Report of an Unusual Case of Delusional Misidentification Syndrome

Case Report

MY DAD IS DHONI – REPORT OF AN UNUSUAL CASE OF DELUSIONAL MISIDENTIFICATION SYNDROME

VG Vinuprasad1*, TR John2 1Assistant Professor, 2Associate Professor Dept. of Psychiatry, MOSC Medical College, Kolenchery, Ernakulam. *Correspondence: Madathil house, Thondayad, Chevarambalam PO, Kozhikkode Dt., Pin: 673017. Email: [email protected]

ABSTRACT

Delusional misidentification syndromes are a group of symptoms seen in different forms in diverse neuropsychiatric conditions. Most reported cases are of adults with psychotic or organic disorders. Here we report a case of a variant of delusional misidentification syndrome in an adolescent boy with subnormal intelligence. During a manic episode, he developed a delusion that it was his father who was playing in disguise as Indian cricket team captain all these years, and also identified his sister as his wife.

Keywords: Manic episode, Capgras syndrome, intermetamorphosis

INTRODUCTION Many cases of DMS, its atypical forms, and cases presenting with a ‘mixture’ of types of Delusional misidentification syndromes DMS have been described in the literature.3 (DMS) include delusional beliefs that the Most of the reported cases are of adults with people, objects, or places around the patient psychotic or organic conditions. Here, we change or are made to change with one describe a case of delusional another. They have in common the concept misidentification syndrome in which an of the double.1,2 The first described and most adolescent in his first episode of mania held studied syndrome among these is the a delusion that it was his father who was Capgras’ syndrome described by Capgras playing in disguise as Indian cricket team and Reboul-Lauchaux in 1923. In this, the captain all these years. patient believes that a person, usually closely related to him, is replaced by an CASE REPORT exact double. Other syndromes described in A 15 year old boy, studying in 10th this category are Fregoli’s syndrome, standard, with history of poor academic syndrome of intermetamorphosis, and the performance and family history of alcohol syndrome of subjective doubles.

Please cite this article as: Vinuprasad VG, John TR. My dad is Dhoni – Report of an unusual case of delusional misidentification syndrome. Kerala Journal of Psychiatry 2015; 28(1):38-41.

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dependence in father, was first brought to us manner. There were no abnormalities of with symptoms of decreased sleep and perception. worries about his disagreements with his After this evaluation, his diagnosis was father, who had been compelling him to changed to bipolar affective disorder, become the priest’s assistant in the church, current episode mania with psychotic resulting in strained relationships. symptoms, according to ICD-10 criteria. His birth and early development were Escitalopram was stopped, and he was uneventful. Physical examination, including started on sodium valproate 600 mg/day neurological examination, was normal. and olanzapine 10 mg/day. His symptoms After detailed evaluation, he was diagnosed slowly improved on this regime. On our last to have moderate depressive episode assessment, done after a month of the manic without somatic syndrome according to switch, he was seen to be maintaining well. ICD-10 criteria, and was started on When asked about his previous belief, he escitalopram 10 mg/day and clonazepam reported that although he was sure about it 0.75 mg/day. His IQ assessment revealed when he was ill, now he does not believe so. borderline intelligence. His depressive However, he added that there is a chance symptoms improved within two weeks. that his old belief might be true. Immediately after that, however, his mother DISCUSSION noticed him to be more talkative, unusually confident and playful most of the time, and Though described as “syndromes” in riding bicycle at a higher speed. literature, DMS denote a group of One day during this phase, while watching symptoms which exist in different forms in cricket on television, he told his mother that various neuropsychiatric conditions. They all these years his dad has been playing in are most commonly associated with disguise of MS Dhoni, the captain of Indian schizophrenia, but are also seen in organic cricket team. He substantiated this argument brain diseases and bipolar disorders.2 In a by pointing out that on that particular day review of 260 case reports of delusional Dhoni was not playing and his dad was at misidentification, 174 patients had a home. Repeated attempts by his mother to Capgras delusion (66.9%). Associated challenge this belief did not succeed. He diagnoses were: schizophrenia, usually also started saying that he is already paranoid type (127/174, 73.0% of Capgras married, and identified his 12-year old sister cases), dementia or other organic mental as his wife. When asked about his sister, he disorders (46/174, 26.4%), mood disorders told that she is married and staying (29/174, 16.7%).5 Silva et al. have reported elsewhere. He also blamed his mother for a series of three cases of DMS in manic hiding these matters from him. Nonetheless, episodes.6 he did not show any inappropriate behavior In this patient, though the delusion was seen towards the sister. during the manic phase of bipolar disorder, He was brought to our OPD within one he did not seem to completely give up the week of onset of these symptoms. During delusion even after the resolution of mania. the interview, he appeared more confident This scenario might have happened due to and euphoric. There were no depressive his subnormal intelligence. Also, most symptoms. He was talking about his father reported cases are of adults, and the in a funny way, rather than in a tensed

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symptom of delusional misidentification is patient, however, the acute symptoms rare among adolescents.4 remitted with olanzapine. It would be worthwhile to keep the patient in follow-up Among the many classical and variant cases to trace the future course of his delusions. of DMS reported, we were unable to find a similar case where a familiar celebrity We were unable to get neuroimaging or exchanged identity with a close relative. projective tests done in this patient due to Our patient manifested delusion of financial reasons, and this limits our ability intermetamorphosis syndrome, where there to make further conclusions regarding the is delusion of exchange of identities. etiology in this case. Previous reports of Besides, he also had a Capgras’ like delusion DMS in adolescents have not demonstrated because he believed that his sister had been any specific or consistent structural brain replaced by his wife. lesions though. Most of the previously reported cases To conclude: DMS can present in a variety involved themes comprising a close relative of forms in many neuropsychiatric or object, as in this case, where the conditions. This case report reveals that characters are his father, sister, and favorite being adolescent and a diagnosis of mood team’s captain. A similar report is available disorder is no exception. Detailed clinical about an adolescent girl with schizoaffective evaluation can reveal unusual and disorder who displayed Capgras syndrome, interesting phenomenological dimensions in metamorphosis, reverse these patients. Follow up of reported cases intermetamorphosis, misidentification of for longer duration might throw light on the reflection, and reduplicative paramnesia.7 course and resolution of these symptoms. Though the neurological substrates of DMS REFERENCES have been extensively studied, no specific 1. Oyebode F. Sims’ symptoms in the mind area/mechanism have been identified so far. (Fourth edition). Edinburgh: Elsevier; Dysfunctional facial recognition and 2008. disconnection between right frontal and 2. Christodoulou GN. Delusional temporolimbic areas have been postulated.8 Misidentification Syndromes. Basel: A psychodynamic explanation that focuses Karger; 1986. 3. Arisoy O, Tufan AE, Bilici R, Taskiran S, on definition of identity too has been Topal Z, Demir N, et al. The Comorbidity postulated as a mechanism behind the origin of Reduplicative Paramnesia, of DMS.9 Being brought up by a dominant Intermetamorphosis, Reverse- father, who demands complete submission Intermetamorphosis, Misidentification of even from an adolescent son, might have Reflection, and Capgras Syndrome in an resulted in alterations in this patient’s Adolescent Patient. Case Rep Psychiatry concepts of identity. Fathers’ habit of 2014; alcohol consumption and resultant http://dx.doi.org/10.1155/2014/360480 disrupted family environment too could 4. Gibson RC, Lowe GA, Morgan KA, have been a contributing factor. Henryl M, De La Haye W, Irons A. Capgras syndrome presenting in an Zanker reports that most cases of DMS are adolescent girl in the Caribbean. West refractory to treatment with available Indian Med J 2013; 62:95–8. antipsychotics.10 This indicates that the 5. Förstl H, Almeida OP, Owen AM, Burns presence of DMS is an indicator of symptom A, Howard R. Psychiatric, neurological severity and unfavorable prognosis. In this and medical aspects of misidentification

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Source of support: None Conflict of interest: None declared Consent: Informed written consent was obtained from patient’s mother for reporting this case.