<p class="frontmatter-fieldnotes disclaimernew" style="margin-bottom:15px;">This work may not be copied, distributed, displayed, published, reproduced, transmitted, modified, posted, sold, licensed, or used for commercial purposes. By downloading this file, you are agreeing to the publisher’s <a href="/pages/termsofuse.aspx" target="_blank">Terms & Conditions</a>.</p>         <div id="x14l01641">
          <div class="story">
            <p class="ltrs-br-ltr-br-title"><span class="bold">Capgras’ and Cotard’s Delusions Associated With a Particular Pattern of Cerebral Activity in a Severely Depressed Patient</span></p>
            <p class="ltrs-br-ltr-br-body-text"><span class="semibold">To the Editor:</span> Major depressive disorder is a heterogenous disease considered as a cluster of symptoms associated with disordered processing within specific neurobiological circuits. We report the case of a patient suffering from a melancholic depression with Capgras’ and Cotard’s delusions in which the clinical picture was associated with a particular pattern of cerebral activity.</p>
            <p class="ltrs-br-ltr-br-body-text">&nbsp;</p>
            <p class="ltrs-br-ltr-br-body-text"><span class="semibold-ital">Case report.</span> Mr A is a 72-year-old man, who was brought to the emergency service with complaints of insomnia, nonsense talk, and aggressive behavior. For 2 weeks, Mr A had lived in complete withdrawal and showed great suspicion toward close relatives and friends. He also presented a depressed mood, pessimism, major sleep disturbances, and marked weight loss.</p>
            <p class="ltrs-br-ltr-br-body-text">Mr A’s psychiatric history was notable for at least 2 depressive episodes that were not treated. Although he lived in a retirement home, he had full cognitive ability and maintained a reasonable level of autonomy.</p>
            <p class="ltrs-br-ltr-br-body-text">At the initial assessment, Mr A claimed that his relatives had been replaced by actors. He also told us that his body vanished and that the devil replaced it with a younger one.</p>
            <p class="ltrs-br-ltr-br-body-text">Initial physical examination, laboratory tests, and magnetic resonance imaging were unremarkable. Single photon emission computerized tomography (SPECT) showed a moderate prefrontal hypoperfusion. Pharmacologic management combining an antidepressant treatment of citalopram 20 mg per day and risperidone 2 mg per day was initiated at the first visit.</p>
            <p class="ltrs-br-ltr-br-body-text">Throughout the following month, Mr A dramatically improved. A second brain SPECT performed at 5-week follow-up showed a persistent prefrontal hypoperfusion. To further explore brain perfusion, the second SPECT was subtracted from the first one using a computer-aided method. A statistically significant increased perfusion (&gt;<span class="thinspace"> </span>2 SD) was shown in the anterior cingulate (ACC) and the left anterior insula (LAI) (<span class="callout"><a href="#" onclick="createFigure('f1'); return false;">Figure 1</a></span>).</p>
            <div id="figure-2"> <a href="#" onclick="createFigure('f1'); return false;"><img src="14l01641F1.jpg" alt="Figure 1" id="f1" border="0" /></a>
              <p class="click-to-enlarge">Click figure to enlarge</p>
            </div>
            <p class="ltrs-br-ltr-br-body-text">&nbsp;</p>
            <p class="ltrs-br-ltr-br-body-text">We report the case of a 72-year-old patient who developed a severe depressive episode with melancholic features as well as Capras’ and Cotard’s delusions. This clinical picture was associated with a particular pattern of cerebral activation. Co-occurrence of Capgras’ syndrome and Cotard’s syndrome has been reported in the literature.<span class="htm-cite"><a href="#ref1">1</a></span> The 2 disorders seem to share similar mechanisms and to arise from a marked external or internal perceptual-affective dissonance, which produces a major feeling of strangeness of the external world and of one’s own body commonly called derealization/depersonalization.<span class="htm-cite"><a href="#ref2">2</a></span></p>
            <p class="ltrs-br-ltr-br-body-text">Cerebral blood flow normalization at 5 weeks of successful antidepressant and antipsychotic treatment suggests that LAI and ACC hyperactivity is probably involved in the pathophysiologic mechanisms of the disease.</p>
            <p class="ltrs-br-ltr-br-body-text">Anterior insula is suggested to be a supermodal structure, involved with ACC, in association with affective and perceptual recognition processes.<span class="htm-cite"><a href="#ref3">3</a></span> Disturbances in anterior insula activity might result in an atmosphere of strangeness in which Cotard’s and Capgras’ delusions seem to emerge.</p>
            <p class="ltrs-br-ltr-br-body-text">If we assume that symptom dimensions in depressive disorder reflect dysfunction in specific neuronal circuits, we could speculate that depression with major depersonalization/derealization in Mr A is related to a complex neuronal network in which LAI and ACC seem to play a major role.</p>
            <p class="ltrs-br-ltr-br-references-head"><span class="smallcaps">References</span></p>
            <p class="references-references-text-1-9"><a name="ref1"></a>1. Joseph AB. Cotard’s syndrome in a patient with coexistent Capgras’ syndrome, syndrome of subjective doubles, and palinopsia. <span class="italic">J&nbsp;Clin Psychiatry</span>. 1986;47(12):605–606. <span class="pubmed-crossref"><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=3782048&dopt=Abstract">PubMed</a></span></p>
            <p class="references-references-text-1-9"><a name="ref2"></a>2. Debruyne H, Portzky M, Van den Eynde F, et al. Cotard’s syndrome: a review. <span class="italic">Curr Psychiatry Rep</span>. 2009;11(3):197–202. <span class="pubmed-crossref"><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=19470281&dopt=Abstract">PubMed</a> <a href="http://dx.doi.org/10.1007/s11920-009-0031-z">doi:10.1007/s11920-009-0031-z</a></span></p>
            <p class="references-references-text-1-9"><a name="ref3"></a>3. Taylor KS, Seminowicz DA, Davis KD. Two systems of resting state connectivity between the insula and cingulate cortex. <span class="italic">Hum Brain Mapp</span>. 2009;30(9):2731–2745. <span class="pubmed-crossref"><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=19072897&dopt=Abstract">PubMed</a> <a href="http://dx.doi.org/10.1002/hbm.20705">doi:10.1002/hbm.20705</a></span></p>
            <p class="ltrs-br-ltr-br-author"><span class="bold">Faycal Mouaffak, MD, PhD</span></p>
            <p class="ltrs-br-ltr-br-author"><span class="hyperlink"><a href="mailto:mouaffakf@gmail.com">mouaffakf@gmail.com</a></span></p>
            <p class="ltrs-br-ltr-br-author"><span class="bold">Pierre Lavaud, MD</span></p>
            <p class="ltrs-br-ltr-br-author"><span class="bold">Franz Hozer, MD</span></p>
            <p class="ltrs-br-ltr-br-author"><span class="bold">Haifa Helali, MD</span></p>
            <p class="ltrs-br-ltr-br-author"><span class="bold">Patrick Hardy, MD</span></p>
            <p class="ltrs-br-ltr-br-author"><span class="bold">Nicolas Hoertel, MD</span></p>
            <p class="ltrs-br-ltr-br-author"><span class="bold">Aurelie Kas, MD, PhD</span></p>
            <p class="ltrs-br-ltr-br-endmatter-fieldnotes"><span class="semibold-ital">Author affiliations:</span> Department of Psychiatry, Paris XI-University, Bicêtre Hospital, Public Assistance Hospital of Paris, the Kremlin Bicêtre (Drs Mouaffak, Lavaud, Hozer, Helali, and Hardy); Public Assistance Hospital of Paris, Department of Psychiatry, Corentin-Celton Hospital, Issy-les-Moulineaux, and Paris Descartes University, PRES Sorbonne Paris Cité, Paris (Dr Hoertel); and Department of Nuclear Medicine, AP-HP, CHU Pitié-Salpêtrière, Sorbonne University, UPMC University of Paris, Paris (Dr Kas), France.</p>
            <p class="ltrs-br-ltr-br-endmatter-fieldnotes"><span class="semibold-ital">Potential conflicts of interest:</span> None reported.</p>
            <p class="ltrs-br-ltr-br-endmatter-fieldnotes"><span class="semibold-ital">Funding/support:</span> None reported.</p>
            <p class="ltrs-br-ltr-br-endmatter-fieldnotes"><span class="semibold-ital">Published online:</span> July 17, 2014.</p>
            <p class="ltrs-br-ltr-br-copyright-doi"><span class="italic">Prim Care Companion CNS Disord 2014:16(4):</span><span class="doi">doi:10.4088/PCC.14l01641</span></p>
            <p class="ltrs-br-ltr-br-copyright-doi"><span class="italic">© Copyright 2014 Physicians Postgraduate Press, Inc.</span></p>
          </div>
        </div>