My patient, a 37-year-old homemaker, gazed at the man in the red plaid shirt as he sat on the couch in her living room.
“Who are you?” she asked.
There was something familiar about him. He wore her husband’s boots, but the shirt made him look like a truck driver.
“Yeah, and who are you?” the man replied with a laugh. “Come here and give me a kiss.”
She gave the man a peck on the cheek, but she felt guilty, fearing that her husband would arrive at any moment and admonish her. Not only did the man want a kiss — he also wanted sex!
Discouraging him, she sat down to talk. The man spoke just like her husband and knew personal facts about her. It occurred to her that her husband had been mysteriously replaced by this fellow. How it happened she had no idea; she knew only that it had.
My patient had a history of schizoaffective disorder, similar to schizophrenia, but with more emotional range. And when she told me of this incident at her weekly visit the next day, I worried that her psychosis was recurring. “Have you been taking your medicine?” I asked.
She admitted that she had not taken her antipsychotic, Clozaril, for a few days because of a side effect, excessive salivation
“With your condition, it’s important to take your medicine every day,” I said gently.
She liked and respected me, but she could not stand it when I gave her orders. “If you knew how embarrassing it is to drool all over yourself, you wouldn’t make me take that medicine,” she told me.
As I tried to extract a promise that she would restart her medicine, she suddenly sat back and stared at me.
“What’s wrong?” I asked.
There was a pause. I saw her composing herself before she spoke. “You have the same voice, but your nose is bigger and your face longer.”
She excused herself 10 minutes early. I allowed her to go, because I knew she could not stand being with me any longer.
Days later, her husband called to say she was going “crazy” again, believing that I and, now, her parents had been replaced by duplicates. I had to hospitalize her and restart her medication.
My patient suffered from a variation of Capgras syndrome, in which people are replaced by inexact duplicates. It has been considered rare, but the more I work with geriatric patients, the more I am diagnosing it.
The disorder was first described in 1923 by the French psychiatrists Joseph Capgras and Jean Reboul-Lachaux. They treated a 53-year-old who believed that her husband, her children, her neighbors and even she had been replaced by exact “doubles” in a plot to steal her property.
In Capgras, there is an uncoupling of perception and recognition that leads many investigators to theorize that there may be a neurological, organic cause that remains unknown. Psychoanalysts have seen Capgras as an unusual form of displacement in which the patient rejects the loved one whenever negative features have to be attributed.
Yet guilt and ambivalence prevent the patient from becoming conscious of the rejection. The bad feelings are displaced to a double, who is an impostor and may safely be rejected. Anna Freud thought this delusion allowed patients to defend themselves against loss and distress about changes in close relationships.
After resuming her medicine, my patient quickly lost her belief that her husband, parents and psychiatrist were doubles. When she was healthy enough to return to outpatient treatment, I asked whether she had ever seen the movie “Invasion of the Body Snatchers.” She said no.
I thought I’d better not explain the plot to her.
Carol W. Berman, a psychiatrist in Manhattan, is a clinical instructor at the N.Y.U. Medical Center.