To the Editor: While I admire the all too rare attempt by Silva et al. (Syndrome of Intermetamorphosis: A New Perspective, Vol. 30, No. 3, 1989) to provide a structure with which to understand this variant of the delusion of substitution,’ there are several points that should be addressed. The descriptions of the patients, as reported, do not correspond to the “classic” ones of Courbon and Tusques* and Bick,’ although there are many other examples to be found. By my reading, all three cases show the Capgras symptom, while case 2 also demonstrates the “reverse” subjective doubles symptom because of the sense of selfsubstitution. Only case 2 showed any organic contributors, consisting of the acute and chronic effects of phencyclidine, cannabis, and alcohol, but no disturbance of the electroencephalogram. Silva et al.” seem to provide a better description of intermetamorphosis in an earlier article. Of 22 cases in the English and French literature, 13 have organic antecedents. In general, these patients are quite disorganized with either confusional states or psychomotor epilepsy. The authors propose a model based on the misidentification of physical and psychological parameters, avoiding the “delusional explanation of metamorphosis” in order to study the relationship between the original reference and changed identity. However, they emphasize distinctions between the personalities that are not apparent in the literature. The interchanged features are often uncertain, variable, or assembled from several people: (Son mari changeait d’allure, de conduite, de visage, et prenait I’txpression mimique de tel ou tel voisin; c’6tait cevoisin qui venait s’incarner en lui. En une seconde, mon mari est plus grand ou plus petit ou plus jeune. . . . Cette illusion que des individus diffkrents s’incarnent, corps et Ime dans le corps de mi?me individu ne doit pas &re confondue avec I’illusion que le m&me individu transform son corps des faqons les plus diff&entes.*

To the Editor: We agree with Dr. Signer in that the three cases reported by us’ do not correspond to the “classic” case of Courbon and Tusques.’ Bick’s’ case as




As noted, these patients

often show an admixture

of substitute



tion of phenomenology A more general


the intermetamorphosis autoscopic-type

the exact delinea-

an exercise in sophistry. is the relationship






to the rest of the delu-

sion of substitution


these two variants experiences.6 While

of marked hallucinatory they share a disturbance in

misidentification, be compared

of the presence

I am not entirely

sure they can

as having a common psychopatholog-

ical basis and the same terms of reference Capgras

as the

and FrCgoli symptoms.

The operations provide a larger substitution formation


of transformation phenomena structure for the delusion of

and related are essential


Ideas of trans-

to the description

of these


Stephen F. Signer, M.D. Southwood



Southwood Academy Chula Vista, CA

REFERENCES 1. Signer SF: Capgras’ syndrome: of substitution. J Clin Psychiatry

The delusion 48:147-l 50,

1987 2. Courbon P, Tusques J: Illusions d’intermdtamorphose et de charme. Ann Med Psycho1 90:401-406, 1932 3. Bick PA: The syndrome of intermetamorphosis. Bib1 Psychiatr 164:131-135, 1986 4. Silva JA, Jalali B, Leong GB: Delusion of exchanged doubles in an immigrant: A new Capgras variant? Int J Sot Psychiatry 33:299-302, 1987 5. Atwal S, Khan MH: Coexistence of Capgras and its related syndromes in a single patient. Aust NZ J Psychiatry 20:496-498, 1986 6. Signer SF: Capgras’ syndrome: Delusion illusion. J Clin Psychiatry 49:204, 1988 (reply)


reported also falls under the “non-classic” category as he did not explicitly list that his patient specifically harbored delusions of transformation. We believe that cases 1 and 3 are not merely Capgras syndrome as Dr. Signer suggests, because

Vol. 3 1, No. 1 (January/February),


pp 84-86

Syndrome of intermetamorphosis: a new perspective.

CORRESPONDENCE To the Editor: While I admire the all too rare attempt by Silva et al. (Syndrome of Intermetamorphosis: A New Perspective, Vol. 30, No...
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