Capgras Syndrome (2024)

Continuing Education Activity

Capgras syndrome is the most prevalent delusional misidentification syndrome and is characterized as a delusion of doubles. Patients falsely believe that an identical person has replaced a person close to him or her. This activity aims to provide insight into this rare syndrome through an in-depth discussion about its symptoms, etiology, and pathophysiology. This activity highlights the interprofessional team's role in the evaluation and management of patients with Capgras syndrome.

Objectives:

  • Identify and explain the symptoms of Capgras syndrome.

  • Outline the pathophysiology of Capgras syndrome.

  • Review the current evidence regarding violence in Capgras syndrome patients.

  • Summarize how interprofessional team management of Capgras syndrome can improve patient outcomes.

Access free multiple choice questions on this topic.

Introduction

Capgras syndrome (CS), or delusion of doubles, is a delusional misidentification syndrome.[1]It is a syndrome characterized by a false belief that an identical duplicate has replaced someone significant to the patient.In CS, the imposter can also replace an inanimate object or an animal.[1] Contrary to the earlier belief that CS mainly affects women, it occurs in both genders.[2] It is widely regarded as the most prevalent of the delusional misidentification syndromes and appears in psychiatric and non-psychiatric cases, including patients with brain damage.[3]

Brain damage in the bifrontal, right limbic, and temporal regions can cause CS.[3] This brain damage leads to aberrant memory functions, self-monitoring, and reality perception. Such neurophysiological deficits cause an inability to integrate emotional information processing and facial recognition correctly.[3] Besides schizophrenia and schizoaffective disorders, Alzheimer disease (AD), dementia, Lewy body dementia, epilepsy, cerebrovascular accident (CVA), pituitary tumors, and advanced Parkinson disease (PD) patients can experience CS.[1][4][5]De Clerambault syndrome and Ekbom syndrome patients may also experience CS.[6] The propensity of violence in CS patients requires its speedy recognition and timely intervention.[4]

Diagnostic and Statistical Manual of Mental Disorders (DSM) Classification

CS has not been addressed within the DSM-5 because of its rare nature.It suits either the persecutory or unspecified delusion type.[5]

Historical Perspective

CS is named after Joseph Capgras, a psychiatrist of French origin. In 1923, Joseph Capgras first defined the disorder in a paper that reported a case of a French-origin woman who complained that corresponding doubles had replaced her husband and other persons she knew. The woman also believed that there existed a double of herself. The authors referred to this syndrome as "I'illusion des sosies," which translates to mean "the illusion of look-alikes."[2]

Initially, CS was regarded as a psychiatric disorder, similar to delusions in schizophrenia. CS was connected to hysteria as seen predominantly in females.[7] Berson explained that CS differed from hallucinations, illusions, memory losses, perceptual malfunctions, and disorientation.[2] In the 1980s, organic brain lesions were identified in patients with CS. Today, CS is understood to be a psychiatric and neurological disorder in which the delusion primarily emanates from organic brain degeneration.[2]

Etiology

Capgras syndrome is a complicated and organic condition caused by structural brain injuries with neuroanatomical damage.[8][9]The cerebral basis of the CS was first explained in 1979 by Alexander et al. as a disorder that correlated with a combination of the right hemisphere damage causing problems with visual recognition and frontal lobe damage-causing difficulties with familiarity.[10]Another study found possible correlations between CS and prosopagnosia in brain-injured patients. Prosopagnosia is a condition in which patients cannot recognize faces.[11]

Some psychologists hypothesized that patients with CS have conscious ability to recognize faces was still potent. Still, they may also present with damage to the system that facilitates emotional arousal to familiar faces.[12]It entails that an individual may recognize someone while feeling that something is 'wrong' about them. Hirstein and Ramachandran also shared similar findings in studying one patient with CS after a brain injury.This brain injury could be a disconnection between the temporal cortex, an area where familiar faces are recognized, and the limbic system involved in emotions.[13]Hirstein revised this theory and suggested that the patient with CS would not recognize familiar faces.[13]

CS can be seen with reduplicative paramnesia, a delusional misidentification syndrome in which a subject believes a location has been relocated. CS and reduplicative paramnesia are linked since they affect the same brain regions.[10]

Epidemiology

A study on the prevalence of Capgras syndrome found that its existence in psychiatric populations is under 1%.[14]Another study found the prevalence of CS in all psychiatric conditions to be 1.3% to 4.1% and around 3% for hospitalized patients with psychosis.[15][16]A longitudinal study of patients hospitalized for a primary psychotic episode found that CS is seen in about one in every ten patients.[14]The prevalence of CS was highest among patients with schizophreniform psychosis (50%), brief psychosis (34.8%), and unspecified psychosis (23.9%).[17]About 15% of major depressive episodes and 11% of the patients with delusional disorders and schizophrenia displayed CS symptoms.[17]

The most common underlying primary psychiatric diagnoses in CS are schizoaffective disorder, schizophrenia, and bipolar affective disorder.[17]In a review of over 4,000 patients, six cases had symptoms of CS.Most CS patients displayed violent behavior towards a familiar person and had neuro-medical comorbid conditions.[5]In another review of 260 case reports of delusional misidentification syndromes, 174 (66.9%) patients had CS. CS cases had a high rate of other psychiatric conditions schizophrenia (73% of CS cases), dementia (26.4% of CS cases), and mood disorders (16.7% of CS cases).[5]It has been reported in association with organic disorders in about 25% to 40% of CS cases.[5]

Pathophysiology

The pathophysiology of Capgras syndrome lacks clarity due to its rare nature. Coltheart et al. described a dual factorial hypothesis of the delusional belief validated by the brain's imaging studies.The first prevents familiar faces from inducing an emotional response, while the second controls the ability to reject the delusional belief.[18]There is a disconnection in the pathway between the temporal lobe, the area that coordinates facial processing, and the limbic circuits associated with the appropriate personal and emotional stimulus.[18]

Undesirable effects from the right hemisphere and frontal lobe dysfunction result in low self-monitoring, ego boundaries, and familiarity with stimuli.Lesions on the bifrontal or right hemisphere cause a disconnection between the frontal lobes and the right temporal-limbic lobes or system, essential for the reconciliation of information about the self-identification of the subject.[19]

Psychodynamics of Capgras Syndrome

In a review of the first five case reports of CS, Capgras noted that each case was distinct, and no single pattern emerged.The study revealed that the doubles were always of people tied to the patient with strong affective ties.[2]

In their early studies in the 1920s, Capgras and Carrette discussed oedipal problems in women. They stated that this syndrome does not occur in men and that it was peculiar in women.Capgras also found feelings of strangeness in a few cases. Mechanisms suggested by many hypotheses by Capgras showed that a patient becomes aware of changes in their responses to significant persons in their lives. These dynamic changes may occur as a result of genuine changes in the other person.[2]

Berson stated that psychodynamic explanations cluster around four primary themes that emphasize oedipal problems, feelings of strangeness, problems with ambivalence, and pathological splitting of internalized object representations.[2]Berson suggested an interaction of three factors, the psychotic regression to primitive thinking, a paranoid state, and indecisiveness.Another early study found that two primary opposing views of the same person are present, and this uncertainty creates the foundation of CS psychopathology.[2]It means that the doubles' invention allows the patient to act with hostility without risking the guilt that may later emerge. Also, the process of splitting internalized object representations is a facilitator for CS. In other words, CS involves the process of splitting an entity into good and bad images. This splitting becomes pathological because of distortions in interpersonal communications that give off maligned internalized object representations.[20]

Violence in Capgras Syndrome

A previous study has shown associations between CS with aggression and homicide.[21]Homicide was reported in 6% of the functional cases, which might indicate the delusion is riskier than first believed.[22]Despite finding associations between aggression and functionality (38%) rather than organic etiology, it was also frequent in the latter (23%). Pandis also suggested, however, that the non-violent Capgras patients constitute the majority.In a review of 4,200 patients in 1983, most cases were determined to have threatened or shown violent behaviors towards a familiar person. Many also had neuro-medical conditions present as confounding contributors.[5]The violence occurs due to psychological regression.[6]

History and Physical

Capgras syndrome patients may present with a variety of symptoms, depending upon the underlying disorder. Irrespective of the etiology that consists of schizophrenia and schizoaffective disorders, Alzheimer disease (AD), dementia, Lewy body dementia, epilepsy, cerebrovascular accident (CVA), pituitary tumors, and advanced Parkinson disease (PD), the CS experience delusion of identical doubles that is close to them.[1][4][5]The patient may also be agitated and aggressive towards the person significant to them due to a defect in recognizing familiar faces.[8][13]

Evaluation

Capgras syndrome is a clinical diagnosis. Its diagnosis is based on clinical assessment of symptoms.[5]

Treatment / Management

Treatment and Management of Capgras Syndrome

Generally, delusional disorders are challenging due to poor patient insight. Lack of empirical data poses a significant challenge to manage Capgras syndrome patients effectively.[23]Therapy, with the support of antipsychotic medications, is a common intervention.[23]Management of CS includes establishing a therapeutic alliance while negotiating mutually acceptable symptomatic treatment goals. It involves expressing empathy and interest in the patients' predicament.[22]It is also necessary to avoid confrontation of the Capgras symptoms.[6]Another study has also shown that using medications appropriately to target the underlying disorder's core symptoms is an effective management strategy.[15]Patient hospitalization is necessary if the patient is engaging in self-harm or violence. Identifying and treating comorbid psychiatric disorders is key to the management of CS.[15][24]

Counseling Patient and Family Education

Due to the risk of violence meted on the misidentified person, it is crucial to assist CS patients' caregivers by utilizing communication techniques, counseling, medications, and reasonable problem-solving skills.Caregivers' feelings must be taken into consideration to reassure them.Better auditory interaction is advocated. Such communication is aimed primarily to circumvent CS patient's difficulty connecting with caregivers through face-to-face encounters. The caregiver needs to announce themselves and communicate clearly while out of sight to establish better emotional ties. The caregiver should self-evaluate to recognize gaps and strengths in managing the patients' condition while also relying on other family, friends, and relatives.[24]

Prognosis and Complications of Capgras Syndrome

The onset of the Capgras syndrome can occur concurrently or later than the initiation of the comorbid psychosis.A study following 20 CS patients found the resolution of Capgras Syndrome symptoms after remission of the depressive disorder. The CS symptoms were more persistent in the schizophrenia patients that present with psychosis.If the onset of CS coincides with psychosis, the reappearance of the psychotic condition may return the CS symptoms.[25]

CS symptoms may result in intrapersonal and interpersonal conflicts, along with poor social relationships. An individual with this kind of disorder is prone to self-harm and violence. There are also implications for the patient's family, as the stress on the caregiver and stigma-related stressors could further compound the issue.[24]Socioeconomic implications include the patient's inability to retain a job, which further impacts household members, including caregivers. In a nutshell, the Capgras Syndrome poses a strain on the health care system and society.

Differential Diagnosis

Differential Diagnosis

Capgras syndrome and delusional disorders generally may co-exist with other illnesses. Table 1 below shows the various medical conditions associated with the development of delusional disorders.[1][4][26]

Capgras Syndrome (1)

Table

Medical conditions Examples of disease conditions

There are fluctuating levels of consciousness, hallucinations, and poor cognitive abilities in delirium cases that are not present in cases of delusional disorders.[2]In substance-related disorder cases, drugs like amphetamines and cocaine are associated with delusions. Hallucinogens, alcohol, and steroids are linked with delusional disorders.[2]In cases of schizophrenia, the delusions are usually bizarre with associated hallucinations.[4]

Prognosis

The onset of the Capgras syndrome can occur concurrently or later than the initiation of the comorbid psychosis.[25]A study following 20 CS patients found the resolution of Capgras syndrome symptoms after remission of the depressive disorder. The CS symptoms were more persistent in the schizophrenia patients that present with psychosis.[25]If the onset of CS coincides with psychosis, the reappearance of the psychotic condition may return the CS symptoms.[25]

Complications

Capgras syndrome symptoms may result in intrapersonal and interpersonal conflicts, along with poor social relationships. An individual with this kind of disorder is prone to self-harm and violence. There are also implications for the patient's family, as the stress on the caregiver and stigma-related stressors could further compound the issue.[24]Socioeconomic implications include the patient's inability to retain a job, which further impacts household members, including caregivers. In a nutshell, the Capgras Syndrome poses a strain on the health care system and society.[24][25]

Consultations

It is necessary to rule out any medical and or neurological condition that may be causing Capgras syndrome.Lewy body dementia patients can have CS. It is also important to rule out any central nervous system lesions, vitamin B12deficiency, diabetes mellitus, and hypothyroidism.[1][4][5][26]Specialists may need to be consulted based on presentation, symptoms, and clinical indications based on laboratory or imaging findings.

Deterrence and Patient Education

In addition to pharmacotherapy, patient counseling and therapy sessions are the mainstays to manage Capgras syndrome effectively.Since the CS patients are at a higher risk of showing aggression and violence towards others, including caregivers, the psychodynamic therapy sessions play a crucial role in CS management.Patient education should focus on establishing emotional ties and effective communication with their caregiver. Overall, the patient should be advised to adhere to the disorder's medical and psychiatric management to control or treat primary underlying disorders.[24]

Counseling Caregiver and Family

Due to the risk of violence meted on the misidentified person, it is crucial to assist CS patients' caregivers by utilizing communication techniques, counseling, medications, and reasonable problem-solving skills.[24]Caregivers' feelings must be taken into consideration to reassure them.Better auditory interaction is advocated. Such communication is aimed primarily to circumvent CS patient's difficulty connecting with caregivers through face-to-face encounters. The caregiver needs to announce themselves and communicate clearly while out of sight to establish better emotional ties. The caregiver should self-evaluate to recognize gaps and strengths in the management of the patients' condition while also relying on other family, friends, and relatives.[24]

Enhancing Healthcare Team Outcomes

Capgras syndrome, or delusion of doubles, is a delusional misidentification syndrome.[1] It is a syndrome characterized by a false belief of identical doubles of someone significant to the patient.[2] In CS, the subject believes that an identical duplicate has replaced a closely related individual, an inanimate object, or an animal. It is widely regarded as the most prevalent of the delusional misidentification syndromes and appears in psychiatric and non-psychiatric cases, including patients with brain damage.[3] Schizophrenia, schizoaffective disorder, Alzheimer disease (AD), Lewy body dementia, epilepsy, cerebrovascular accident (CVA), pituitary tumors, and advanced Parkinson disease (PD) patients can experience CS. CS is linked to brain damage in the bifrontal, right limbic, and temporal regions.[3] The damage leads to aberrant memory functions, self-monitoring, and reality perception. Such neurophysiological deficits cause an inability to integrate emotional information processing and facial recognition correctly.

  • Capgras syndrome is equally found both in males and females.[2]

  • Capgras is the clinical diagnosis. However, laboratory workup and imaging must be done to rule out other organic causes.[5]

  • Timely and accurate diagnosis of underlying disorders or medical conditions can assist in managing CS.[15]

  • Psychodynamic therapy intervention is vital in controlling CS symptoms and violence related to it.[24]

Since managing CS is challenging, an interprofessional team is required to provide care effectively. Psychopharmacology and psychotherapy are important to manage CS. The team could consist of a psychiatrist, psychologist/therapist, physician, social worker, and caregivers/ relatives. Due to the lack of research data on CS, treating CS poses a considerable challenge. Antipsychotics have been found effective in managing symptoms.[23] Moreover, psychodynamic therapy and therapeutic alliance with patient plays a vital role in patient management. Hospitalization is imminent in CS patients if they pose a risk of self-harm or violence towards others.[15][24] Clear and effective communication by caregivers with patients helps to build emotional ties and avoid aggressive episodes.[24]Good interdisciplinary communication leads to better patient outcomes in Capgras syndrome.

References

1.

Groth CL, Pusso A, Sperling SA, Huss DS, Elias WJ, Wooten GF, Barrett MJ. Capgras Syndrome in Advanced Parkinson's Disease. J Neuropsychiatry Clin Neurosci. 2018 Spring;30(2):160-163. [PubMed: 29132271]

2.

Berson RJ. Capgras' syndrome. Am J Psychiatry. 1983 Aug;140(8):969-78. [PubMed: 6869616]

3.

Hillers Rodríguez R, Madoz-Gúrpide A, Tirapu Ustárroz J. [Capgras syndrome: a proposal of neuropsychological battery for assessment]. Rev Esp Geriatr Gerontol. 2011 Sep-Oct;46(5):275-80. [PubMed: 21944325]

4.

Ng KP, Wong B, Xie W, Kandiah N. Capgras Syndrome in the Young: Schizophrenia or Alzheimer Disease? Alzheimer Dis Assoc Disord. 2020 Jan-Mar;34(1):94-96. [PubMed: 31913960]

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Salvatore P, Bhuvaneswar C, Tohen M, Khalsa HM, Maggini C, Baldessarini RJ. Capgras' syndrome in first-episode psychotic disorders. Psychopathology. 2014;47(4):261-9. [PMC free article: PMC4065173] [PubMed: 24516070]

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Chadda RK, Jain BK. An unusual case of Capgras' syndrome. Am J Psychiatry. 1990 Mar;147(3):369-70. [PubMed: 2309960]

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Merrin EL, Silberfarb PM. The Capgras phenomenon. Arch Gen Psychiatry. 1976 Aug;33(8):965-8. [PubMed: 949230]

8.

Fishbain DA. The frequency of Capgras delusions in a psychiatric emergency service. Psychopathology. 1987;20(1):42-7. [PubMed: 3628676]

9.

Young AW, Reid I, Wright S, Hellawell DJ. Face-processing impairments and the Capgras delusion. Br J Psychiatry. 1993 May;162:695-8. [PubMed: 8149127]

10.

Alexander MP, Stuss DT. Capgras syndrome: a reduplicative phenomenon. J Psychosom Res. 1998 Jun;44(6):637-9. [PubMed: 9678743]

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Bauer RM. Autonomic recognition of names and faces in prosopagnosia: a neuropsychological application of the Guilty Knowledge Test. Neuropsychologia. 1984;22(4):457-69. [PubMed: 6483172]

12.

Ellis HD, Young AW. Accounting for delusional misidentifications. Br J Psychiatry. 1990 Aug;157:239-48. [PubMed: 2224375]

13.

Hirstein W, Ramachandran VS. Capgras syndrome: a novel probe for understanding the neural representation of the identity and familiarity of persons. Proc Biol Sci. 1997 Mar 22;264(1380):437-44. [PMC free article: PMC1688258] [PubMed: 9107057]

14.

Mazzone L, Armando M, De Crescenzo F, Demaria F, Valeri G, Vicari S. Clinical picture and treatment implication in a child with Capgras syndrome: a case report. J Med Case Rep. 2012 Nov 27;6:406. [PMC free article: PMC3520716] [PubMed: 23186382]

15.

Khouzam HR. Capgras syndrome responding to the antidepressant mirtazapine. Compr Ther. 2002 Fall;28(3):238-40. [PubMed: 12360636]

16.

Edelstyn NM, Oyebode F, Barrett K. The delusions of Capgras and intermetamorphosis in a patient with right-hemisphere white-matter pathology. Psychopathology. 2001 Nov-Dec;34(6):299-304. [PubMed: 11847489]

17.

Silva JA, Leong GB, Weinstock R, Sharma KK, Klein RL. Delusional misidentification syndromes and dangerousness. Psychopathology. 1994;27(3-5):215-9. [PubMed: 7846240]

18.

Coltheart M, Langdon R, McKay R. Delusional belief. Annu Rev Psychol. 2011;62:271-98. [PubMed: 20731601]

19.

Soares HR, Cavalcante WCP, Martins SN, Smid J, Nitrini R. Capgras syndrome associated with limbic encephalitis in a patient with diffuse large B-cell lymphoma. Dement Neuropsychol. 2016 Jan-Mar;10(1):63-69. [PMC free article: PMC5674917] [PubMed: 29213434]

20.

de Pauw KW. Psychodynamic approaches to the Capgras delusion: a critical historical review. Psychopathology. 1994;27(3-5):154-60. [PubMed: 7846232]

21.

Brighetti G, Bonifacci P, Borlimi R, Ottaviani C. "Far from the heart far from the eye": evidence from the Capgras delusion. Cogn Neuropsychiatry. 2007 May;12(3):189-97. [PubMed: 17453900]

22.

Pandis C, Agrawal N, Poole N. Capgras' Delusion: A Systematic Review of 255 Published Cases. Psychopathology. 2019;52(3):161-173. [PubMed: 31326968]

23.

Barrelle A, Luauté JP. Capgras Syndrome and Other Delusional Misidentification Syndromes. Front Neurol Neurosci. 2018;42:35-43. [PubMed: 29151089]

24.

Kyrtsos CR, Stahl MC, Eslinger P, Subramanian T, Lucassen EB. Capgras Syndrome in a Patient with Parkinson's Disease after Bilateral Subthalamic Nucleus Deep Brain Stimulation: A Case Report. Case Rep Neurol. 2015 May-Aug;7(2):127-33. [PMC free article: PMC4464017] [PubMed: 26078747]

25.

Christodoulou GN. Course and prognosis of the syndrome of doubles. J Nerv Ment Dis. 1978 Jan;166(1):68-72. [PubMed: 619004]

26.

Turgiev SB. [Clinical picture of hallucinatory-paranoid psychoses in cerebral atherosclerosis]. Zh Nevropatol Psikhiatr Im S S Korsakova. 1978;78(3):421-6. [PubMed: 645322]

Disclosure: Kaushal Shah declares no relevant financial relationships with ineligible companies.

Disclosure: Shailesh Jain declares no relevant financial relationships with ineligible companies.

Disclosure: Roopma Wadhwa declares no relevant financial relationships with ineligible companies.

Capgras Syndrome (2024)

FAQs

What does it feel like to have Capgras syndrome? ›

Capgras syndrome is the most prevalent delusional misidentification syndrome and is characterized as a delusion of doubles. Patients falsely believe that an identical person has replaced a person close to him or her.

What is a cognitive explanation of Capgras syndrome? ›

The Capgras delusion is the delusional belief that another person, often a partner or family member, has been replaced by an identical or near-identical looking impostor (Ellis & Young, 1990).

How rare is Capgras delusion? ›

The prevalence of Capgras syndrome among the general population is 0.12%, while in the psychiatric population rises to 1.3% [6-8]. The etiology of Capgras syndrome can be variable, being in most of the cases associated with preexistence neuropsychiatric conditions [4].

What is reverse Capgras syndrome? ›

Reverse Capgras Syndrome is a DMS that refers to the self replaced by an imposter rather than a familiar other.

Does Capgras go away? ›

Unfortunately, there's currently no cure for Capgras syndrome, and even treatment can be challenging. If a person with this condition has another mental disorder that has been linked to the condition, treating that mental disorder can sometimes ease symptoms of Capgras syndrome.

What triggers Capgras syndrome? ›

People with CS experience the belief that an imposter has replaced someone they know or recognize. It can be caused by brain injury, structural changes in the brain, or other conditions such as schizophrenia. Treating the cause of CS may help improve the symptoms.

What are the triggers for Capgras syndrome? ›

There are many different risk factors for Capgras syndrome, including having dementia or Parkinson's. Some people develop it after using large amounts of recreational drugs or alcohol. Others have had health issues like low thyroid, another metabolic condition, or a nutrient deficiency, like being short on vitamin B12.

What are some interesting facts about Capgras syndrome? ›

People with Capgras syndrome usually believe the supposed imposter has bad intentions. This can lead to aggression or violence, sometimes putting other people at risk. The exact cause is unknown, but people with Capgras syndrome often live with other mental health conditions, such as schizophrenia or dementia.

Can Capgras syndrome be temporary? ›

The Capgras syndrome was described almost a century ago. It is characterized by the recurrent and transient (ranging from minutes to months) belief that a person, usually someone closely related, has been replaced by an imposter.

What is the difference between Capgras syndrome and prosopagnosia? ›

They proposed two distinct routes to facial recognition: one for the actual identification of the face, and the other to give the face its emotional significance. They proposed that prosopagnosia results from a disruption of the first route, whereas Capgras syndrome is 'a mirror image' of prosopagnosia.

What is Fregoli syndrome? ›

Fregoli syndrome is the delusional belief that one or more familiar persons, usually persecutors following the patient, repeatedly change their appearance.

What is nihilistic delusion? ›

Nihilistic delusions, also known as délires de négation, are specific psychopathological entities characterized by the delusional belief of being dead, decomposed or annihilated, having lost one's own internal organs or even not existing entirely as a human being.

Is Capgras syndrome scary? ›

Individuals with Capgras syndrome believe that an imposter or an identical double is standing in for a loved one. This delusion can be extremely scary for the person suffering from it, as well as deeply painful for the person's loved ones.

What to do if you have Capgras syndrome? ›

Being patient and sympathizing, as Capgras syndrome can cause real fear and anxiety. Limiting exposure to the “imposter” when an episode is taking place. Having the “imposter” speak before they are seen, as their voice may be recognized. Acknowledging the feelings surrounding the identity confusion when they occur.

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