Bril. J. Psychiat. (1977), 130, 68—71

Capgras' Syndrome and Cerebral Dysfunction
By MARTIN

A. HAYMAN

and RICHARD

ABRAMS

Summary.

Two cases of Capgras' syndrome in association with coarse brain

disease

presented.

are

The

authors

suggest

that

prosopagnosia

(face

non

recognition) may be the primary expression of a specific cerebral dysfunction
which forms the basis for a delusional elaboration resulting in Capgras' syndrome.

INTRODUCTION

macular

sparing

suggested

Capgras'
syndrome
(Capgras
and Reboul
Lachaux,
1923) is considered a rare, colourful

right temporal

radiation.

MacCailum

(1973)

illness in which the patient believes that a
person, usually a close relative, has been
replaced by an exact double or impostor and
maintains this false belief despite evidence to
the contrary. Although it often occurs as an
isolated finding, the Capgras syndrome has
usually been described as a manifestation of

Capgras'

syndrome

involvement

presented
in

association

five

of the
cases
with

of
the

following primary conditions: (a) toxicity and
cerebral
anoxia
secondary
to broncho
pneumonia;
(b)
right-sided
hemiplegia
secondary to basilar migraine; (c) an alcohol
paranoid state; (d) poorly controlled diabetes
mellitus, with a buttock infection and folate

schizophrenia.
Enoch, Trethowan
and Barker
(1967) assert that, since the syndrome occurs
in a clear sensorium, ‘¿it
is obvious that there is

deficiency;
and (e) possible malnutrition.
In
each of these cases resolution
of the primary
organic

illness

resulted

in remission

of Capgras'

no organic basis to the condition; but it is symptoms. In the second case with right-sided
rather a functional illness and as such is ex
hemiplegia secondary to basilar migraine, an
EEG revealed bilateral theta waves more
plained on a psychodynamic
basis'. Other
prominent
on the left side. In the fourth
case
authors (Vogel, 1974 Todd, 1957; Haslam,
(diabetes,
infection,
and
folate
deficiency)
1973) have also stressed this viewpoint.
spatial disorganization was elicited by drawing
However, in recent years an increasing
number of reports have appeared describing the tests (not specified). This suggests non-dominant
hemisphere dysfunction (Wheeler and Reitan,
Capgras syndrome as a manifestation of organic
brain disease.Weston and Whitlock (i@7i) 1962).
presented a case of Capgras' syndrome in a
Hay, Jolley and Jones (i@7@) discussed a
case of Capgras' syndrome which developed
20-year-old male who was unconscious follow
ing head injuries sustained in an automobile
after a course of ECT in a middle-aged mentally
retarded
woman
with
pseudohypopara
accident.
He had subsequently
developed
thyroidism.
EEG revealed
a background
of
evidence of bilateral temporo-parietal damage,
medium voltage dominant theta activity, with
a frontal lobe syndrome, a severe memory
defect with mixed dysphasic involvement, and low voltage delta activity spreading into all
areas, more marked on the left. A subsequent
generalized intellectual impairment.
The pre
sence of ptosis of the left upper eyelid, left EEG resembled the initial tracing, with some
divergent squint with diplopia, and anisocoria
evidence of focal abnormality in the left temporal
with the left pupil larger than the right mdi
region. Interestingly, the EEG dysrhythmia
cated a left third nerve lesion. Further,
an
coincided with the florid Capgras' symptoms
incongruous left homonymous hemianopia with
and improved as the symptoms resolved.
68

MARTIN

A. HAYMAN

AND

RICHARD

69

ABRAMS

Faber and Abrams (1975) presented the case
of a 47,XYY male with symptomatic schizo
phrenia who, in addition to mild mental
retardation, displayed Capgras' syndrome. EEG
revealed predominantly left-sided slow activity.
To alert physicians to the frequency of brain
disease in patients with Capgras' syndrome we
report the following two cases in which the
syndrome was associated with organic brain
disease; the cases were seen during a four
month period on an acute treatment adult
general psychiatric unit.

a capacitor for electromagnetic waves. He also
thought his parents had been replaced by

CASE REPORTS

presence of constructional apraxia. His WAIS
was abnormal in that his performance IQ was

impersonators

(Wheeler
Case i

(T.J.)

This

37-year-old,

white,

engineer

was

admitted

the

to

divorced
University

Psychiatric Service with a two-year history of
misidentification

of familiar

faces.

He insisted

that his ex-wife, siblings, and physicians were
impostors,

and

claimed

he could

detect

slight

differences between the ‘¿actual'
individuals and
these impostors.
He had been well until seven years before the
index admission, at which time he suffered a

and that

they had conversations

with famous people. Incomplete
auditory
hallucinations were the only perceptual dis
turbance
present. No first rank symptoms
of Schneider were present, and cognitive
functioning
and orientation
were complete.
Admission physical findings included left hemi
plegia and hemianaesthesia. An EEG revealed
a right-sided temporo-parietal slow focus. A
Reitan-Indiana
Aphasia
Screening
Test
and

88 while

Reitan,

his verbal

1962)

IQ

was

showed

ioo.

the

There

was

no family history of mental illness. The patient
showed a moderate response to haloperidol,
30—50

mg

hydantoin,
30

mg

b.i.d.

improved,
syndrome.

daily;

he

also

received

diphenyl

ioo mg t.i.d. and phenobarbital,
He

was

discharged

but with residual

to

his

mild

own

care,

Capgras'

Case 2

(R.S.) This si-year-old,
white, widowed
mother of three was admitted to the University
Psychiatric Service with the delusional idea
that her two sons, who lived with her, were
actually ‘¿boarders',
that her real sons were
dead, and that three years previously someone
left with a persistent left spastic hemiparesis
and thalamic hemisensory syndrome, minimal
had killed her daughter.
disorientation,
and mild difficulty
in per
She had been well until four years before the
forming sequential
tasks. Psychological
testing
index admission, at which time she was admitted
a year later showed a normal intelligence with
to hospital for similar symptoms, responding
some difficulty in performing higher mathe
well to neuroleptics. At age i6 she was in an
matics. At this time he had the first of his left automobile accident and suffered brief loss of
brachio-facial
focalmotor seizures,
which were consciousness. About 20 years before the index
subsequently
controlled
withdiphenyihydantoin admission she used to drink ‘¿a
bottle of rum
and phenobarbital. During the next year delu
fortnightly and continued to do so for five years.
sional ideas developed and these eventually led
She was an endomorphic woman and showed
to three admissions to psychiatric hospital
lability of mood but no blunting of affect, mild
withina two-yearperiod,and a year laterto impairment
of recent
and remote
memory,
theindexadmission.
poor judgement and insight, and disorientation
On admission he appeared as a friendly, alert to time. Thought disorder was not present. She
man without
blunting
of affect
and with
expressed several delusional ideas: she thought
cuthymicmood. His speechwas tangential
and that her neighbours
could ‘¿listenin' on her
he used the stock word ‘¿wedlock'
repeatedly.
conversation and that someone was trying to

rupture

of capillary

telangiectases

of the right

frontal lobe, resulting in a huge right fronto
parietal, right lateral ventricular, and right
basal ganglia hematoma, demonstrated at open
surgical evacuation. He recovered, but was

There

was no other

evidence

of formal

thought

disorder. He had the delusional idea that he was

‘¿breakin' to her home.

She said that

Richard

Nixon livednearbyunder thename ofRichard

CAPGRAS' SYNDROME AND CEREBRAL DYSFUNCTION

7°
Smith. Intelligence
Physical

@

tion

of the

tactile

was estimated as borderline.

examination
hand

revealed

stimuli

discrimination

bilateral

on double

and

extinc

simultaneous

a left palmomental

reflex. She was obese and mildly hypertensiiie.
Waking EEG showed symmetrical biparietal
slow activity

Indiana

in the theta range.

Aphasia

structional

Screening

apraxia.

Skull

The

Reitan

Test showed con
X-rays,

brain

scan

and CSF were normal. Blood testing revealed
mild diabetes.

A sister was confined

to a state

mental hospital because of epilepsy; but there
was no other family history of mental illness.
The patient's misidentification of her children
persisted despite a four-week course of halo
peridol, 20—45mg a day. Marked urinary
retention
made it necessary to discontinue
drug therapy. This was followed within one
week by disappearance of the Capgras syndrome
and improvement
in het other delusions. She

was discharged to return to her family; but her
sudden improvement remains unexplained.
DIscussIoN

Although Capgras' syndrome has been equated
with schizophrenia, neither of our patients would
satisfy rigorous criteria for this diagnosis because
of the presence of signs and symptoms of coarse
brain

disease.

A ‘¿released'psychosis

Meadows
(,@7@) gathered
42 cases of proso
pagnosia from published
reports over a period

of
years, in 8 of which necropsy was per.
formed. He reported that the right occipito..
temporal region is always involved, though in
each case there has been some lesion in the left
hemisphere
too. Commenting
on Meadows'
study,

The Lancet (i@@)

also be implicated

such

as a family

palmomental

reflex

history

and

of schizo

constructional

apraxia, and the aetiology was presumed to be
head injury. Pincus and Tucker

(i@i@) suggest

that a specific type of visual agnosia, non
recognition of faces, originates in a single retro
rolandic parietal lobe lesion and occurs three
times more frequently with lesions of the right
cerebral hemisphere than with lesions in the left.
Bodamer (x@7) suggested that the inability to
recognize

familiar

variant

of visual

faces

was

agnosia

a quite

which

prosopagnosia (i.e. ‘¿face
non-recognition').

because

of

of pattern

and

topography.

We suggest that in our patients prosopagnosia
may have been the primary expression of a
specific cerebral dysfunction and that this
formed the basis for a delusional elaboration
resulting

in Capgras'

syndrome.

This

process

could be considered analogous to the develop
ment in patients with Korsakov's psychosis of
confabulations, which then function to mask
the amnesic defect. With these points in mind,
we further

suggest

Capgras'

syndrome

that

physicians

encountering

should

patients for underlying
and more particularly

examine

their

organic brain disease,

for prosopagnosia.

is unlikely

phrenia or a premorbid schizoid personality.
There was evidence for right-sided cerebral
dysfunction in both cases. The first patient
had demonstrable right-sided brain damage
with consistent EEG and behavioural abnor
malities. In the second patient, right cerebral
dysfunction was inferred from the presence of a
left

concluded

in prosopagnosia

its role in the recollection

because of the absence of identifiable predispos
ing factors

tentatively

‘¿that
the essential damage is of cortex adjoining
the striate and parastriate areas, and also of the
underlying tracts, among which is the optic
radiation'. The non-dominant hemisphere might

he

specific

called

REFERENCES

BODAMER,J. (i@7)

Die Prosopagnosie

Physiognomieerkennens).

(Die Agnosie des

Archives

.Wervenkrank, 579, 6—53.
C&voitas, J. & RanouL-LAcIxAux,

P@hiatrisch,

J. (,ga@) Illusion

des

sosies dans tin d6lire systématisé
chronique. Bulletin
de la SociltéClinique de Medicine Mental., II, 6-i6.
Eo@.u@z. (ig7i@) Prosopagnosia.
Lancet, ii, 388—9.
ENOCH,

M.

D.,

TiutmowAN,

W.

H.

& BARKER, J.

C.

(1967) Some Uncommon Psychiatric Syndromes, pp 1-12.
Bristol: John Wright & Sons.
FABER,

R.

&

47,XYY

ABRAMS, R.

male.

(1975)

British Journal

Schizophrenia

in

of Psychiatry,

a

127,

401—3.

H*5LAM,M. T. (ig7@) A case of Capgras' Syndrome.
American Journal of Psychiatry, 530(4), 493-4.
HAY, G. G., JOLLEY,

D. J. & Jorens,

R. G. (i97@)

A case

of the Capgras syndrome in association with pseudo
hypoparathyroidism. Ada Psychiatrica Scandinavica,
50,

73—7.

MACCALLUM,

W. A. G. (‘973) Capgras'

symptoms

with an

organicbasis.BritishJournalofPsychiatry,
123,639-@z.
MEADows, J.
pagnosia.

@.(i@@@)The anatomical basis of proso
Journal of Xeurology, Xeurosurgery and

Psychiatry, 37, 489—501.

MARTIN

A. HAYMAN

AND RICHARD

Pirwus, J. H. & TUCKER, G. (@7a@) Behavioral' Neurology,

pp 106-7. New York: Oxford University Press.
TODD,

J.

(i957)

The

syndrome

of

Capgras.

Psychiatric

ABRAMS.

7'

WESTON, M. J. & WHrrLocK, F. A. (‘97') The Capgras
syndrome following head injury. British Journal of
Psychiatry, 559, 25—31.

Wiw.aiz@t, L. & ‘¿P.m@u.,
R. M. (1962) Presence and

Qyarterly, 3', 250-65.

Voor.z., B. F. (i@7i@)The Capgras syndrome and its

laterality

of brain damage predicted from responses

psychopathology. American JOuriial of Psychiatry,

to a short

aphasia

131(8), 922—4.

Skills,. 15, 783—99.

Martin A. Hayman,
Richard

Abrams,

screening

test. Perceptual

and Motor

M.D., Resident in Psychiatry, Assistant Instructor of Clinical P@hiatry,

M.D., Associate Professor of P@ychiafty,

From the Department of P@ychiatry and Behavioral Science, State University of New Tork at Stony Brook,

Stony Brook, New Tork iz,@,

USA

Requests for reprints should be addressed to Dr Hayman, 20 Redwood Drive, Great River, New York 11739, USA.
(Received 23 February 1976)

Capgras' syndrome and cerebral dysfunction.
M A Hayman and R Abrams
BJP 1977, 130:68-71.
Access the most recent version at DOI: 10.1192/bjp.130.1.68

References

This article cites 0 articles, 0 of which you can access for free at:
http://bjp.rcpsych.org/content/130/1/68#BIBL

Reprints/
permissions

To obtain reprints or permission to reproduce material from this paper, please write
to permissions@rcpsych.ac.uk

You can respond
to this article at
Downloaded
from

/letters/submit/bjprcpsych;130/1/68
http://bjp.rcpsych.org/ on October 16, 2015
Published by The Royal College of Psychiatrists

To subscribe to The British Journal of Psychiatry go to:
http://bjp.rcpsych.org/site/subscriptions/