Co-occurrence of Intermetamorphosis and Frégoli Syndrome in Schizophrenia

Abstract

To the Editor: Fregoli syndrome is a misidentification syndrome in which the patient falsely identifies familiar people in strangers.1 Intermetamorphosis is defined as a belief that an individual is transformed both physiologically and physically into another. Both are relatively rare phenomena, though intermetamorphosis is rarer.2 The reports of the co-occurrence of these syndromes is sparse in the literature.3,4 We hereby report a patient with paranoid schizophrenia in whom Fregoli syndrome and intermetamorphosis coexisted and responded to aripiprazole. Case report. Ms A, a 40-year-old married woman, presented in 2008 with an illness of 20 years’ duration characterized by delusions of reference and auditory hallucinations. On examination, she reported that her husband would transform into a “demon” while she was watching him—his entire appearance would become “darker,” and he would have a peculiar facial expression and act as if he were trying to harm her. She would not see anything different, but was sure that her husband had become a demon. She also believed that strangers in her neighborhood were actually the same person whom she had known 20 years earlier, appearing in disguise and trying to harm her family. These beliefs were not shared by her family and persisted despite evidence to the contrary. Her total 18-item Brief Psychiatric Rating Scale (BPRS)5 score at baseline was 27. There was no family or past history of psychiatric illness or substance use. Metabolic investigations, electroencephalogram, and contrast computed tomography scan of the brain revealed no abnormalities. Before presentation, Ms A had received treatment with trifluoperazine 10–15 mg/d for 5 years and olanzapine 10 mg/d for 3 months without much improvement. She did not tolerate either medication due to excessive sedation and weight gain of 5 kg with olanzapine. Hence, it was decided to treat her with aripiprazole, which was titrated to 30 mg/d over 1 week. She tolerated this medication well, and at the end of 4 weeks, her beliefs related to her husband and strangers had remitted. Her BPRS score at this time was 10, indicating response to aripiprazole.6 This patient had a delusion that her husband was physiologically and psychologically changed into a demon and that a particular persecutor was appearing in the guise of strangers, leading to an impression of intermetamorphosis and Fregoli syndrome occurring in same patient. An organic etiology for the same was ruled out. Delusional misidentification syndromes have been reported to occur in certain organic conditions. Many theories could explain these misidentification syndromes, such as right temporolimbic-frontal disconnection, interhemispheric disconnection of cortical areas,7 and cognitive theories such as face recognition defect in schizophrenia.8 The patient reported in this case does not have any obvious organic etiology. However, functional disconnectivity between brain regions that might be undetectable on gross evaluation with imaging may account for these experiences. It is interesting to note that the patient responded to aripiprazole, though she did not respond to or tolerate prior medications. Given the rarity of the disorder and the significance of face recognition theory in schizophrenia, the fact that these phenomena occurred together is worth mentioning.