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Year : 2014  |  Volume : 19  |  Issue : 2  |  Page : 83-84

A case of Fregoli syndrome and Erotomania associated with anemia

1 Department of Psychiatry, M.S. Ramaiah Medical College and Hospitals, Bangalore, Karnataka, India
2 Department of Medicine, M.S. Ramaiah Medical College and Hospitals, Bangalore, Karnataka, India

Date of Web Publication20-Mar-2015

Correspondence Address:
Hemendra Singh
Department of Psychiatry, M.S. Ramaiah Medical College, and Hospitals, Bangalore - 560029, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0971-8990.153716

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Although anemia due to the cobalamin deficiency has been described as a cause of a wide range of psychiatric disorders, the role of iron deficiency anemia in psychiatric disorders remains unexplored. We report a rare case of simultaneous presence of simultaneous presence of Fregoli syndrome with Erotomania which occuring in the context of iron and cobalamin deficiency anemia. The index patient improved after correction of anemia. But what is notable is that the patient continues to be free from psychotic symptoms even after 4 months of discharge. This case report shows a rare combination of two different delusional disorders that might be associated with anemia. This stresses the importance of doing a complete hematological work up in patients with psychiatric disorders.

Keywords: Anaemia, erotomania, fregoli

How to cite this article:
Singh H, Ganjekar S, Ghandhi PB, Thyloth M. A case of Fregoli syndrome and Erotomania associated with anemia. J Mental Health Hum Behav 2014;19:83-4

How to cite this URL:
Singh H, Ganjekar S, Ghandhi PB, Thyloth M. A case of Fregoli syndrome and Erotomania associated with anemia. J Mental Health Hum Behav [serial online] 2014 [cited 2023 Feb 1];19:83-4. Available from: https://www.jmhhb.org/text.asp?2014/19/2/83/153716

  Introduction Top

Fregoli syndrome is a type of delusional disorder where the affected person believes that others can assume different physical identities while retaining their psychological identity. In delusional disorders like erotomania, a person has a delusional belief of being loved by another person. In existing literature, only a few cases of the simultaneous presence of Fregoli syndrome and erotomania have been reported. [1],[2],[3],[4] There are many case reports which support the occurrence of pernicious anemia and other causes of the cobalamin deficiency as being responsible for a wide range of psychiatric illnesses. [5] However, we have not come across any literature which points to an association between iron and cobalamin deficiency anemia with the development of delusional disorders. The case presented below, for which informed consent was taken, illustrates the co-occurrence of Fregoli syndrome and erotomania in the presence of iron and cobalamin deficiency anemia, suggesting that there might an association between the two.

  Case Report Top

A 23-year-old Ms. G was brought to our hospital by her family with the complaint that she falsely claimed that she was in love with a man since the past 6 months, and she had got married to him in the previous month. Furthermore, she wanted to live with him despite having no idea about his whereabouts. She claimed that she saw him in every person, and felt that other people resembled him a lot. According to her, he took their form in order to meet her. She frequently entered into quarrels and arguments with her parents and siblings as she claimed that she had met this person and must live with him in order to start a family. Her family had made many attempts to convince her that all these claims of hers were not true. Even then, she continued to be strongly convinced that she was married to this man and that he was around. Her diet was predominantly vegetarian, but she took nonvegetarian food once a month. She had no past and family history of any psychiatric illness. She also had a history of easy fatigability and lack of appetite since 1 year, which was insidious in onset and also constant. She denied any history of head trauma or any seizure disorder in the past. Her menstrual history was irregular since the last 6 months, and she was diagnosed as having polycystic ovary. A general physical examination showed that she had a body mass index of 27.24 kg/m 2 with marked pallor, a bald tongue, and platynychia involving all the nails. Other physical and systemic examinations did not show anything significant.

Her investigations were carried out at our hospital laboratory, which has a National Accreditation Board for Testing and Calibration Laboratories certificate. Her hematological parameters showed low hemoglobin (4.9 g/dl) with normal total blood cells and platelet count. Her peripheral smear showed predominately microcytic hypochromic anemia with severe anisopoikilocytosis, tear drop cells, elliptocytes, pencil-shaped cells, and schistocytes. Her thyroid, renal, and liver parameters were within the normal range. Her ultrasound abdomen showed bilateral polycystic ovaries. Her iron profile revealed low serum ferritin 3.41 ng/ml (15-150), serum iron 19 μg/dl (30-145), and transferrin saturation of 4.5% (22-55) with increased total iron binding capacity of 417 μg/dl. Her coombs test results, intrinsic factor antibody, parietal cell, and antinuclear antibodies were negative. Serum Vitamin B 12 level was 101.2 pg/ml (deficiency <150) and folic acid was 6.89 ng/ml (deficiency <3). Her stool for occult blood, ova, and cyst was negative. Computed tomography (CT) scan brain was normal. She was treated with 500 ml of packed red blood cell transfusion, multivitamins, iron supplements, and oral risperidone up to 6 mg/day. Her hemoglobin increased to10 g/dl and her psychotic symptoms improved rapidly within a week. As it was felt that her psychotic symptoms had possible organic etiology, which resolved after correction for anemia, her antipsychotic medication was tapered to 4mg/day in week 2, 2mg/day in weeks 3-6 and then stopped. She was found to be asymptomatic during her regular follow-up visits for next 4 months duration. Her hemoglobin improved to 10.9 g/dl. The patient is presently on oral multivitamins and iron supplements, and continues to be well.

  Discussion Top

Our patient had Fregoli syndrome with erotomania, which supports the co-occurrence of two rare delusional disorders. [1],[2],[3],[4] Delusional behaviors are usually associated with organic brain affection, which is excluded as a cause by a normal CT brain. Our case did not have pernicious anemia or megaloblastic anemia, because her intrinsic factor antibody and parietal cell antibody were both negative, and her peripheral smear showed no evidence of megaloblastic anemia. Furthermore, there was no report of any signs and symptoms which suggest of cardiopulmonary system involvement. Although the psychotic symptoms occurred only 6 months before, the patient had a history of easy fatigability and lack of appetite for more than 6 months prior to her psychiatric illness. In the case of our patient, nutritional anemia was primarily iron deficiency with the cobalamin deficiency. For the treatment of delusional syndromes, sufficient pharmacotherapy is important. But as our patient had severe anemia, we treated her for this to see if there was any improvement. We found that after transfusion of 500 ml packed red blood cells, iron and multivitamin supplements, along with gradual tapering oral risperidone 6 mg/day, considerable subjective and objective improvement occurred within 1 week. Thereafter, risperidone was gradually tapered and stopped within 6 weeks. During the follow-up visits which were up to 4 months duration after discharge there was no recurrence of the patient's psychotic symptoms. Since the patient was not taking any antipsychotics after discharge, this suggests that there might be an association between treatment of anemia and an improvement in the patient's health. Vitamin B12 deficiency causes a decrease in monoamine neurotransmitter synthesis and neuronal destruction with increased levels of methyltetrahydrofolate levels. [6] Iron is required for the development and functioning of the different neurotransmitter systems, including the dopamine, norepinephrine, and serotonin systems. [7],[8],[9] A recent nationwide population-based study showed that patients with iron deficiency anemia did have a higher risk of psychiatric disorders, including mood disorders, autism spectrum disorders, attention deficit hyperactivity disorder, and developmental disorders. [10] While stressing on the association between treatment of anemia and an improvement in the patient's health, we cannot ignore the possible role of risperidone. This is because the risperidone normalizes the imbalance in neurotransmitters. In our case, psychotic symptoms could probably have occurred due to an imbalance of monoamine neurotransmitters caused by iron and cobalamin deficiency. This is, thus a rare case of iron and cobalamin deficiency anemia whose presentation is a combination of two delusions of Fregoli with erotomania. The current knowledge with respect to the pathogenesis of Fregoli syndrome with erotomania is in the preliminary level of understanding. This case report stresses the importance of doing a routine hemoglobin level and complete blood count in patients with psychiatric disorders.

  References Top

Collacott RA, Napier EM. Erotomania and Fregoli-like state in Down's syndrome: Dynamic and developmental aspects. J Ment Defic Res 1991;35:481-6.  Back to cited text no. 1
Wright S, Young AW, Hellawell DJ. Frégoli delusion and erotomania. J Neurol Neurosurg Psychiatry 1993;56:322-3.  Back to cited text no. 2
Brüggemann BR, Garlipp P. A special coincidence of erotomania and Fregoli syndrome. Psychopathology 2007;40:468.  Back to cited text no. 3
Hintzen AK, Wilhelm-Gobling C, Garlipp P. Combined delusional syndromes in a patient with schizophrenia: Erotomania, delusional misidentification syndrome, folie a deux and nihilistic delusion. Ger J Psychiatry 2010;13:96-9.  Back to cited text no. 4
Kate N, Grover S. Pernicious anaemia presenting as bipolar disorder: A case report and review of literature. Ger J Psychiatry 2010;13:181-4.  Back to cited text no. 5
Rajkumar AP, Jebaraj P. Chronic psychosis associated with vitamin B12 deficiency. J Assoc Physicians India 2008;56:115-6.  Back to cited text no. 6
Parks YA, Wharton BA. Iron deficiency and the brain. Acta Paediatr Scand Suppl 1989;361:71-7.  Back to cited text no. 7
Beard J. Iron deficiency alters brain development and functioning. J Nutr 2003;133:1468S-72.  Back to cited text no. 8
Burhans MS, Dailey C, Beard Z, Wiesinger J, Murray-Kolb L, Jones BC, et al. Iron deficiency: Differential effects on monoamine transporters. Nutr Neurosci 2005;8:31-8.  Back to cited text no. 9
Chen MH, Su TP, Chen YS, Hsu JW, Huang KL, Chang WH, et al. Association between psychiatric disorders and iron deficiency anemia among children and adolescents: A nationwide population-based study. BMC Psychiatry 2013;13:161.  Back to cited text no. 10


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