Low-Dose Clozapine for an Adolescent with TBI-Related Fregoli Delusions

Abstract

regoli delusion, first described by Courbon and Fail in 1927, named after an Italian actor Leopoldo Fregoli, is a rare delusional misidentification syndrome which entails that different people are in fact the same person in disguise who is able to change their appearance [1]. It is commonly linked to schizophrenia, schizoaffective disorder, and other organic brain syndromes including head trauma, ischaemic strokes, AD, Parkinson’s disease, epilepsy or metabolic derangements [2]. Neurologically, it represents a disconnectivity syndrome of hyperidentification (cf. Capgras) [3]. As TBI sequelae, psychotic symptoms may occur early or late [4]. In the early postinjury period, psychotic symptoms are most commonly manifestations of post-traumatic delirium. In the late postinjury period, these symptoms may be either part of a schizophrenia-like psychosis, comprising predominantly persecutory delusions, auditory hallucinations and dearth of negative symptoms, or be associated features of a mood disorder. The best available epidemiological evidence suggests that TBI confers a modest increased risk for schizophrenia-like psychosis especially if coupled with a positive family history of psychosis and male gender [5]. TBI renders patients more susceptible to neurologic side effects of antipsychotics [6].Here, we are reporting an adolescent with TBI that later on developed Fregoli delusions. He had supersensitivity to multiple antipsychotic trials with no response at all. When shifted to low-dose clozapine, delusions entirely remitted with great tolerability. A 15-year-old Palestinian youngster was casualty petitioned in accompaniment of his parents for paranoid ideations of 3 months duration. He is the youngest of 3 sibs emanating from nonconsanguenious monogamous family with no genetic load of neuropsychiatric disorders. Unremarkable developmental trajectories. Distinguished scholastic achievement. No history of smoking or illicit drug use. No medical comorbidities. Had a history of MVA, 10 months ago, incurred severe TBI, admitt ed to ICU, discharged on prophylactic Valproate 1000 mg/d for posttraumatic seizures. He was faring well following this accident, as reported by parents, apart from occasional complaints of low-grade headaches and giddiness. Lately, he started to voice out non-sensical talk that the man who hit him by the car is disguising and morphing in the bodies of neighbours, doorkeeper and servants, stalking him in order to kill him. He was panic-stricken by the idea. Fragmented sleep. Lost appetite. Dropped from school attainment. He was seen by a private psychiatrist, a diagnosis of psychotic depression was entertained, and fluoxetine (Prozac