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Delusional misidentification syndromes constitute a number of disorders that involve a myriad of delusions related to the identity of self or other. The forms of delusion range from misattribution of identity related to self, other, as well as parts of the body. Although rare, these syndromes are encountered in a number of different forms by medical and psychiatric personnel, as well as other types of mental health workers. This is especially true since many of the syndromes have organic etiology and are treated via medical rather than psychological intervention. Nevertheless, delusional misidentification syndromes often co-exist with psychiatric issues which can be helped by concurrent psychological treatment. Given that identity is central to human beings and their cultures, it is not surprising that delusional misidentification is represented in a number of cultural beliefs. Some cultural expressions of delusional misidentification may function as coping mechanisms for anxiety over loss of identity or the trauma of infant mortality.
Journal of Health and
Medical Sciences
Volkan, Kevin. (2020), Delusional Misidentification Syndromes: Psychopathology
and Culture. In: Journal of Health and Medical Sciences, Vol.3, No.3, 288-301.
ISSN 2622-7258
DOI: 10.31014/aior.1994.03.03.124
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The Asian Institute of Research
Journal of Health and Medical Sciences
Vol.3, No.3, 2020: 288-301
ISSN 2622-7258
Copyright © The Author(s). All Rights Reserved
DOI: 10.31014/aior.1994.03.03.124
Delusional Misidentification Syndromes:
Psychopathology and Culture
Kevin Volkan1,2
1!Department of Psychology, California State University Channel Islands, Camarillo, CA, USA
2!Graduate Medical Education Program, Community Memorial Health System, Ventura, CA, USA
Correspondence: Kevin Volkan, Department of Psychology, California State University Channel Islands,
Camarillo CA 93012, USA. Tel: +1 805 437 8867. E-mail:
Delusional misidentification syndromes constitute a number of disorders that involve a myriad of delusions related
to the identity of self or other. The forms of delusion range from misattribution of identity related to self, other, as
well as parts of the body. Although rare, these syndromes are encountered in a number of different forms by
medical and psychiatric personnel, as well as other types of mental health workers. This is especially true since
many of the syndromes have organic etiology and are treated via medical rather than psychological intervention.
Nevertheless, delusional misidentification syndromes often co-exist with psychiatric issues which can be helped
by concurrent psychological treatment. Given that identity is central to human beings and their cultures, it is not
surprising that delusional misidentification is represented in a number of cultural beliefs. Some cultural
expressions of delusional misidentification may function as coping mechanisms for anxiety over loss of identity
or the trauma of infant mortality.
Keywords: Capgras Syndrome, Fregoli Delusion, Prosopagnosia, Alien Hand, Body Dysmorphic Disorder
1. Introduction
Psychiatric disorders that are related to the concept of misidentification are labeled together as delusional
misidentification syndromes (DMS) and are somewhat rare. In these syndromes someone, or something, is incorrectly
identified as a person, part of the body, place, or thing. Thoughts and attribution of thoughts are also misidentified, in
many cases to the point of being delusional. Most of these syndromes are more often than not related to organic
abnormalities of the brain, or they may be a combination of organic problems with psychological issues, or in rare
instances, may be purely psychological. Many DMS are often associated with psychoses and have only rarely been
reported in non-psychotic individuals. They are, nevertheless, fairly uncommon, occurring in about 4% of patients
presenting with functional psychoses (Melca et al., 2013).
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2. Capgras Syndrome
This is a misidentification syndrome where a person holds a delusion or belief that an acquaintance, typically a close
family member, has been replaced by an identical looking imposter. This syndrome can be transient, developing very
quickly after a brain injury, or can take a chronic form where the delusion is long standing. The syndrome is named
after the French psychiatrist Joseph Capgras (1873-1950) who first described the disorder in a 1923 paper and used the
term ‘illusion of doubles’ to describe a case of woman who had various doubles that had taken the place of people she
knew. For some people with Capgras syndrome, even inanimate objects such as chairs and animals can be imposters.
Often patients are so disturbed with seeing their doubles that they remove all mirrors from house. In some cases, if the
Capgras sufferer can be convinced that one person is not an imposter, they will transfer the Capgras delusion to someone
else (Sinkman, 2008).
Capgras Syndrome can also be co-morbid with other mental health and medical problems including; Alzheimer’s
disease, Cotard’s syndrome, epilepsy, Farh’s disease, Fregoli delusion, Hashimoto’s hypothyroidism, incubus
syndrome, neurodegenerative disease, Diogenes syndrome, and Parkinson’s disease (Bourget & Whitehurst, 2004;
Ceylan et al., 2010; Chiu, 2009; Donnelly et al., 2008; Fischer et al., 2009; Josephs, 2007; Mishra et al., 2009; Pande,
1981; Rodríguez et al., 2011; Yalin et al., 2008). Capras syndrome has also been associated with the administration of
morphine and ketamine (Bekelman & Hallenbeck, 2006; Corlett et al., 2010) as well as with lithium toxicity (Nagasawa
et al., 2012).
Since the time Capgras syndrome was first described (and even a bit before) a number of theoretical explanations have
been put forth as to its origins. As might be expected many of the early theories were psychoanalytically based. A
comprehensive account of these early conceptualizations of Capgras has been compiled by de Pauw (1994). In this
article de Pauw notes that many of the psychoanalytic explanations are mutually incompatible. These psychoanalytic
theories include; defense against unconscious homosexuality, a regression to the early stage of primary narcissism
(which some writers believe was due to anxiety), and a novel resolution to the Oedipal and (especially) the Electra
complexes. Psychodynamic explanations seemed to make sense because the people being replaced by imposters were
almost always close family members. However, on closer scrutiny of the literature this argument falls apart as other
people or things are often found to also be imposters; including doctors and nurses, as well as entire buildings and other
inanimate objects. In general, according to de Pauw psychoanalytic explanations tend to be “generally post hoc and
teleological in nature, postulating motives that are not introspectable and defense mechanisms that cannot be observed,
measured, or refuted” (p. 158). He concludes that while the presence of brain injury also does not fully explain Capgras
syndrome this may be due to a breakdown in the manner in which sensory information is brought into the brain and the
way it is stored (and presumably retrieved). In another review of the psychoanalytic explanations of Capgras syndrome,
Christodoulou, et. al. (2009) report that Capgras symptoms were originally thought of as psychological defense
mechanisms against repressed desires. These authors also state that the psychoanalytic ideas of projection and splitting
might play a role in Capgras syndrome. A person who is unable to integrate repressed or ‘bad’ aspects of themselves
might project these on to another person who would take on these characteristics in the form of a double. It may be that
mechanisms such as projection and splitting do play a role in DMS. Cerebral pathology may make it difficult for the
sufferer to process information related to the identity of others leading to confusion and possibly the inability to integrate
other people with identity, feelings, and memories. Projection and splitting could then be a defense mechanism that
helps the Capgras sufferer make meaning of their confusion. These ideas deserve further study.
Another issue in the published case literature on Capgras syndrome is the focus on the delusion of the imposter to the
exclusion of other aspects of the syndrome. Closer scrutiny often demonstrates other DMS and psychotic/schizophrenic
symptoms in Capgras syndrome cases. Many patients suffer from a sort of expanded Capgras syndrome where there are
many other delusions present. Some of these delusions may be somatic in nature, with the patient experiencing bizarre
changes to their bodies that can seem strange and alien. Even the patient’s sense of self can change and subject to
delusion. These symptoms are reminiscent of schizophrenia and it is no surprise that some cases of Capgras syndrome
have a co-morbid diagnosis of schizophrenia, usually of the paranoid variety. Upon closer examination it can become
difficult to make a differential diagnosis between Capgras syndrome and schizophrenia in many sufferers. Or the
Capgras symptoms may be another aspect of the schizophrenic illness. In fact, studies have shown that misidentification
symptoms occur in a large number of cases of schizophrenia, maybe even as high as 40% (Sinkman, 2008). Capgras
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patients can be prone to acts of violence, especially against people they have misidentified (Bourget & Whitehurst,
2004). Given the relation of Capgras to paranoid schizophrenia this makes sense.
Modern clinicians and researchers now believe that Capgras syndrome and other DMS have an organic basis, which is
specifically related to cerebral dysfunction. Neuroimaging studies have shown that lesions in the right hemisphere of
the brain are common among Capgras syndrome sufferers. Some studies have demonstrated bilateral damage to the
hemispheres in Capgras syndrome patients (Bourget & Whitehurst, 2004). In one small study 81% of Capgras syndrome
sufferers also had neurodegenerative disease, usually involving the Lewy body. As would be expected, these Capgras
syndrome sufferers were older than Capgras patients without neurodegenerative disease. This latter group were also
more likely to suffer from paranoid schizophrenia, schizoaffective disorder, methamphetamine abuse, or other
cerebrovascular problems. All patients in the study with Capgras syndrome and Lewy body disease also experienced
visual hallucinations (Josephs, 2007).
While structural deficit models of the brain related to Capgras syndrome and other DMS are important, these biological
explanations are not able to extricate the meaning of the specific delusions for DMS patients, and do not explain why
the mind of these individuals creates imposters and doubles (Christodoulou et al., 2009). Therefore, psychological and
cognitive processes remain important lines of research into DMS.
There is evidence to support the idea that an emotional processing module in the brain, especially as it related to feelings
of familiarity and unfamiliarity, and its connection to facial recognition is flawed in Capgras sufferers (Pacherie, 2009).
This flaw in emotional processing can be demonstrated via facial recognition tasks and eye movement patterns (Brighetti
et al., 2007; Grignon & Trottier, 2005; Walther et al., 2010). Similar differences in audio perceptions related to working
memory have also been reported for Capgras syndrome sufferers (Papageorgiou et al., 2002). In one dramatic case a
Capgras syndrome patient had sexual relations with his wife, thinking she was a ‘double’. He had no feelings of
familiarity with his wife whatsoever and essentially felt as if he were having sex with a different woman; so much so
that he even changed his sexual behavior. The authors (Antérion et al., 2008) note that this may be the only known
documentation of a patient who was able to make his wife into his mistress!
Some researchers believe that DMS results from a breakdown of the cognitive process of identification, in which a small
discrepancy in input of stimuli results in misidentification and a denial the other’s true identity. Other researchers
characterize a two-factor model in which an abnormality prompts a delusional belief. A second abnormality prevents
the sufferer from rejecting this delusional belief even in the presence of strong evidence to the contrary. It may be that
the initial delusions come about when the DMS sufferer attempts to explain their odd abnormal perceptions
(Christodoulou et al., 2009).
As might be expected the typical treatment for Capgras syndrome is anti-psychotic medications. However, when anti-
psychotic medication is only partially effective or not effective, the use of electroconvulsive therapy has been shown to
be helpful. This is especially the case when Capgras syndrome is co-morbid with Parkinson’s Disease (Chiu, 2009).
3. Fregoli Delusion
Another, related misidentification syndrome is Fregoli delusion. This syndrome is named after the Italian actor Leopoldo
Fregoli, who often changed appearances and identities during his performances. This type of delusion occurs when a
person believes that a number of different people are actually one person who has the ability to change their appearance.
The different people are usually familiar and are often considered to be hostile or persecutory to the Fregoli sufferer.
This delusion is often thought of as a variant of Capgras syndrome and it seems the underlying neuropathology is similar,
usually involving lesions to the right hemisphere of the brain. It has been difficult however, to clearly trace the delusional
misidentification directly to the organic pathology since the syndrome is so often comorbid with psychotic disorders
(Mojtabai, 1994; Novakovic et al., 2010).
In addition to psychoses, Fregoli delusion has been associated with a number of other disorders. Bruggemann and Garlip
(2007) report a case of erotomania combined with Fregoli delusion in a 24-year-old woman. This woman believed a
colleague who was the target of her erotomania, appeared as other people. While they did not find any overt pathology,
they did note EEG differences in the right temporal lobe. This woman, as is typical for people with Fregoli syndrome,
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also suffered from psychotic symptoms such as imagining she had become pregnant by her colleague and that she was
his fiancée. She was treated via psychotherapy and neuroleptic medication, which lessened her symptoms. When the
patient stopped taking her medication her psychotic symptoms returned. The authors conclude that the Fregoli delusion
was secondary to paranoid schizophrenia. Fregoli delusion has also been associated with bipolar schizoaffective disorder
and Hashimoto thyroiditis (Ceylan et al., 2010).
Melca et. al. (2012) describe two patients with Capgras syndrome and Fregoli delusion who also suffered from treatment
resistant obsessive-compulsive disorder (OCD). One of the two patients also was diagnosed with paranoid personality
disorder while the other with pervasive developmental disorder. Both patients in the study exhibited varying amounts
of insight related to their OCD. The authors speculate that there may be a relationship between OCD and DMS.
Fregoli delusion has also been associated with violent behavior. Delavenne & Garcia (2011) report on a case of a
paranoid schizophrenic woman who was convinced that a boyfriend was able to appear as other people so he could
follow her. This patient had an episode of violent behavior associated with her Fregoli delusion. She had stopped taking
her anti-psychotic medication six months prior to her violent outburst. Facial recognition tests and a CT scan of her
brain revealed no abnormalities. Even though she was put back on anti-psychotic medication, her delusions returned
after 10 days.
4. Variants of Delusional Misidentification Disorder
One research study has reported that Capgras syndrome, Fregoli delusion, and psychoses can be distinguished from one
another by observing facial recognition reaction times. Patients suffering from DMS took longer to perform facial
recognition tasks than psychotic patients, with Fregoli patients taking longer than Capgras patients. This may indicate
differences in underlying pathology among psychotic, Capgras, and Fregoli disorders (Walther et al., 2010). However,
facial processing does not explain why there are various subtypes of DMS, why the subject of a delusional
misidentification is visually identified correctly, and why some DMS patients report having multiple doubles
(Christodoulou et al., 2009). Young (2010) compared patients with DMS with other non-delusional facial recognition
disorders. He concluded that the patients’ experience is an important factor in the genesis and maintenance of the DMS.
Some writers, notably Christodoulou, view DMS as consisting of four subtypes: Capgras syndrome, Fregoli delusion,
intermetamorphosis syndrome, and subjective doubles syndrome. As stated above, Capgras syndrome involves the
delusion that someone close to the sufferer has been replaced by a double. Fregoli delusion involves the sufferer having
the delusion that a familiar person, who is typically hostile or persecutory, is taking on the forms of strangers.
Intermetamorphosis syndrome is where the sufferer believes a familiar person has become a stranger (like in Fregoli
delusion) but this stranger is also physically and psychologically similar to the familiar person, interchanging with them.
Finally, subjective doubles syndrome is where a person has the delusion that other people are physically transforming
into them (Christodoulou et al., 2009; Christodoulou et al., 1995; Christodoulou, 1986; Shah, 2012; Young, 2010).
Another way, perhaps to look at these is as two subtypes, with intermetamorphosis being a variant of Fregoli delusion
and subjective doubles syndrome being a variant of Capgras syndrome (where the familiar person being replaced is
5. Prosopagnosia
Prosopagnosia is the official term for face blindness, a disorder in which a person is unable to recognize the faces of
others. This is a neurological condition that is not related to other syndromes or illnesses and can be caused by injury to
the brain or congenital abnormalities of the brain (Van Belle et al., 2011; Van den Stock et al., 2012). The condition
derives from a dysfunction in the medial cerebral hemisphere, more specifically the fusiform gyrus area of the temporal
lobe in Brodmann area 37. Disruption in nerve pathways in this region lead to problems of face recognition, while the
ability to recognize of other aspects of people and things, as well as cognitive and emotional processing, remains intact.
The lack of facial recognition may be related to an inability to perceive emotions from facial stimuli. The mechanism
by which faces are not recognized may be related to a lack of emotion when the person with prosopagnosia sees the face
of someone they know. This may lead to the perception that the person isn’t who they appear to be, and in this sense,
the person is misidentified.
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People with prosopagnosia are thought to compensate for the inability to recognize faces by using other cues, such as
parts or of the body, or characteristics such as movement, almost anything except visualizing the face. One research
study indicates that auditory cues such as voice recognition may be an important way in which people with
prosopagnosia recognize others (Hoover et al., 2010).
6. Alien Hand Syndrome
Alien hand syndrome is where the hand or arm of a person seems to have a life of its own. It is a neurological problem,
but it is intertwined with psychological constructs such as will (Sacco & Calabrese, 2010). It is a rare condition that
usually turns up after a stroke, though it can also result from other trauma to the area of the brain which controls limb
function when neurological messages somehow get scrambled in meaning.
There are some variations of alien hand syndrome, but all types are thought to be related to lesions in the medial frontal
lobe, the corpus callosum and the parietal areas of the brain. Alien hand syndrome has also been seen in patients with
neurodegenerative diseases involving corticobasal degeneration (e.g. prion-disease) and may be a precursor to the
expression of neurodegeneration (Sacco & Calabrese, 2010).
Patients suffering from alien hand syndrome experience their hand as being controlled by external forces and are often
astonished and frustrated by the errant hand (Biran & Chatterjee, 2004). A typical clinical presentation of the syndrome
is as follows:
Two weeks after stroke onset, the patient started to present involuntary and intermittent movements of the right
arm, irregular in speed and usually with a slow onset. Also, levitation of the right arm occurred. She did not
always seem aware of the problem. Her right hand frequently stroked the bed, but she never looked at it or
attempted to intervene to stop the movements. The patient failed to recognize the affected limb as her own,
personifying it and expressing the idea that it was under someone else’s control.” (Bartolo et al., 2011,p. 484)
It has been postulated that three factors contribute to the sense of alien-ness of the affected limb; 1. There is disinhibition
of the affected limb and it is disproportionately reactive to environmental stimuli; 2. The limb is under less volitional
control by the sufferer and engages in perseverative, stereotyped movements which are linked together; 3. The sufferer
is cognitively intact to the level where they are aware that the movements are abnormal (Biran et al., 2006).
There is no known cure, but alien hand syndrome tends to disappear after a few weeks or months. This usually coincides
with the fading of the stroke trauma. The estimated prevalence of alien hand syndrome could be as much as one out of
100 among stroke patients (Nowak et al., 2014).
The idea of the alien hand has made a few appearances in popular culture. The film The Hands of Orlac (Gréville, 1961)
which was later released under the title The Hands of a Strangler, tells the story of a famous concert pianist who sufferers
horrendous injuries to his hands in a car accident. Fortunately, new hands are able to be successfully transplanted
allowing the pianist to resume his career. However, unbeknownst to the pianist, his new hands were taken from an
executed murderer. The new hands seem to have a will of their own which manifests as a desire to strangle people to
Biran and Chatterjee (2004) point out an excellent example of alien hand syndrome in the film Dr. Strangelove or: How
I Learned to Stop Worrying and Love the Bomb (Kubrick, 1964). In the film the main character Dr. Strangelove,
brilliantly played by Peter Sellers, has a right hand that seems to have a mind of its own. Strangelove’s hand sometimes
tries to choke him by grasping his throat and other times involuntarily giving a Nazi salute. During these episodes
Strangelove does his best to restrain his right hand with his left one.
Lastly, it would be remiss not to mention the television show The Addams Family (The Addams Family, 1964) and the
later film remake (Sonnenfeld, 1991). The television show and the film depict an eccentric, if not, goth-like family that
includes “Thing” who is a hand. Thing is fully autonomous and mysteriously animated appendage with a will of his
own who seems to have done away with the need of body.
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7. Cotard’s Syndrome
Cotard’s syndrome is another rare syndrome possibly related to misidentification. Debruyne et. al. (Debruyne, 2017;
Debruyne et al., 2013; Debruyne et al., 2013) have published a number of excellent reviews of Cotard’s syndrome which
are summarized here. In this syndrome, which was first described by Jules Cotard in 1880, a person has the delusion
that they somehow, in all or part, do not exist. This manifests as the person believing they are dead, or have lost their
soul, or no longer have any organs, etc. Cotard initially characterized the disorder as consisting of anxious melancholia
related to ideas of damnation or rejection, insensitivity to pain, delusions of bodily non-existence and immortality.
Cotard’s syndrome is not included in the DSM V as a specific diagnosis. This is due to its rarity and its conceptualization
under other disorders typically schizophrenic delusions and depression. There has not been systematic scientific
research done on the syndrome with most of the literature consisting of case studies which may or may not include
neuroimaging. One of the rare scientific studies done in the modern era used data reduction techniques to analyze 100
cases of Cotard’s Syndrome. This resulted in three types of syndromes related to Cotard’s syndrome. The first type
consists of psychotic depression with features of anxiety, melancholia, delusions of guilt, and auditory hallucinations.
The second type called Cotard’s type I was associated with hypochondriacal and nihilistic delusions in the absence of
clinical depression. The third type, Cotard’s type II includes anxiety, depression, auditory hallucinations, nihilistic
delusions, delusions of immortality, and suicidal behaviors (Berrios & Luque, 1995). Prevalence rates for Cotard’s
syndrome are difficult to determine because of diagnostic overlap with other disorders. A study in China of older adults
with psychiatric issues found an overall prevalence rate of 0.57%, However, when only severely depressed older adults
were examined the prevalence rate jumped to 3.2%. In the study cited above by Berrios and Luque (1995), the mean
age of Cotard’s patients was 52, however, the disorder has been found in people of all ages, including in rare instances,
adolescents and children. Women seem to suffer from the disorder more than men.
Sahoo and Josephs (2017) report that Cotard’s syndrome has been associated with a number of other morbidities with
uni-polar and bi-polar depression being the most common, followed by psychosis. Other psychiatric disorders associated
with Cotard’s syndrome include voluntary starvation, hydrophobia, lycanthropy, and folie a’ deux (shared psychotic
disorder). A number of organic conditions have also been associated with Cotard’s syndrome. These include dementia,
developmental disability, typhoid fever, stroke, superior sagittal sinus thrombosis, brain tumors, Capgras syndrome,
cerebral arteriovenous malformation, various types of epilepsy, migraine, multiple sclerosis, Parkinson’s disease, brain
injury, etc. The authors examined 14 patients with Cotard’s syndrome and found it to be associated with frontal lobe
volume and blood supply loss, and right-side and bi-lateral hemisphere lesions. Research on Cotard’s syndrome has not
definitively found a cause for the disorder but has generated some plausible theories as to its etiology.
Treatment for Cotard’s syndrome can include both psychological and medical modalities, though the psychiatric
treatments are more prevalent, psychotherapy, including behavior therapy, is also used with Cotard’s syndrome patients.
Psychiatric medications for Cotard’s syndrome include antipsychotics, sometimes in combination with SSRI
antidepressants (Chan et al., 2009; Moschopoulos et al., 2016) Electroconvulsive therapy (ECT) has been used
successfully for Cotard’s syndrome. This is especially true for type I Cotard’s syndrome, while for type II antipsychotic
medication is the preferred treatment (Madani & Sabbe, 2007). The above treatment regimens appear to have good
With regard to expressions of Cotard’s syndrome-like aspects in popular culture, there are many examples. Probably
the most obvious would be people who consider themselves to vampires, werewolves or zombies. The cultural
representations of this in literature, film, and television are too numerous to list.
8. Body Dysmorphic Disorder
It is also possible to understand some other syndromes as being related to DMS. For instance, body dysmorphic disorder
is where a person has the delusion that a limb or limbs, or other parts of the body do not belong to them.
Estimates of up about 2% of the population may suffer from BDD, while the prevalence may be higher among college
students and clinical populations at around 5%. Outpatient psychiatric populations have been estimated to be 5.8% while
In specific incidences BDD has been labelled apotemnophilia, body integrity disorder, and xenomelia. These terms have been used
somewhat interchangeably in the research literature.
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inpatient psychiatric populations could be as high as 7.4% (Hong et al., 2019). However, it seems safe to assume that
more extreme cases, for instance where a person makes an attempt to amputate a limb, are far fewer. BDD is now
included in the DSM V as a diagnostic category where it is defined as the alteration or removal of a body part because
it is thought by the sufferer to be somehow abnormal. Many people with this disorder report that amputation of the body
part makes them feel whole or complete. In some cases, the person with BDD has a wish or compulsion to live as an
amputee or a disabled person (American Psychiatric Association, 2013). The first scientific study of the disorder
occurred in 2005 when First and Fischer studied 52 subjects and were able to report some more specific characteristics
of the disorder. Among the findings were that most individuals with the condition are men, there is a preference for
amputation on the left side, and a preference for amputation of legs rather than arms (First & Fisher, 2011).
It is not known if BDD has an organic etiology, or if it is psychological, or both. Sedda and Bottini (2014) give an
excellent review of 37 years of studies which includes both psychological and neurological approaches to the disorder.
Early psychological approaches to understanding BDD examined sexual motives and concluded that the disorder
represented a paraphilia. Explanations for BDD included ideas such as;
1. Body modification is a way for bisexual subjects to preserve their masculinity
2. The fear of losing a limb transmutes to an impulse to amputate so that a person can feel superior
3. A desire for amputation is a learned response reinforced by a rehearsal of experiences with images of
4. A desire for amputation can be an eroticized hatred of the mother figure
5. A desire for amputation is a learned response in childhood from seeing someone with crutches or an amputation
getting attention and being happy
6. Body modification is related to a psychotic disturbance where the person is told by voices to remove a limb.
First and Fischer believed that apotemnophilia (an older term denoting the severe urge to amputate a limb) should not
be included in BDD because the individuals in their study did not perceive a defect in the limb they wanted to amputate
and did not complain about its appearance. They felt that sexual motivations in apotemnophilia were secondary and that
the disorder was more akin to gender dysphoria, where the sufferer identifies as a person without the limb. The authors
proposed the use of the term body integrity identity disorder to capture the nuances of the disorder. Other researchers
argued that the sexual aspects of the disorder were more relevant than identity issues (De Preester, 2013). Sedda and
Bottini (2014) characterize the psychological literature succinctly:
“In summary, psychological/psychiatric explanations for the desire to amputate a healthy limb include two main
hypotheses: a sexual compulsion, belonging to the paraphilic core, and an identity disturbance, paralleling gender
identity disorder. At present, no new psychological/psychiatric explanations have been proposed.” (p.1259)
Brang, McGeoch, and Ramachandran (2008) make the case that the specific form of BDD known as apotemnophilia is
neurological disorder. They found that two patients with apotemnophilia had heightened skin conductance in limbs
below where they wish to have an amputation. They concluded that this arises from a congenital dysfunction in the right
superior parietal lobe and its connection to the insula. This area of the brain “receives and integrates input from various
sensory areas and the insula to form a coherent sense of body image” (p. 1306). Indeed, there seems to be a trend in
understanding BDD to be a neurologic disease, however, there have only been a limited number of studies with
inconsistent methodology, so it the issue is far from settled (Sedda & Bottini, 2014).
Treatment for BDD runs the gamut of psychological and psychiatric solutions. With regard to psychotherapeutic
treatments cognitive behavior therapy (CBT) seems to be the most common modality and is generally thought to be
effective in treating BDD (Rasmussen et al., 2017). However, a number of authors state that CBT is not effective for
everyone suffering from BDD (Hong et al., 2019; Weingarden et al., 2019).
One recent study found the electroconvulsive therapy was effective in eradicating the symptoms of BDD (Başgül et al.,
A German study found there were a number of barriers to treatment. These included a lack of perceived need for
treatment, shame, younger age, and a preference for cosmetic and medical treatment over psychiatric treatment. The
authors also found a number of characteristics associated with BDD including high BDD symptom severity, poor patient
insight into their condition, a previous suicide attempt related to patient appearance, a co-morbid eating disorder, and
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current major depressive disorder. Interestingly, the majority of subjects in this study were female and their appearance
concerns included a wide range of areas in decreasing order of prevalence skin, nose, hair, breasts, mouth, genitals,
eyes, muscularity, hands, legs, ears, stomach, buttocks, and other facial features. The authors state that there are effective
treatments for BDD and advocate for a stepped treatment model that first provides information about the condition and
its prevention followed by online CBT, smartphone treatment apps, or specialized face-to-face treatments (Schulte et
al., 2020).
An Iranian study using single-subject methodology found that CBT improved patient’s BDD symptoms as well co-
morbid depression and disability (Abbarin et al., 2018). A case study of a single adolescent female patient found that
intensive CBT and exposure/response prevention reduced levels of general anxiety and increased functioning (Neziroglu
et al., 2018).
Greenberg et. al. (2019) found that greater readiness/motivation to change, greater treatment expectancy, better baseline
BDD related insight, significantly predicted better outcomes with CBT among BDD patients.
Wilhelm et. al. (2019) compared CBT to supportive psychotherapy and found that both therapeutic modalities were
effective in treating BDD, but that CBT had greater efficacy. Another small (n=10) 12-week study by the same group
examined the use of smartphone based Cognitive Behavioral Therapy (CBT) for the treatment of BDD. The results
indicated that this modality of CBT resulted in good response 90 days post treatment with measures of BDD severity
decreasing along with improvement of in BDD insight, functional impairment, and quality of life (Wilhelm et al., 2020).
Another study using internet-based CBT reported good outcomes in treating BDD patients as well (La Lima, 2018).
Weingarden et. al. (2019) studied the use of d-cycloserine augmented CBT in patients with BDD in a small clinical trial.
The authors were looking for a way to enhance standard CBT which they reported as not always being effective with
BDD. They found that CBT augmented with d-cycloserine significantly reduced BDD related stress.
A neurological-oriented treatment study found the BDD subjects had abnormal amygdalatemporal connectivity at rest
compared to healthy controls as measured by MRI. The administration of intranasal oxytocin was found to reverse
resting state abnormality (Grace et al., 2019).
Hong et. al. (2019) writes that BDD is typically treated using CBT and pharmacotherapies, but these are not always
effective. The authors review current pharmacotherapies which include anti-depressants, fluoxetine, and suggest that
novel treatments such as intranasal oxytocin, atypical antipsychotics and neuromodulation treatments such as
transcranial magnetic stimulation hold promise for treating BDD.
Other novel psychotherapy treatments have been suggested for BDD patients but have not yet been implemented.
Scandiffio (2018), studied the feasibility of using two Japanese forms of psychotherapy Morita therapy and Naikan
therapy for treating BDD sufferers using a manualized approach. He had five experts judge whether the use of these
therapeutic modalities alone or as an adjunct to CBT would be beneficial. The judges tended to think these therapies
could be beneficial.
BDD is a dramatic disorder that has been subject to being sensationalized. For instance, The Jerry Springer Show aired
an episode titled “I’m Happy I Cut Off My Legson November 2, 2006 (, n.d.)
. In this episode a transsexual
woman named Sandra describes in detail how she amputated both of her legs. Sandra describes how from an early age
her legs just didn’t feel right and that after she amputated them (using a handheld electric saw) she felt relieved as if a
weight was lifted from her. To make the show even more sensational Springer has Sandra confront a man who was born
without legs who berates her for being ungrateful for having legs to begin with. What Sandra describes is a textbook
example of BDD. It is too bad that the show didn’t explore her transition from being a man to a woman, since gender
dysphoria is considered to be a separate diagnosis from BDD, and Sandra would be the rare case where it might be
possible to study the intersection of both syndromes. The Jerry Springer Show aired an update with Sandra on January
17, 2007 in which she re-enacted the amputation of her legs from her trailer home.
Unfortunately, the official site of the Jerry Springer Show (Videos - The Jerry Springer Show, n.d.) doesn’t keep episodes this old on the
site. In order to see this episode, it is necessary to search where it can usually be found posted.
Asian Institute of Research Journal of Health and Medical Sciences Vol.3, No.3, 2020
9. Neuro-Psychoanalysis and Delusional Misidentification Disorders
While organic disturbances may cause delusional syndromes, the delusions themselves may play a role in repairing a
damaged ego or sense of self. Freud (1924) believed that delusions served this function and were a compromise when
some aspect of external reality overwhelms the ego’s ability to function in it. The delusion puts a sort of band-aid over
the inability of the ego to deal with external reality. However, reality continues to try to manifest itself so the delusion
must be constantly renewed in a defensive fashion. This idea fits well with the neuropathology of DMS. The damage to
brain function is the external reality and the delusion works as the defense against the impairment.
Neuroscientists, as outlined previously, have identified a relationship between focal brain damage and various delusional
misidentification syndromes. The abnormal beliefs that people with these syndromes present is typically interpreted
using a cognitive psychological framework. While cognitive interpretations can account for the formation of false
beliefs, they are not satisfactory for explaining bizarre and persistent delusional states and why these states are resistant
to being challenged. The newly emerging field of neuro-psychoanalysis is now attempting to understand why this is so.
In many (but not all) cases of delusional misidentification, patients demonstrate some level of pathology in their self-
awareness as well as regression to immature styles of thinking and defense mechanisms. It is thought that delusional
patients that do not suffer this regression possibly have more cognitive reserves (Venneri & Shanks, 2010).
Brain abnormalities in the right medial-frontal and orbitofrontal regions result in ego-disequilibrium which in turn
causes problems with ego boundaries and the inability of the ego to observe its own processes (Feinberg, 2010, 2011).
This presents as difficulties in patients not knowing themselves and also, presumably, not knowing where they end, and
others begin. Feinberg has proposed a four-tiered hierarchical model of delusional neuropathologies. This model begins
with first level cognitive deficits which then lead to second level self-related deficits. The self-related deficits in turn
lead to various primitive level defenses which include denial, projection, splitting and dissociation. This third level then
results in the fourth level which are the presence of various delusional syndromes including delusional misidentification
disorders (Feinberg, 2010). This model fits quite well with DMS, especially Capras syndrome, Cottard’s syndrome, and
Fregoli delusion where recognition of self and others are problematic. Disorders such as prosopagnosia would seem to
spare regions of the brain that are related to ego-function and in disorders such as alien hand syndrome self/no self-
confusion is mostly time-limited. In BDD, especially the apotemnophilia variety, sense of self/not self appears to be
disrupted. Ego splitting has been also been noted (Thess, 2014). Dissociation of the body-self, as well as the parts of the
body, from the ego points to the possibility of object relations pathology (Sarasohn, 2002).
It is not surprising to discover that insight oriented psychodynamic psychotherapy that challenges delusional beliefs
systems exacerbates negative transference and emotional withdrawal of the patient. A more relational approach,
addressing early object relations, as well as addressing super ego issues related to body hating and how these are enacted
in the transference are possible successful psychoanalytic therapeutic approaches (Lemma, 2009; Thess, 2014).
10. Delusional Misidentification and Popular Culture
Appearances of DMS in popular and traditional cultural expressions are extensive. For the sake of brevity only a few
are examined here. One of the best examples of a sort of Fregoli delusion which is central to the film Being John
Malkovich (Jonze, 1999). In this film there is a tunnel in a strange half floor of an office building. Travel through this
tunnel allows people to experience ‘being’ the actor John Malkovich for a short time. Later in the film, John Malkovich
himself discovers the existence of the tunnel and goes through it. When he emerges everyone else is a version of
Malkovich, with his face and everything they say coming out as the word Malkovich.
Science fiction has been an especially fruitful ground for the emergence of modern stories related to imposters
masquerading as humans. This can be seen most readily in stories about robots or androids. In many cases these stories
revolve around the ‘imposters’ wanting to become human, or being indistinguishable from humans, as in the Phillip K.
Dick story Do Androids Dream of Electric Sheep? (1968/1996), which was made into the movie Blade Runner (Scott,
1982), or the Isaac Asimov Robot series (1982) which has had a number of film adaptations including most recently the
film I Robot (Proyas, 2004). In these modern portrayals, humans are generally anxious about the imposter status of the
robots and androids as well as being paranoid about their intentions. It is possible that the popularity of the imposters
among us theme relates to a subconscious fear of misidentification in general and loss of identity in particular.
Asian Institute of Research Journal of Health and Medical Sciences Vol.3, No.3, 2020
An older instance of DMS can be found primarily in the British Isles. In times past British or Celtic babies were
sometimes thought to be kidnapped by fairies and replaced by identical looking children. The replacement children,
called changelings, were often sickly and exhibited abnormal behavior.
Evans (2000) describes the Irish belief in changelings that is typical of the British Isles;
“Mothers and babies were thought to be especially liable to be abducted by the fairies, and protective charms
were hidden in a baby's dress or placed in the cradle. When children were taken to be baptized, too, special
preparations were made and precautions taken, for example, a County Antrim clergyman reported that his
parishioners would place a piece of bread and cheese in the child's clothing.
The old custom of dressing boys in girls' clothes, in long frocks, until they were ten or eleven years of age has been
explained as a means of deceiving the fairies, who were always on the lookout for healthy young boys whom they
could replace by feeble ‘changelings’.
For the same reason it is unwise to praise a child without adding a saving ‘God bless him’, and young boys are
still half jocularly referred to as ‘rogues and Tories’.
The belief in ‘changelings’ may have arisen as an explanation of the high mortality rate among baby boys as
compared with girls.” (p. 289)
Indeed, changeling legends may be related to high infant mortality rates in general. When an infant becomes sick and
dies for no apparent reason, the human mind will seek an explanation for such a tragic event. If no logical reason can
be found the human mind invents a reason that can provide meaning to the tragedy and lessen its sting. There is always
a chance the original child can be returned by the fairies, or the thought the original child is being raised by the fairies
and has been given special powers can be of comfort to the grieving parents. The death of a child is so difficult to accept
that the trauma must be repaired with a delusion. In this case, the imposter delusion keeps the child alive
11. Conclusion
Even though DMS are rare, they present with diverse forms that include delusion, cognitive deficits, and
misidentification related to problems confusing and distinguishing between self and other. DMS primarily have an
organic basis and therefore the primary modes of treatment for the disorders are medical. Nevertheless, brain
abnormalities found in many DMS do give rise to psychological issues. Addressing these psychological issues may help
people suffering from DMS better deal with disturbances in brain function. A number of psychological treatment
modalities show promise in being able to accomplish this. The many instances of DMS-related cultural phenomena
remind us that perhaps some level of delusion and misidentification is part of the human condition, serving to defend us
from loss of identity and our mortality.
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Background: Although effective treatments are available, most individuals with body dysmorphic disorder (BDD) do not receive an appropriate diagnosis or treatment. We aimed to examine treatment utilization and barriers to treatment, and to identify associated socio-demographic and clinical characteristics. Methods: German individuals completed an online self-report survey of appearance concerns. A sample of N = 429 individuals met criteria for BDD. We examined the frequency of treatment utilization and barriers, analyzed comparisons between treated and untreated individuals and assessed the relationships of socio-demographic and clinical features with mental health treatment utilization and treatment barriers, respectively. Results: Only 15.2% of the individuals with BDD had been diagnosed with BDD, and lifetime rates of mental health treatment were low (39.9%). Individuals endorsed multiple barriers to mental health treatment, especially shame, low perceived need and a preference for cosmetic and medical treatments. Associated features were identified, including age, a BDD diagnosis, body dysmorphic symptom severity, a likely major depressive disorder, prior cosmetic surgery, and insight. Conclusions: The results of this largest study to date highlight that BDD is still underrecognized and undertreated even in a country with extensive mental health care and few financial barriers. We discuss modifiable factors and strategies to foster awareness of BDD in sufferers and professionals to improve treatment dissemination and to reduce treatment barriers.
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Body dysmorphic disorder (BDD) has a severe presentation and chronic course when untreated. Although effective BDD treatments exist, most individuals do not have access to them. We therefore developed and pilot tested the first smartphone-delivered individual cognitive-behavioral therapy (CBT) treatment for adults with BDD. The digital service was developed via user-centered design, integrating input from engineering, design, and psychology experts, plus BDD patient consultants. We conducted a 12-week open pilot trial (N = 10) to describe preliminary results for feasibility, acceptability, and treatment outcome. Attrition rates (0%) and feedback on usability and satisfaction indicated that smartphone-based CBT for BDD may be feasible, acceptable, and satisfactory. Initial results suggest that smartphone-based CBT for BDD may hold promise for improving BDD symptom severity, BDD-related insight, functional impairment, and quality of life, as scores from baseline to posttreatment improved with large-to-very large effects; depression improved with a medium effect. Ninety percent of participants were responders at posttreatment and 3-month follow-up. Smartphone-based CBT for BDD may have strong potential as a standardized, low cost, and accessible treatment for this debilitating illness. A test of efficacy is merited as a next step, using a well-powered, randomized control trial design.
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Cognitive behavioral therapy (CBT) is the leading psychotherapeutic treatment for body dysmorphic disorder (BDD), yet not all patients improve. To address the treatment response gap, CBT may be augmented with cognitive enhancers such as d-cycloserine (DCS). DCS-augmented behavior therapy has been tested with mixed results in related disorders. To initially test whether DCS may augment CBT for BDD, we conducted the first preliminary efficacy trial of DCS versus placebo-augmented CBT for BDD, via a randomized, double-blind study. We analyzed data using mixed-effects models in a modified intent-to-treat sample (N = 26). Over 10 weeks of treatment, primary (BDD severity) and secondary (insight, depression) outcomes improved significantly across both conditions, but there were no significant group differences in response. Exploratory analysis revealed that BDD-related distress, specifically, reduced significantly more in the DCS condition compared to placebo. This is the first study testing DCS-augmented CBT for BDD. Implications, limitations, and future directions are discussed. Trial registry: Identifier NCT00842309
Our case report is on the use of electroconvulsive treatment (ECT) in an adolescent with Bipolar Disorder (BPD), Substance Use Disorder (SUD) and comorbid Body Dysmorphic Disorder (BDD). In our case, ECT was not considered at the first stage, but we encountered medication noncompliance and treatment resistance. Symptoms of body dysmorphic disorder completely disappeared after ECT, which is consistent with the literature. ECT is a treatment with a low side effect profile in treatment-resistant cases. In addition, it will be useful to increase the knowledge and experience of clinicians on ECT and to provide conditions for ECT in child and adolescent psychiatric clinics.
The aetiology of body dysmorphic disorder (BDD) is poorly understood. Recent evidence from functional brain imaging studies suggests that BDD is associated with aberrant task-based functional connectivity and that intranasal oxytocin (OXT) may improve network connectivity in BDD patients. Thus, the aim of this study was to investigate the effect of intranasal OXT on amygdala resting-state functional connectivity (rsFC) in BDD. In a randomized, double-blind, cross-over design, 19 BDD participants and 17 demographically matched healthy control participants received intranasal OXT (24 IU) or placebo prior to resting-state functional magnetic resonance imaging. The left and right amygdala were seeded as regions of interest, and temporal correlations between the amygdalae and all other voxels comprising cortical and subcortical grey matter were investigated. Compared to healthy controls, BDD patients showed greater baseline (placebo) rsFC between the left amygdala and two clusters within the left temporal lobe and one cluster within the superior frontal gyrus which was reversed following OXT administration. The control group also showed significantly greater rsFC between the left amygdala and anterior prefrontal cortex in the OXT session compared to placebo. Whilst preliminary, these findings suggest that BDD patients exhibit abnormal amygdala-temporal connectivity at rest, and OXT might have a role in changing this functional relationship.
Importance Cognitive behavioral therapy (CBT), the best-studied treatment for body dysmorphic disorder (BDD), has to date not been compared with therapist-delivered supportive psychotherapy, the most commonly received psychosocial treatment for BDD. Objective To determine whether CBT for BDD (CBT-BDD) is superior to supportive psychotherapy in reducing BDD symptom severity and associated BDD-related insight, depressive symptoms, functional impairment, and quality of life, and whether these effects are durable. Design, Setting, and Participants This randomized clinical trial conducted at Massachusetts General Hospital and Rhode Island Hospital recruited adults with BDD between October 24, 2011, and July 7, 2016. Participants (n = 120) were randomized to the CBT-BDD arm (n = 61) or the supportive psychotherapy arm (n = 59). Weekly treatments were administered at either hospital for 24 weeks, followed by 3- and 6-month follow-up assessments. Measures were administered by blinded independent raters. Intention-to-treat statistical analyses were performed from February 9, 2017, to September 22, 2018. Interventions Cognitive behavioral therapy for BDD, a modular skills–based treatment, addresses the unique symptoms of the disorder. Supportive psychotherapy is a nondirective therapy that emphasizes the therapeutic relationship and self-esteem; supportive psychotherapy was enhanced with BDD-specific psychoeducation and treatment rationale. Main Outcomes and Measures The primary outcome was BDD symptom severity measured by the change in score on the Yale-Brown Obsessive-Compulsive Scale Modified for BDD from baseline to end of treatment. Secondary outcomes were the associated symptoms and these were assessed using the Brown Assessment of Beliefs Scale, Beck Depression Inventory–Second Edition, Sheehan Disability Scale, and Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form. Results Of the 120 participants, 92 (76.7%) were women, with a mean (SD) age of 34.0 (13.1) years. The difference in effectiveness between CBT-BDD and supportive psychotherapy was site specific: at 1 site, no difference was detected (estimated mean [SE] slopes, –18.6 [1.9] vs –16.7 [1.9]; P = .48; d growth-modeling analysis change, –0.25), whereas at the other site, CBT-BDD led to greater reductions in BDD symptom severity, compared with supportive psychotherapy (estimated mean [SE] slopes, –18.6 [2.2] vs –7.6 [2.0]; P < .001; d growth-modeling analysis change, –1.36). No posttreatment symptom changes were observed throughout the 6 -months of follow-up (all slope P ≥ .10). Conclusions and Relevance Body dysmorphic disorder severity and associated symptoms appeared to improve with both CBT-BDD and supportive psychotherapy, although CBT-BDD was associated with more consistent improvement in symptom severity and quality of life. Trial Registration identifier: NCT01453439
Body dysmorphic disorder (BDD) is a common and distressing or impairing preoccupation with a perceived defect in physical appearance. Individuals with BDD engage in time-consuming rituals to check, hide, or “fix” their appearance or alleviate distress. BDD is associated with substantial psychosocial impairment and high rates of depression, hospitalization, and suicidality. Cognitive-behavioral therapy (CBT) is the treatment of choice for BDD, but not everyone benefits. We examined predictors of CBT-related improvement, an important topic that has received very limited investigation. Treatment was delivered in weekly individual sessions over 18–22 weeks. Results indicated that greater motivation/readiness to change (University of Rhode Island Change Assessment Questionnaire), greater treatment expectancy (Treatment Credibility/Expectancy Questionnaire), and better baseline BDD-related insight (Brown Assessment of Beliefs Scale) significantly predicted better CBT response at posttreatment. Baseline BDD symptom severity and depression did not predict outcome, suggesting that even patients with more severe BDD and depressive symptoms can benefit from CBT for BDD. Efforts should be aimed at enhancing readiness to change and confidence in the treatment at treatment onset as well as addressing the poor insight that often characterizes BDD.
Body dysmorphic disorder affects 2.4% of the U.S. adult population, with the most common age of onset between 12 and 13 years. However, research in the area of adolescent BDD is minimal. This case study describes the intensive approach of treatment used for a 14-year-old female diagnosed with BDD. Treatment included an individualized course of cognitive behavioral therapy and exposure and response prevention. BDD symptoms decreased after 27 full-day sessions in an outpatient clinic. In addition, general levels of anxiety decreased and level of functioning increased. Tailoring standard treatments and utilizing developmentally appropriate techniques were significant factors for the adolescent’s success. Implications for future research and treatment are discussed.
Body dysmorphic disorder is a challenging disorder that manifests as erroneously perceived flaws in one's physical appearance and repetitive behaviors in response to appearance concerns. This disorder is also frequently comorbid with other psychiatric disorders, including major depressive disorder and autism spectrum disorder. It is currently understood to arise from a combination of biological, psychological, and environmental factors. Treatment of body dysmorphic disorder typically consists of a combination of pharmacotherapy and cognitive behavioral therapy. However, not all patients respond to treatment, and BDD symptoms remain even in those who do respond. This review outlines current pharmacological and neuromodulation treatments for body dysmorphic disorder, and suggests directions for future studies of novel treatments such as augmentation with atypical antipsychotics and the use of intranasal oxytocin in cases of body dysmorphic disorder that show residual symptomatology even with tailored monotherapy. There is emerging evidence suggesting that non-invasive neurostimulatory techniques, such as repetitive transcranial magnetic stimulation, may be of value in treatment-resistant cases.