Clinical features and imaging findings in a case of Capgras syndrome
A 53-year-old Caucasian woman was referred to our Psychiatry Unit for hospitalization by her general practitioner. Anamnestic data collection revealed that the patient had had a difficult adolescence, due to the fact that her father had had a mistress and suffered from pathologic gambling. Notwithstanding, she had not experienced any previous psychopathologic problems in the past. She was a housewife with two daughters, and the eldest daughter had always been in conflict with her mother. On the day of her admission to hospital, the patient had a fatuous expression, seemed apathetic, and was suffering from considerable psychomotor retardation. She was distrustful of other patients because they were “too intrusive”. However, when approaching other patients, she showed a childish attitude and was disrespectful of conventional interpersonal distances. The patient had the delusional belief that her eldest daughter, whom she thought had disappeared for 12 months, had been replaced by an impostor. In fact, the previous year the patient’s daughter had left her house without telling her mother. The patient tried to get in touch with her, and the girl answered the phone saying that she was at work. Because her workplace was quite far off from her house, the patient thought that it was not possible for her daughter to arrive at work in such a short time. Hence, she believed that the person she had spoken to over the phone was an impostor who was replacing the daughter whom she thought had disappeared.\nHer delusional belief was characterized by incorrigibility and unwarranted subjective conviction. The patient had two “proofs” to justify her belief: the distance of the workplace and the impostor’s makeup, which was heavier than that worn by her daughter.\nThe patient was experiencing not only the tragedy of a mother who had lost her daughter, but also the frustration of continuous deception by the “double”/impostor. Indeed, the patient thought that the “double” was imitating her daughter’s way of speaking so as to convince her (the patient) that she (the “double”) was her daughter. The patient had no idea where her daughter could be. However, she did nothing to find out where she was. In addition, even though she considered the impostor to be a menacing presence, the patient had a passive attitude towards the impostor, and treated her with indifference. Her mood was deflected owing to her daughter’s disappearance. Obviously, the patient had no insight into her illness. The Capgras delusion was the only unusual belief presented by this patient, who did not show any other psychotic symptoms. The clinical picture of this patient was peculiar: she was tormented by the thought of the “double” who, in addition, provoked a feeling of disgust. This feeling was caused by the fact that the “double” treated the patient in a confidential way in order to deceive her without feeling any real affection. This thought, which was particularly intrusive, caused her considerable distress and even disturbed her sleep; almost every night, she had difficulty in falling asleep at the thought of the painful condition of deception that she had to endure. In addition, this delusional belief was presented to the medical interviewers in an obsessive way, with perseveration regarding the subject (she constantly repeated that the woman was not her daughter), and the thought content restricted to it. The story about her daughter was the answer to simple questions that had nothing to do with the topic. The intrusive thoughts pertaining to her daughter’s disappearance and to the impostor were always present and did not fluctuate much over time.\nGeneral physical examination was within normal limits. She did not drink alcohol or coffee, and did not use any illicit or recreational drugs. The Mini-Mental State Examination (MMSE) was 27/30, indicating normal cognition. Items of the MMSE that the patient was less able to complete pertained to calculation and to short-term and long-term memory. The Structured Clinical Interview for DSM-IV Axis II Personality Disorders indicated an unspecified personality disorder, with a preponderance of paranoid and obsessive-compulsive personality traits. The electroencephalogram was characterized by background alpha activity and rapid rhythms in the frontocentral regions, bilaterally, as shown in . Magnetic resonance imaging (images obtained through fluid-attenuated inversion recovery, spin echo, and turbo field echo techniques, diffusion weighted in axial, sagittal, and coronal planes) showed moderate lesions in the frontal subcortical white matter and in the semioval centers on both sides. In particular, in long repetition time sequences, these cerebral areas showed hyperintensities compatible with a picture of gliosis, as shown in .