FREGOLI DELUSION
Description
Fregoli delusion (also called Fregoli syndrome) is a rare psychiatric condition that falls under the category of delusional misidentification syndromes (DMS).
🔹 Definition
Fregoli delusion is a false belief that different people are actually a single person in disguise, repeatedly changing their appearance or identity.
Example: A patient may believe that strangers, friends, or even celebrities are in fact the same individual who is persecuting or following them.
🔹 History
First described in 1927 by psychiatrists Courbon and Fail, who reported a patient believing that famous actresses were disguising themselves to persecute her.
Named after Leopoldo Fregoli, an Italian actor famous for his rapid costume and identity changes.
🔹 Clinical Features
1. Core Delusion
A person insists that multiple individuals are actually the same person in disguise.
2. Common Themes
Paranoid content: Often linked with persecution (the disguised person is trying to harm or manipulate them).
Hyperfamiliarity: Normal faces feel too familiar, leading to misidentification.
3. Associated Symptoms
Visual hallucinations
Thought disorder
Impaired reality testing
4. Comorbidities
Schizophrenia (especially paranoid type)
Schizoaffective disorder
Bipolar disorder with psychosis
Dementia (Alzheimer’s, Lewy body dementia)
Traumatic brain injury (especially right frontal lobe and temporoparietal lesions)
🔹 Neuropsychology
Involves abnormal face recognition pathways:
Fusiform gyrus (face recognition) may remain intact (faces are recognized).
Limbic/emotional tagging pathway (linking familiarity to emotions) is disrupted.
This mismatch leads to inappropriate feelings of familiarity → misidentification.
🔹 Differential Diagnosis
Capgras delusion: Belief that familiar people are replaced by impostors (opposite direction of misidentification).
Intermetamorphosis: Belief that people swap identities with each other.
Reduplicative paramnesia: Belief that places or locations are duplicated.
🔹 Causes & Risk Factors
Psychiatric disorders: Schizophrenia, bipolar disorder
Neurological conditions: Dementia, epilepsy, Parkinson’s disease
Brain injury: Particularly affecting the right hemisphere and frontal lobe
Medications: Rarely associated with dopaminergic drugs (e.g., in Parkinson’s disease treatment)
🔹 Management
1. Pharmacological
Antipsychotics (e.g., risperidone, olanzapine, haloperidol) for psychosis
Mood stabilizers if bipolar features are present
Cognitive enhancers (donepezil, rivastigmine) in dementia-related cases
2. Psychological Support
Cognitive behavioral therapy (CBT) to reality-test beliefs (though often limited effectiveness)
Supportive therapy for reducing anxiety and distress
3. Neurological Care
Treat underlying brain injury, dementia, or seizures if present
🔹 Prognosis
Course depends on underlying disorder:
In schizophrenia → may be chronic, with partial treatment response
In dementia or brain injury → prognosis depends on progression of cognitive decline
Protocol
🔹 Problems Faced by Nurses in Fregoli Delusion
1. Safety Risks
Patients may believe nurses are "disguised persecutors," leading to fear, hostility, or aggression.
Risk of harm to self, staff, or other patients.
2. Non-cooperation with Care
Refusal of medication, meals, or personal care due to mistrust.
Misinterpretation of nursing interventions as threatening.
3. Communication Barriers
Delusional beliefs may dominate conversation.
Difficulty building rapport and maintaining therapeutic communication.
4. Emotional Strain on Nurses
Repeated accusations of being “the persecutor in disguise” can be stressful.
Frustration, fear, and burnout risk among staff.
5. Risk of Social Isolation
Patient avoids group activities, perceives others as “the same persecutor.”
Difficulty engaging in therapeutic programs.
6. Medication Adherence Problems
Suspicion that medications are poisoned or part of a conspiracy.
7. Overlap with Other Symptoms
Hallucinations, disorganized thinking, or comorbid neurological issues (dementia, TBI) complicate care.
🔹 Nursing Management Strategies
1. Ensuring Safety
Maintain low-stimulation environment to reduce paranoia.
Remove sharp objects or potential hazards.
Use de-escalation techniques if patient becomes aggressive.
Implement close observation if risk of self-harm or violence is high.
2. Building Trust & Communication
Approach calmly and consistently; avoid sudden changes in staff assignment.
Introduce yourself clearly each time (“I am Nurse X, here to help you with medication”).
Avoid arguing or directly challenging the delusion — instead, focus on feelings (“I can see you feel unsafe”).
Provide clear, simple, reality-oriented explanations.
3. Promoting Adherence & Engagement
Give medications in front of the patient, explain purpose and side effects.
Involve the patient in daily routines to increase sense of control.
Offer structured activities that reduce isolation but respect tolerance levels.
4. Psychological Support
Encourage expression of fears in a supportive setting.
Teach coping skills for anxiety and distress (deep breathing, grounding).
Facilitate supportive therapy sessions with mental health team.
5. Family & Caregiver Involvement
Educate family about the nature of Fregoli delusion and importance of consistent communication.
Provide guidance on handling paranoid accusations calmly.
Offer family counseling/support groups if needed.
6. Collaboration with Multidisciplinary Team
Work closely with psychiatrists (medication management).
Involve neurologists if brain injury or dementia suspected.
Psychologists for behavioral interventions.
7. Nurse Wellbeing
Regular debriefing and peer support to manage stress.
Rotation of staff if patient fixates on a particular nurse.
Training in managing psychosis and aggression.
Notes
Case Rep Psychiatry. 2011 Jul 14;2011:351824. doi: 10.1155/2011/351824