Case Report

John R. MartinelliMSIII, SGUSOMBergen Regional Medical CenterDepartment of Psychiatry

Patient Identification

• Patient L.O.• 50-year-old Hispanic Female.• Resides in Englewood, NJ.• Inpatient at BRMC.

Chief Complaint

• BRMC ED– “My brother-in-law called the police”.

• PESP Outreach Report– Agitation, unable to care for self at times

(unspecified duration), and passive suicidal ideation without plan (unspecified duration) per brother-in-law.

History of Present Illness

• Meningioma of brain 2001– Resection 2002.

• Per collaterals (ex-husband, sister, brother-in-law), px developed odd thoughts and behaviors after her surgery which gradually intensified and increased in frequency.– Mood lability and agitation.– Verbal arguments with family members and children.– Unspecified suicidal ideations.– Odd beliefs.

History of Present Illness

• Multiple psychiatric/psychological evaluations.

• Psychiatric hospitalization in 2006.• Working psychiatric diagnosis made in 2009.• Per collaterals, in 2013 px began to exhibit

rapid and further decline in daily functioning.• Psychiatric hospitalization in 2013.

History of Present Illness

• Continued practicing as dentist.• Poor compliance to therapy.• No history of AH, VH, HI, or suicide attempts.• 3/23/14 Ex-husband witnessed rapid change

in mood, verbal aggression, and unspecified SI.

• 3/24/14 Called px guardian to report incident -> PESP -> BRMC -> Admission.

Current Medication

• Olanzepine (Zyprexa) 20mg– 1 Tab PO QD

Initial Vitals/Lab Results• Vitals

– 5’ 5”, 113lbs– BP: 117/78– Pulse: 72– RR: 18– PulseOx: 98%– T: 98.3

• CBC– WNL

• BMP– WNL

• Utox (-), BAL (-)

Past Psychiatric History

• Evaluated & treatment attempted by several psychiatrists beginning 2002 (NJ & NY).

• Psychotic d/o NOS.• Refuses medical treatment.• Psychiatric admission.– 2006, SI, plan to jump off bridge(Englewood).

Past Psychiatric History• Diagnosed with Capgras Syndrome in 2009 after

evaluation by forensic psychiatrist.• Began treatment and followed on out-patient

basis by NY psychologist in 2013.• Bipolar d/o NOS.• Psychiatric admission.– December 2013, SI, no plan (BRMC).– Court ordered guardian (unable to care for self/$$$).

• Psychiatric admission.– March 2014, SI, no plan (BRMC).

Past Psychiatric History

• Admission March 2014 attributed to continued refusal of medical treatment, decompensation, SI.

• Per collaterals.– Rapid and progressive decline.– Disheveled, unclean living conditions.– Driving unsafe car in unsafe manner with children in car.– Violent language toward sister, (-)HI.– Increasing non-specific SI’s.– Stated to sister and brother-in-law she believed they are

not who they say they are. – “You are no more what you used to be before”.

Past Psychiatric History

• Per legal documents obtained.– NJ dental license suspended due to patient

complaints of bizarre behavior and conversations.– Claimed to NJ dental board patients were

imposters and not her patients (Variations in dental impressions and dental bridges ordered did not fit patients).

– Insurance fraud investigation (Excessive and unnecessary dental impressions of patients then billing insurance).

Past Medical History

• Brain Meningioma (2001).• Resection (2002).• No previous or current medications.• NKDA/NKA.

Social & Family History• Divorced x2 to same individual.• 3 children (13F, 10M, 7M)

– Father/ex-husband with full custody.– Weekend supervised visitation.

• Dentist in NJ/NY with private practice.– 2013 NJ dental license suspended. Currently petitioning board.’– NY dental license current.

• Lives alone in private home.– Foreclosure proceedings pending due to lack of income.

• No history of substance abuse or dependence.• Court appointed legal guardian (2013).• Current litigation (NJ).

Mental Status Examination• Appearance

– Clean & neat, showered, hair pulled back, groomed, hands/nails clean & trimmed, good eye contact

• Musculoskeletal– Strength/Tone: Normal– Gait: Normal– Activity Level: Reading legal documents

• Speech– Normal

• Thought Processes– Coherent

• Thought/Associations– Intact

• Thought Content– (-)SI, (-)HI

• Judgment– Fair

• Insight– Poor

• Orientation– AAOx3

• Memory– Recent/Remote Intact

• Attention/Concent– Intact

• Language– Intact (English/Spanish)

• Knowledge– Current/Past Intact

• Mood– “ I feel good”

• Affect– Appropriate

• MMSE: 30

Biopsychosocial Formulation

• This is a 50yo Hispanic female, divorced, living in Englewood, NJ. H/o brain meningioma with resection (2002), psychotic d/o NOS (2002), Capgras Syndrome (2009). Non-compliant and refusal of medical treatment. History of three in-patient psychiatric admissions (2006, 2013, 2014). PESP outreach (2014) for inability to care for self and unspecified SI.

Biopsychosocial Formulation• Predisposing Factors

– Brain Meningioma & Resection.– Non-compliance to medical treatment.

• Precipitating Factors– Non-compliance to medical treatment.

• Perpetuating Factors– Lost custody of children.– Suspension of dental license, unemployment.– Insurance litigation.– Financial struggles/Foreclosure.

• Protective Factors– Access to healthcare/health insurance.– Px now appears willing to accept help/compliance.– Family support.

• Prognostic Factors– Guarded due to history of poor compliance and medical predisposition.

Diagnostic Impression• AXIS I– Medical/Surgical induced psychotic d/o (Capgras).

• AXIS II– Deferred.

• AXIS III– Brain Meningioma with resection (2002).

• AXIS IV– Loss of child custody, perceived lack of social support,

unemployment, litigation, financial struggles, foreclosure and possible homelessness.

• AXIS V– GAF 25

Treatment Plan

• Restart/Trial Olanzepine (Zyprexa) 20mg– 1 Tab PO QD

• Family Therapy• Group Therapy• Individual Therapy• Milieu Therapy

ResearchFennig S, Naisberg-Fennig S, Bromet E. [Capgras' syndrome with right frontalmeningioma]. Harefuah. 1994 Mar 15;126(6):320-1, 367. Hebrew. PubMed PMID: 8194787.

We present a 43-year-old woman with a right frontal parasagittal meningioma of the brain who developed the delusion that her husband and children had been replaced by doubles (look-alikes). This type of delusion is typical for Capgras' syndrome. After removal of the tumor the delusion disappeared. The majority of such patients are diagnosed as paranoid schizophrenia. However, in the past decade there has been an increasing number of cases in which the etiology is suspected of being organic, involving mainly the right hemisphere. The case presented is unique because it is the first with meningioma as a possible pathogenic factor in the syndrome, as evidenced by the cessation of the delusion when the tumor was removed.

ResearchMadoz-Gúrpide A, Hillers-Rodríguez R. [Capgras delusion: a review of aetiological theories]. Rev Neurol. 2010 Apr 1;50(7):420-30. Review. Spanish. PubMed PMID: 20387212.

According to cognitive models, Capgras syndrome cannot be exclusively conceived as a dysfunction in facial recognition but in recognizing a person globally considered. Feeling of familiarity is absent due to the inability to integrate successive memories about a person along episodic experiences, thus generating delusional doubles in accordance to the patient's needs or drives. From the neuropsychiatry point of view Capgras delusion arises from the failure in reconciling information about identification of the person and its associated emotions by the disconnection between frontal lobes and right temporo-limbic regions (hippocampus), in addition to bilateral frontal damage. Delusions are more commonly associated with right hemisphere lesions because of the impairment of several functions such as self monitoring, reality monitoring, memory and feelings of familiarity as well as the necessary preservation of the left hemisphere.

ResearchOlanzapine in the treatment of Capgras Syndrome: A case reportJulio Torales, Hugo Rodríguez, Andrés Arce, Martín Moreno, Viviana Riego, Emilia Chávez, Marcos Capurro International Journal of Culture and Mental Health Vol. 7, Iss. 2, 2014

•Capgras Syndrome is a delusion characterized by the patient's belief that his or her relatives (or close friends) have been replaced by impostors who have a close resemblance to the originals. Here we describe the clinical picture and the therapeutic approach to a 41-year-old, divorced, Caucasian female with acute delusions and problematic behavior. Treatment with olanzapine was initiated, based on its reported efficacy in the treatment of monosymptomatic hypochondriacal psychosis. Our case shows that treatment with olanzapine can lead to a good clinical outcome with a remission of the psychotic symptoms. In our experience, the starting dose should be as low as possible in order to avoid the occurrence of adverse effects (which are often responsible for the dropout). According to the severity of symptoms and the risk to the patient and family, the patient's admission to an inpatient unit should be considered.