Victims of Capgras syndrome often cannot recognize their own image
Tuesday, September 23, 2003
By Karen Hoffmann, Post-Gazette Staff Writer
In his room at the Western Psychiatric Institute and Clinic, Joseph looked in the mirror. There, he saw a man he had never seen before. He pinched himself. The man in the mirror pinched himself. But it still wasn’t Joseph.
“Do I look different?” he asked people around him. “Am I still the same person?”
Rosamond, a prim, proper, grandmotherly woman from Queens, also was having trouble with the image she saw in the mirror. But in her case, she believed the woman whose reflection she encountered in the mirrors and windows around her house was there to torment her, to steal her husband - the woman was clearly a stalker. Rosamond called her a “hussy” and went into hysterics whenever she saw her.Rosamond’s husband finally covered up all the shiny surfaces in their house to prevent her outbursts, but he was afraid she would hurt herself in an effort to attack the “other woman.” And there was no way he could cover every reflective surface - the plate glass of store windows, or the rearview mirror of the car.
Joseph and Rosamond, whose real names are not being used, are two of a rare group of patients whose mental illnesses involve the parts of the brain that allow us to know we are who we think we are. Their strange disorders also demonstrate that it’s not enough for us to recognize ourselves in a mirror - we have to feel emotionally attached to our image before we think it is our own reflection.
The technical name for Joseph’s and Rosamond’s delusion is “mirror self-misidentification.” It is the most striking of the Capgras delusions, in which someone recognizes an object but feels no connection with it. The syndrome, named for French psychiatrist Jean Marie Joseph Capgras, is unusual, but still probably afflicts thousands of people in the United States at any given moment, said one expert, Dr. Todd Feinberg, associate professor of neurology and psychiatry at the Albert Einstein College of Medicine in New York.
Joseph’s psychiatrist, Dr. Matcheri Keshavan, clinical director at the Pittsburgh Center for the Neuroscience of Mental Disorders, said the delusion can also involve another person in the patient’s life. “The main illusion [Capgras] patients have is that a dear one is an impostor, or not their real self.”
Keshavan explained the underpinnings of the delusion this way:
“We all have representations of the external world inside us, and that includes identities of other people and our own identities. Along with these representations of other people and ourselves, the emotional tone that goes with such memories is also linked, so when we remember our mothers or friends we remember them with the emotions that go with them.
“But what if there is a dysfunction in parts of the brain that link emotions with our memories? When that happens, the brain at the subconscious level is puzzled and looks for an alternative explanation of why that person feels different.”
And suddenly, the person in the mirror becomes someone else, because when the deluded person cannot feel the emotions she normally has toward that person, that is the explanation that makes the most sense.
An impostor poodle
Not all Capgras delusions are focused on people. Sometimes, patients think there is something wrong with their pets or objects they own - and in those cases, the same sense of emotional dissociation may be at work.
In “Phantoms in the Brain,” Dr. V.S. Ramachandran, director of the Center for Brain and Cognition at the University of California, San Diego, wrote about one Capgras patient who thought his poodle has been replaced by an identical but different dog.
Keshavan said he has a patient now who, every morning, believes that his running shoes and other items have been replaced by identical fakes during the night.
And Feinberg described a patient who thought the same thing had happened with the dishes and towels in her kitchen.
Keshavan said that when people have an emotional reaction to someone they know, they sweat slightly, making the skin more conductive. That can be measured as a galvanic skin response.
But when Capgras patients see certain familiar faces, their galvanic response does not increase, he said.
Feinberg, who wrote a book about identification disorders called “Altered Egos,” said he believes there is more to understanding Capgras than just the emotional disconnection with a familiar person or object, however.
Take Rosamond, his patient who thought her own image was another woman.
She didn’t have a problem identifying anyone but herself. She properly identified her husband and the things around her, he said. And the emotional disconnection theory doesn’t completely explain why Rosamond reacted as strongly as she did to her image. “Why would she scream and yell and become so emotionally upset?” he asked.
One possible reason, Feinberg said, is that people with Capgras already have ambivalent or strained feelings toward the person they misidentify - including themselves. One common example, he noted, is an aging mother who has problems with a daughter who is taking care of her, and then begins to believe that the daughter is an impostor.
As bizarre as these cases seem, both Keshavan and Feinberg said that they are only more extreme versions of experiences we all go through in everyday life.
Keshavan noted, for instance, that often we think someone we know well has become “a different person” when in fact our own feelings about the person or life in general that have changed.
“If we are feeling depressed or angry we might view that person in another light and we might think that person has changed, when in fact they are the same, but our feelings have changed.”
Like deja vu?
And Feinberg said most of us have times when we “dissociate” from objects or events. The familiar feelings of deja vu, when a new experience feels as though it has happened before, or jamais vu, in which a familiar experience feels brand new, are both examples of that.
“Who hasn’t had a situation where you buy a new pair of shoes and you look at the old pair of shoes and you just can’t believe you were wearing those shoes for the last six months. They look all ragged and in disrepair. But the fact is, the shoes haven’t changed - you’ve changed in your sense of relatedness to those shoes.”
And in dreams we often have Capgras-like delusions, he added. We may meet two versions of a person we know in a dream. Or we may be in our room or our office, but it looks nothing like our actual room or office.
Keshavan said that about a third of patients who suffer from Capgras delusions have either epilepsy of the temporal lobes or malformed lobes. The temporal lobes are the parts of the brain on the sides of the head above the ears. And Feinberg said that there tends to be more pathology in the right hemisphere of the brain, which is the side that “is dominant for self and self-other relationships.”
Is the delusion curable?
In both Joseph’s and Rosamond’s cases, it was - but in different ways.
Joseph was eventually diagnosed as having schizophrenia, Keshavan said. When he was prescribed the antipsychotic clozapine, his delusion went away.
Rosamond was cured because Feinberg tried a novel therapy on her.
“Rosamond’s husband casually mentioned that she didn’t see [the other woman] when she looked in the mirror of her makeup compact,” said Feinberg.
That gave him a brainstorm - why not try to have her look at images of herself in increasingly larger mirrors?
“I went around the office - we had other mirrors of different sizes - and went out and bought a series of mirrors,” he said. “I was ultimately able to convince her that an image of slightly larger size was her.”
Eventually, Rosamond recognized that her reflection in a full-sized mirror was indeed herself. “I was quite surprised that it worked, but it did,” Feinberg said.
What lessons do Joseph’s and Rosamond’s experiences hold for us?
One conclusion, Feinberg said, is that our identities are not as rigid and fixed as we might imagine.
“Although we tend to think of ourselves as having fixed structures - we know where our body begins and ends and we have a sense of who we are in the world - in actuality,” he said, “our identity is in a constant state of transformation and is always changing.”
Victims of Capgras syndrome often cannot recognize their own image Tuesday, September 23, 2003By Karen Hoffmann, Post-Gazette Staff Writer
In his room at the Western Psychiatric Institute and Clinic, Joseph looked in the mirror. There, he saw a man he had never seen before. He pinched himself. The man in the mirror pinched himself. But it still wasn’t Joseph.“Do I look different?” he asked people around him. “Am I still the same person?”Rosamond, a prim, proper, grandmotherly woman from Queens, also was having trouble with the image she saw in the mirror. But in her case, she believed the woman whose reflection she encountered in the mirrors and windows around her house was there to torment her, to steal her husband — the woman was clearly a stalker. Rosamond called her a “hussy” and went into hysterics whenever she saw her.Rosamond’s husband finally covered up all the shiny surfaces in their house to prevent her outbursts, but he was afraid she would hurt herself in an effort to attack the “other woman.” And there was no way he could cover every reflective surface — the plate glass of store windows, or the rearview mirror of the car.Joseph and Rosamond, whose real names are not being used, are two of a rare group of patients whose mental illnesses involve the parts of the brain that allow us to know we are who we think we are. Their strange disorders also demonstrate that it’s not enough for us to recognize ourselves in a mirror — we have to feel emotionally attached to our image before we think it is our own reflection.The technical name for Joseph’s and Rosamond’s delusion is “mirror self-misidentification.” It is the most striking of the Capgras delusions, in which someone recognizes an object but feels no connection with it. The syndrome, named for French psychiatrist Jean Marie Joseph Capgras, is unusual, but still probably afflicts thousands of people in the United States at any given moment, said one expert, Dr. Todd Feinberg, associate professor of neurology and psychiatry at the Albert Einstein College of Medicine in New York.Joseph’s psychiatrist, Dr. Matcheri Keshavan, clinical director at the Pittsburgh Center for the Neuroscience of Mental Disorders, said the delusion can also involve another person in the patient’s life. “The main illusion [Capgras] patients have is that a dear one is an impostor, or not their real self.”Keshavan explained the underpinnings of the delusion this way:“We all have representations of the external world inside us, and that includes identities of other people and our own identities. Along with these representations of other people and ourselves, the emotional tone that goes with such memories is also linked, so when we remember our mothers or friends we remember them with the emotions that go with them.“But what if there is a dysfunction in parts of the brain that link emotions with our memories? When that happens, the brain at the subconscious level is puzzled and looks for an alternative explanation of why that person feels different.”And suddenly, the person in the mirror becomes someone else, because when the deluded person cannot feel the emotions she normally has toward that person, that is the explanation that makes the most sense.An impostor poodleNot all Capgras delusions are focused on people. Sometimes, patients think there is something wrong with their pets or objects they own — and in those cases, the same sense of emotional dissociation may be at work.In “Phantoms in the Brain,” Dr. V.S. Ramachandran, director of the Center for Brain and Cognition at the University of California, San Diego, wrote about one Capgras patient who thought his poodle has been replaced by an identical but different dog.Keshavan said he has a patient now who, every morning, believes that his running shoes and other items have been replaced by identical fakes during the night.And Feinberg described a patient who thought the same thing had happened with the dishes and towels in her kitchen.Keshavan said that when people have an emotional reaction to someone they know, they sweat slightly, making the skin more conductive. That can be measured as a galvanic skin response.But when Capgras patients see certain familiar faces, their galvanic response does not increase, he said.Feinberg, who wrote a book about identification disorders called “Altered Egos,” said he believes there is more to understanding Capgras than just the emotional disconnection with a familiar person or object, however.Take Rosamond, his patient who thought her own image was another woman.She didn’t have a problem identifying anyone but herself. She properly identified her husband and the things around her, he said. And the emotional disconnection theory doesn’t completely explain why Rosamond reacted as strongly as she did to her image. “Why would she scream and yell and become so emotionally upset?” he asked.One possible reason, Feinberg said, is that people with Capgras already have ambivalent or strained feelings toward the person they misidentify — including themselves. One common example, he noted, is an aging mother who has problems with a daughter who is taking care of her, and then begins to believe that the daughter is an impostor.As bizarre as these cases seem, both Keshavan and Feinberg said that they are only more extreme versions of experiences we all go through in everyday life.Keshavan noted, for instance, that often we think someone we know well has become “a different person” when in fact our own feelings about the person or life in general that have changed.“If we are feeling depressed or angry we might view that person in another light and we might think that person has changed, when in fact they are the same, but our feelings have changed.”Like deja vu?And Feinberg said most of us have times when we “dissociate” from objects or events. The familiar feelings of deja vu, when a new experience feels as though it has happened before, or jamais vu, in which a familiar experience feels brand new, are both examples of that.“Who hasn’t had a situation where you buy a new pair of shoes and you look at the old pair of shoes and you just can’t believe you were wearing those shoes for the last six months. They look all ragged and in disrepair. But the fact is, the shoes haven’t changed — you’ve changed in your sense of relatedness to those shoes.”And in dreams we often have Capgras-like delusions, he added. We may meet two versions of a person we know in a dream. Or we may be in our room or our office, but it looks nothing like our actual room or office.Keshavan said that about a third of patients who suffer from Capgras delusions have either epilepsy of the temporal lobes or malformed lobes. The temporal lobes are the parts of the brain on the sides of the head above the ears. And Feinberg said that there tends to be more pathology in the right hemisphere of the brain, which is the side that “is dominant for self and self-other relationships.”Is the delusion curable?In both Joseph’s and Rosamond’s cases, it was — but in different ways.Joseph was eventually diagnosed as having schizophrenia, Keshavan said. When he was prescribed the antipsychotic clozapine, his delusion went away.Rosamond was cured because Feinberg tried a novel therapy on her.“Rosamond’s husband casually mentioned that she didn’t see [the other woman] when she looked in the mirror of her makeup compact,” said Feinberg.That gave him a brainstorm — why not try to have her look at images of herself in increasingly larger mirrors?“I went around the office — we had other mirrors of different sizes — and went out and bought a series of mirrors,” he said. “I was ultimately able to convince her that an image of slightly larger size was her.”Eventually, Rosamond recognized that her reflection in a full-sized mirror was indeed herself. “I was quite surprised that it worked, but it did,” Feinberg said.What lessons do Joseph’s and Rosamond’s experiences hold for us?One conclusion, Feinberg said, is that our identities are not as rigid and fixed as we might imagine.“Although we tend to think of ourselves as having fixed structures — we know where our body begins and ends and we have a sense of who we are in the world — in actuality,” he said, “our identity is in a constant state of transformation and is always changing.”
