Is Capgras A Delusion Or Is It Just Another Form Of Perception?

Despite the terminology of Capgras Delusion and Imposter Syndrome I propose that the experience of a loved one as a double is a symptom of greater psychosis or a reasonable response to the incomprehensible distancing from a familiar someone they have a close relationship to. (Bortolotti, 2005:191, Colheart et al, 2011:280, Davies et al, 2001:136, Pacherie, 2008:105, Ratcliffe, 2008:139). I will argue that terming this particular experience as a delusion or a syndrome is inaccurate in many instances and could be limiting our understanding of the experience. By focusing on a single type of experience that is considered to be a delusion, I will explore whether the scope of healthy, non-delusional perception is wider than currently clinically accepted, and the reasons certain experiences have been medicalised in the first place.

I have used medical terminology such as patient to aid the reading of the essay, rather than to necessarily argue that I think those experiencing Capgras -whether it be a delusion in all cases or not- are sill and their behaviour and thoughts should be medicalised. I have used the term subject throughout to refer to the person the patient is perceiving as an imposter. If a wife is seeing her husband as a double, the wife is the patient and the husband is the subject. I use the term affective to describe the emotions and feelings, or lack thereof, most often in reference to the patient, in accordance with Pacherie s terminology (Pacherie, 2008:105).

There are many conflicting definitions of the term delusion from within both the realm of philosophical literature and the diagnostic usage within the psychiatric field. Defining delusion plays a key role in the diagnostic process, Coltheart et al outline three belief properties they examine patients for in order to determine whether or not they are delusional. These are (a) impossibility or falsity, (b) incorrigibility, and (c) unwarranted subjective certainty. (Coltheart et al., 2011, 281) From a philosophical standpoint (a) is epistemically challenging, especially when it comes to specific types of delusion such as Capgras. These are almost identical to the DSM V criteria for delusion.

According to the latest edition of the Diagnostic and Statistical Manual of Mental Disorders, delusion can be defined as: the possession of false beliefs incorrect inferences about external reality and problems with incontrovertible and obvious proof or evidence to the contrary . (Leeser and O Donohue, 1999:687) With this, we can see if the psychiatric approach could help the development of the philosophical ideas and vice versa.

To explore these ideas further I will look at Davies, Coltheart, Langdon, and Breen s categorisation of delusions as being either monothematic or polythematic (Davies et al., 2001:133-154). I will also be looking at Pacherie s binary terminology of circumscribed compared to elaborated kinds of delusion and whether or not firstly, Capgras can fit into one of these categories, and secondly, whether or not doing so is useful.

Firstly, I will demonstrate how the Two-Factor Account proposed by Martin Davies et al (Davies et al, 2001:133-154), provides an explanation of how the second-factor can be understood as a route from experience to delusional belief. Secondly, I will examine the differences between Elisabeth Pacherie s endorsement and explanationist models to account for various kinds of delusion.

To explore the question What is Delusion? it is first necessary to make some preliminary distinctions between delusions of different kinds. Monothematic delusions, as described by Coltheart et al, are present when the patient exhibits just a single delusional belief or else a small set of delusional beliefs that are all related to a single theme. (Coltheart et al., 2011, 271). The most common delusional themes are persecution and self-referentiality persecutory delusions revolve around the belief that one is in danger or under threat from others (Coltheart et al., 2011, 277), whereas referential delusions involve beliefs that unrelated objects, people or events, have significant personal connection (Coltheart et al., 2011:277).

On the other hand, in the case of polythematic delusions, the patient exhibits delusional beliefs about a variety of topics that are unrelated to each other (Coltheart et al., 2011:271). Themes more associated with polythematic delusions involve control, passivity, or loss-of-boundary delusions (Coltheart et al., 2011:278). Those affected by boundary delusions might believe that: thoughts are being inserted into or withdrawn from their mind thoughts are being broadcast for other to access that others can read their minds and/or they are being influenced and controlled by an external alien force (Coltheart et al., 2011:278).

Furthermore, Bortolotti differentiates between circumscribed and elaborated delusions: They [delusions] are circumscribed if the content of the delusional states does not affect significantly the other beliefs and the behaviour of the subject. [Monothematic] delusions can be elaborated, if the subject draws consequences from her delusional states and forms other beliefs that revolve around the theme of delusion. This distinction applies to both monothematic and polythematic delusions, but in general polythematic delusions tend to be elaborated rather than circumscribed. (Bortolotti, 2005:191) So, it appears that a sufficient definition of delusion must allow for both circumscribed and elaborated delusions. However, as the essay progresses, I suggest that circumscribed instances of the Capgras delusion, should not be considered to be delusion at all.

Moreover, we rely on such things as our already formed beliefs based upon our a priori experience of the world to explain how we perceive things, as well as leaning from the experiences of others, and from a posteriori speculation. One way in which beliefs can be confirmed is via the approval of others and how they too experience the world around them. For those who experience Capgras delusion and are therefore convinced that their nearest and dearest have been swapped with an imposter, they outright refuse one of these methods of belief confirmation their personal experience of the immediate state of the world causes them to refuse previous reason, or directly oppose what they believe to be reasonable, because their affective response to their loved one has changed so dramatically. I first need to explore what is considered perception, and why Capgras should or should not be categorised in the same way. If Capgras can fit into a definition of perception, why is it important that it is not labelled a delusion, and what could this mean for other delusions and other disorders currently on the psychiatric spectrum.

I have opted to not explore the aetiology of the Capgras delusion in great depth because the organic factors alone are neither necessary [n]or sufficient to explain the particular and peculiar content of the delusion (Enoch and Ball, 2001:10).

Capgras is described by Enoch and Ball as a delusional belief and not a disorder of perception (Enoch and Ball, 2001:1). I want to challenge this based on how we categorise beliefs and perception in the first place. Perhaps beliefs and perception are not so at odds with one another and could in fact be one and the same when considered in a certain way. Jacques Vie...termed Capgras Syndrome as the illusion of negative doubles , whereby there is a perception of non-existent differences resulting in a negation of identities (Enoch and Ball, 2001:2). My concern with this particular definition is the use of non-existent . If this is all a discussion of perception, these differences are existent for the perceiver, so they must be non-existent in a metaphysical way. However, we are not discussing the metaphysics of the matter, but rather the epistemological implications of viewing delusion in this way and making assumptions as a result.

All of the initial cases of Capgras delusion -from 1923 up until 1936- were attributed to females. (Enoch and Ball, 2001:3) This makes me think that Capgras is more socio-political than only psychological perhaps it was women s way to reason in a world that treated them as unthinking, unreasonable beings. Why is Capgras so beyond the realm of possibility in comparison to other issues women faced at the time. I think we may be able to learn a lot about the syndrome based on the fact that it is primarily diagnosed in women (Buchanan, 1993:127)

Could this be supported by the fact that the first reported case -Murray 1936- of a man suffering the syndrome occurred in a homosexual male. (Enoch and Ball, 2001:3). Could also fit the Wagner (1966) case, of a young woman recently jilted by a medical student (Enoch and Ball, 2001:3). The blame lies on those who are historically and politically considered lesser. Could Capgras developed as a way of silencing those people that wider society, or those accused of being imposters just did not want to hear. After all, hysteria used to be considered a psychiatric affliction, but through a modern lens, it is viewed as social ignorance. But, before it is possible to fully explore these issues, it is first necessary to examine whether or no Capgras is really a delusion in the full psychiatric sense, or whether it is a convenient way of filing away a potentially intuitive response to strange happenings surrounding the patient.

Christadoulou, on the other hand, regarded Capgras as a hypoidentification (Enoch and Ball, 2001:2). This terminology creates more problems than it solves. Could hypoidentification suggest that there is a aspect of identifying Capgras that is lacking, or underdeveloped. This raises the question of whether Capgras patients are added to their experience by creating new identities and imposters, having additional affective responses in addition to old ones leading to a disjunct and confusion between the two. Or is it better understood as lacking a previous ability to recognise and identify their loved ones. I think that those with Capgras fit better into the second category here there is something lacking in their ability to produce appropriate (for them) affective responses to faces they recognise as familiar. Those with Capgras do not conjure up an imposter, but rather they lose a loved one, and can only rationalise this disappearance with an imposter having replaced them. After all, the person is still physically there, they have not disappeared, but the usual affective responses of the patient have disappeared.

However, Christadoulou also suggests that if we consider Capgras to be a symptom of another co-morbid disorder, it has been seen to respond to treatment if we treat the underlying psychosis with anti-psychotic medication, the Capgras symptom tends to dissipate and disappear entirely (Enoch and Ball, 2001:16). It seems to be medically more useful to not view Capgras as a delusion in and of itself, and perhaps this can be helpful when understanding Capgras philosophically. Perhaps Capgras alone if not an error in the patient s belief system, nor in her ability to recognise and identify faces, it could be a reasonable response to the patient s wider change in perception.

Enoch and Ball present three cases of Capgras delusion in Uncommon Psychiatric syndromes in which we can see the manifestation of this delusional belief in the actions of those whom experience it. Based on the cases presented, Enoch and Ball describe Capgras as having the following features: it is nearly always co-morbid there is inconclusive evidence of an organically occurring aetiology and the majority of cases occur as a feature of either functional or affective psychosis (Enoch and Ball, 2001:7). It also seems as though Capgras forms as a defensive response to difficult circumstances in the patient s life. In Case 1, the patient concludes that his increasingly emotionally distant wife, must be an imposter. Perhaps an easier rationale than concluding his marriage was falling apart (Enoch and Ball, 2001:5). Secondly, the patient in Case 2, responded to her husband s ambivalence to her romantic and sexual advances with the development of Capgras delusion. (Enoch and Ball, 2001:6). Finally, Enoch and Ball mention a case of a man developing Capgras after his mother refused to exhume the body of his recently deceased father and another patient started to believe his brother was an imposter after the death of the patient s wife (Enoch and Ball, 2001:7). The question here is whether Capgras is directly caused by these instances of emotional strain or weather they just occur alongside it. In all these occurrences of the Capgras delusion, the patient reasons their feelings to avoid dealing with rejection. Perhaps we consider those with Capgras delusion to lack sanity because of a history of mental illness or based on Capgras delusion alone.

It is also important to note that misidentification in Capgras is persistently regarding the same person, or the main double - usually the most prominent person in the patients lives. However, the misidentification can spread to other people with whom the patient is closely involved (Enoch and Ball, 2001:8). This seems to highlight the importance of the patient s emotional involvement and closeness to the imposter. Enoch and Ball also raise the question of whether or not the nature of belief the same in both normal, or healthy, and pathological populations. If anything, those with Capgras seem to at least create logically sound inferences from their unusual experiences, which is not necessarily the case for the majority of the so-called normal or healthy population. It could be seen that the Capgras delusion is improving the patient s knowledge of their personal world perhaps this delusion is not only a defence mechanism but is a way of processing newly gained knowledge. It is perception and knowledge entwined. If we know someone has a history or criminal activity, do we ascribe certain harsh characteristics to their features, just as if we are aware that someone is grieving, do we see them through a lens of sympathy.

Capgras becomes a way for those experiencing ambivalence from an object of their affection, to rationalise the hatred received by the object they are projecting their love onto. It could be argued that Capgras enables the patient to perceive the world at a deeper level to their egoless colleagues. Courbon and Fail described Capgras as a disorder of coenaesthesia (Courbon, P. and Fail, G. (1927) Bull Soc Cli Med Ment 15, 121.) in (Enoch and Ball, 2001:13)), whereby the patients become acutely aware of their ego contrary to normal occurrence. It stands to reason that as a result of this acute awareness of oneself, any suggestion of ambivalence or dislike towards the patient would become magnified as a direct attack on their ego. Enoch and Ball claim that this hypersensitivity of the ego occurs in healthy persons during times of exhaustion (Enoch and Ball, 2001:13). But cannot it be understood that a husband whose advances of affection have repeatedly been rejected by his beloved wife would have grown exhausted. Is raises the question that the persistence and length of the experience categorises is as a state of delusion or not.

However, as in the cases I will present and explore show, the Capgras delusion has varying lengths of persistence is 23 hours too short, but one day long enough. This tentative categorisation should not be an adequate guideline for categorising one s experience of perception as delusion or healthy.

The greatest issue with Capgras is the clear splitting of the object of hatred and affection into two distinct people. On the one hand, there is the object of old affection, but on the other hand there is an imposter who is the manifestation of all the harboured resentment the patient feels for the person they also adore. Is it this inability to rationalise and reason these two distinct emotions that lead to a splitting. Is it not reasonable to suggest that this is quite a natural response, do not we all have a splitting of some sort when we are jilted or betrayed there is the person whom you trust and love, but another side of them that you detest. This is clearly very different from the development of a second person entirely though. Therefore, arguably Capgras is an extreme response to otherwise normal circumstances, which could tempt us to categorise Capgras as a delusion.

In regard to the nosology -or classification- of Capgras, it has long been debated whether it is a syndrome in and of itself, or a symptom or a wider diagnosis. (Enoch and Ball, 2001:15) I would like to initially suggest that it is neither a syndrome nor a symptom, but it is a rational response to an unusual affective experience. People react in a plethora or different ways to difficult situations, are we in danger of pathologising potential normal behaviour and reactions. Not only could it be medically incorrect to term Capgras a delusion, but potentially damaging to the autonomy of many people. It is not clear as to why this specific unusual reaction is a medical issue whilst many other potentially peculiar actions and reactions are not.

Regarding treatments for Capgras, reported cases have frequently responded to the treatment of the underlying condition, as opposed to the Capgras directly. Treating the underlying disorders -such as psychotic or depressive disorders- often eliminate the Capgras symptoms. Capgras could be termed as merely a symptom of other disorders rather than a delusion itself (Enoch and Ball, 2001:16). Moreover, treatment of the Capgras symptom requires the object of the misperception to co-operate and gain insight and understanding of their partner s (etc) condition (Enoch and Ball, 2001:16). This alone should negate the notion that Capgras is a delusion, a problem of the patient. If the treatment involves other people surrounding the patient, and not just the patient herself changing their behaviour. This suggests that the patient does not necessarily have a perception issue, in fact they are effectively navigating complex emotional issues brought about by miscommunications and ascribing different meanings to perceived behaviours in their partners, rather than in themselves.

Another reason to throw out the labelling of Capgras as a delusion is that Capgras has corresponding diagnoses in the clinical setting, However, Capgras does not necessarily follow the course of the corresponding psychosis and can begin before the onset of psychosis and persist after it s disappearance (Enoch and Ball, 2001:17). Although this seems as though it would cause problems for my assertion that Capgras delusion is a symptom, because why would a symptom persist when the underlying cause of said symptom in this case the primary psychosis is no longer present. However, symptoms often onset prior to the presentation of the illness in its entirety. Even the common cold beings to display symptoms before the virus can be detected, and they can remain, long after the virus can still be detected. This could be the same for Capgras and any underlying psychoses.

Another central issue in Capgras delusion, raises the question of the patient s clarity of perception and sanity. The problem we face is that patients rarely exhibit an attempt to distance themselves from or report this supposed imposter in their home they continue to think that they are a double, a replacement, of their loved one, whilst failing to act upon the strange scenario. Those cases where Capgras patients have been violent or acted out towards their so-called imposter, have been attributed to the other existing psychosis or psychoses present at the time. Buchanan highlights one case of the Capgras delusion that would align more with the elaborated types of delusion which I will explore later on in the essay, but perhaps is not a case of Capgras at all. The case is described as: a 57-year-old woman who pointed a loaded gun at two meter readers believing that one of them was a homosexual who had been impersonating her by wearing a mask since he was eight. He had acted like a prostitute and sullied her reputation (Buchanan, 1993:127). I disagree here with Buchanan s categorisation of this woman as suffering from Capgras as there is a lack of intimacy in the relationship between the patient and the subject. Moreover, this patient believes that she herself has been replaced by an imposter, which goes against the categorisations of the Capgras delusion we have seen so far.

Many questions are raised when viewing such a different (potential) manifestation of the Capgras delusion. Perhaps Capgras can manifest in various ways in different patients violent vs non-violent, action provoking vs not. We do not have a clear picture of which attributes are Capgras, and which are other disorders. I hope to provide some clarity to this and offer some distinctions between delusion and perception throughout this essay.

It appears that any peculiar actions that arise in Capgras patients can be more closely linked to another underlying psychotic condition, as Capgras is not monothematic. In recent more studies, Capgras has been described as not monothematic : We identified 84 individuals and extracted diagnosis-matched comparison groups. Capgras was not monothematic in the majority of cases (Bell et al.,2017:183). This supports my suggestion that the 57-year-old woman who exhibited violent tendencies was not only, if at all, suffering from Capgras delusion. On the whole, Capgras delusion is persecutory, but not action-based. Most patients do not act upon their peculiar experiences, and it is hard to find a case where patients have been violent. Therefore, those instances where patients exhibit violent tendencies or outbursts and more likely to be attributed to other psychotic conditions present in addition to Capgras or instead of it.

Bortolotti provides great insight into the Capgras delusion in particular, especially from a philosophical viewpoint. Without a pre-prescribed notion of what rationality is, it can be argued that delusions cannot be said to be irrational. Only with a rationality constraint , can certain beliefs be deemed to lack rationality and thereby be considered as delusional beliefs. The rationality constraint (RC), deems that one must be rational in order for beliefs to be attributed to them (Bortolotti, 2005:189). The question here, is whether or not a rational belief might still be considered a delusional belief. With the case of Capgras delusion, patients are arguably having a rational response to a strange phenomenon that they are experiencing if the patient is no longer having an affective response to a familiar person, could believing that the person is not themselves a rational belief. One issue encountered with rationality in the Capgras delusion is the actions many patients take as a result of their belief that an imposter is impersonating their kin. Would a rational person not call the police, would someone with intact rationality lay next to the man they belief has replaced their husband. This hardly seems the response of a rational being. The rationality constraint is therefore inadequate to tell us whether Capgras is a delusion, or a form of perception.

Perhaps it could be argued that the newly formed belief is rational after all it is only because the majority of the patients beliefs have the right causal relations with the external world, that she/he adapts this one belief to suit the rest of her/his normal experience and behaviour. (Bortolotti, 2005:190). After all, it is surely more peculiar for a person is this situation to change her entire belief system to accommodate a single instance of difference than just the explanation for one case of misperception. Bortolotti points out that delusions can play the same role as beliefs in explanation, argumentation and action guidance (Bortolotti, 2005:190). So, delusions may not be beliefs, but act as beliefs. This raises the question of whether belief, or just the role belief plays is necessary for perception. If it is the latter, and we just need something like a belief to perceive, it seems as though delusion can be akin to perception. The issue that arises here is whether or not perception relies on truth, and can we obtain truth in this fashion. If so, to what extent do we see representations of our external world, or do we experience the world veridically. I will not explore this issue any further in this essay however, because it does not help us to categorise and understand the nature of the Capgras delusion within the constraints I am examining it. Moreover, although Bortolotti examines delusions caused by brain damage as well as psychotic disorders without a known cause, I will only focus on the latter because, as case studies that I have included show, the Capgras delusion predominantly occurs monothematically without any known origin. It has been attributed as a symptom of other co0morbid psychotic disorders, but it is inconclusive whether or not the aetiology of Capgras lies in one specific disorder, or even in a certain group of other disorders.

Borolotti goes on to claim that the Capgras delusion is monothematic because it does not significantly affect any other beliefs (Bortolotti, 2050:191). However, there is one reported case of a patient, Ms. A whom, after five years of delusion that her parents were imposters, killed her mother (Bortolotti, 2005:192). The question arises again, of whether it was the delusion alone that is the cause for this. Capgras manifests in polar ways in different patients. On the one hand, they can be action guiding as in the case of Ms. A it was due to her experiencing her parents as imposters that led to her eventually murdering them. On the other hand, many Capgras patients are almost unconcerned about the alleged disappearance and replacement of their loved ones (Bortolotti, 2005:192). The commonality here is both instances is a belief that one s objects of affection has vanished and been substituted by a doppelganger, a belief that is firmly held and unshakeable in the face of other people s objections raising the question of what leads to these dichotomous responses.

This draws us to the distinction that Bortolotti raises between elaborated and circumscribed delusions. Simply put, patients with elaborated delusions form other beliefs as a result of their initial misperception, whilst those with circumscribed delusions have mostly unaffected beliefs and other behaviours outside of the specific content of the delusion (Bortolotti, 2005:191).

Another case mentioned in Bortolotti s 2005 paper reports a patient who believed his wife was replaced by an alien but failed to contact the police because he stated that he knew he would not be believed by the authorities (Bortolotti, 2005:193). His belief that his wife had been replaced, and his belief that the police would think he was lying demonstrates how delusion can guide patients behaviour. As Young points out, Capgras patients act in ways consistent with the delusion (Young, 2000: 49). I would disagree with Young on this point, because as Bortolotti points out, most Capgras patients do not act upon the unusual beliefs they experience. Surely, a consistent way to act with an imposter replacing your spouse or other loved ones would be to report them to authorities of seek confirmation from others that this person is indeed an imposter.

However, one reason confirmation from others may not seem adequate to negate the experience of the delusion could be due to the intimacy of the relationship with the perceived imposter. Say it is the spouse that has been replaced , then who is the authority on whether that person is really then the person`s husband or wife or not. A big problem with Capgras delusion is the patient s resistance to evidence provided by doctors, family members, or others with a close relationship with the patient. The patients insistence that no-one else is correctly perceiving the subject of the delusion, raises questions about the nature of the acquiescence of knowledge.

One reason could be as mentioned before that the authority on if the object of the delusion is really themselves is the spouse. However, could it just be the general nature of beliefs that the subject is not prepared to change their convictions of what is or is not their reality when contrary evidence becomes available. If we consider for a moment, those people who maintain strong religious beliefs scientific and other contradictory evidence is seldom enough to shake many of these beliefs. What is it about belief systems that are so different from systems of perception and why do they, in many instances of the Capgras delusion, fail to match up. Sass, as mentioned by Bortolotti, claims that delusions do not reach the criteria for beliefs because they do not respond to reality (Bortolotti, 2005:193). If we assume for the sake of argument that there is such thing as the real world, when it comes to the Naive Realist position with regard to the physical world, does this definition not throw out many beliefs as potential delusions, such as religious beliefs (Nudds, 2009:340). If we want to avoid the definition of delusion suggesting that those who hold religious beliefs are delusional, Leeser and O Donohue (1999:687) point of the DSM-IV categorisation of delusion should only include things that are not believed by others in the relevant subculture (Leeser and O Donohue, 1999:687). Capgras would therefore abide by the clinical definition of delusion, because the patient alone experiences the subject of delusion as peculiar, and others in her proximity attempt to explain her experiences away.

Bortolotti goes on to suggest that: The world of the [patient s]...experience would not be, and would not be thought to be, even by the [patient]...the real world (Bortolotti, 2005:193). This seems contrary to the case of Ms. A. and potentially to patients in general who experience elaborated cases of the Capgras delusion. Why would Ms. A. have been driven to the extreme point of murdering her own mother if she had the underlying assertion that in the real world her mother was not really an imposter, she just appeared that way to her. This brings us back to the primary issue of patients with Capgras delusion if they can rationalise that they are misperceiving, why does this experience persist, and in the case of Ms. A., if Capgras patients know that they are not aware of the world around them how it really is, it is irrational that they would act as a result of the content of their delusions. Therefore, it seems that in the first instance of Ms. A., Capgras delusion was potentially not a direct cause of the aggressive behaviour she exhibited towards her parents, it could be the case that were there other underlying personality traits or predispositions to these kinds of behaviour prior to her imposter delusions, or they may have been caused by the manifestation of other paranoid delusions on top of the existing Capgras.

However, as Young points out, despite the patient being able to recognise the absurdity of their delusional content, this is not a sufficient condition for the patient to retract his or her delusional beliefs (Young, 2000:52). This may be due to the fact that many patients have, as mentioned in the case of the woman whose husband was growing distant from her, reason to react this way. Do the patients have strange reactions to strange behaviour exhibited by their loved ones or is this just a desperate attempt to reason and rationalise their changed affect.

It is important to understand what is meant by a sense of familiarity when discussing the nature of the Capgras delusion. Bortolotti (2007: 42) and Young (2007:35) both note that Capgras patients have altered feelings of estrangement and familiarity, however, Young argues that patients can identify the subject of their delusion as someone who should be familiar, but due to lacking their usual affective response to the subject, reason that this person they see, must be an imposter (Young,2007:32). As Enoch and Ball present in a case of a man who begins to exhibit Capgras syndrome, who declares that the woman who visited him is not my wife but a double (Enoch and Ball, 2001:7) The patient clearly knows that the so-called imposter looks just like his wife, but due to his lacking usual affective response to the woman, he reasons that she is an imposter. Young terms this phenomenon that is central to the Capgras delusion as estrangement (Young,2007:32).

Bortolotti (2008) argues against Young (2007) regarding the breadth of the term familiarity and its use when categorising Capgras as a delusional belief. Both agree that the term is used too broadly when describing Capgras, but Bortolotti claims that Young s notion -that the lack of familiarity when perceiving the so-called imposter can be called estrangement- is inadequate.

Young says that if the patient had no recognition of the face of the subject, they would just be a stranger, an unknown person, rather than an imposter. There must be a sense of familiarity for the Capgras delusion to occur.

Furthermore, Bortolotti examines Capgras patients relationship with the recognition of the supposed imposter and the feelings of estrangement from them. She points out three distinct cases of the experience of unfamiliarity. Firstly, a patients failure to identify the subject, and thus experiencing them as novel - I ve never seen this person before (Bortolotti, 2008:39). This seems not to be the case for Capgras patients although they may claim never to have seen the imposter before, they are able to recognise the subject of their delusion as someone who resembles a familiar person, but who is not that relative/friend/spouse or whomever, that they claim to be.

Secondly, the failure to recognise the subject and thus feel estranged from them could be attributed to the patient s experience differing from prior instances of the same experience I m looking at my wife, but I do not feel the sense of comfort I am used to feeling in her presence . This categorisation of recognition and estrangement seem to closely fit with the examples laid out earlier in the essay and could potentially be explained away by the theory that when a spouse - or other beloved subject of the delusion- becomes increasingly emotionally distant, the patient reasons that this must be another person, the object of my affection would not turn against me, they must have been replaced , or as Bortolotti puts it It is not , because it looks different from . (Bortolotti, 2008:39).

Although this second outline of how a patient s ability to recognise their loved ones might be impaired, and consequently they feel estranged from the supposed imposter, the third experience that Bortolotti lays out is also what Young ascribes to when explaining the experience of Capgras. Young s categorisation of the Capgras delusion can be outlined as the ability to recognise a familiar face as familiar , then undergo the phenomenological experience of recognition (Bortolotti, 2007:40). However, I believe that Bortolotti is arguing that in the instance of the Capgras patient, the recognition is only partial, therefore manifesting a strange affective response. After all, if the patient found the subject of their delusion entirely novel and unfamiliar, there would be no cause for concern, when an affective response was lacking affective responses are not expected and are often lacking when in the presence of strangers. It is interesting to note that the ability to recognise familiarity and feel a sense of unfamiliarity in the context of the Capgras delusion, is not limited to the visual. Those patients who lack the sense of sight, and are thus visually impaired, have reported Capgras in their primary sense of sound. Blind patients experience Capgras as an auditory delusion rather than a visual one (Pacherie, 2008:115).

Moreover, it seems as though Capgras is not an inability for a patient to recognise someone that they should know, but more an issue of ineffective, or at least false reasoning. To respond to Bortolotti s claim that the Capgras patient should be able to recognise this radical change in their emotional response to the subject of their affection is redundant. As in the cases I have explored earlier in the essay, especially of the woman whose husband grew increasingly estranged from her due to his actions of becoming colder and more distant towards her over time, it is perhaps because of an unshaken emotional closeness to the person who is pulling away, that a switched is flipped. The patient is so suddenly treated differently, that this change can only be justified by the replacement of the spouse by an imposter.

Capacity for recognition remains intact, but their corresponding affective response has altered. Whether this be a direct response to the lack of affection and emotional display from the subject as a coping mechanism for rejection, or something more sinister, I think that both the Capgras patient s capacity for recognition and reason remain intact. However, the patients by-pass the Ockham s razor solution to their peculiar experience my husband does not love me anymore and go directly to a less plausible solution my husband still loves me, the man who is displaying coldness and aggression towards be must have kidnapped and replaced my loving husband (Blackburn, 1994: 307). Perhaps it is emotionally easier to conjure up this narrative than deal with the harsh reality of the situation.

Bortolotti concludes her paper arguing that she resist[s] the suggestion that lack of recognition and estrangement in the experience of Capgras patients should be sharply distinguished (Bortolotti, 2007:42) However, I am more inclined to agree with Young, these two notions- recognition and estrangement- should be distinguished, especially when it comes to our understanding of Capgras patients. Recognition can be described as the ability to ascribe familiarity to a person, but this need not be in any great detail I might recognise a woman I once saw on the train and feel a mild sense of familiarity. However, I would not describe this as in any way linked to my affective responses. I can compute that I have seen her before, but I feel no intimacy nor emotional attachment towards her in any way. However, the term estrangement suggests a loss of a previous sense of familiarity. One might become estranged from her brother after years of not speaking, but this does not necessarily impede one s ability to recognise that man as one s brother. Of course, he may look different and be harder to recognise based on his physical appearance, but that is just it the lack of recognition would not be due to a lack of affect in this instance. I would go so far to say that those with the Capgras delusion do not have a problem with lacking recognition, in fact it is this ability to recognise the subject that causes the jarring affective response. Instead, it is due to the emotional distance and feelings of estrangement that contribute to the development of the Capgras delusion.

Colheart et al. distinguish two delusional themes: persecutory and referential delusions (2011:277). Persecutory delusions pertain to beliefs that others are wanting to threaten or harm the patient, whereas referential delusions manifest in patients ascribing special personal significance to common occurrences, whether those be events, objects or other people (Colheart et al, 2011:277). It is clear to see that in the case of Ms. A., and elaborated delusions, that they tend to be persecutory the patients perceive a direct threat from the imposter. However, in neither manifestation of Capgras, neither elaborated not circumscribed, do patients display referential delusions. In regards to placing Capgras into one of these outlined delusory themes, we could say that elaborated cases of Capgras, like Ms. A. could be consistent with currently held definitions of delusion, but circumscribed scenarios of the Capgras delusion, may not be delusions at all. We would need to expand the current definition of delusion to accommodate for circumscribed instances of Capgras to be defined as a delusion.

Pacherie highlights the importance of the role that studying delusions plays in understanding the route that takes us from our experiences to the formation of our beliefs. She raises the questions of whether these systems of experience and interpretation are modular, meaning do they each operate individually, or do all these systems of perception and experience entwine to form an in-depth picture of the world in which we live (Pacherie, 2008:105).

Ratcliffe also regards the Capgras delusion as a monothematic, circumscribed delusion, meaning that its content is restricted to the imposter claim and that it is not usually elaborated in complicated ways (Ratcliffe, 2008:143). The primary focus for Ratcliffe is that those with this belief that their familiar is an imposter or alien does not affect other mental states. The patient does not make any attempt to rectify the peculiar situation nor do they exhibit any concern for their apparently missing loved one. Ratcliffe also explores what is meant by affect . This is a term central to understanding the Capgras delusion and how it manifests in patients perception.

One way to understand the term affect is to refer to the patient s phenomenological experience of the delusion, or what it is like for the patient to perceive their familiar. It is this what it is likeness or phenomenological character of the experience that is distorted in Capgras patients, leading them to the conclusion that this person is not my husband, but a cleverly disguised imposter (Ratcliffe, 2008:148). However, Ratcliffe also explores that others treat affect as an unconscious physiological response, the absence of which leads to an altered experience (Ratcliffe, 2008:148). Perhaps it is the case that Capgras patients respond to a familiar with an altered physiological response due to other underlying diseases or disorders, perhaps even other physiological rather than mental disorders too. It has been shown that Capgras patients have a reduced galvanic skin response to faces (Davies et al, 2001:140). For example, a patient may not feel physically warm when in the proximity of a familiar, however if the patient usually feels a sense of warmth when they see their familiar, and suddenly this response has stopped they are led to attribute this strange physiological response to the replacement of their familiar by an imposter. However, it is still unclear why this flattened affective response leads directly to the assumption that the subject must be an imposter, rather than the patient assuming something is wrong with them. Perhaps it is because the patient, let us say a wife, is surely the authority on who her husband (the subject) is. This is something they would know better than any doctor, so it seems consistent that the patient would not belief the doctors account, and instead form this alternative reasoning to explain the unfamiliar sensational response. As Davies et al states delusions are false beliefs that arise as normal responses to unusual experiences (Davies et al, 2001:154), and this can most certainly be seen in the example of the Capgras delusion.

Furthermore, Davies et al, purport that monothematic delusions are often circumscribed, however they stipulate that this is usually a result of brain injury (Davies et al, 2001:135). As I have explored throughout this essay, the Capgras delusion, although monothematic cannot necessarily be attributed to being a side effect of brain injury. Davies et al describe the Capgras delusion as: One of my closest relatives has been replaced by an imposter (Davies et al, 2008:136), but go on to say that, like Christadoulou s hypoidentification can also occur, meaning that the imposter is not necessarily a close relative or friend (Davies et al, 2001:136).

This categorisation potentially causes problems with my conclusion that the Capgras delusion could be a reasonable response to being treated with ambivalence by a spouse or close friend. However, if I want to maintain my theory that a close relationship between the patient and the subject of delusion is necessary for this response to ambivalence from a loved one to occur, it is possible that in cases where there is this element of hypoidentification, the perceptual experience cannot be attributed to the Capgras delusion. Furthermore, this supports my idea that Capgras is not a delusion at all, but a symptom of a wider problem. Whether that problem be identifiable in the na ve realist sense of reality, such as an unfaithful husband s ambivalence being felt by his wife, or whether it be a manifestation of other psychotic feelings, Capgras alone, is not a delusion.

At the outset of this essay, I hoped to demonstrate that Capgras was neither a delusion in and of itself, nor a symptom of any other underlying psychotic delusion. However, I find it difficult to state that those experiencing an imposter in place of a spouse or close relation, have an accurate or even useful way of perceiving the world around them. As Capgras is a hindrance to perception, it is not merely an expression of a difference of opinion.

On the other hand, we have seen how Capgras can be a useful tool for perception, because of the positive outcomes that have arisen in the cases of spouses reconciling for example. However, if action-guided instances of the delusion can lead to lethal consequences, it is extraordinarily impeding to the patient. Overall, Capgras impairs patients ability to interact successfully with the world around them, leading me to think that it is a hindrance, not a help to perception as a whole.

Only those instances of Capgras that can fit into the definition of elaborated and persecutory delusion can be considered delusions in the existing metric. Other types of Capgras that I have presented that do not result in persecutory behaviour and which are circumscribed, may not be delusions at all, simply a reasonable reaction to unusual experience. Or, as Viktor E. Frankl put it An abnormal reaction to an abnormal situation is normal behaviour. .

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