Non-Capgras Delusion

Fregoli Delusion

This delusion seems to be the opposite of Capgras delusion, and is where the patient feels a familiar person has the characteristics of a stranger (Sims 2003) and has tended to receive less attention than Capgras delusions.

Any kind of damage to the brain seems to be associated with Fregoli delusions. A 30-year-old lady developed disorganised behaviour, loosening of associations, auditory hallucinations, and delusions of persecution and Fregoli, in that she mistook members of the health care staff as family. In her past, she had developed complex partial fits after a road traffic accident, with her last partial seizure being a month previously. An EEG two weeks after admission showed left temporal spike and sharp waves. Her interictal psychosis indicated a left sided brain defect (Duggal 2004). A 68-year-old female schizophrenic with a 40-year history of delusions developed a CVA, with the MRI showing infarction in the right parahippocampus, hippocampus, lingual and fusiform gyri, with preserved right amygdala. She then developed Fregoli delusions, in that she confused another patient for her husband. Tests showed she had prosopagnosia and unilateral neglect. She was started on risperidone and gradually her symptoms responded. The authors speculated that the infarct damage altered inputs to the amygdala, resulting in greater emotional significance being attached to facial expression (Moriyama 2007). Other reports have also mentioned damage to the right frontal and left temporal area (Feinberg 2005). A 23-year-old schizophrenic with Fregoli, intermetamorphosis and reduplication had bitemporal lobe atrophy, as well as a posterior fossa lesion (Joseph 1985). It has been found in puerperal psychosis and the authors also mentioned that their case series had several women with transient DMS who did not meet inclusive criteria (O’Sullivan 1991).

Once again, Fregoli can exist with other delusional forms, e.g., one case describes a 33-year-old woman with Fregoli delusions with erotomania. It turned out she had an arachoidal sac in her left temporal lobe. Her working memory was also impaired, as was learning, recall and executive function, but she had normal facial recognition (Andreou 2006; Wright 1996). Typically, Fregoli involves the involvement of other people who are somehow transferred to someone familiar, but there is a case where the Fregoli delusion involved the sufferer himself. A 37-year-old man felt his sister was different, but still felt that she was his real sister. He also felt that minds were being duplicated, including his own. He felt that these minds, including his own, were copied into other people’s mind. He also displayed intermetamorphosis, in that he saw / felt that others had been transformed physically and psychologically (Silva 1991).

As with Capgras, Fregoli is associated with other psychiatric illnesses. A 35-year-old divorced schizophrenic, with auditory hallucinations, first rank symptoms, grandiosity and erotomania toward an American TV star, displayed misidentification. Capgras in that in that she felt her boyfriend was this TV star and Fregoli syndrome in that she felt her boyfriend’s friends were also the TV star (Wright 1993). It has been found with bipolar disorder. A 59-year-old with developed Fregoli delusion after a relationship with a woman who he alleged was a prostitute had ended. Afterwards, he stalked several women and later admitted that these other women were in fact the original woman from 15 years before (Atta 2006). A 68-year-old woman with schizophrenia developed it after a CVA in the right medial temporal and occipital lobe, with prosopagnosia. An MRI showed damage to the right parahippocampus, hippocampal, lingual and fusiform gyrus. Then after two months Fregoli delusion developed (Moriyama 2007). Violence has occasionally been associated with Fregoli, e.g., a 30-year-old schizophrenic felt that her boyfriend had transformed himself into a stranger, to follow her, and had broken the GP’s windows due to these beliefs (Delavenne 2011).

When looking at the dataset there were a total of 53 cases with Fregoli, of whom 27 were female, 10 were employed (n=11), 15 were married (n=31), 22 had a medical history (n=24), 32 had a psychiatric history (n=41). 12 had children (n=13), 11 were aggressive.

14 had Capgras, 6 had intermetamorphosis, 6 had duplication, 1 had the mirror sign, 3 had copies and 6 misidentified aspects of themselves. 21 hallucinated (n=22) and 35 had other delusional types (n=50)

This is where individuals feel that familiar people have been duplicated and was originally described by Pick in 1903 (Budson date unknown, Joseph 1999). Apparently, these cases often occur after disturbances of consciousness and are associated with short term memory problems, confabulation and disorientation. The double is not seen or experienced in the same place in space time as the patient, which distinguishes it from autoscopy where the double is seen and felt (Nagy 2009). Even places such as cities have been misidentified; a schizophrenic believed his hometown was duplicated and contained duplicates of his family (Thompson 1980). A 32-year-old fireman claimed his town had been duplicated, with the town looking different to him somehow, though the symptom was probably related to his amphetamine abuse (Ball 1989).

Organic factors are involved here. A 71-year-old man, with sudden left sided weakness, reduplicated the hospital but located it in another city. He showed frontal, visuospatial and facial recognition defects. MRI / CT showed a right thalamic bleed with extension into the posterior interior capsule. Leukoaraiosis was found in the peri ventricular areas. SPECT showed decreased perfusion in the right thalamus / basal ganglia / frontal lobe and left cerebellum (Berthier 1993). One patient had a lesion of the genu extending frontally, felt her daughter was her son in law, the hospital was her home and she believed she was in two cities at the same time (Bez 2009). Another case series of ten patients with duplication, who were compared to psychiatric controls, found 37 atrophic areas - in the frontal, temporal, parietal and cerebellar areas (Joseph 1999). A 71-year-old man suddenly developed duplication of his home and the hospital. He had right frontal haemorrhaging, left sided visual inattention, mild word list learning impairment, impaired non-verbal memory, and frontal lobe defects on problem solving / sustained attention (Kapur 1988).

Alcohol use had been associated with reduplication paramnesia. A 45-year-old man with alcohol withdrawal symptoms showed clumsiness, autotopagnosia of the right hand, had reduced performance on attention and inhibition tasks, with right sided neglect, along with visuospatial impairment. MRI showed white matter lesions in the left temporo parietal occipital area. He said that he had two rooms but could not explain why. A case series of 50 patients with alcohol-related acute events found that four had reduplicative Paramnesia: two for place, one for place and person and one for place and body parts. Three had right hemispheric lesions and these three had superior verbal skills, were poor at regulating themselves and had intact language function (Hakim 1998).

It has also been found in head injury. In a series of 346 patients, three developed reduplication that persisted at least 18 months. Another series of head injury patients with delusions were compared to other groups of brain injured patients. The delusional group had longer post traumatic amnesia, had more brain stem signs (chi2 =10.22, df=1, p=<0.01); more neuropsychological deficits and neurological insults (chi2 = 4.1, df=1, p<0.05). The authors took this to indicate that forces had reached the mesencephalic core and caused more damage in the deluded group. Those patients with contact injuries were not delusional (Sabhesan 1988). Another case series of three patients with head injury showed reduplicative paramnesia, which often persisted for many months before gradually recovering (Benson 1976). Another individual suffered six weeks of reduplicative paramnesia for the hospital after suffering a head injury (Benson 1990).

The paper, authored by Malloy (1994), provided data on patients with reduplicative paramnesias and somatic delusions, as found on CT, MRI, EEG, neurological exam and psychological testing. The data was entered into STATA IC 9.0, with the type of delusions being the dependent variable (coded ‘0’ for reduplication and ‘1’ for somatic type delusions).

After correcting of multiple comparisons, fishers exact test did not show any association between the variables and the type of delusion
Mean verbal IQ was 98, (SD=19). Mean performance IQ was 78 (SD=18) and mean scores of the memory quotient was 91 (SD=32)
After a logistic regression, reduplicative delusions were associated with abnormal psychological testing (OR = 0.04, p=0.012) and EEG abnormalities was associated with somatic delusions (OR=16.7, p=0.024). A principal component analysis found that the first cluster was dominated by frontal lobe damage, performance IQ scores and the memory quotient scores. The second cluster was dominated by an interaction between the site of hemisphere damage and frontal lobe damage; and the third cluster was dominated by site of hemisphere damage.

Although duplication may be delusional in nature, the problem we have to be aware of is that people may have the sense of déjà vu – that they knew the place produces a big sense of familiarity in the person. It is important to distinguish this from reduplication and other DMS forms where doubles exist, e.g., Capgras (Vartzopoulos 1991).

Clonal pluralisation of the Self seems to be a new view of DMS which has originated from Japan, in that there is a Capgras type of DMS (where we have misidentifications with replacements) and the Clonal pluralisation type (with duplicates). The first group contains the classic DMS types, where delusions concern other people (Capgras, Fregoli and intermetamorphosis or subjective doubles), and where others are misidentified with the sufferer’s own self. The second group, Clonal pluralisation, which includes pluralisation of the person or the self and is where sufferers feel that there is more than one copy of themselves or others. Another difference between Clonal pluralisation of the self and subjective doubles is that the latter refers to a misidentification of a real person, with identical physical attributes to their own, being seen in the misidentified others. The Clonal pluralisation does not refer to a misidentified other, but refers to a duplication of the self with identical physical and psychological characteristics (Nagy 2009). Clonal pluralisation seems to be related to reduplication paramnesia and, when places are duplicated, this term is often used. Some authors feel that, as there is no misidentification of the clone, they do not fall under the heading of DMS (Ranjan 2007; Voros 2003).

In my case series, there were 46 cases where more there was more than one of the misidentified target. The graphs below show the number of cases where there was more than one copy of the misidentified target, over the different categorical variables.

Reduplication Paramnesia

Graph showing numbers of patients with copy type misidentification for various demographics.

Graph showing the copy misidentification and brain damage.

This shows that presence of other delusional types, hallucinations and other misidentification delusions in those with copies.

The objects of the misidentification in those with copy delusions

It occurred to me that I have two variables that involve the presence of more than one of the misidentified object, duplication and ‘copies’, where there was more than one copy of the misidentified item and again it involves people and objects. So why not combine them? When I started this project, duplication was nearly always considered to involve non-humans, but the concept of there being more than one copy of the misidentified item came many decades later. So as I do not have an a priori reason to suggest that duplication of human and non-human objects involve different mechanisms, I decided to analyse the data using the combined variable ‘many

Those with more than 1 copy were older than those with no copy (45.81 v 51.47, t=-2.56, p=0.01). In terms of correlations, some of the interesting ones are

Age is negatively correlated with other delusions and misidentification to parents.
Males with misidentification were less likely to have children, but more likely to have DMS to parents
The presence of children is positively correlated with DMS to spouse, but negative to DMS to parents
The presence of more than one of the targets of DMS, is less likely with capgras and DMS to others / humans / parents

Running a series of univariate logistic modelling, the following variables were significantly associated with the presence of more than 1 of the misidentified item.

Here, brain impairment might be needed before we see more than one copy. Interestingly any human target of DMS may not be associated with such copies.

The large parameter estimate for the number of DMS types worries me; it shows some problem with the model. There is a very large positive correlation (0.5) between the dependant variable which indicates more than one of the misidentified target and the number of DMS types, presumably because the combined variable is itself a combination of 2 variables. There is also a positive correlation (>0.3) between the number of DMS types and the duplication and ‘copies’ variables. So I dropped the variable coding for number of DMS types. The results of running multiple regression analyses are found below.

Table – p values of <0.001 marked as ‘*’.

Intermetamorphosis - this is the expression of physical and psychological changes in other people, with some people experiencing depersonalisation (Malliaras 1978). The original case of intermetamorphosis described a woman who felt her husband and son had transformed physically and psychologically into others. These authors feel that the difference from Capgras is that the intermetamorphosis does not involve doubles, as there is a change of identity. But there are several case studies where intermetamorphosis coexists with other DMS types. There seems to be the requirement for two identities to be identified, the original person’s physical and psychological make-up and the other person’s physical and psychological make-up (Silva 1989). Silva (1989) also made the point that this intermetamorphosis does not necessarily mean that there is a delusional interpretation and that there might be cultural influences on such transformation - Lycanthropy.

There is a case of a person with intermetamorphosis, who responded to antiepileptic treatment (Christodoulou 1978). It has also been found in Alzheimer’s disease; a 76-year-old man felt that his wife was really his mother and, later, his sister. He also felt that his son was his brother, and his granddaughter was his daughter, which seemed to be found in both the visual and auditory modalities, as he could not recognise them on the telephone. He correctly identified his own face, but misidentified pictures of faces belonging to family. Here, familiar people were replaced by other familiar people, which may distinguish it from Capgras and Fregoli (Assal 2003).

Now let us go back to lycanthropy, this is where people feel that they change into an animal, most often a wolf. Now the limited research suggests that people feel that their physical characteristics have changed, in keeping with intermetamorphosis, but maybe not so their psychological characteristics, though the research is less clear on this point. So if we combine data on lycanthropy and Intermetamorphosis, this may expand the pool of misidentification where there is a change in the identity of the target. But the concept of reverse fregoli, is where people their physical self’s have changed, not their psychological self’s and this is similar to the definition of lycanthropy.

The mirror sign - is where people fail to recognise their own reflection in a mirror and it tends to be found, very rarely in advanced dementia, though my cases series has 3 patients aged 26 or under, out of a total of 18 cases. Due to the rarity of these cases, formal testing is not often found or done, and it is often associated with prosopagnosia (Breen 2001; Phillips 1996). Some theorists have suggested that to emotionally identify with our reflected movements, emotions, etc. requires that we have a representation of the ‘self’, e.g., recognising our faces or bodies results in activity in the right anterior insula cortex, the adjacent inferior frontal lobe and the anterior cingulate cortex. This starts to bring into play the insula cortex, which is hypothesised to play a role in integrating bodily sensations, feelings with homeostatic information, to create the beginnings of a sense self, as well representing awareness (Craig 2010).

An 87-year-old man with a TIA in the previous year felt his reflection was someone else, who was following him around and he talked to it on occasion. He would shave but never look at his reflection. Gradually, he misidentified his wife’s reflection as the wife of the man in the mirror. The CT showed periventricular lacunar infarcts and reduction in periventricular white matter. A 77-year-old man had signe du miroir for several months. His past medical history showed meningitis aged five, past alcohol dependence, a road traffic accident with loss of consciousness, atrial fibrillation, cardiac arrest, multiple myeloma at 63 and emphysema. He felt the reflection lived close to him and was not a danger to him. He later developed reduplicative Paramnesia for the hospital and had difficulty in recognising other people’s reflections. MRI six months afterwards showed diffuse atrophy, ischaemic lesions in the deep white matter and periventricular regions and a small infarct in the posterior right frontal area. The SPECT showed perfusion defects in the posterior parietal. Both patients had impaired visuo-constructional abilities, visual memory and executive tasks (Breen 2001).

Signe du miroir is relatively common in Alzheimer’s and people have been known to talk to their reflection. Sometimes patients can recognise their reflections, but perceive another person in that reflection. Two patients with Alzheimer’s displayed signe du miroir and both also felt there was another figure in the reflection: duplication as well as signe du miroir (Molchan 1990).

Reverse DMS - is where the direction as it were of the misidentification has altered. Though it is best to bear in mind, that in cases this type of presentation was labelled under the ‘syndrome of subjective doubles’ heading (Christodoulou 1978). Reverse Intermetamorphosis, is where the patient feels that someone else has replaced them physically and psychologically (Arisoy 2014). Reverse Fregoli, where people feel their physical selves have only been altered (Roderigues 2006), which is like lycanthropy. Reverse Capgras is where people feel they look at themselves but do not think it is them (Corlett 2010) or that they have been replaced (Fialkov 1978), i.e., where their psychological identity has altered (Roderigues 2006)

A 44-year-old man with PTSD, felt that there were duplicates of himself, three in total, with minds identical to his own and that he was not the original. Additionally, he felt his therapist had been replaced by a duplicate, but this replacement had different psychological characteristics. He had a history of alcohol, cannabis misuse and tested positive for cocaine. The points that differentiated him from normal subjective doubling, was that the replica included exact copies of his mind and not ones with different psychological features (termed reverse subjective doubling) (Miller 2003).

I pulled together 50 cases where the label reverse was used, but as they cover different DMS types, do I consider this as an overarching organising principle, or something representative of a fundamental attribute?