“You’re not my husband.”
“Huh? Yes I am.”
“No, you may look like my husband, but you’re not him.”
“What are you talking about? Of course I’m your husband. See? It’s me?”
“Nope. You’re not him. Now get out of my house.”
Capgras Syndrome, or Imposter Syndrome, is an uncommon phenomenon that occurs in dementia, particularly when the frontal lobe is involved. Although Imposter Syndrome is not a frequent occurence, it is a good idea to be prepared in case it does happen.
I’ve seen Imposter Syndrome happen most often after a hospitalization, usually when there’s been a complicated illness, trauma, anesthesia, or delirium. I’ve also seen it in cases of frontotemporal dementia (FTD), Lewy Body Dementia (LBD), and Alzheimer’s disease. Although it can be very upsetting for the misidentified caregiver, it can be equally upsetting to the patient.
There seems to be a disconnect between the visual cortex (what he/she sees) with the frontal cortex (relationships, emotions). The person can agree with all the basic truths about the person- looks like him, sounds like him, acts like him- but cannot reconcile the feeling “but it’s not him.”
And sometimes the imposter is not a person.
I once knew a woman who had been through a long, arduous hospitalization. When she finally returned home, she seemed nearly back to her baseline level except for some residual weakness and deconditioning. She was delightful, agreeable, and happy to be “home”, although she couldn’t wait to go to her “real home”. Her sense of “home” had an altered reality, and she shared this cautiously with me, revealing only a little bit at a time that she knew about the “hoax”. She calmly explained to me that although the house looked like her house, she believed that it was an exact replica of her “real house”. Her husband, a sweet man who cared for her, was someone who was playing the role of her husband until she could return to her “real husband”. Even as she grew stronger and more independent in her environment, she could not shake the belief that this house was not her home and these people were not her family. Her children and grandchildren came to visit- all very similar to her “real family”- but all imposters.
The one strategy that is least helpful is battling back with logic. Once the delusion is formed in the brain, there is little you can do or say to convince the person otherwise. In fact, your vehement disagreement only further solidifies their convictions- because naturally an imposter would deny it. If you walk into the room and you are suddenly misidentified as an imposter, it’s probably best to just leave the room for a while. Then, hollering in from another room in a cheerful voice, ask if everything is ok. Keep talking as you re-enter the room to help the person anticipate the positive, familiar voice with the person they see. Keep the conversation happy and light-hearted. This soothes the emotional centers in the brain and helps associate the visual cortex with the frontal lobe- like matching what they see with what they feel.
In this woman’s case, I encouraged the family to go for a drive together and visit familiar sites in the community. I had them share positive memories of places and events as they drove past a favorite restaurant, a relative’s home, or a familiar country road. Then as they neared the house, they identified neighbors’ homes and tried to tie memories of their own home into the fabric of the neighborhood. When they pulled up into their own driveway, they looked around at the landscape, the cars, the features of their home- all tied to positive memories and emotions. Then as they entered the house together, they kept the positive, familiar interactions going, and stayed within her visual purview.
This strategy didn’t work 100% the first time, but it did lessen some of the anxiety for the family and the patient each time they did it. Over time the sense of having exactly two copies of the same reality (the original and the replica), started to merge into one. I’m not sure she ever fully reintegrated back into an imposter-free reality… such is the complexity and power of the human mind. But the family felt a little better just understanding the brain dysfunction.