Capgras Syndrome in the Modern Era: Self Misidentification on an ID Picture

Dear Editor: While living in a supervised apartment, Ms KL, aged 31 years, was hospitalized for a psychotic relapse in the course of undifferentiated schizophrenia. At admission, she presented with intense delusional (mostly persecutory) ideation, auditory hallucinations, severe anxiety, and mild depression. Her behaviour was grossly disorganized, and she required close supervision to tend to daily life activities. Her drug treatment was changed from risperidone 4 mg daily to olanzapine 30 mg daily, which elicited a partial symptom remission. Further improvement occurred with the addition of venlafaxin 225 mg daily, but she remained symptomatic and severely impaired, which led to the discussion and proposal of clozapine treatment, an option that, as of this report, she has refused. During the course of the olanzapine and venlafaxin treatment, the patient presented with a new clinical relapse, including notably increased persecutory ideation and different components of Capgras syndrome. First, she discarded her health insurance (RAMQ) plastic card because she thought that its photograph was not her own and, more specifically, because she did not recognize her nose. Of note, the patient had held this card for years without particular concern. When rechallenged with the photograph, she still contended that it had been replaced or tampered with and did not recognize her face. second, she also discarded various personal objects (such as her satchel, clothes, toilet items, and magazines) because she was convinced that they were not hers. She retrospectively admitted that she had already done so in the past; however, this behaviour was not active in the hospital before her relapse. Third, she became suspicious of her roommate, although with fluctuating conviction, because she thought that the latter had been replaced by someone charged with killing her. While the second and third symptoms are fairly classic, this case adds the plastic ID card, a highly meaningful feature of contemporary life, to the long list of objects (in a broad sense) misidentified in Capgras syndrome: it stands at the limit of object (in a narrow sense), face, and self-recognition. Moreover, the quality of most ID photographs is poor (which was admittedly particularly pronounced in the present case), and the patient was therefore presented with a degraded picture, the recognition of which is notably difficult for patients with schizophrenia. Because we had the opportunity to assess the occurrence of Capgras syndrome in an emerging state, we would also like to speculate on its clinical course in patients with schizophrenia. …

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