case study postpartum psychosis

• Case report
• Open access
• Published: 20 March 2021

Capgras delusion in postpartum psychosis: a case report

• Sulochana Joshi   ORCID: orcid.org/0000-0001-5421-5849 1 ,
• Mankaji Thapa 1 ,
• Anusha Manandhar 1 &
• Rabi Shakya 1  

Annals of General Psychiatry volume  20 , Article number:  21 ( 2021 ) Cite this article

4796 Accesses

2 Citations

1 Altmetric

Metrics details

Capgras delusion is one of the delusional misidentification syndromes characterized by the belief by the patient that the close person is replaced by an imposter who looks physically the same. It rarely occurs in Postpartum Psychosis. An intriguing phenomenon with ongoing debates, particularly about its feature and prevalence, its course, occurrence, and phenomenon in the postpartum period are poorly understood.

Case presentation

A 26-year-old Nepalese woman presented to the emergency for abnormal behavior on her 9th postpartum day. Capgras delusion was observed for 2 days during her hospital stay. Other psychotic symptoms appeared progressively and were treated as a case of Postpartum Psychosis.

This case describes the temporal sequence of various psychopathologies during Postpartum Psychosis including Capgras delusion. We attempt to explain the occurrence of Capgras delusion in Postpartum Psychosis.

Capgras delusion is a belief by a patient that a double exists who is physically, yet not psychologically, identical to him/herself and/or to his/her closed ones. It occurs in clear consciousness [ 1 , 2 , 3 ] and is associated with various neurological and psychiatric conditions [ 2 , 3 ]. It is considered a nonspecific delusion rather than a distinct disorder [ 4 ]. It is encompassed in the syndrome of delusional misidentification along with other delusional misidentifications like Fregoli syndrome, Subjective doubles, Inter-metamorphosis [ 3 , 5 ]. It is a negative misidentification with defensive maneuver and ambivalent emotions of love-hate and paranoid interpretation [ 6 , 7 ]. It is the most common delusion among the misidentification syndromes but a rare syndrome in itself [ 2 , 8 ].

During the postpartum period, the most common psychiatric illness is postpartum depression, followed by postpartum psychosis and postpartum blues [ 9 ]. Capgras delusion is not common in the puerperium period [ 10 , 11 ]. Postpartum psychosis, a serious psychiatric condition with a prevalence of one to two per 1000 childbirth in the general population, is 100 times more common in women with bipolar disorder or a history of postpartum psychosis [ 12 , 13 ]. The clinical features include odd affect and mood incongruent unusual psychotic symptoms related to a child’s altered identity, persecution, and changeling [ 9 ]. It is generally considered an episode of bipolar disorder with accompanying psychotic symptoms [ 9 , 14 , 15 ]. In this case report, we describe the occurrence of Capgras delusion in Postpartum Psychosis.

A 26-year-old housewife from a rural mid-western part of Nepal presented to the emergency on her 9th postpartum day. She had undergone Caesarean Section for a transverse lie. Her husband complained of her talking out of context, frequent change of clothes, and pulling off her clothes as well as fisting her hands for the last 6 days. She had had similar symptoms 15 months back when she lost her 6 month pregnancy. With Olanzapine 10 mg, she had been stable but she discontinued her medication 6 months back after she discovered her pregnancy. She had no history of substance use or chronic illnesses including diabetes mellitus or hypertension. She had a well-adjusted premorbid personality.

She was doing well until her 3rd postpartum day when she learned that her baby had developed jaundice. She became restless and started talking out of context saying ‘the witch will take away her baby’. She frequently changed her clothes, cried, and threw away her own and the baby’s clothes. She used to pull her ornaments, self-mutter, fist her hands, and stare at the family members. Such behavior continued till the 9th postpartum day when the patient was brought to the emergency. On her mental state examination, she was irritable and uninterested, had increased psychomotor activity, hallucinatory behavior, and persecutory idea without insight. Baseline investigations (Complete Blood Count, Renal Function Test, Urine Routine, and Microscopic Examination and Thyroid Function Test) were normal. The Brief Psychiatric Rating Scale (BPRS) score was 48 (Table 1 ) and Clinical Global Impressions-Severity(CGI-S) score was 6 (Table 2 ) then.

From day 3 (12th postpartum day) in the psychiatry ward, she frequently expressed that her husband and the baby would be taken away by the ‘witch’. After a few days, she started quarreling with her husband claiming that he was, instead, an imposter of her husband. She was firm on her belief and became irritable when confronted with. She did not elaborate much except claiming that she ‘knew’ he was not her husband. She would not talk to her husband and would become angry when approached.

On day 4, she also expressed that ‘evil spirit’ talked in her ears saying they have come to take her away which made her fearful and self-muttering. Her mental state examination showed irritable affect, auditory hallucination, persecutory delusion, and Capgras delusion.

From day 5, she began recognizing her husband but expressed that his clothes were her enemies. She claimed that he was trying to harm her, had brought her here to ‘sell’ her. She further expressed that he had been cheating on her. She continued to express persecutory, referential delusion, and auditory hallucinations until day 19 when she gradually became shakeable on her belief. After day 19, her persecutory belief involved around the neighbors and towards the females only claiming the neighbors to be the evil spirits trying to harm her.

From day 27, she became almost premorbid with partial insight and without signs and symptoms of hallucination and suspiciousness. After maintaining well for 1 week, she was discharged on Sodium Valproate 500 mg twice a day and Olanzapine 20 mg once a day at bedtime. Olanzapine was started on the first day of hospitalization with 5 mg which was gradually optimized to 20 mg with Clonazepam 0.5 mg as the adjunct. Similarly, Sodium Valproate was started after day 17 when she had not improved with 20 mg of Olanzapine. The Clinical Global Impressions-Improvement(CGI-I) scores show gradual improvement with time and medications (Table 3 ).

Conclusion and discussion

In this case report, we describe the case of Capgras delusion in the postpartum period from the evolution of delusion until its resolution along with other associated symptoms in temporal sequence, which is the strength of the case report. To our knowledge, only two cases of Capgras delusion with psychotic features have been reported during the postpartum period, highlighting that delusion in postpartum psychosis is rare [ 16 , 17 ]. Its true prevalence remains unknown. A systematic review of published studies between 1923 and 2016 has found 255 case reports with Capgras delusion [ 11 ]. In our case, the 2 days (in the hospital stay) of Capgras delusion later transformed into persecutory delusion along with the development of auditory hallucination and referential delusion which remained for a longer duration (24 days). This case report elaborates on the course of Postpartum psychosis with a brief duration (2 day in-hospital stay) of Capgras delusion which might, in part, explain its rarity. It is possible to be missed if it is present only for a few days as in our case or when the patient has not been under the regular supervision of an expert.

On one hand, Capgras delusion is believed to be amorphous. On the other hand, postpartum psychosis is considered to be an overt presentation of bipolar disorder with symptoms including various types from affective, psychotic to catatonic [ 9 , 11 , 12 , 13 , 14 , 15 ]. As postpartum psychosis is characterized by varied symptoms especially delusions and hallucination and affective symptoms, this Capgras delusion could be the initial symptom among many other symptoms of Postpartum Psychosis as in our case [ 9 , 13 , 15 , 18 , 19 ]. Hence, the case report attempts to suggest that Capgras delusion could be the initiating phenomenon in Postpartum Psychosis.

Thus, we have attempted to explain that Capgras delusion can be present, though rare, in Postpartum Psychosis.

Written informed consent was obtained from the patient’s caretaker for publication of this case report. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Availability of data and materials

Not applicable.

Berson RJ. Capgras’ syndrome. Am J Psychiatry. 1983;140(8):969–78.

Article   CAS   Google Scholar  

Tamam L, Karatas G, Zeren T, Ozpoyraz N. The prevalence of Capgras syndrome in a university hospital setting. Acta Neuropsychiatr. 2003;15(5):290–5.

Article   Google Scholar  

Salvatore P, Bhuvaneswar C, Tohen M, Khalsa H-MK, Maggini C, Baldessarini RJ. Capgras Syndrome in First-Episode Psychotic Disorders. Psychopathology. 2014;47(4):261–9.

Koritar E, Steiner W. Capgras’ Syndrome: A Synthesis of Various Viewpoints. Can J Psychiatry. 1988;33(1):62–6.

Arturo Silva J, Leong GB, Miller AL. Delusional Misidentification Syndromes. CNS Drugs. 1996;5(2):89–102.

Merrin EL. The Capgras Phenomenon. Arch Gen Psychiatry. 1976;33(8):965.

Todd J, Dewhurst K, Wallis G. The Syndrome of Capgras. Br J Psychiatry. 1981;139(4):319–27.

Oyebode F, Edelstyn NMJ, Humphreys GW, Booker E. Facial processing and the delusional misidentification syndromes. Cognit Neuropsychiatry. 1998;3(4):299–314.

Sit D, Rothschild AJ, Wisner KL. A Review of Postpartum Psychosis. J Womens Health. 2002;15(4):352–68.

Ratan DA, Friedman T. Capgras syndrome in postpartum depression. Ir J Psychol Med. 1997;14(3):117–8.

Pandis C, Agrawal N, Poole N. Capgras’ Delusion: A Systematic Review of 255 Published Cases. Psychopathology. 2019;1:1–13.

Google Scholar  

Spinelli MG. Postpartum psychosis: detection of risk and management. Am J Psychiatry. 2009;166(4):405–8.

Rohde A, Marneros A. Postpartum psychoses: onset and long-term course. Psychopathology. 1993;26(3–4):203–9.

Sharma V. Treatment of postpartum psychosis: challenges and opportunities. Curr Drug Saf. 2008;3(1):76–81.

Davies W. Understanding the pathophysiology of postpartum psychosis: challenges and new approaches. World J Psychiatry. 2017;7(2):77–88.

Cohn CK, Rosenblatt S, Faillace LA. Capgras’ syndrome presenting as postpartum psychosis. South Med J. 1977;70(8):942–942.

De Leo D, Galligioni S, Magni G. A case of Capgras delusion presenting as a postpartum psychosis. J Clin Psychiatry. 1985;46(6):242–3.

PubMed   Google Scholar  

Jones I, Chandra PS, Dazzan P, Howard LM. Bipolar disorder, affective psychosis, and schizophrenia in pregnancy and the post-partum period. Lancet Lond Engl. 2014;384(9956):1789–99.

Kamperman AM, Veldman-Hoek MJ, Wesseloo R, Robertson-Blackmore E, Bergink V. Phenotypical characteristics of postpartum psychosis: a clinical cohort study. Bipolar Disord. 2017;19(6):450–7.

Download references

Acknowledgements

Author information, authors and affiliations.

Department of Psychiatry, Patan Academy of Health Sciences, Lagankhel, Lalitpur, Nepal

Sulochana Joshi, Mankaji Thapa, Anusha Manandhar & Rabi Shakya

You can also search for this author in PubMed   Google Scholar

Contributions

SJ and RS conceived the study and participated in its design. SJ participated in coordination and drafting the manuscript. MT and AM contributed in drafting the manuscript.RS contributed in revising the manuscript critically. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Sulochana Joshi .

Ethics declarations

Ethics approval and consent to participate, consent for publication.

Written informed consent was obtained from the patient’s caretaker for publication of this case report.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher's note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Joshi, S., Thapa, M., Manandhar, A. et al. Capgras delusion in postpartum psychosis: a case report. Ann Gen Psychiatry 20 , 21 (2021). https://doi.org/10.1186/s12991-021-00342-6

Download citation

Received : 22 July 2020

Accepted : 07 March 2021

Published : 20 March 2021

DOI : https://doi.org/10.1186/s12991-021-00342-6

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Delusional misidentification syndrome

Annals of General Psychiatry

ISSN: 1744-859X

• Submission enquiries: [email protected]

Rare and tragic cases of postpartum psychosis are bringing renewed attention to its risks and the need for greater awareness of psychosis after childbirth

Clinical Assistant Professor of Psychiatry, Cornell University

Disclosure statement

Ziv E. Cohen does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.

View all partners

Lindsay Clancy, a labor and delivery nurse at the prestigious Massachusetts General Hospital in Boston, is the latest tragic and high-profile example of a mother allegedly taking the lives of her own three children.

On Jan. 24, 2023, Clancy allegedly strangled the children with an exercise band while her husband ran an errand . Clancy then slit her wrists, cut her neck and jumped from the second floor of their home. She has been hospitalized since, apparently paralyzed from the waist down following her suicide attempt.

At her arraignment, Clancy’s defense lawyer stated that she may have been suffering from an extreme form of postpartum depression called postpartum psychosis. Other women have made this claim, including Andrea Yates, a Texas woman who in 2001 drowned her five children in a bathtub . She was convicted of capital murder at her first trial, but after a successful appeal, she was found not guilty by reason of insanity in her second trial .

The Centers for Disease Control and Prevention estimate that 1 in 8 mothers, or approximately 12%, experience postpartum depression . Cases of parents killing children, in contrast, are exceedingly rare, with estimates of about 500 of these tragic events per year in the U.S.

Many people wonder whether a psychiatric condition, no matter how severe, could justify or explain the killing of innocent children, especially by their own mother.

As a clinical and forensic psychiatrist , I routinely treat patients after delivery for depression, and I have evaluated women accused of killing their children. The potentially fatal outcomes make it imperative to increase awareness and understanding of postpartum depression and psychosis.

Postpartum depression explained

It is important to make a distinction between “postpartum blues” and postpartum depression. Research shows that between 15% to 85% of women have “postpartum blues,” and the incidence peaks around the fifth day following delivery . Postpartum blues can include low mood, tearfulness, irritability and feeling overwhelmed. It is a totally normal, transient condition thought to be a result of the rapid drop in hormone levels following delivery.

True postpartum depression is more severe than postpartum blues. This term refers to when the patient is experiencing symptoms of a clinical depressive episode , also called “major depressive episode,” usually within the first month after delivery .

Postpartum depression is defined as experiencing two weeks or more of some or all of the following symptoms: depressed mood for most of the day, diminished interest or pleasure in most activities, weight loss, inability to sleep or excessive sleep, physical slowing or agitation, fatigue, poor concentration and, in severe cases, suicidal thoughts. The medical community estimates that postpartum depression is very common, with rates of 10% to 20% in the U.S., and the true numbers may be higher.

The onset and duration of postpartum depression can vary greatly . For some patients, the first weeks and months after delivery may go well or mood symptoms may be manageable, followed months later by a “crash.” For others, mood symptoms may begin during pregnancy and worsen after delivery .

Diagnosis can be difficult since the time of onset is variable and because some of the symptoms of depression are normal, temporary changes that occur after delivery. In addition, research shows that cultural factors can influence the reporting and development of postpartum depression, and some patients may not disclose symptoms due to guilt or shame.

Risk factors for postpartum depression

Some key risk factors for postpartum depression include a history of depression or mental illness prior to pregnancy, stressful life events during and after pregnancy, marital conflict and young maternal age.

New mothers are under a great deal of pressure – personal, familial and societal – to immediately bond with and love their children. The stress and burden of being a new parent, and the tasks that go along with this role, such as breastfeeding, often make bonding with the child a challenge. The patient may struggle with feelings of guilt and shame, which can delay or prevent seeking help.

While the physical causes of postpartum depression remain mysterious, researchers believe the condition is caused by hormone fluctuations during and especially after pregnancy . For example, research suggests that sex hormones like estrogen, which reach high levels during pregnancy and then fall precipitously after delivery, as well as hormones like oxytocin that are involved in lactation and maternal-baby bonding , likely play an important role. During and after pregnancy, the brain is on a hormonal roller coaster, and this can wreak havoc on mental health.

Postpartum depression treatments

For mild cases, psychotherapy alone may be sufficient to reduce the symptoms and gradually restore a sense of well-being. Approaches such as interpersonal psychotherapy and cognitive behavioral therapy have been shown to be helpful for those suffering with postpartum depression. Interpersonal psychotherapy, for example, focuses on improving interpersonal connections, while cognitive behavioral therapy focuses on correcting distorted thinking, such as believing that one is a “bad” parent.

The mainstay of treatment for postpartum depression is medication. Given the probably strong biological underpinnings of this condition, medication is thought to be helpful in restoring neurochemistry to alleviate symptoms , such as by raising brain levels of the neurotransmitter serotonin.

Breastfeeding patients may prefer psychological treatment to medication therapy since antidepressants can enter breast milk . To date, however, antidepressants do not appear to have an affect on the infant’s health or development .

How postpartum psychosis differs

Postpartum psychosis is a condition where maternal mental health is affected not just by depression, but by a break with reality .

The break with reality, called “psychosis,” generally includes seeing or hearing things that don’t exist – called hallucinations – having jumbled or disconnected thoughts or having fixed false beliefs, often of a bizarre or extremely implausible nature, such as the devil having entered into one’s child. For example, in the Andrea Yates case, she professed to believing that she was marked by Satan and that the only way to save her children from hell was by killing them . Some patients may hear an auditory hallucination - meaning a powerful voice - commanding suicide or an attack on the infant.

This condition is much less common than postpartum depression and is thought to occur in 1 in 500, or 0.2%, of deliveries in the U.S. Also, unlike postpartum depression, which can begin months after delivery, postpartum psychosis usually begins within the first three days following childbirth.

Due to the severe nature of these symptoms, their rapid onset and the frequent presence of thoughts of harming oneself or the baby, postpartum psychosis is considered a psychiatric emergency. It usually results in psychiatric hospitalization for the patient’s and the baby’s safety. In many cases, postpartum depression and its extreme form, postpartum psychosis, go undetected by loved ones and health care providers because of a reluctance to acknowledge that the patient may be a danger to oneself or the child.

What experts know about Clancy’s Case

Lindsay Clancy reportedly suffered from anxiety about going back to work in September 2022, four to five months after giving birth to her third child. She was diagnosed with anxiety and prescribed anti-anxiety medications and antidepressants.

In December 2022, Clancy was evaluated at a women’s psychiatric clinic, where she was told she did not have postpartum depression. However, a short time later she told her husband she was having thoughts of harming herself and the children, and was admitted to a psychiatric hospital. She was discharged after a few days and reported that her suicidal thoughts had resolved. However, just a few days later, she allegedly strangled her three children.

If accurate, this timeline indicates how difficult it can be to diagnose possible postpartum depression and psychosis, and that symptoms may fluctuate on a daily or even hourly basis. Mothers may not always disclose symptoms due to guilt, shame or fear about how it could impact their family.

Clancy’s tragic story illustrates how important close mental health follow-up and treatment is for women suspected of having postpartum depression. And when suicidal thoughts or thoughts of harming the children are present, they must be treated as a potential psychiatric emergency.

• Antidepressants
• Postpartum depression
• Cognitive behavioral therapy
• Centers for Disease Control and Prevention (CDC)
• Psychiatric conditions
• Psychiatric disorder
• Postpartum psychosis
• SSRI antidepressants

Public Policy Editor

ARDC Project Management Office Manager

Laboratory Officer (Animal Anatomy Teaching Facility)

Lecturer / Senior Lecturer in Indigenous Knowledges

Commissioning Editor Nigeria