Diseases and Disorders

A Strange Brain Disorder: Capgras Syndrome

Daisy Zhou


As one of the strangest delusions that is not being widely recognized, Capgras Syndrome is a disorder in which patients believe their close friends or family members are imposters because they do not have any emotional attachment to them. The following essay is a general overview of Capgras Syndrome, given its symptoms, neurological causes, treatments, and precautions in caretaking. The first section summarized the ‘landmark’ symptoms of this psychiatric disorder, the second section outlined several possible pathological causes with relevant statistics, then possible treatments are identified, and at last precautions for the family members of CS patients are given. This article does not only provide an introduction to people with this psychiatric delusion, but also spreads awareness of this disorder and encourages more research to be done.



Imagine a man who believes his wife is no longer his wife but her doppelgänger. While you may think this is a ridiculous joke, there are patients in the world who are struggling with this delusion every day — the Capgras Syndrome (figure 1).

Capgras Syndrome (CS), or Capgras Delusion, is the most common type of delusional misidentification syndromes (DMSs) that involves the everlasting denials of familiar people or objects as if they are replaced by imposters, and patients believe they can see through the “disguise” as they are aware of the replacement (figure 1). This delusion may result in violence and anger towards the “imposters,” anxiety and stress towards someone’s own life, or changes and effects in social behaviors. This disorder hardly ever exists in its pure form and it is normally accompanied by other neurological or psychiatric conditions. One of the four conditions can occur in a CS patient: 1. the person is recognized, and the patient asserts the resemblance of the double to the misidentified significant other; 2. no identity is attributed to the double, who has neither name nor existence; 3. the double is an imposter, pretending to be the original they are replacing; 4. the original has disappeared, his/her absence remaining unquestioned. [2] One of the most intriguing phenomena in CS patients is that they recognize the close relation and the significant other’s face, but utterly deny the person’s identity [3]. 

The absence of consensual clinical criteria for Capgras Syndrome diagnosis renders the epidemiological data uncertain and makes the prevalence of CS more likely to be underrated. [4] Among 60% of CS patients are suffered from schizophrenia spectrum disorders and 20%- 40% of the patients also have other organic illnesses. [5] Also, family history of psychosis is reportedly present in half of CS patients. [6]. 

Explanations for Capgras Syndrome 

There are two components of the visual recognition of a familiar face: the conscious recognition of faces and the memory of their related semantic information, and limbic-mediated emotional arousal, or familiarity. As CS patients are able to recognize but not acknowledge familiar faces, the syndrome suggests that there are two separate circuits in the brain for facial recognition: a cognitive circuit impaired in prosopagnosia, or face blindness, and an affective circuit which is impaired in CS. [8] In the affective circuit, the dorsal visual track that gives the face its emotional significance is damaged (figure 3). 

The pathological reasons for the occurrence of the delusion are still unknown. However, various theories suggest possible neurological causes. One of the theories was proposed by Hirstein and Ramachandran in 1997 after they observed that CS was more frequently caused by lesions in the ventral (occipitotemporal) pathway that connects the amygdala [9]. Because the amygdala is an emotional center in the limbic system, the scientist extrapolated that there might be a disconnection between the amygdala and Fusiform Face Area (FFA), a region specialized for face recognition. As these regions disconnect, even if a person succeeds to recognize the face of a familiar person, the limbic system can no longer invoke the sense of familiarity, which in turn leads to the lack of emotional attachment of this person. Also, it has been suggested that CS results from the disconnection of the face processing regions in the inferior temporal lobe from structures in the limbic system, especially the amygdala, which is very important in assigning emotional value to familiar faces. [10] Another theory in the book Mapping the Brain suggests that there might be a disconnection between the limbic system and the frontal lobe. Because the frontal lobe is involved in the acknowledgment of the sense of familiarity that the person receives after his family members are processed in the limbic system, the signals cannot be delivered in the frontal lobe when it’s damaged, so the person does not ‘feel right’ even though he noticed that there are emotional linkage between the familiar person and himself. [11]

Also, other theories suggest Lewy body dementia (28% of the cases) or other neurodegenerative diseases like Alzheimer’s (15% cases of CS) can induce the delusion as they alter the patient’s perception about the world around them [12]. Besides, schizophrenia may induce various delusions, and epilepsy may trigger damage or hypersynchrony of neural activity so they are regarded to have potential relevance to CS [13]. Interestingly, more widespread bilateral frontal and temporal cortex atrophy in schizophrenia patients with CS than schizophrenia patients without the syndrome by using computerized tomography (CT). [14] Neuroanatomical examinations of CS patients suggest a higher chance of structural and metabolic abnormalities in the right frontal, temporal, or parietal brain regions.

Lastly, psychodynamic theories suggest that CS might be an anxiety-induced regression of cognitive and emotional functioning, pathological splitting of internalized object representations, insufficiently repressed conflicting or ambivalent feelings toward the implicated person, and the projection of negative emotions that come to light from these conflicting feelings. 


Possible Treatments 

As the physiological causes of CS have not been exactly identified, the treatment of its symptoms is still in the phase of ‘trial-and-error’. Many possible medications or medical procedures can be taken to control the symptoms of CS:


Precautions to Family Members of CS patients 

As violence towards familiar people might be prevalent, especially violence induced by male patients, families may consider carefully the frequency and the time of visit during the day, and caretakers should continuously reassure patients that they are safe. Also, the family members of the patients can announce the identity of themselves before being seen by the patients to gradually establish trust and emotional connection with them. Another useful tip is to utilize auditory interactions rather than visual ones as patients are highly sensitive to visual cues, which may in turn trigger aggressive or anxious behaviors due to the delusion.


  1. Laughman, Rachel. “Capgras Syndrome by RachelLaughman on DeviantArt.” By RachelLaughman on DeviantArt, www.deviantart.com/rachellaughman/art/Capgras-Syndrome-548377759. Retrieved: 3/3/2020

  2. Christodoulou, G. (1977). The Syndrome of Capgras. British Journal of Psychiatry, 130(6), 556-564. doi:10.1192/bjp.130.6.556

  3. Bourget D, Whitehurst L. Capgras syndrome: A review of the neurophysiological correlates and presenting clinical features in cases involving physical violence. The Canadian Journal of Psychiatry. 2004;49(11):719-725. DOI: 10.1177/070674370404901102. Retrieved: 3/3/2020.

  4. Enzel Koc, A. and Hocaoglu, C. (12/1/2020). What is Capgras Syndrome? Diagnosis and Treatment Approach. Little Known Syndromes in Psychiatry. Retrieved: 2/3/2020.

  5. Enzel Koc, A. and Hocaoglu, C. (12/1/2020). What is Capgras Syndrome? Diagnosis and Treatment Approach. Little Known Syndromes in Psychiatry. Retrieved: 2/3/2020.

  6. Silva, A., Leong, G., Weinstock, R., Sharma, K. and Klein, R. (1994). Delusional Misidentification Syndromes and Dangerousness. Psychopathology, 27(3-5), pp.215-219. Retrieved: 2/2/2020.

  7. Madhav, Indhu. (5/2/2016). CAPGRAS SYNDROME. LinkedIn SlideShare. www.slideshare.net/mobile/indhumadhav/capgras-syndrome-57917752. Retrieved: 30/11/2019.

  8. Darby, R. and Prasad, S. (2016). Lesion-Related Delusional Misidentification Syndromes: A Comprehensive Review of Reported Cases. The Journal of Neuropsychiatry and Clinical Neurosciences, 28(3), pp.217-222. Retrieved: 3/3/2020.

  9. Garfield, Simon. (10/10/2013). On the Map: a Mind-Expanding Exploration of the Way the World Looks. Gotham Books. Retrieved: 1/11/2019.

  10. Capgras Delusion. Capgras Delusion - an Overview. ScienceDirect Topics. www.sciencedirect.com/topics/neuroscience/capgras-delusion. Retrieved: 1/11/2019.

  11. Carter, R. and Frith, C. (2010). Mapping the mind. Berkeley: University of California Press. Retrieved: 3/3/2020.

  12. Enzel Koc, A. and Hocaoglu, C. (12/1/2020). What is Capgras Syndrome? Diagnosis and Treatment Approach. Little Known Syndromes in Psychiatry. Retrieved: 2/3/2020.

  13. Scharfman, H., Kanner, A., Friedman, A., Blümcke, I., Crocker, C., Cendes, F., Diaz-Arrastia, R., Förstl, H., Fenton, A., Grace, A., Palop, J., Morrison, J., Nehlig, A., Prasad, A., Wilcox, K., Jette, N. and Pohlmann-Eden, B. (2018). Epilepsy as a Network Disorder (2): What can we learn from other network disorders such as dementia and schizophrenia, and what are the implications for translational research?. Epilepsy & Behavior, 78, pp.302-312. Retrieved: 3/3/2020.

  14. Edelstyn, N., Oyebode, F. and Barrett, K. (2001). The Delusions of Capgras and Intermetamorphosis in a Patient with Right-Hemisphere White-Matter Pathology. Psychopathology, 34(6), pp.299-304. Retrieved:3/3/2020.]

  15. Ellis, H. and Lewis, M. (2001). Capgras delusion: a window on face recognition. Trends in Cognitive Sciences, 5(4), pp.149-156. Retrieved: 3/3/2020.

  16. Enzel Koc, A. and Hocaoglu, C. (12/1/2020). What is Capgras Syndrome? Diagnosis and Treatment Approach. Little Known Syndromes in Psychiatry. Retrieved: 2/3/2020.

  17. Gotter, Ana. (12/6/2018). “What Is Capgras Syndrome.” Healthline. “What Is Capgras Syndrome?” ParkinsonsDisease.net. parkinsonsdisease.net/clinical/capgras-syndrome/. Retrieved: 1/11/2019.

  18. Enzel Koc, A. and Hocaoglu, C. (12/1/2020). What is Capgras Syndrome? Diagnosis and Treatment Approach. Little Known Syndromes in Psychiatry. Retrieved: 2/3/2020.

  19. Torales, J., Rodríguez, H., Arce, A., Moreno, M., Riego, V., Chávez, E. and Capurro, M. (2013). Olanzapine in the treatment of Capgras Syndrome: a case report. International Journal of Culture and Mental Health, 7(2), pp.224-228. Retrieved: 3/3/2020.

  20. Jariwala, Prashant & Shah, Nilima & Dave, Kamlesh & Mehta, Ritambhara. (2018). Delusional Misidentification Syndromes in Patients of Paranoid Schizophrenia: Case Series and Review. Telangana Journal of Psychiatry. July-December 2017. 125-129. 10.18231/2455-8559.2017.0027. Retrieved: 3/3/2020.

Daisy Zhou

Daisy Zhou

This author has not yet uploaded a bio.