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Capgras syndrome (CS), late-onset schizophrenia (LOS) and refractory schizophrenia are relatively common conditions in psychiatric practice. However, the combination of these three conditions in a single case is a very rare event and so far seldom reported1. We report a case of a patient with LOS presenting with of CS and super-refractoriness since its first crisis. A 53-year-old woman was admitted to a psychiatric hospital in an acute psychotic episode. On admission, she was convicted that her family had been enrolled in a plot in which they were replaced by lookalikes. This was the first time she presented psychotic symptoms and no treatment had yet been instituted. Physical examination, laboratory tests and brain MRI presented no abnormalities. She was diagnosed with late-onset schizophrenia (LOS) and Capgras Syndrome (CS). Haloperidol, risperidone and olanzapine, all in monotherapy, were tried at optimal doses for a period of four weeks each, with unsatisfactory response. Then, clozapine was started in a dose up to 425 mg daily leading to serum levels of 587 ng/mL (reference value: 50 to 700 ng/mL), with no clinical signs of response after 33 weeks. Subsequently, electroconvulsive therapy was prescribed as adjuvant therapy to clozapine. After 17 bitemporal sessions, psychosis with Capgras delusion persisted, maintaining high risk of aggression against her family and the need to remain hospitalized. Schizophrenia is a relatively common disorder in clinical practice. Predominantly, it onsets in adolescence or early adult years, however 23,5% of these patients have this condition triggered after 40 years and are classified as LOS2. This subtype schizophrenia have a preponderance of cases among women and the presence of schizoid and paranoid personality traits are frequent2. Several hypotheses have been proposed to understand schizophrenia, especially cases that occur with CS, a condition characterized by delusions that a close subject, usually parents or spouse, has been replaced by a lookalike. In CS, some studies indicate the affection lack when in their relatives’ presence. Delusion development would be an attempt to explain it3. No complementary test is necessary for the schizophrenia diagnosis. In LOS, laboratory exams and brain images are advisable, especially in the elderly. Particularly, in this population, there is a higher incidence of potentially serious neurological conditions, such as stroke or dementia, which could also present with psychotic symptoms and be misdiagnosed as schizophrenia at first sight4. Given the unsatisfactory response to two different antipsychotics, clozapine is an important option to be considered, despite its potential side effects. Nonresponders patients are classified as superrefractory. However, the literature lacks well-designed studies with large enough samples to draw subsequent guidelines. Also of note, electroconvulsive therapy proved to be effective in association to clozapine5. This case highlights the unusual combination of three different conditions that is rarely reported in the literature1, the occurrence of CS in a case of LOS and super-refractory schizophrenia since its first crisis. In addition, it is important to emphasize the need for more well-designed studies to shed light on the treatment of refractory schizophrenia.

Capgras syndrome in a first-episode, late-onset and super-refractory schizophrenia case