What is a Disciple?

        

          The issue of Discipleship in the modern context of the church presents a rather frustrating and confusing topic for many Christians. Many Christians are confused on what a disciple is and are further mystified on what a disciple does. Theological confusion among churches and pastors has not helped the situation. Sermons topics on discipleship range from seeing disciples primarily as learners, or believers, or committed believers who become disciples, or as the conditions of salvation. I too, like many Christians across the denominational spectrum, have experienced existential turmoil and pain because I wasn’t sure if the characteristics of discipleship were conditions of salvation, if Jesus’ message to the apostles were intended for me, and if I met the qualifications for a “second tier” of Christian spirituality. Because of this ongoing frustration I have felt burnout by my Christian experience, always wondering if I was good enough to be considered a disciple.

For some time I wondered if there ever would be an answer to these questions or if this was area of mystery that I would have to take up with God upon my death. Yet this is not the position God wishes for His children to be in, God desires for those He has given to Christ to be empowered, encouraged, and impassioned to follow after His Son, not discouraged, burnt out and confused, throwing their hands in the air hoping for their death so that they can finally understand what God meant. Therefore, God has not left us with a fractured piecemeal picture of discipleship which leaves the interested student wondering. Through careful study of God’s word we can build a theology of what a disciple is and what he does. It is true that orthodoxy produces orthopraxy, this gives us confidence that if we are faithful to God’s word in our understanding then we will be empowered and encouraged to live out the Spirit empowered life of discipleship that Jesus intended.

In his book Following the Master: A Biblical Theology of Discipleship Michael Wilkins builds his biblical theology of discipleship by first examining the etymology of the word “disciple” which in the Greek language is Mathetes. The definition of the word is “learner”; however, the meaning of the word is not limited to its definition.  In the Ancient Near East during the mid 1^st century the word also included the additional sense of adherent. This would indicate that a disciple was much more than an interested student. In the case of a Christian disciple an adherent would be a believer in Jesus Christ for this is what Jesus made evident in His teaching, “For this is the will of my Father, that everyone who looks on the Son and believes in him should have eternal life, and I will raise him up on the last day” (John 6:40). There are numerous passages especially in the Gospel of John where Jesus made this abundantly clear (John 3:15-18, 36, 6:47, 11:25-26, 20:30-31) also Peter in Acts and Paul in his Epistles. In order to follow Jesus you must believe that He is the Son of God, anything less will not please God. Also, the way Mathetes was used in the early church recorded in Acts was synonymous with the terms Christian, Brother/Sister, Believer, and Follower of the Way. Therefore, we can conclude from the etymology of the word Mathetes, from the way it was used in the Ancient Near East and in the early church recorded in Acts, that a disciple was someone who learned from and believed in Jesus.

It would seem from the Biblical and cultural-historical data that a disciple was a convert, suggesting a 1 to 1 relationship— convert equaled disciple. However this view is not held by many, some hold the view that a disciple was merely a learner, others seem to think a disciple was a minister, and still others think discipleship was a secondary step of the committed Christian. I’ve demonstrated that a disciple cannot be simply a learner, but what does scripture have to say about these other options?

At this point it is important to understand what a disciple does. It is critical to identify the point at which Jesus was teaching the masses, the disciples or the apostles. First of all, Jesus gave a general call to discipleship. Jesus when He was addressing the masses put forth this invitation, “Now great crowds accompanied him, and he turned and said to them, ‘“If anyone comes to me and does not hate his own father and mother and wife and children and brothers and sisters, yes, and even his own life, he cannot be my disciple. Whoever does not bear his own cross and come after me cannot be my disciple”’ (Luke 14:25-27).  This call was to hate your mother and father and brother and so on, basically communicating that the disciple was to possess a love for their heavenly Father that made all other love look like hate. Let me be clear, Jesus was not advocating hate,  but a love that looks like hate in comparison to the intensity of love for the heavenly Father, our love for God should be supreme (v. 26). Secondly, in order to be a disciple one had to take up their cross and to come after Jesus (v. 27).  Jesus’ general call of discipleship, not His call of Apostleship, also included abiding in belief (John 15:4) and again obedience by taking up ones cross (Matthew 16:24, Mark 8:34, Luke 9:23).

This call was drastically different than the call to Apostleship, which was to leave home and family (Luke 9:60), sell all you have (Luke 12:33), and come physically follow Jesus (Mark 1:17). Jesus selected twelve for this special task. For three years Jesus trained and taught the apostles/disciples, then He died, resurrected, ascended and poured out His Spirit at Pentecost. This enabled the Apostles to remember Jesus’ teaching and be anointed to carry out miracles for the purpose of spreading the Gospel and establishing the church. This was a very specific call, one that was not intended for the disciple.

Jesus intention was that He should die, be resurrected and ascend into heaven. However, this creates a problem because how was a disciple to follow after Jesus if Jesus was not physically present. As Jesus discussed in John 14 through 16, He was leaving so that one better will come in His place. The Holy Spirit provides the presence of Christ so that all can follow Jesus regardless of location and time periods. This is another reason why it makes sense that Jesus’ general call to all disciples was not one to sell everything one had and to physically leave family and home to come and follow. Jesus foreknew that this would be an impossible task for all of the billions of believers that would follow after His death, resurrection and ascension to the right hand of the Father. Jesus desired for the whole world to hear the gospel, be saved and follow Him (Matt. 28:19). The specific call to sell everything, leave family and home, and physically follow Jesus was intended only for His Apostles. So this rules out the possibility that a disciple was only a minister. In fact, every disciple is called to minister and serve, Jesus died so that He might have a nation of priests (I Pet. 2:5-9). Observe what Wilkins has to say about this issue, “Therefore our preliminary observation is that as disciples the Twelve give us an example of how Jesus works with all believers, and as apostles the Twelve give us an example of how Jesus works with leaders of the church” (pg. 36).

However, the issue of a disciple being a committed believer still lingers. The view that there are Christians and there are disciples, a disciple being a committed and obedient Christian. To understand this issue better consider the account of the disciples not able to believe the hard sayings of Jesus in John 6, “After this many of his disciples turned back and no longer walked with him” (v. 66). It is important to note that Jesus was speaking to a mix of disciples, the masses (v. 22 “the crowd”), Jews (v. 41) and the Apostles. It would seem that based on the context surrounding verse 66 that the term disciple was being used loosely here. Wenham, Motyer, Carson and France note in New Bible Commentary “The grumbling of many of the disciples (60-61) shows that the word ‘disciple’ is used here in a loose sense for those fringe followers of Jesus. They were not true believers for they found it hard to accept his teaching (60). They could not even imagine anyone accepting it. Jesus knew their real position and proceeded to advise” (pg. 1039, emphasis in the original).

Looking at the previous verses it can be gathered that Jesus knew the true intentions of those He was speaking to, and so He spoke evangelistically to persuade them to belief, “Jesus answered them, “This is the work of God, that you believe in him whom he has sent” (v. 29) and using His words to act as a winnow for He knew that some could not believe after hearing His words concerning Himself being the bread of life, “But there are some of you who do not believe” (v. 64). Therefore, some “disciples” walked away among the mix of people, not possessing true belief in Jesus, contrast that with the belief of the true disciples found among the twelve, “So Jesus said to the Twelve, “Do you want to go away as well?” Simon Peter answered him, “Lord, to whom shall we go? You have the words of eternal life, and we have believed, and have come to know, that you are the Holy One of God” (v. 67-69). The twelve here model true discipleship, which is belief that Jesus is the Son of God upon whom we depend for eternal life.

It would seem, there is no secondary step of Christian spirituality, these “disciples” did not walk away and cease to follow Jesus because they didn't want to live a committed life of obedience, it was because they could not believe that Jesus was who He said He was. Therefore, keeping in mind the definition of disciple which was a learner and adherent, they did not qualify as disciples since they did not believe. It is also important to note that a disciple was never conceptualized outside the context of a community. To be a disciple was to identify and participate in a community of disciples. This idea was developed further in Acts and the Epistles, when the nascent church was established and the body of Christ was starting to operate in its redemptive capacity.

Some people after reading this might raise the objection that if Mathetes meant learner and adherent, then it is a copout to say based on the context of John 6 the meaning of the word would allow for someone who was not fully a believer. In response to this objection it is important to understand Jesus’ mission and how that mission unfolded. Jesus first came on the scene in Matt. 3 when He was baptized by John the Baptist; this event identified Jesus with John’s ministry of preparing the way for the Messiah. It is important to know that Jesus not only was born, matured to adulthood, did some teaching, then died on the cross and then went to heaven. But He entered into a movement which served as a vehicle for His ministry, that was the Messianic Movement prepared by John the Baptist. This movement unfolded over time, for example after the temptation in Matt. 4:1-11 Jesus then preached about the Kingdom (Matt. 4:17) and only later did He perform signs and wonders to demonstrate that He was the Messiah, anointed one of God, Divinity in human form (Matt. 8-10). There was a progressive unfolding of the Movement and therefore, an unfolding understanding of who Jesus was.

It is possible to see this unfolding through five stages in the gospels. First, in John 1:25-42 people took the personal initiative to follow Jesus out of curiosity or to question Him in order to find out more, therefore a full understanding of Jesus' identity had not fully emerged. The second stage can be found in Matt. 4:18-22 (also Mark 1:16-20) where Jesus called people to follow Him, this was a challenging and costly call that entailed two separate calls, the first to discipleship and the second to apostleship. At this point we see the third stage, Jesus began sifting those who truly believed from those who didn't this was the account described above in John 6. After this the fourth stage was a smaller group of committed believers/disciples, and stage five the establishment of the church through the guidance of the Holy Spirit. Taking this into account, it is entirely possible to see how there was a progression of the Jesus Movement, understanding of the Messianic nature of Jesus and His message of belief in Him. So that by the time we come to the early church described in Acts, disciple had a robust meaning of learner and adherent with associations to other terms such as Christian, Brother/Sister, Believer, and Follower of the Way. And most importantly, we can conclude that those disciples who walked away from Jesus in John 6 had up to that point an underdeveloped belief in Jesus, because full knowledge had not yet been unfolded.

In conclusion, based on the Biblical and cultural-historical data a disciple was a learner and an adherent who responded to the costly call of life commitment to following Jesus with belief. Discipleship begins at the point of salvation, we all are disciples if we are Christians, and there is no upper or secondary tier of Christian. A key component of following Jesus is to participate in His New Covenant post-resurrection community.

A Short Meditation on Pain and Redemption

     Pain has a funny way of creeping in between your bones; it fills all the crevasses and seeps into your soul. For me, the onset of the timeless ancient condition was not a sudden dispensation, but a subtle, insidious and violent introduction into my psyche. Pain had niggled its way into all the good, innocent and bad parts of me, taking what was once or could have been a sweet well balanced person, and transformed me, in all the negative connotations that one can summon to mind, into something that could have only pleased the will of Satan. One day all that pain took its ultimate toll on my heart, and I died. The goodness that was in Jesus’ mind when He made me was killed by the sin that we all participated in through my abuser. The very words make little sense to the rational nous, but upon realization at the right moment, the spiritual mystery is recognized. We all participated in Adam’s sin, we all are guilty. It is the collective conscious that Jung realized, yet he could only see it partially, he could not recognize it for its fullest theological meaning. We all collectively have shared in something, the sin of Adam. And it was that very sin which stole something from me, which stole something from Jesus. Jesus came to kill that which hurt me; he came to conquer it with the sharpest knife imaginable, love.

     Yes, it was His love that conquered sin, championed the defeat of my pain. To restore that which was broken Jesus died. He gave His life for mine. What was taken can never fully be replaced, what Jesus first created, but in its place is something better, a prize soaked in the blood of Jesus’ sacrifice. He atoned the sin of he who was hurt and then hurt, He atoned the sin of me who hurts because I was hurt. How precious is this blood, this blood that ransomed me, that cleansed me through and through, so I can be free. So I say to you, live this day, live this day! Know that what has been taken from you will not be returned, nor replaced, but transformed. It has been transformed into something far better and greater than what we could have imagined before all hell broke loose in our lives.

Healthcare

            The reason why the elderly are taken care of regardless of income by the federal government and not children and adults I think comes from three assumptions.
First, if your a child it is assumed that you are being taken care of by your parents or an adult guardian. The unfortunate reality is that 10.7% children do not receive any healthcare.
Second, the reason why adults are not offered healthcare regardless of income or meeting a certain criteria I think is because it is expected in this culture that an able-bodied adult works and provides for themselves. Our society is built upon individualistic standards and expectations; every citizen is expected to earn a living and climb the ladder of success.
Third, I think this may be the most negative assumption made by our culture and government is that no one cares enough to take care of our nation’s elderly; therefore, it is the government’s responsibility to take care of them. This is extremely unfortunate because the influence of the elderly can be incredibly enriching for a person, community and country.

            These assumptions reflect one of our culture’s primary values, individualism. If you can work then you work, if you cannot work then you should be of no burden to an able-bodied person and therefore the government’s responsibility. I am not devaluing the value of work; I think it’s a valuable element in the human experience and necessary for a society to function. However, this value should not be over-emphasized to the point that it alienates certain populations in our society for the sole reason that they cannot work.

Should we Consider Pyschological Disorders as Diseases?

            The problem with the perception of psychological disorder is that it is seen as a disease than a dysfunction. Disease has the connotation of limitation and restriction, meaning that a person labeled as having a disease is then seen as damaged. This not only affects the person greatly, but also the type of health care they receive. In an attempt to remedy this perception the field of psychology is changing its perspective on those with psychological disorders, in which the textbook defines as “a psychological dysfunction within an individual associated with distress or impairment in functioning and a response that is not typical or culturally expected” (Abnormal Psychology, pp.2). Instead of perceiving someone as having a psychological disorder the goal is now to observe how certain behaviors are inhibiting “cognitive, emotional or behavioral functioning”(Abnormal Psychology, pp.2). If someone was exhibiting behaviors that could be classified as a disorder, but in their day to day lives these behaviors did not impede their ability to live, work or interact socially, intervention is not necessary. There is nothing wrong with their functionality as long as the person is not experiencing more than the daily distress we all face or that they are impaired. But there is another element to this discussion which can be quite variant, cultural expectations. The DSM-IV-TR has a more complete description in light of the added element, “behavioral, psychological, or biological dysfunctions that are unexpected in their cultural context and associated with present distress and impairment in functioning, or increased risk of suffering, death, pain, or impairment”(Abnormal Psychology, pp.3). So there is some variation, what may seem like a disorder in one culture may not be in another, what the bottom line is, does it inhibit the person’s functionality?

Reference

Abnormal Psychology: An Integrative Approach (David H. Barlow & V. Mark Durand)

How Family-of-Origins Impact Future Marital Relationships

        This study discussed the effects that a dysfunctional family-of-origin has on premarital couples and the maladaptive behaviors brought henceforth into future marriages. Many factors lead to marital dissolution and unhappiness, however, one of the leading causal factors in marital discord is hostile conflict. Researchers (Amato, 1996; Holman & Birch, 2001) have shown that disrupted and dysfunctional family-of-origin histories exert influence on future marital discord if issues are not recognized and worked through. I've heard it said that families are the laboratory of life, which means that we do most of our learning in the family context. The family is where we do the majority of leaning that impacts the rest of our lives. I think of it like training, the way your family of origin deals and respond to conflict teaches us how to deal with and respond to conflict in future relationships. How families manage money, perceive time, work, love, affection and so on affects all our future relationships. 

        Many people who come from "broken" family contexts leave thinking that they're leave all the drama, conflict and pain behind, only to unwittingly respond to future issues in similar ways they did when in their family context. Wherever we go we take with us all our past hurts, joys, pains, relationships, events and actions. Our response to various stimuli is a complex interaction of past events, actions and relationships with the new set of variables. This isn't to say that we don't grow and change, but to some varying degrees, we can never extricate ourselves from our family contexts. Our past and memories largely constitute our identity.

The intention of this study was to understand was to demonstrate empirically what was discussed above, how “select family-of-origin variables, measured premaritally, were predictive of hostile conflict in early marriage” (Topham, Larson & Holman, 2005). For premarital couples, having an understanding of what factors may cause hostile marital conflict in their future marriage would be incredibly valuable information. Unfortunately little to no research has been conducted on the connection between premarital factors and marital hostile conflict, there have only been correlations discovered between premarital factors and marital dissolution and unhappiness.  

        The theoretical frameworks Topham et al based their hypotheses on were Social Learning theory, Multi-generational family theory and Attachment theory. Each of these theories look at the role family-of-origin play in offspring’s future marital satisfaction, stability and the transmission of dangerous behaviors. Six hypotheses were tested but for the sake of brevity I will only mention those which provided statistical significance. The predictive factors for marital conflict included the wives’ family-of-origin environment and approach to discipline. This reinforces the notion that wives are the “gate-keepers” of marriage relationships, since those factors didn't significantly affect husbands. Topham et al proposed this may be that after marriage the wife's family maintains active contact with their daughter and new husband. This, in general, is not true of the husband’s family, they tend to "let go" easier. Therefore, it is likely that unhealthy behaviors, relationships and mindsets are maintained because of the wives’ continued contact with her family. This has been consistent with my own observations as well.

        The theories were well chosen for the issue of research and provided much insight into the phenomenon. The importance of this study is that it provides a tool for couples coming from dysfunctional families, allowing them to consciously recognize their family’s influence on their behavior and cognitions, and take steps to ensure a stronger and better informed marriage. To be forewarned is to be forearmed. The better understanding one can have of the problem, the more effectively one can step towards healing and growth.

References:

Amato, P. R. (1996). Explaining the intergenerational transmission of divorce, Journal of Marriage and the Family, 58, 628–640.

Holman, T. B. & Birch, P. J. (2001). Family-of-origin structures and processes and adult children’s marital quality. In T. B. Holman & Associates (Eds.), Premarital prediction of marital quality or break up: Research, theory, and practice. New York: Plenum Press.

Topham, G. L., Larson, J. H., & Holman, T. B. (2005). Family-of-origin predictors of hostile conflict in early marriage, Contemporary Family Therapy: An International Journal, 27, 101-121.

Should There Be a Time Limit on Federally Funded Housing?

            This issue feels almost strange to address since traditionally the focus has always been on the struggle impoverished people have in just getting into section 8 housing. For those who do not know, "The Housing Choice Vouchers Program (often referred to as “Section 8”) is the federal government’s primary program to provide housing for Americans who are living in poverty, as well as the elderly and disabled. It provides qualifying families with assistance in paying the monthly rental fee for homes and apartments that are located anywhere, not just in subsidized housing projects. In every major market in the country it is administered locally by municipal public housing agencies, which certify the tenants and residences for participation in the program" (http://www.gosection8.com/what-is-section8.aspx).  The statistics are not very comforting; there is a 3-5 year wait to get into section 8 housing. Obviously there is a great need for the housing and an incredibly high demand, but what is the policy for when poor people do get the housing they need? In order to discuss these pressing questions I think it’s important to address some antecedent concerns such as: what is the primary purpose of section 8 housing? Based off those purposes for section 8 housing does there need to be accountability of the occupants?

            Focusing on the antecedent concerns of federally funded housing we must initially examine the purpose of offering the housing to the poor (this may sound like a cold question, but I think it’s a necessary one when considering what is the best and most effective use of resources). Is the purpose mainly to provide impoverished people with a permanent and secure form of shelter or a temporary residence in the hopes of putting them back on their feet? If the purpose is providing a semi-permanent form of shelter then I think there should be a time limit, the reasons why I think this way are: others also have a great need for the housing, it only makes sense to create a rotation cycle in order to share the resources so that all can at least have that shelter for some time.
           Furthermore, if the selection process is not based on providing a resource for those most likely to pull themselves out of their situation, then it logically must mean that the selection is more focused on giving the worst off the resource. Therefore the selection is based on a “first come, first serve” process because many meet the “worst off” criteria, which some may argue is a mere application of a band-aid on a much bigger crises. The alternative use for federally funded housing would be for the purpose of those with the desire and best possible chance for pulling themselves out of their situations. If this were the case then there would be no need for a time limit, the emphasis should then be on accountability with goals for employment, bolstering of savings account or the paying off of certain outstanding bills and so on.

Aren't Daoism and Confucianism the Same?

            Both Daoism and Confucianism spawned forth from ancient Chinese practices and beliefs about spirits. The ancient beliefs eventually migrated to Korea and Japan, but we can see the ancient beliefs having there largest impact on China. The ancient beliefs manifest themselves mainly in the form of ancestor worship and the belief that humans are closely connected with the powers of the spirit world. In order to appease and gain favor with the ancestors or spirits one must honor them through rituals and rites. Instruction on how to conduct these ceremonies is found in the texts of the “Li”; one does this either for protection or for favor, the ancestors and spirits can be vindictive when not properly honored or they can reward when pleased. The ancients then went on to develop to more major ideas, the “Shang Ti”, which is the lord of all the ancestors and the “heaven’s gate” or simply “heaven”, the belief that the universe is made up of an impersonal force (Fisher, p 183). The latter concept mentioned influenced one of the more popular and well known beliefs in ancient china, which is called the “Chi”. Chi is the manifestation of the impersonal cosmic force that is in everything; it is made up of two characteristics, the “Yin”, which is dark, receptive, feminine and the “Yang”, bright, assertive and masculine. Many scholars and believers of Daoism and Confucianism take a pluralistic approach to their differences in beliefs. In that they see the contradictory teachings not as two separate teachings, but as two complementary teachings of the Way or Dao.

Contrasts between Daoism and Confucianism:

            After belief in ancestor worship, spirit appeasement, “Shang Ti”, “Heaven’s gate” and Chi had been established by the ancient Chinese two divergent paths of following the ancient traditions began to form. The Dao, which means “the Way”, was first developed by the writings of a sage named Lao Zi, he wrote down 5,000 characters constituting into the “Taote Ching” meaning “the Classic of the Way and its Power” (Fisher, p. 187). This work and many others make up the texts from which the Daoists derive their beliefs, which is a belief that there is no right or wrong only harmony with the Way or natural flow of all things into a unity of oneness. The Way or the Dao cannot be known or understood and it is incredibly elusive, if one thinks he has it he does not or if one is filled with any type of anxiety, happiness, sadness, greed or desire he is not in harmony with the Dao.

            At the same time that Lao Zi was writing the “Taote Ching” there was another philosopher who took seriously the beliefs of the ancients, his name was Confucius. He was born into a time of extreme political turbulence and national chaos, where political leaders were seeking their own gain and advancement. As a young man, Confucius pleaded with political leaders to return to the practices of the “Li” and a lifestyle of virtue, but none would listen to him. Confucius then turned to the youth of the nation and began to teach, his teaching focused around perfecting the world through moral living and political justice and order. He didn’t center his teachings on having mystical harmony with the cosmic forces, he was more concerned with the here and now, that in order to be good one must live morally, honoring relationships (most important the relationship between ruler and subject) and practice filial piety.

References:

Fisher, Mary Pat. (2008). Living Religions. Upper Saddle River, New Jersey: Pearson Education Inc.

            Bockover, Mary I. (October 2007). Metaphors of Self in Confucius and Descartes. Religion East and West, Volume 7, 107-120.

            Poskaite, Loreta. (2003). The Problem of Identity and Difference in Classical Chinese Philosophy. Dialogue and Universalism, 1, 177-197.

            Li, Li. (2007, May 17). Taoism Opens the Way: China Looks to the Wisdom of its Ancient Philosophy to Spread the Message of Harmony. Nation, 28.

            Tsai, PhD., Julius N. (December 2006) Eye on Religion: By the Brush and by the Sword: Daoist Perspectives on the Body, Illness and Healing. Southern Medical Journal, 99, 1452-1453.

Minimum Wage

             There are many opinions today on Minimum wage. Some think it should be raised, others think it should stay the same or be lowered? Whose right? The majority of minimum wage workers are teenagers, for their purposes the rate of compensation is appropriate. However, the main concern is when a person has to work a minimum wage job with a family, they may have to do this for a myriad of reasons: lack of education, little job skills, felony record, drug addiction or any other besetting predicament. The fact that minimum wage is too little to live on is not the problem; the problem is that the cost of living is too high. Personally I would much rather have a lower rent and heating bill every month than an hourly boost in my paycheck. Yet there is a double edged sword to the simply solution to raising the minimum wage.

             A minimum wage increase raises inflation and forces employers to lower the number of hours that can be worked or at worst fire employees. This would remove a family’s only resource albeit a poor one. The fact that families have to pay so much for health care, child care, transportation, and housing is creating a stranglehold on today’s families in America.

            Exploring possible solutions for lowering cost of living I believe is the only solution. This can be done by funding and popularizing public transit. Creating more bus stations with convenient routes coupled with a campaign highlighting “the new and improved” transit system more people would use it. I would also lower the monthly rent for those leasing apartments. These ideas and other innovations of lowering the cost of living will relieve the pressure upon our state’s minimum wage workers.

Ever Wonder if Your Mom was a Double? Part 3

Treatment for Capgras Syndrome

When looking for treatments of Capgras Syndrome, the search yielded little results. Most of the research offered psychodynamic interventions for patients suffering from Capgras Syndrome. The lack of neurological treatment for CS is largely due to the fact that not much is known organically about CS. In the past CS was thought to be purely a psychological issue, therefore explanations and subsequent treatments have been based on psychodynamic theory. Yet there is much debate over etiology, therefore, much research on psychopathology and neuropathology has continued. CS is usually co-morbid with schizophrenia and other mental illnesses. Treatment typically follows a therapeutic regimen of antipsychotic medication and supportive therapy in which areas of cognitive-behavioral strength are used to overcome weaker areas of functioning.  

Evidence is lacking that medications, principally antipsychotics, are effective in treating delusional disorder, yet delusions in the context of another psychotic disorder, such as schizophrenia, may respond better to treatment. It is necessary to note that subtypes of delusional disorder as specified in the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) tend in general to be resistant to treatment. Particularly when assessing geriatric patients with delusions, it is important to consider delirium, dementia, and other organic etiologies underlying the thought disturbance.

Antipsychotics: 1^st Generation

The first-generation diphenylbutylpiperidine agent Pimozide (Orap) has been most closely studied in the context of the broader category of schizophrenia-like disorders but has been suggested by some to be differentially effective in the management of delusional disorder. Again, however, systematic trials are lacking (Manschreck, 2000) and initiation of the use of Pimozide to treat at least one form of delusional disorder (somatic delusions) has been traced to a case report involving no more than 5 patients (Elmer, George, & Peterson, 2000). These authors detailed the numerous adverse side effects associated with Pimozide use, particularly extrapyramidal reactions, the risks of Tardive Dyskinesia, and, notably, cardiac conduction defects. Other authors have not found Pimozide to be an effective agent in management of delusional disorder (Silva et al, 1998). A recent Cochrane review (Sultana & McMonagle, 2000) found that the use of Pimozide did prolong time to relapse in a range of psychotic disorders, including delusional disorder, although with a relatively wide confidence interval.

The cardiac side-effect profile of Pimozide is significant, and the U.S. Food and Drug Administration (FDA) has recently instructed the manufacturers of Pimozide to expand the warning label to reflect the risk of cardiac events (prolongation of the QT interval) when this medication is combined with numerous other compounds. This letter also addresses the risks of using Pimozide in patients with imbalances in serum potassium or magnesium (Food and Drug Administration, 2002). Baseline electrocardiography and special informed consent are recommended prior to its use.

Antipsychotics: 2^nd Generation

DeVane & Mintzer, (2003) reviewed studies which tested the efficacy of the drug Risperidone in a geriatric population with dementia, schizophrenia, delusional disorder, and other psychological and neurological disorder. There were some positive results, yet as Devane and Mintzer pointed out there were several problems with these studies that may invalidate their positive results. Just a few examples of the problems these studies had, the population were on several other drugs, the reductions of symptoms noted in the studies were of aggression and agitation and not of psychotic symptoms. DeVane and Mintzer (2003) did cite one study where adults and elderly patients were given low doses of Risperidone and rated on their improvement. On average, patients with schizophrenia, schizophreniform and delusional disorder were rated by therapists as having improved.

Lee et al. (2004) also did a meta-analysis of the research being done on Second Generation Atypical Antipsychotics, and found mixed results. Some studies showed a superiority of SGA’s to placebo, other studies showed little difference between second and first antipsychotics and others that found positive results. Their conclusion was that the evidence was mixed and in desperate need of further investigation before SGA’s can be recommended as a preferred treatment.

Even though atypical (i.e., second-generation) antipsychotics are increasingly prescribed for delusions or other behavioral or psychological manifestations of dementia and other neurological disease, none are indicated for this condition in the United States. These cautions notwithstanding, a recently published Expert Consensus Guideline for management of delusional disorder in older persons recommended risperidone, 0.75–2.5 mg/day, as the preferred treatment. Olanzapine, 5–10 mg/day, and quetiapine, 50–200 mg/day, were also listed as “high second line” treatments. Clozapine and first-generation antipsychotics were listed as third line treatments (Alexopoulos, Strehm, Carpenter, & Docherty, 2004).

Since SGA’s have low side effects much research has been done on this drug class, yet mostly with elderly populations. This is because elderly patients who have been unsuccessful with other medications have shown positive responses to SGA’s. Yet, SGA’s are not the perfect medication; they do cause weight and increase the risk for diabetes, which are huge risk factors for elderly patients. Their also associated with cardiac conduction problems, sedation, and orthostatic hypotension.

            Psychotropics have been shown not to be an effective medication for treating delusions. Because some patients with severe depression may express delusions (Maina, Albert, Bada, & Bogetto, 2001), and because delusions may have a strikingly obsessive quality to them, some authors have recommended treatment with antidepressants, particularly the selective serotonin reuptake inhibitors. This application, however, has not received systematic review, and the literature is limited to a handful of case studies. In a small case series (n = 4), patients with somatic delusions responded to the antidepressant clomipramine (Wada, Kawakatsu, Nadaoka, Okuyama, & Otani, 1999). As is the case for pharmacological treatment of delusional disorder, systematized studies of nondrug interventions are few. Some authors have presented data suggesting that cognitive-behavioral treatment was efficacious in treating delusions, but much of this is also based on single case studies (Garcelan & Yust, 2000).

Other authors have found that treatment of various psychoses, including delusional  psychosis, with an integrated model utilizing psychological and psychosocial treatments with a minimal medication regimen resulted in outcomes that were equal to or somewhat better than outcomes for patients treated with a standard medication regime. Lehtinen, Aaltonen, Koffert, Raekkoelaeinen, and Syvaelahti (2000) found that provision of an integrated treatment model allowed a much larger percentage of patients (42.9%) to avoid medication after the initial course of treatment. In contrast, only 5.9% of those in standard treatment groups required no medication.

We have only general guidelines to guide the use of psychopharmacology in delusional disorder. Limited data suggest that the disorder is not particularly responsive, and that response is not dose-related. It seems that low dose may be the best route for patients. The few case studies that address combined treatments suggest that patients have more sustained response and require less medication than those treated with drugs alone. There are not, however, standard rules that suggest the most efficacious integrated treatment regimens. Further study of the relative contributions of psychotherapy and medication in managing this challenging disorder are needed. However, it seems that an integrated treatment model have proven to be the most helpful thus far.

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Ever Wonder if You're Mom was Double? Part 2

Search for an Explanation

        What makes CS such an interesting subject for neuroscientists is the fact that CS patients believe that loved ones such as family members, long-time friends, and close co-workers have been replaced. But this delusional belief of doubles or impostors does not extend to those who they have no emotional connection with. In most CS cases the patients do not regard acquaintances, nurses, grocery store clerks or anyone else that they do not have a strong emotional tie with as a double or impostor (Ramachandran, 1998). Furthermore, in most CS case reports, patients believe that they are addressing their actual loved ones or family members when speaking to them on the phone (Yalin et al, 2008; Ramachandran, 1998). This point was further illustrated by a study done by Pick (1903), in which he studied a young man who believed that his mother had been replaced by an impostor when he looked at her. However, “her voice still elicited a strong feeling of familiarity.” This suggests that the cause of CS may be contained to an optical malfunction or lesion in the visual pathway; since patients do not experience any CS symptoms when listening to their loved ones.

        Ellis, Lewis, Moselhy & Young, (2000) and Schweinberger & Burton, (2003) wanted to see if there was any validity to the optical theory. They discovered that individuals with Capgras syndrome do not have any optical impairment. If patients did this finding would explain their inability to recognize family members, friends and co-workers faces. But the research showed that they do recognize faces; however, they lack the ability to match a face that they recognized with the any emotions. “Opposite to the pattern observed in prosopoagnosia, Capgras subjects recognize the structural features of familiar faces but may have impairments in the affective route to face recognition as documented by the SCR hyporesponsiveness”( Brighetti, Bonifacci, Borlimi & Ottaviani, 2007). Ellis et al. and Schweinberger et al. demonstrated that CS patients have no optical malfunctions and that they can recognize loved ones faces normally. CS patients possess the ability of emotional expression and of facial recognition; however, there seems to be a severing in the link between the primary emotional and recognition centers. In his book, “Phantoms in the Brain”, Ramachandran proposes his own theory for CS. He thought there was a neurological disconnection between temporal lobe areas involved with facial recognition, such as the Hippocampus, and the emotional center in the brain, the amygdala. Along with Ramachandran many other neuroscientists are arriving at similar conclusions, that CS has an organic basis in the brain.

        As stated before, investigations into the neurological causation of Capgras Syndrome are a recent phenomenon, taking place within the last forty years. One of the first studies that drew attention to the organic etiology of CS was done by Gluckman in 1968. The woman he studied believed that her husband was an impostor; she was subsequently diagnosed with paranoid Schizophrenia. Gluckman put her through a computerized axial tomography scan and found “severe cerebral atrophy” (Doran, 1990). This study and the growing suspicion of other researchers, that CS has an organic causation, opened the door to further neurological research. Three years later Weston & Whitlock (1971) presented their case of a twenty year old man who underwent severe head trauma and then exhibited symptoms of CS. Weston & Whitlock (1971) described the damage as “frontal lobe syndrome with evidence of bilateral temporoparietal damage, a severe memory defect, and mixed dysphasia along with generalized impairment” (Doran, 1990). They suggested that this damage to the temporal and parietal lobes lead to the patient’s inability to “integrate memory, perception, and affect.” And that these dysfunctions were primary factors in the formation of CS (Doran, 1990).

         Other studies have demonstrated a strong link between CS and physical disorders. In certain cases CS symptoms remitted at the same time that the physical illness remitted (Christodoulou, 1977b).  Further evidence of CS’s organic basis was found by MacCallum (1973). In three out of five cases MacCullum demonstrated the onset of CS as a result of “anoxia, basilar migraine, [and] alcoholic encephalopathy” (Doran, 1990). He also observed that when the physical symptoms were remedied so were the delusional perceptions and beliefs of the patients.  Based on these results, “MacCallum hypothesized that these organic conditions caused a change in the patients' affects and perceptions, which then led to the appearance of the Capgras syndrome. With a remission of the organic condition, affect and perception returned to normal” (Doran, 1990). These findings strongly support the suggestion that CS is caused by organic factors. Other studies have linked CS with “right-sided cerebral dysfunction” (Hayman & Abrams, 1977), which turns the focus of this discussion to current emerging theories of CS.

        Doran (1990) reviewed the current neurological theory on Capgras Syndrome. He pointed out that initial importance is given to the distinction between the reduplication of a person or place. In neurological literature the reduplication of a place is termed “reduplicative paramnesia”; however, within psychiatric literature the reduplication of a person is termed Capgras Syndrome. The common perception is that these reduplicative disorders are one in the same; the only difference between the two is the object of the duplication, a person or a place. Doran went on to say that, “The cerebral localization and mechanism of action could essentially be the same.” Alexander, Stuss & Benson (1979) and Staton, Brumback & Wilson (1982) both had cases in which duplication of a “person” and of a “place” were demonstrated in their patient. Lesions in the right hemisphere have been found to be the primary cause of duplicative symptoms.

        This finding leads to the central thrust of this theory, the right hemisphere. Research of the,

“Right hemisphere lesions may lead to disturbed visuospatial analysis (Paterson & Zangwill, 1944), impaired facial recognition and memory (Hacaen & Angelergues, 1962; Milner, 1968), abnormal sensations of general familiarity andjamais vu (Mullan & Penfield, 1959), and abnormally flat or euphoric disorders (Gainotti, 1972)”(Doran, 1990). Furthermore, the right hemisphere has connections between “facial recognition, visual memory, and feeling and familiarity” (Quinn, 1980; Schraberg & Weitzel, 1979; Synodinou, Christodoulou, & Tzavaros, 1977).

         According to these findings, Alexander (1979) and numerous other researchers concluded that the “right hemisphere is the seat of dysfunction producing the delusional symptom of Capgras” (emphasis in original).  The dysfunctions that occur if the right hemisphere is damaged fit the descriptions of Capgras Syndrome perfectly. Staton (1982) hypothesized that a disconnection occurs between old memory stores and new memory registration. He also suggests this area of damage happens specifically in the “right posterior hippocampus and right temporo-parieto-occipital junction.” Another recent study proposes that the dysfunction is subcortical (Anderson, 1980). Based on this evidence, it is hypothesized that Capgras Syndrome is the result of a disconnect between the “hippocampus and the hypothalamic/amygdala circuit” (Doran, 1990). In other words, a CS patient still recognizes a loved one in every sensory way, but does not recognize them emotionally; due to a disconnection between emotion and memory. This conclusion, again, supports the previous assertion that Capgras Syndrome is the result of an organic disconnection between emotion and memory made by Ramachandran, Ellis (2000), and Schweinberger (2003).