“Mary, aged 40 years, was referred for psychiatric evaluation out of concern that a mental health diagnosis was interfering with her ability to appropriately and safely care for her child. The patient had stated on numerous occasions that her 9-year-old daughter, Sarah, had been placed in the custody of Child Protective Services and replaced by an imposter. Mary also reported that she had given birth to twins but that the hospital record only documented the birth of Sarah. On occasion, she had shown up at her daughter’s school, refusing to pick her up, screaming, “Give me my real daughter; I know what you’ve done.”

“Despite reassurance from multiple health care providers and relatives, Mary continued to express concern that her daughter was not, in fact, her own. Furthermore, she related several episodes in which her daughter was “whisked away before I could talk to her” while going about her daily business. For example, Mary related that a car driven by an unknown person, with Sarah in the passenger seat, passed by her while she was running errands but sped away once she was noticed…

[…]

“A case has been described in which a mother believed her adult daughter had been replaced with a look-alike imposter. On delving into the patient’s history, it was found that the patient had to leave a very serious relationship with a man she loved because she was pregnant with another man’s child. The baby eventually grew into the adult daughter who the patient believed had been replaced. The patient’s resentment for having to leave her lover when she was pregnant was believed to be the psychodynamic source for the current delusion.

“With Capgras syndrome, the family member who is believed to have been replaced is most often a spouse, parent, or sibling. For unknown reasons, the “replaced” family member is rarely the child of the delusional person and even more rarely is the child younger than 20 years. Although violence aimed at any person is a significant threat, violence aimed at children is particularly worrisome. Mary’s case is unique because the increased potential for violence in her relationship with her daughter needs to be taken into consideration when assessing the patient’s ability to be a safe and effective parent.

“Although violence can be seen in all psychiatric disorders, there is a higher incidence of severe violence in patients with delusional disorders. In patients with Capgras syndrome, the violence is often directed at the imposter or, in some cases, the people the patient believes replaced the loved one with the imposter.

“Bourget and Whitehurst found several demographic features that increase the likelihood of violence in persons with Capgras syndrome. Specifically, if the imposter lives with the patient or if the delusional person is male, has a persistent and long-term delusion, or has a history of violence or substance abuse, the risk of violence is increased. The sources of violence can be frustration or fear of the imposter, but it can also be cultural.

“Silva and colleagues found that some folklore and regional legends suggest that if a child is thought to have been replaced by another person or even by a demon, battering and being physically aggressive toward the imposter might bring the “real” child back. One Swedish fairy tale recounts the story of a woman who believed her child was an imposter. In the story, she is advised to put her baby into a hot oven; when she does this, her “true” child is returned. This is a severe case that is not necessarily the norm for patients with misidentification delusions; however, it is evidence that violence in delusional persons can happen.”

Text: That’s Not My Child: A Case of Capers Syndrome, by Jeremy Matuszak, MD and Matthew Parra, MD, Psychiatric Times.

Pic: The Lovers 2, 1928 by Rene Magritte