CASE
Shared delusional disorder: a case report of folie a famille
Prosenjit Ghosh
Assistant Professor, Department of Psychiatry, Silchar Medical College Hospital, Silchar, Assam, India
Abstract
Induced delusion of having syphilis in the two members of a family from the elder sister who had no past history of psychiatric illness. Early diagnosis, antipsychotics, and physical separation showed marked improvement within two months. The psychopathology and socio-demographic variables showed marked variation from earlier concepts regarding the shared delusional disorder.
Ghosh P. Shared delusional disorder: a case report of folie a famille. Dysphrenia. 2014;5:141-4.
Keywords: Hypochondriasis. Sexually Transmitted Diseases. Assam.
Correspondence: p_ghosh72@yahoo.com
Received on 15 December 2013. Accepted on 12 May 2014.
Karl Jaspers (1883–1969) contributed significantly on the phenomenology and psychopathology of delusions,[1] and his work continues to influence the views of many psychiatrists. From the 1970s onwards, interest in paranoia began to reappear[2-4] and in 1987, the revised third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R)[5] renamed it delusional (paranoid) disorder, now simplified to delusional disorder in the fourth edition (DSM-IV)[6] and the tenth revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10).[7] Delusional disorder has many subtypes based on the theme of the delusion. The somatic delusional disorder is also known as monosymptomatichypochondriacal psychosis. Hypochondriasis refers to a persistent conviction of illness in absence of any evidence of illness. Hypochondriacal delusional disorder may have various themes involving delusion involving skin, delusion involving bodily shape, delusion of bodily odour, and delusion of having sexual disorders.[8]
Delusion of sexually transmitted disease[9]
Hypochondriasis is, of course, rampant around the topic of sexually transmitted disease. A subgroup of delusional disorder patients develop the conviction that they have venereal disease, often when there is no evidence of risk-taking behaviour having occurred. In the past, syphilis was probably the greatest fear; but nowadays, it is usually acquired immunodeficiency syndrome (AIDS). There are complex psychological and social issues that impact a family’s ability to cope with human immunodeficiency virus (HIV)/AIDS infection.[10] Repeated tests showing negative serology have no reassuring effect.
Shared delusional disorder
A delusional disorder shared by two or more people with close emotional links. This phenomenon is listed as a psychiatric disorder in DSM-IV (shared psychotic disorder, 297.3)[6] and in ICD-10 (induced delusional disorder, F24).[7]
Folie à deux is a venerable term used to describe a situation in which mental symptoms, usually but not invariably delusions, are communicated from a psychiatrically ill individual (the ‘primary patient') to another individual (the ‘secondary patient') who accepts them as truth. However, à deux may sometimes be a misnomer since several people can be involved, and then we read of folie à trois, folie à plusieurs, folie à famille etc.
This report looks at an unusual case of three members of a family developing a somatic delusional disorder with the theme of having sexually transmitted disorder.
Case report
Mrs. A, young female of rural background , aged around 28 years, separated from husband for last one year after seven years of marriage, childless, and presently living in her paternal house with parents, brother, and sister-in-law, was referred for psychiatric consultation by a general surgeon. Her complaints were persistent lower abdominal pain, itching in the genital area, and a sensation of germs crawling under the skin of her lower abdominal and genital area for last six months. Because of her persistent complaint, she had undergone two abdominal operations in last six months – exploratory laparotomy and cholecystectectomy. But her symptoms persisted, although she can perform her daily activities and had intact interpersonal relationships.
She had no past history of psychiatric illness; there was no family history of psychiatric illness either. Her birth, developmental milestones, and early childhood history were normal. The family was very close knit and they used to take food together even from the same utensil. She studied up to class eighth standard. She had no history of substance abuse, married but separated, had no premarital or extramarital sexual experience. She had no child and gives a history of irregular menstrual cycle. Premorbidly she was cheerful, religious, was dominating, and had good moral values.
Her mental status examination revealed an encapsulated delusion of being infested with the virus of syphilis. She had a strong conviction about her delusional belief and the negative results of multiple Venereal Disease Research Laboratory (VDRL) tests could not shake her belief. She said that at night the germs crawl under her skin and comes out of her vagina. She also believed that the virus is responsible for her infertility, weakness, and white discharge per vagina. She also had an anxious mood. Her cognitive functions were intact. She was diagnosed as a case of delusional disorder, somatic type. She was put on aripiprazole 15 mg at night and other supplementary medicines. She received various psychological inputs. She was also given psychoeducation about the nature of illness.
Mr. B, brother of Mrs. A, aged about 26 years, had also come for consultation on the same day. His complaints were weakness, lethargy, loss of appetite, abnormal sensation under the skin of lower abdomen and lower limbs, and tingling sensation in the feet for last five months. He had no significant past medical or psychiatric illness. He was a driver, married, had one child, and had no history of substance abuse, no history of sexual exposure to sex workers.
On mental status examination, the findings were anxious mood, somatic preoccupation, a somatic delusion of being infected with the virus of syphilis. He said that in their household they take food and water from the same utensils. He was very close to his sister and they often drink water from the same glass, and he is convinced that the virus entered his body through water from the mouth of his sister. He said that the abnormal sensation in his skin is due to the movement of the virus. He had no perceptual abnormalities and had normal cognitive functions. He was diagnosed as a case of somatic delusional disorder. He was put on aripiprazole 10 mg at night and psychoeducation was given.
Mrs. C, wife of Mr. B, aged about 21 years, housewife, had come with the complaints of weakness, abnormal sensation in the lower limbs and lower abdomen, nervousness, loss of appetite for last four months. She had no past or family history of psychiatric illness. She was married for last three years, had one child, and had no history of pre or extra marital sexual relationship. Her physical examinations were normal. Her mental status examination revealed anxious mood, somatic preoccupation, somatic delusion of being infected with the virus of syphilis. She showed multiple black spots on the sole of her feet as evidence of the infection. She also said that at night her sufferings were more. She was convinced that she acquired the infection from her husband through food. Her blood investigations were normal. She was diagnosed as a case of somatic delusional disorder. She was put on aripiprazole 5 mg daily.
Mr. B and Mrs. C were advised to stay away from Mrs. A for thirty days. On follow up after thirty days, there was remarkable improvement in Mr. B and Mrs. C. Mrs. A was also showing improvement. After eight weeks, all the three cases were much improved. After six months, Mrs. A was on aripiprazole 5 mg daily, and the other two patients were not on any medications, all were improving.
Discussion
Harvey described the first case of phantom pregnancy associated with induced psychosis in two sisters in 1651; the term folie à deux dates to a classic report by Lasègue and Falret in 1877.[11] In 1942, Gralnick[12] published a classification of four folie à deux subtypes. These subtypes are as follows:
Subtype A is termed folieimposée. The delusions of a person with psychosis are transferred to a person who is mentally sound. Both persons are intimately associated, and the delusions of the recipient disappear after separation.
Subtype B is termed foliesimultanée. The simultaneous appearance of an identical psychosis occurs in two individuals who are both intimately associated and morbidly predisposed.
Subtype C is termed folie communiqué. The recipient develops psychosis after a long period of resistance and maintains the symptoms even after separation.
Subtype D is termed folieinduite. New delusions are adopted by an individual with psychosis who is under the influence of another individual with psychosis.
Our cases met the current operational criteria for shared delusional disorder as described in DSM-IV and ICD-10. Mr. B and Mrs. C were closely related with Mrs. A, and were staying together for a considerable period time. Both Mr. B and Mrs. C had no prior history of psychiatric illness, and the contents of their delusional belief were identical to that of Mrs. A. Temporal evidence shows that delusion was transferred to Mr. B and Mrs. C (secondary) by close contact with Mrs. A (primary). The conviction level was highest in the primary (Mrs. A) regarding the delusion of being infected with syphilis; she also needed higher doses of antipsychotic for a longer period. Both the secondary cases (Mr. B and Mrs. C) showed remarkable improvement after separation from the primary, and they also needed lower doses of psychotropics for a shorter period. In fact, Mrs. C had weaker conviction level regarding her delusion. Folie a famille is said to be present when more than two members of the same family are involved. So, the three members of the same family developing similar delusional belief in close proximity fulfill the criteria to be called shared delusional disorder, folie a famille, imposee subtype.
Although the phenomenon of shared delusional disorder is not very common, recently they are being increasingly reported. A case of folie a deux was reported earlier from India, which occurred in non family members.[13] Ramachandran and Manickam[14] described a case of induced delusional disorder or folie a deux in a 19-year-old girl from India whose 16 years old younger sister had paranoid schizophrenia. Netto[15] from Pune reported a case of folie a deux, where 64 years old male Mr. X and his 53 year old wife Mrs. Y were brought by their relatives. They were married for the last twenty five years, and both shared persecutory ideas against their cook and neighbours. The couple felt that they were plotting against them to kill them and take away their ancestral property. Bora and Baruah[16] reported an interesting case of four children of the same family of Merapani area of Golaghat district of Assam near the Nagaland border, who were living in the most unusual way in their rooms day and night without any interaction with any person except with the mother since about eight to ten years. Netto and Shah[17] described a case of shared delusional disorder, where a 60 years old father transferred his persecutory delusion to his wife and one daughter.
Contrary to earlier belief, it has been shown that shared delusional disorder can affect any age group. Lazarus,[18] reviewing fifteen twin case reports, found one of the partners to be 20 years of age. In case of Merapani children, the age of onset was about eight to ten years.[16] Dodig-Curković et al.[19] presented a case of folie à deux in which paranoid delusions were shared by a mother and her 15-year-old son. In our case, all the three subjects are young adults. Out of the three cases, two were females and one was male. The primary was elder to both the secondaries. In most of the cases reported from India, the inducer was elderly to the acceptor. However, Ramachandran and Manickam[14] reported a case where the inducer/primary was younger to the acceptor/secondary.
Our subjects had close emotional relationship. The primary was the dominant person among the three. The relationship of the affected was sister-brother and sister-in-laws. This may explain that both genetic/early childhood experience and environmental factors are important in the causation of shared psychotic disorder. The relationship between the inducer and the induced has been traditionally viewed in terms of a dominant-submissive axis. Dippel et al.[20] also described a case of folie a six, where the delusion of the central figure was transmitted to her husband, two sons, sister-in-law, and nephew. However, our subjects were not socially isolated, and had almost normal social functioning. Dippel et al.[20] also did not find any adverse social or environmental circumstances. Shimizu et al.[21] examined demographic data of shared delusional disorder case reports published from the 19th to the 21st century, and found that some of the earlier hypotheses, such as females being more susceptible, older and more intelligent individuals are more likely to be inducers, and sister-sister pairs being the most common relationship, were not supported.
Our cases had a delusion of being infected with the virus of syphilis. To the best of our knowledge, there is no published report of shared delusional disorder involving the theme of sexually transmitted disease. Majority of the reported cases of shared delusional disorder involve persecutory delusions.[16,22,23] The dominating primary case is most commonly represented by persons with schizophrenia, delusions, or mood disorders. In Western countries, both the original delusions in the dominant person and the induced delusions in the submissive person are usually chronic, and either persecutory or grandiose in nature. In Japan, acute psychotic reactions have been noted to be delusions of a religious nature.[24]
None of our cases had any past or family history of psychiatric illness. Most of the earlier reports had found past history of schizophrenia, psychosis, or personality disorder in the inducer/primary case.[14,15] Our cases had significant improvement within six weeks of treatment; reason may be lack of past history of psychiatric illness and separation of the primary case from the secondary cases. We have used antipsychotics and psychotherapy along with physical separation. Bankier,[25] following the traditional literature, recommends physical separation, antipsychotic medication, and psychotherapy to treat folie à deux. Medications administered along with psychotherapy accelerate the process of recovery.
Conclusion
Our case report emphasises the following points needed to be remembered by a psychiatrist: Shared delusional disorder is not uncommon. If not properly diagnosed, the patients may undergo unnecessary investigations and procedures. The role of family in sustaining delusional belief should be addressed. The phenomenon of shared delusional disorder can occur in absence of social isolation, past history of psychiatric illness, and subnormal intelligence. Both genetic and environmental factors are important in the causation of such disorders. The shared delusional disorder can affect any age group. The management should include drug therapy, psychotherapy, and physical separation if needed.
Source of support: Nil. Declaration of interest: None.
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