleading because of the heterogeneity of possible etiologies. Symptoms of delu-sional misidentification may be a more accurate description because it can occurin varied presentations. Some clinicians have suggested that the use of multipleand colorful descriptions of delusions of misidentification may not be as helpful asa thorough and careful differential diagnosis based on neuropsychological andpersonality testing, as well as neuroradiological evidence. Ms. C. was psychoticwith paranoid features, had a delusion of misidentification of a significant other,and had neuropsychological impairment in the absence of prosopagnosia or anacute confusional state.Treatm ent typically follows a therapeutic regimen of antipsychotic medicationand supportive therapy in which areas of cognitive-behavioral strength are used toovercome weak er areas of functioning. Ms. C.'s case was useful for documentingthe many competing explanations that clinicians are forced to rule out in ahypothesis-testing model when m aking a differential diagnosis; her history includedalcohol abuse and withdrawal, along with neuropathological invo lvem ent, such ashead trauma, paranoid delusions, and psychodynamic issues. With regard toassessment, differential diagnosis, and subsequent treatment, the context of thereferral and its specific question should dictate wh ether neuroradiological, neuro-psychological, and psychodynamic perspectives ought to be considered. It may bemore appropriate to use the term symptoms of, rather than syndrome, whendescribing delusions of misiden tification because of the heterogeneity of etiologiesand varied clinical presentations.

ReferencesBenton, A., & Hamsher, K . deS. (1976). Multilingual Aphasia Examination. Iowa C ity:

University of Iowa.Berson, R. (1983). Capgras syndrome. American Journal of Psychiatry, 140, 969-978.Bick, P. (1984). The syndrome of intermetamorphosis. A merican Journal of Psychiatry, 141,588-589.Bienenfield, D., & Brott, T. (1989). Drs. Bienenfield and Brott reply. Journal of Clinical


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Capgras Syndrome 14 9Psychiatry, 5 0, 475.Bornstein, R. A. (1984, August).Normative data on intermanual differences in neuropsycho-logical performance. Paper presented at the 92nd Annual Convention of the AmericanPsychological Association, Toronto, Ontario, Canada.

Capgras, J., & Reboul-Lachaux, J. (1923). L'illusion des sosies, dans un delire systematisechronique [Delusion of a double, in systematic chronic delirium]. Bulletin de la SocieteClinique de Medecine Mentale, 11,6-16.Christodoulou, G. N. (1977). The syndrome of Capgras. British Journal of Psychiatry, 130,556-564.Daniel, D . G., Swallows,A., & Wolff, F. (1987). Capgras delusion and seizures in associationwith therapeutic dosages of D isulfiram. Southern Medical Journal, 80, 1577-1579.Delis, D., Kramer, J., Kaplan, E., & Ober, B. (1987). California Verbal Learning Test:Manual, adult version, research edition. Sa n Antonio, TX: Psychological Corp.de Pauw, K., Szulecka, K., & Poltock, T. (1987). Single case study: Fregoli syndrome aftercerebral infarction. The Journal of Nervous and Mental Disease, 175, 433-438.Fishbain, D. A. (1989). Capgras syndrome and minor head injury. Journal of ClinicalPsychiatry, 5 0, 474-475.Folstein, M. F., Folstein, S. E. , & McHugh, P. R. (1975). Mini-Mental State. Journal ofPsychiatric Research, 12, 189-198.Fromm-Auch, D., & Yeudall, L. (1983). Normative data for the Halstead-Reitan neuropsy-chological tests. Journal of Clinical Neuropsychology, 5 , 220-238.Golden, C. (1978). Stroop Color and Word Test: A manual fo r clinical and experimentaluses. Chicago: Stocking.Halstead, W., & Wepman, J. (1978). The Halstead-Wepman Aphasia Screening Test.Journal of Speech an d Hearing Disorders, 8, 135-141.Hayman, M., & Abrams, R. (1977). Capgras syndrome and cerebral dysfunction. British

Journal of Psychiatry, 130, 68-71.Heaton, R. (1981). WisconsinCard Sorting Test manual. Odessa, FL: Psychological Assess-ment Resources, Inc.Hooper, H. (1985). The Hooper Visual Organization Test manual. Los Angeles: WesternPsychological Services.Joseph, A. (1986). Cotard's syndrome in a patient with coexistent Capgras' syndrome,syndrome of subjective doubles, and palinopsia.Journal of Clinical Psychiatry, 47 , 605-606.Joseph, A., & O'Leary, D. (1987). Anterior cortical atrophy in Fregoli syndrome. Journal ofClinical Psychiatry, 48 , 409-411.Joseph, A. E., O'Leary, D. H., & Wheeler, H. G. (1990). Bilateral atrophy of the frontal an dtemporal lobes in schizophrenic patients with Capgras syndrome: A case-control studyusing computed tomography. Journal of Clinical Psychiatry, 5 1, 322-325.Kiriakos, R., & Ananth, J. (1980). Review of 13 cases of Capgras syndrome. AmericanJournal of Psychiatry, 137, 1605-1606.Lipkin, B. (1988). Capgras syndrome heralding the development of dementia. British Journalof Psychiatry, 153, 117-118.Loring, D.', Martin, R., Meador, K., & Lee, G. (1990). Psychometric construction of theRey-Osterrieth complex figure. Methodological considerations and interrater reliability.Archives of Clinical Neuropsychology, 5 , 1-14.Madakasira, S., & Hall, T. B. (1981). Capgras syndrome in a patient with myxedema.American Journal of Psychiatry, 138, 1506-1507.

Moskowitz, J. A. (1975). Capgras syndrome in male siblings [letter to the editor]. AmericanJournal of Psychiatry, 131, 1.O'Reilly, R., & Malhatra, L. (1987). Capgras syndrome An unusual case and discussion ofpsychodynamic factors. British Journal of Psychiatry, 151, 262-265.Shaw, V. R., & Pool, K. D. (1990, February). Orga nic factors in Capgras syndrome. Paper


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750 Scott W . Sauteretal.presented at the Annual Meeting of the International Neuropsychological Society,Orlando, FL.Sullivan, J. L., Cavenor, J. O., Maltbie, A. A., & Silverstein, E. (1978). Capgras syndromeA biochemical marker? The Journal of Nervous an d Mental Disease, 166 , 275-279.

Todd, J., Dewhurst, K., & Wallis, G. (1981). The syndrome of Capgras. British Journ al ofPsychiatry, 139, 319-327.Vogel, B. F. (1974). The Capgras syndrome and its psychopathology. Ame rican Journa l ofPsychiatry, 131, 922-924.Wechsler, D. (1945). A standardized memory scale for clinical use. Journal of Psychology,19, 87-95.Wechsler, D. (1981). WAIS-R manual. New York: Psychological Corp.Weston, M. J., & Whitlock, F. A. (1971). The Capgras syndrom e following head injury.British Journal of Psychiatry, 119, 25-31.Wilcox, J., & Waziri, R. (1983). The Capgras syndrome and nond om inant cerebral dysfunc-tion. Journal of Clinical Psychiatry, 44, 70-72.Yeudall, L. (1987). Normative data for the Halstead-Reitan Neuropsychological Testsstratified by age and sex. Journal of Clinical Psychology, 43, 346-366.

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Sautter1991 Capgras syndrome