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: 1st 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: 2nd 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.
References
Alexopoulos, G. S., Strehm, J., Carpenter, D., & Docherty, J. P. ( 2004). The expert consensus guideline series: Using antipsychotic agents in older patients. Journal of Clinical Psychiatry, 65, (Suppl.2) 1– 41.
American Diabetes Association, et al. ( 2004). Consensus development conference on antipsychotic drugs and obesity and diabetes. Journal of Clinical Psychiatry, 65, 267– 272.
American Psychiatric Association. ( 1994). Diagnostic and statistical manual of mental disorders ( 4th ed.). Washington, DC: Author.
Alexander, M.P., Stuss, D.T., & Benson, D.F. (1979). Capgras's syndrome: A reduplicative phenomenon, Neurology, 29, 334-339.
Anderson, J.R. (1980). Cognitive psychology and its implications, San Francisco: W.H. Freeman.
Bekelman, D. B., & Hallenbeck, J. (2006). Capgras syndrome associated with morphine treatment, Journal of Palliative Medicine, 9, 810-813.
Berson, R. (1983). Capgras syndrome, American Journal of Psychiatry, 140, 969-978.
Berrios, G. E., Luque, R. (1995). Cotard’s syndrome: analysis of 100 cases, Acta
Psychiatr Scand, 91, 185-8.
Bourget, D., Whitehurst, L. (2004). Capgras syndrome: a review of the neurophysiological correlates and presenting clinical features in cases involving physical violence, Can J Psychiatry, 49, 719-25.
Brighetti, G., Bonifacci, P., Borlimi, R., & Ottaviani, C. (2007). ‘‘Far from the heart far from the eye’’: Evidence from the Capgras delusion, Cognitive Neuropsychiatry, 12, 189-197.
Christodoulou, G.N. (1977b). Treatment of the syndrome of doubles, Acta Psychiatrica Belgique, 77, 254-259.
DeVane, C. L., & Mintzer, J. ( 2003). Risperidone in the management of psychiatric and neurodegenerative disease in the elderly: An update. Psychopharmacology Bulletin, 31, 116– 132.
Doran, J. M. (1990). The Capgras syndrome: Neurological/neuropsychological perspectives, Neuropsychology, 4, 29-42.
Elmer, K. B., George, R. M., & Peterson, K. ( 2000). Therapeutic update: Use of Risperidone for the treatment of monosymptomatic hypochondriacal psychosis. Journal of the American Academy of Dermatology, 43, 683– 686.
Ellis, H. D., Lewis, M. B., Moselhy, H., & Young, A. W. (2000). Automatic without autonomic responses to familiar faces: Differential components of implicit face recognition in a case of Capgras delusion, Cognitive Neuropsychiatry, 5, 255 -269.
Enoch, D., Ball, H. (2001). Uncommon psychiatric syndromes, 4th edn. London : Arnold , 1–19.
Fialkov, M. J. and Robins, A. H. (1978). An unusual case of the Capgras syndrome, British Journal of Psychiatry, 132, 403-404.
Food and Drug Administration. ( 2002, Nov. 22). Letter to Teva Pharmaceuticals. Retrieved February 7, 2005, from www.fda.gov/cder/foi/appletter/2002/17473slr038ltr.pdf
Garcelan, S. P., & Yust, C. C. ( 2000). Effectiveness of individual cognitive-behavioural therapy applied to psychotic symptoms: Review of single case experimental designs applied to the treatment of delusional beliefs. Psychology in Spain, 4, 3– 12.
Gainotti, G. (1972). Emotional behavior and hemispheric side of the lesion, Cortex, 8, 41-55.
Gluckman, I.K. (1968). A case of Capgras syndrome, Australian and New Zealand Journal of Psychiatry, 2, 39-43.
Hacaen, H., & Angelergues, R. (1962). Agnosia for faces (prosopagnosia), Archives of Neurology, 7, 92-100.
Hayman, M.K., & Abrams, R. (1977). Capgras syndrome and cerebral dysfunction, British Journal of Psychiatry, 130, 68-71.
Koritar, E., & Steiner, W. (1988). Capgras syndrome: A synthesis of various viewpoints, Canadian Journal of Psychiatry, 33, 62-66.
Lee, P. E., Gill, S. S., Freedman, M., Bronskill, S. E., Hillmer, M. P., & Rochon, P. A. (2004). Atypical antipsychotic drugs in the treatment of behavioral and psychological symptoms of dementia:Systematic review. British Medical Journal, 329, 75– 78.
Lehtinen, V., Aaltonen, J., Koffert, T., Rakekkoelaeinen, V., & Syvaelahti, E. ( 2000). Two year outcome in first-episode psychosis treated according to an integrated model: Is immediate neuroleptization always needed?European Psychiatry, 15, 312– 320.
MacCallum, W. A.G. (1973). Capgras syndrome with an organic basis, British Journal of Psychiatry, 123, 639-642.
Manschreck, T. C. ( 2000). Delusional disorder and shared psychotic disorder. In B. J.Sadock & V. A.Sadock, Comprehensive textbook of psychiatry ( 7th ed., (pp. 1243– 1264). Baltimore: Williams & Wilkins.
Maina, G., Albert, U., Bada, A., & Bogetto, F. ( 2001). Occurrence and clinical correlates of psychiatric co-morbidity in delusional disorder. European Psychiatry, 16, 222– 228.
Milner, B. (1968). Visual recognition and recall after right temporal lobe excision in man,
Neuropsychologia, 6, 191-209.
Mullan, S., & Penfield, W. (1959). Illusions of comaprative interpretation and emotion, Archives of Neurology and Psychiatry, 81, 269-284.
Nejad A.G., Toofani K. (2006). A variant of Capgras syndrome with delusional conviction of inanimate doubles in a patient with grandmal epilepsy, Acta Neuropsychiatrica, 18, 52–54.
Paterson, A., & Zangwill, O.L. (1944). Disorders of visual spatial perception associated with lesions of the right cerebral hemisphere, Brain, 67, 331-358.
Pick, A. (1903). Zur pathologie des bekanntheitsgefu¨ hls (Bekanntheitsqualita¨ t), Neurol Centralblatt, 22, 2–7.
Ramachandran, V. S., & Blakeslee, S. (1998). Phantoms in the brain, Quill, 158-173.
Quinn, D. (1981). The Capgras syndrome: Two case reports and a review, Canadian Journal of Psychiatry, 26, 126-129.
Sautter, S. W., & Farkas, L. B. K. (1991). A neuropsychological profile of Capgras syndrome, Neuropsychology, 5, 139-150.
Schraberg, D., & Weitzel, W.D. (1979). Prosopagnosia and the Capgras syndrome, Journal of Clinical Psychiatry, 40, 313-316.
Schweinberger, R., & Burton , M. (2003). Covert recognition and the neural system for face processing, Cortex, 39, 9-30.
Sinkman, A. (2008). The syndrome of Capgras, Psychiatry, 71,371-378.
Silva, H., Jerez, S., Ramirez, A., Renteria, P., Aravena, N., Salazar, D., & LaBarca, R. ( 1998). Effects of pimozide on the psychopathology of delusional disorder. Progress in Neuropsychopharmacology and Biological Psychiatry, 22, 331– 340.
Staton, R.D., Brumback, R.A., & Wilson, H. (1982). Reduplicative paramnesia: A disconnection syndrome of memory, Cortex, 18, 23-36.
Stewart, J. T. (2004) Capgras syndrome related to diazepam treatment, Southern Medical Journal, 97, p65-66.
Sultana, A., & McMonagle, T. ( 2000). Pimozide for schizophrenia or related psychoses. In Cochrane Database of Systematic Reviews, 2000: Vol. 2Retrieved from www.cochran.org
Synodinou, C., Christodoulou, G.N., & Tzavaros, A. (1977). Capgras' syndrome and prosopagnosia, British Journal of Psychiatry, 132, 413-414.
Wada, T., Kawakatsu, S., Nadaoka, T., Okuyama, N., & Otani, K. (1999). Clomipramine treatment of delusional disorder, somatic type. International Clinical Psychopharmacology, 14, 181– 183.
Weston, M.J., & Whitlock, F.A. (1971). The Capgras syndrome following head injury, British Journal of Psychiatry, 119, 25-31.
Yalin, S., Varol Tas, F., Guvenir, T. (2008). The coexistence of Capgras, Fregoli and Cotard’s syndromes in an adolescent case, Archives of Neuropsychiatry, 45, 149-151.
No comments:
Post a Comment