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Introduction

Delusional disorder is an illness characterized by one month or longer of delusions but no other psychotic symptoms and apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired, according to (DSM-5-TR). Mostly delusional disorder subtypes are erotomania, grandiose, jealous, persecutory or somatic. [1]

The Fregoli delusion is a rare subtype of delusional misidentification syndromes (DMSs) in which a person believes that various people are manifestations of a single individual who changes appearances or disguises themselves. [2] In this case report, we provide an insight into the diagnostic challenges and therapeutic considerations associated with Fregoli delusional disorder in a unique situation. Furthermore, this case illustrates the importance of considering a variety of diagnoses when treating patients with delusional disorders. [3] An initial treatment approach should focus on treating the underlying psychosis, using antipsychotic medications as the first line of treatment and behavioral therapy can be used to manage the underlying delusions. [4]

Case Description

A 23-year-old man presented to Razi Psychiatric Hospital with a welfare coach following a physical assault and harbouring paranoid beliefs. As a result of being kidnapped two years ago and subjected to physical and mental abuse, he has self-inflicted harm. The severity of his mental illness is evidenced by his history of multiple hospitalisations for suicidal behaviour, the first a decade ago. Additionally, the patient exhibits pre-emptive beliefs that the kidnappers disguise themselves and follow him to harm him as well as paranoia and delusions about his mother's fidelity. The person had been abusing a variety of substances, including alcohol, opium, cannabis, and amphetamines on a sporadic basis but had stopped using them more than 2 years ago. At present no mood disorder is detected. Neuroimaging revealed enlarged ventricles demonstrating non-specific developmental anomalies, complicating the clinical presentation.

Discussion

Delusional misidentification syndromes (DMS) are a group of disorders characterized by the inability to identify people, places, or objects. Fregoli Delusion is one of the more complex manifestations of DMS. [2,3] Differential diagnoses are required to distinguish Fregoli Delusion from other forms of DMS. The differentials include Capgras Syndrome, intermetamorphosis, reduplicative paramnesia, and subjective double syndrome. It is important to note that, contrary to Capgras Syndrome, Fregoli Delusion is characterized by the belief that multiple individuals are a single person in disguise or altered appearance. Moreover, these subtle but significant differences can be instrumental in developing customized treatment plans and in improving diagnostic accuracy. [4,5]

It is not uncommon for patients to have multiple DMSs at the same time, which complicates their diagnosis and emphasizes the importance of performing a comprehensive clinical examination. As in this case, the patient has persistently believed that disguised kidnappers are following him, which is consistent with the hallmark characteristics of Fregoli Delusion. However, it may also be associated with paranoia, which is also observed in other psychotic conditions. The recognition and differentiation of these overlaps is important for gaining a more complete understanding of the etiology of this disorder. [5]

The trauma history of the patient, including kidnapping and abuse, is likely to be a significant contributing factor to delusional misidentification in this case. Symptoms of trauma, such as hypervigilance and mistrust, may lead to alterations in perception and cognition, resulting in alteration of identity. It is essential for clinicians to explore these psychological and neurobiological underpinnings so as to better understand the role trauma-informed care plays in the treatment of Fregoli Delusions. As a result of the complexity of this case, an integrated treatment plan is required. [5] Psychotherapy and pharmacotherapy are both essential components of trauma recovery. Due to the patient's history of substance abuse and noncompliance with medication, it is necessary to monitor the patient closely and to reevaluate the patient on a regular basis. Psychiatrists, psychologists, and social workers must collaborate in order to achieve long-term treatment success and minimize the possibility of relapse. Clearly, more research is needed to better understand the epidemiology and aetiology of DMS, including Fregoli Delusion. Future studies should examine the coexistence of multiple DMS subtypes and the long-term effects of integrated interventions for improving clinical management and quality of life for DMS patients. [5]

Conclusion

Fregoli Delusion is a complex condition, which necessitates a holistic, patient-centered approach, which incorporates pharmacological treatment, trauma-informed care, and cognitive-behavioural therapy. As a result of our experience, we have gained several important lessons, including the need to actively monitor medication compliance and relapses, as well as to provide robust patient support systems to ensure compliance with treatment. [2] To achieve longterm success, it is necessary to address underlying factors, such as trauma, and provide patients with nonconstructive coping mechanisms. Continuity of care and effective management of complex cases are assured through collaboration between multidisciplinary teams. [3,4] In the future, it would be beneficial to investigate integrated interventions designed to improve quality of life, symptom remission, and relapse prevention, as well as increase awareness of overlaps with other delusional misidentification syndromes, in order to develop more personalized therapeutic approaches.

Acknowledgements

For this work, there was no funding.

Data Availability

The data that support the findings of this study are available from the corresponding author upon reasonable request

Conflict of Interest

The authors declare no conflict of interest. The funders were not involved in the design, data collection, analysis, or interpretation methods, manuscript writing, or publication decision of the study.

Author Contributions

Author Farnaz Ghannadi conceived the study and wrote the initial draft and contributed to the interpretation of the data and provided critical revisions to the manuscript. Author Mohammadsaleh Talebinejad collected the data and performed the analysis. Author Morvarid Ahadi supervised the project and is the guarantor and taking overall responsibility for the work.

Ethical Standards Disclosure

This study was conducted according to the guidelines laid down in the Declaration and all procedures involving research study participants were approved by the ethics committee of University of Social Welfare and Rehabilitation Sciences approved the Study. (IR.SWRS.1403.267).

Written informed consent was obtained from the patient.