A RARE CASE OF FREGOLI RESULTED IN HOMICIDE.

INTRODUCTION: Frégoli syndrome belongs to the group of delusional misidentification syndromes and was first described in 1927[(1)]. The hallmark of Frégoli syndrome is the belief that a familiar person is disguised as a strange person, that is the familiar person has taken on a different physical appearance but remains the same person psychologically. The syndrome has been associated with organic cerebral dysfunction, in particular of the right hemisphere; however, most cases occur in the setting of schizophrenia[(3)].In hospital settings, patients with Fregoli syndrome often misidentify members of the treatment team who work closely with the patients [(4)] This misidentification may result in assaultive behaviour towards the staff or other patients. Unfortunately, however, violence in Fregoli patients has been under studied. Here, we present a case of Fregoli which resulted in homicide of another patient at hospital. CASE REPORT: Mr A, 55 yr old diploma educated married man with history of continuous mental illness for 30 yrs duration who had been admitted in hospital after he become increasingly paranoid and made threatening comments to his neighbours. He was admitted in hospital for six times in the past and was diagnosed as a case of paranoid schizophrenia.Patient had poor drug compliance over the period of 5 years since treatment initiated. At the time of admission patient had suspicions,hallucinatory behaviour and irritability.No history suggestive of organicity. Mental illness was reported in one second degree relative. Temperamentally he was an easy child. He had received various antipsychotics at different periods of time but adherence was poor and at the time of admission he was on T clozapine 75mg/day and T risperidone 4mg/day. On MSE he had persecutory delusion of neighbours and family members doing harm and grandiose delusions of having the power of god and control over the world Christian community. No active suicidal or homicidal thoughts. There was second person auditory hallucination, voices stating that all the hospital staffs, neighbours is against him and planning to harm him to take his wealth after receiving incentives from his paternal brother. Investigations were done and his MRI brain revealed diffuse brain atrophy prominent in R hemisphere, located mostly on frontal and parietal regions. During the course of hospital stay, he continued to form new delusions,that staff in the ward was trying to poison him through food and staff were responding to external voices commanding to harass him. His psychiatric condition continued to be unstable and on one early morning at 5:45AM he assaulted and killed one of his co patient in cell by strangulating him. Later on questioning the patient reported that he believed that person was only masquerading as apatient and he was actually his father’s enemy who have been trying to take off their ancestral property for years. He also said that this same person tried to harm him while he was in childhood and he was taking appearance of a patient at hospital to kill him and he assaulted him to protect himself from being murdered. The patient was subsequently diagnosed with fregoli syndrome. This episode of fregoli syndrome was brief and there was no previous reports delusion of misidentification in Mr A’s history. Due to nature of delusion and considering high risk of violence he was kept in single room under close observation DISCUSSION: The syndrome is considered a rare neuropsychiatric condition commonly linked to schizophrenia, schizoaffective disorder, and other organic mental illnesses [(2)]. The frequency of violence in Fregoli syndrome is unclear. Silva has described 144 cases of patients who exhibited violence towards misidentified people; of these, only 6 had Fregoli syndrome, 86 had Capgras. The most common diagnosis was paranoid schizophrenia (59.8%) [(4)]. our patient was also diagnosed with paranoid schizophrenia. MRI of patients with fregoli symptoms have shown R hemispheric lesion with damage in parahippocampal, hippocampal and ant fusiform gyrus. Under activity in the perirhinal cortex seems to be responsible for loss of familiarity in Capgras, whereas over activity in R temporolimbic connection between facial recognition unit and amygdale seems to account for hyper familiarity seen in the Fregoli [(4)].Traumatic events in Mr. A’s early upbringing in the form of losing his mother at an early age and subsequent abuse by his step mother and paternal brother elicited feelings of mistrust in others.Predicting assaults by psychiatric patients is difficult, and members of clinical staff and other inpatients are often either thevictims or the first responders. Due to the nature of the delusion, patients with Fregoli syndrome may present a subgroup of patients who are of particularly high risk for violence CONCLUSION: This case report stresses the importance of early recognition of fregoli syndrome by clinicians in order to decrease the assault risk and to ensure better patient care. REFERANCES: 1. Courbon P., Fail G. Syndrome d?llusion de Fréli et schizophrenie. Bull SocClin Med Ment. 1927; 15: 121?124 2. R. O’Reilly and L. Malhotra, ?Capgras syndrome?an unusual case and discussion of psychodynamic factors,? British Journalof Psychiatry, vol. 151, pp. 263?265, 1987. 3. O. Devinsky, ?Delusional misidentifications and duplications: right brain lesions, left brain delusions,? Neurology, vol. 72, no. 1, pp. 80?87, 2009. 4. A. Sinkman, ?The syndrome of Capgras,? Psychiatry, vol. 71,no. 4, pp. 371?378, 2008.