CASE: Spirits replacing body parts
Mrs. P, age 63, is admitted involuntarily to our inpatient unit after elopement from another emergency room the prior day. For several weeks she had been leaving her house multiple times and wandering the streets in the middle of each night.
Mrs. P is experiencing auditory and visual hallucinations of evil spirits and religious and hypersexual delusions. She cannot recognize her face and believes her voice has been replaced by another’s. She also thinks that her face, nose, lips, voice, and abdomen are not her own. She believes evil spirits that reside within her body are continuously replacing her body parts. She claims these spirits inhabit her left vaginal wall, deposit money there, and are sexually assaulting her each night. She feels that a constant battle between good and evil spirits occurs within her body. She is very angry and states she does not need medication but rather an exorcism.
During her admission, Mrs. P continues to display psychomotor agitation, pressured speech, disorganized thought, religious and hypersexual delusions, grandiosity, and auditory and visual hallucinations. A workup that included a basic metabolic panel, complete blood count, thyroid tests, and abdominal/pelvic CT finds no medical causes for her symptoms. Ob/Gyn is consulted, but Mrs. P refuses a vaginal ultrasound.
The author’s observations
Mrs. P demonstrated symptoms consistent with both mood and thought disorders. Her symptoms of pressured speech, grandiosity, hypersexuality, and decreased need for sleep suggest a manic episode in bipolar disorder. The thought disorganization, delusions, and hallucinations were in line with psychosis.
HISTORY: Failed medications
Mrs. P was first hospitalized at age 29 and has had multiple inpatient admissions for mania, depression, and psychosis. As an outpatient, she was noncompliant with her medications and regularly decompensated and required acute inpatient admission.
Past failed medication trials include risperidone, risperidone long-acting injection, paliperidone, ziprasidone, quetiapine, haloperidol, lamotrigine, and valproic acid. These trials failed because of intolerable side effects or lack of efficacy. She takes lithium, 600 mg every morning and 900 mg at bedtime, for mood stabilization but refuses to try antipsychotics again because she feels the devil is going to attack her through the medications.
The authors’ observations
During her initial hospitalization at age 29, Mrs. P was diagnosed with schizophrenia. In subsequent years she appeared more manic, so her diagnosis was changed to schizoaffective disorder-bipolar type.
Based on our clinical interview, we decide that Mrs. P exhibits a variant of Capgras syndrome, a type of delusional misidentification syndrome in which a person believes other people are not their true selves but have been replaced by identical imposters ( Table ).1 Patients will at some level recognize a person, but they cannot experience the familiarity that is usually felt when seeing that person. Mrs. P’s case was unusual because instead of believing her loved ones were imposters, she could not recognize herself—her body, face, and voice were foreign to her.
We consider and rule out other misidentification syndromes, including mirrored-self misidentification, a condition in which patients cannot recognize themselves (and sometimes others) in a mirror. Mrs. P’s inability to recognize herself is not limited to her reflection. She is adamant that her hands and a part of her abdomen are not her own but another woman’s. She maintains this delusion even when looking directly at herself.
Breen2 argued that a face-processing deficit alone may not account for a mirror delusion; an inability to understand mirror spatial relations in reflections also may be present. Similar to Capgras, in mirrored-self misidentification there may be a perceptual deficit as well as a reasoning deficit that allows the patient to hold on to the delusion. In both delusions, there is a failure of reality testing.3
4 types of delusional misidentification syndromes
|Capgras syndrome||Belief that a loved one has been replaced by an identical impostor|
|Fregoli delusion||Belief that different people are actually the same person in disguise|
|Intermetamorphosis||Belief that one has switched identities with another individual or that others believe the afflicted to be someone else|
|Subjective doubles||Belief there exists a double of oneself living a separate life|
|Source: Reference 1|