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Imagine waking up one day convinced that your loved one is not who they claim to be, but an imposter perfectly mirroring their appearance. People with such experiences have a rare neurological disorder called Capgras Syndrome (CS), which is characterized by the persistent belief that someone close to them—typically, one’s spouse, family member, pet, or even a random object—has been replaced by an identical imposter.
The disorder was first described in 1923 by a French psychiatrist, Joseph Capgras, in a paper detailing the case of a French woman who believed that her husband and other people she knew had been replaced by identical doubles. She also thought that a duplicate of herself existed. Capgras referred to this syndrome as “L’illusion des sosies,” meaning “the illusion of doubles.”
The following decades consisted of various research attempts in trying to understand this bizarre occurrence. Initially, CS was regarded as a psychiatric disorder, similar to the delusions experienced by patients with schizophrenia. Additionally, due to its common identification with hysteria, the disorder was believed to occur mostly in women. However, more recent evidence shows that CS does, in fact, show up in men as well.
Today, it is regarded as the most prevalent delusional misidentification disorder. NEUROANATOMICAL CORRELATES:
The following brain areas have been implicated in Capgras Syndrome:
● Frontal Lobes: Damage to the frontal regions can impair reality testing and self-awareness, leading to delusional beliefs;
● Limbic System: Lesions in the right limbic areas (specifically the amygdala) are involved in processing emotions and familiarity, which may disrupt the emotional response to familiar faces, leading to feelings of unfamiliarity;
● Temporal Lobes: The fusiform gyrus plays an especially important role in facial recognition. Damage here can result in a disconnect between facial recognition and emotional response.
The aforementioned brain damages that trigger the onset of CS may result from a variety of neurological (e.g., Alzheimer’s disease, traumatic brain injuries, infections) and psychiatric (e.g., schizophrenia, substance use disorders) conditions.
THEORETICAL UNDERPINNINGS:
According to the Dual-Route Theory, facial recognition involves two neural pathways:
1. The Cognitive Route: this pathway processes the visual elements of a face, allowing us to consciously recognize someone’s identity. Damage to this route is found in people with prosopagnosia (face blindness).
2. The Affective Route: this pathway creates a connection between face perception and the emotional system, triggering a sense of familiarity and emotional reaction to someone we recognize.
In Capgras Syndrome, the cognitive route is intact, which is why people are able to visually recognize faces. However, the affective route seems to be disrupted, leading to a lack of familiarity or emotional response with the recognized person. This is why patients with CS often conclude that the familiar person has to be an ‘imposter’.
PREVALENCE, AGE OF ONSET, GENDER DIFFERENCES:
Capgras Delusion is a relatively rare disorder, affecting around 0.12% of the general population. The typical age of onset is around 31.5 years. Several studies have also found a higher occurrence of CS in women, with some reports claiming a 2:1 female-to-male ratio.
TREATMENT:
The complexity of this disorder, along with the variability in the patient’s responses, make for a challenging course of treatment. However, several therapeutic interventions have shown promising results.
Antipsychotic medications—such as Pimozide and Risperidone—have effectively been able to reduce symptoms of delusion, paranoia, and irritability in patients. In certain cases, antidepressants have been prescribed, especially when the delusional beliefs are accompanied by depressive symptoms.
In terms of the psychotherapeutic approaches, Cognitive-Behavioural Therapy (CBT) has helped patients challenge and modify their dysfunctional beliefs by identifying their cognitive distortions.
In cases where patients pose a risk to others or themselves as a result of their intense delusions, hospitalization may be necessary to ensure the safety of all parties. Another important consideration of the treatment process is psychoeducation, which involves educating the patient, family, and caregivers about the disorder, symptoms, and the available treatment options. This step of the process is crucial to ensure that there are no misunderstandings regarding the condition, as well as to build a stable supportive network and enhance the patient’s adherence to the treatment plan.
By Sara Jankovic
sara.jankovic01@icatt.it
References:
Ellis, H. D., & Lewis, M. B. (2001). Capgras Delusion: A Window on Face Recognition. Trends in Cognitive Sciences, 5(4), 149-156. https://doi.org/10.1016/S1364-6613(00)01620-X
Sutton, S., Tiruveedhula, V., Jain, U., & Sharma, A. (2014). Capgras Syndrome In An Elderly Patient With Dementia. Primary Care Companion for CNS Disorders.16(1). https://doi.org/10.4088/PCC.13l01570
Salvatore, P., Bhuvaneswar, C. Tohen, M., Khalsa, H. M. K., Maggini, C., & Baldessarini, R.J. (2014). Capgras’ Syndrome in First-Episode Psychotic Disorders. Psychopathology. 47(4), 261-9. https://doi.org/10.1159/000357813
Tamam, L., Karatas, G., Zeren, T., & Ozpoyraz, N. (2003). The prevalence of Capgras syndrome in a university hospital setting. Acta Neuropsychiatrica. 15(5), 290-295.
https://doi.org/10.1034/j.1601-5215.2003.00039.x
Mazzone, L., Armando, M., Crescenzo, F. D., Demaria, F., Valeri, G., Vicari, S. (2012). Clinical picture and treatment implication in a child with Capgras syndrome: a case report. J Med Case Rep. 6, 406. https://doi.org/10.1186/1752-1947-6-406
Tueth, M. J., Cheong, J. A. (1992). Successful treatment with pimozide of Capgras syndrome in an elderly male. J Geriatr Psychiatry Neurol. 5(4), 217-9.
https://doi.org/10.1177/002383099200500406 Chhaya, T. (2017). She’s Not My Mother: A 24-Year-Old Man With Capgras Delusion. Fed Pract. 34(12), 38-41. https://pmc.ncbi.nlm.nih.gov/articles/PMC6370465/
A.P.E. 
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