Towards a redefinition of dissociative spectrum dimensions inside Capgras and misidentification syndromes in bipolar disorder: case series and literature review

Introduction: Misidentification phenomena and Capgras Sym- drome (CS) occur in different psychiatric (psychotic or ma- jor affective illnesses) and neurological (traumatic brain injury, epilepsy, neurosyphilis, delirium, migraine, multiple sclerosis,arteriovenous malformation, tumor, stroke and dementia) disor- ders [1]. Patients with CS report that one or more well-known persons (usually familiy members) or even the patient himself have been replaced by a “double” or impostor. This core symp- tomatology may occur within nihilistic delusions of Cotard’s Syn- drome (the delusional perceptions of physical transformation or of not being alive) and can be accompanied by intermetamorphosis, autoscopy, heautoscopy, depersonalization and derealization as well as by erotomanic or jealousy delusions [2]. The aim of this report is to redefine dissociative spectrum dimensions inside CS and misidentification syndromes in patients with Bipolar Disorder (BD).Method: Five inpatients presenting with BD and CS were assessed with the SCID-P for Axis I diagnosis. As regards psy- chopathological evaluation, the patients were also administered the Structured Clinical Interview for Derealization and Depersonaliza- tion Spectrum (SCI-DER), the Depersonalization Severity Scale (DSS) for dissociative spectrum symptoms, the Hamilton Rating Scale for Depression (HRSD) to quantify depressive features as well as the Young Mania Rating Scale (YMRS) to measure manic symptoms. The SCI-DER was developed at the Departments of Psychiatry, Neurobiology, Pharmacology, and Biotechnologies of the University of Pisa by experienced psychiatrists. It includes 49 items exploring “presence” or “absence” of lifetime spontaneous symptoms of DP organized into four domains: (1) Derealization, (2) Somatopsychic depersonalization, (3) Autopsychic depersonal- ization, and (4) Affective depersonalization. All patients received a neurological and general medicine review as well as a first-level brain imaging examination (CT and/or MRI). We conducted a systematic literature review with the principal scientific databases (PubMed, Embase, PsychInfo) using the key terms “Capgras Syndrome” and “Misidentificaition”.Discussion and Conclusion: To our knowledge in the literature there are no studies that evaluated dissociative spectrum symptoms in CS in BD. Our findings suggest that autopsychic and affective depersonalization are the effective dissociative dimensions when CS or misidentification phenomena occur within type-I BD. Disso- ciation and self-concept clarity were strongly correlated providing evidence that they may form a unitary underlying concept of ‘self- concept integration’. This particular condition of identity and self fragmentation, as well as reduction of self clarity, could be the key to shedding light on the interconnection between affective and nonaffective psychotic disorders from schizophrenia to BD, and may underscore the possible validity of the concept of the unitary psychosis (Einheitpsychose) proposed by Griesinger [3−5]. Fur- ther research is warranted to replicate our clinical and qualitative observations and, in general, quantitative studies in large samples followed up over time are needed. Methodological limitations, clinical implications and suggestions for future research directions are considered.References [1] Fishbain D.A., 1987. The frequency of Capgras delusions in psychiatric emergency service. Psychopathology 20:42−47. [2] Salvatore P., Bhuvaneswar C., Tohen M., Khalsa H.M.K., Maggini C., Baldessarini R.J., 2014. Capgras’ Syndrome in first-Episode Psychotic Disorders. Psychopathology 47(4):261−9.[3] Griesinger W., 1882. Mental pathology and therapeutics, in: Griesinger W., Book third, Forms of mental disease, New York, Hafner Pub. Co., p.144–145. [4] Reininghaus U., Priebe S., Bentall R.P., 2013. Testing the psychopa- tology of psychosis: evidence for a general psychosis dimension. Schizophr Bull 39(4):884−95. [5] Kumbier E., Herpeterz S.C., 2010. Helmut Rennert’s universal gen- esis of endogenous psychoses: the historical concept and its signif- icance for today’s discussion on unitary psychosis. Psychopathology 43(6):335−44.