Folie a trois: atypical presentation as shared transient psychotic episode.

Shared psychotic disorder or induced delusional disorder can occur in different clinical settings and profile and is not uncommon. A case of Folie a trois with atypical clinical presentation as shared acute transient episode in a bereavement setting is reported. Suggestibility, close association and intimacy of the affected persons and major stress as psychological trigger act as psychopathological factors.

INTRODUCTION

Shared sychiatric isorder (SPD) is defined as “the transfer of delusional ideas andor abnormal behavior from one person to another or one person to several others related or unrelated who have been in close association with the primary affected person” (Granlnick, 1942).[1] Lasègue and Falret first described the phenomena of the transference of delusional ideas from a ‘primary’ affected individual to one or more ‘secondaries,’ in close association. They coined the term Folie à Deux.[2] This syndrome is known by various names such as communicated insanity, contagious insanity, infectious insanity, psychosis of association, and double insanity. ICD-10 adopts the term ‘Induced delusional disorder’ (ICD-10),[3] and DSM-IV uses the term ‘Shared psychotic disorder’ (DSM-IV).[4] Terms like ‘Folie Imposée’, ‘Folie Simultanée,’ ‘Folie Communiqué,’ and ‘Folie Indiute’ designate subtypes of the phenomena of ‘Folie à Deux’.[5] It can extend from original subject to three, four, five persons or even a whole family.

In ICD-10 induced delusional disorder is diagnosed when two people share the same delusion or delusional system and support one another in this belief. They have unusual close relationship. There exist temporal or contextual evidence to indicate that delusion was induced the passive member by contact with the contact partner.

DSM IV TR defines shared psychotic disorder to consist of delusion developing in an individual in the context of close relationship with another person or persons, who have an already established delusion. The delusion is similar in content to that of the person who already has an established delusion. The disturbance is not better accounted for by another psychotic disorder (E.g. Schizophrenia) or a mood disorder with psychotic features and is not due to the direct physiological effects of a substance (E.g. Drug abuse, medication) or a general medical condition.

In DSM-5 shared psychotic disorder is listed under Other Specified Schizophrenia Spectrum and Other Psychotic Disorder (298.8 F28). It is labeled as “delusional symptoms in partner of individual with delusional disorder.” It makes a note that “in the context of a relationship, the delusional material from the dominant partner provides content for delusional belief by the individual who may not otherwise entirely meet criteria for delusional disorder.”[6]

CASE REPORT

Trio I — Mr. S (Primary)

Mr. S is 36-years-old graduate male, working in Indian Oil Corporation as Quality Control manager (Calcutta) for the past two and half years. He is married for the past 10 years and is a consanguineous love marriage. His wife is a handicapped person and house wife. They have no child. Presently, for the past two and half months, the pt and wife are separated due to her extra marital affairs and the resultant misunderstanding with him. He is a sensitive, innocent, hard-working person. Due to separation of his wife, he is depressed and worried. There is a strong emotional bond between him and his sisters as well as his parents, especially with his mother. For the past few months, he is staying with his parents. He is deluded that his wife did black magic and foul play on him and his mother.

Trio II — Mrs. M

She is 34-years-old housewife with a postgraduate degree in Tamil. She is married for the past 11 years. Her husband is a civil engineer at Chennai. She has two children — one son studying sixth standard and one daughter studying second standard. Basically, she is a soft-hearted person. Since childhood, she is very much attached to other two siblings and her mother. She has a habit of taking every issue deep into heart and brooding on it continuously. She usually does not share any conflicts or sufferings.

Trio III — Mrs. Su

She is 28-years-old graduate housewife. She is married for the past three years and stays at Chennai. Her husband works as a regional manager in a private company at Chennai. She has two-years-old son. Basically, she is a soft-hearted person. She is very attached to other two siblings and her mother since childhood. She has a strong emotional attachment towards her mother, and she is the youngest one in the family.

Evolution of symptoms and illness

Mr. S stays with his parents for the past three months because of the problem with his wife. He is deluded that his wife has done black magic and foul play on him and on his mother. Mother of Mr. S fell sick due to febrile illness (chicken pox). During the illness, she threw a convulsion and subsequently she died. Mr. S felt that the illness of his mother and the fits were due to black magic and foul play by his wife. Mr. S was by the side of his mother at the time of her last breath of life. Mr. S saw a black image coming out of his mother's body, and this figure was haunting in the room. He manifested acute panic episode and was rolling on the floor shouting. He became very apprehensive and felt that there was an impending danger to him and other family members due to the black image that has come out of his mother's dead body. He strongly felt all these were due to the foul play by his wife.

Mr. S sisters, Mrs. M and Mrs. Su arrived by evening to attend the funeral of their mother. When they arrived, Mr. S become again panic while narrating to his sisters what all happened. Both sisters out of grief and bereavement became panic and restless. They also started to visualize a black image daunting and haunting in their house. They too strongly attributed the death of their mother to the foul play manifested and the evil spirit sent by wife of their brother.

The funeral of their mother took place; she was buried because her death happened during the phase of chicken pox. Usually, in their family, burning ritual should have happened.

On the same night, Mr. S, Mrs. M, and Mrs. Su, all three slept in the same room. All the three were feeling panic, restless, and experiencing the impending danger to their life waiting to happen. They were holding each other's hand tightly and almost hugging each other to escape from panic and danger. Spending sleepless night, Mrs. Su felt that her eyes were squeezed and she could not move her eyes and attributed it to the effect of evil soul in the house. She woke up the other two. There was an enactment pain situation and scene. The restlessness and agitation persisted next day also. Mrs. Su had a phoneme commanding her to run away from home. This was repetitive, and she expressed this to two others. To escape from impending danger by the black image and black soul that has come out of the dead body of their mother, they decided to leave the home. All the three left the house unaware of others holding each other's hands together and almost hugging each other. Their bizarre and disorganized behavior was very obvious to the onlookers. Travelling by an auto, they reached Nellai bus stand. All the three boarded a bus bound to Madurai, the city at a distance of nearly 120 kilometers from Nellai.

This was conveyed to the family members of Mr. S by a well-wisher of the family who was witnessing the bizarre and disorganized behavior of the three. Mrs. Su's husband informed this information of the travel of the three to one of his friends at Madurai with a request to guard them once they reach the destination at Madurai, and fortunately this friend was able to do so.

The disorganized behavior was persisting, and all the three refused to follow the rescuer. The rescuer sprinkled turmeric water onto them, and subsequently was able to put all the three in a taxi. All the three by this time started to get an instructive voice from her mother that they should reach Sreedi (Sai Baba temple) to protect themselves from the evil soul that followed them at Madurai too. They resisted the return to their house at Nellai. The whole night, all three were inside the car, and Mr. S insisted to go around Madurai streets. They refused to get out of the car in fear of impending danger to their life. All the three were chanting a Hindu ritual rhyme (in Tamil) “Kakka Kakka” (Meaning: Please save and protect us). They changed their dress in car itself. They didn’t sleep the whole night, and by this time, the husbands of Mrs. M and Mrs. Su arrived. With much difficulty and efforts, they were admitted in Ram Psychiatry Hospital for management of their disorganized behavior and illness.

COURSE OF ILLNESS IN THE HOSPITAL

All three Mr. S, Mrs. M, and Mrs. Su were hospitalized. Mrs. M and Mrs. Su were kept in a room and Mr. S in another separate room. Initially, they resisted staying in different rooms; however, they later accepted to be so. Psychiatric assessment of Mr. S revealed that he had a predominant delusion of foul play by his wife onto him and to his family (Primary or Inducer). He had a mood of fear and apprehension and felt possessed by evil spirit. He had hallucinatory comments from the evil spirit. He experienced impending danger to his life. Tendency to become aggressive and to weep was evident. Psychiatric assessment of Mrs. M and Mrs. Su was almost the same. Both shared the delusions of foul play and other psychotic disorganized behavior of the primary. There was no h/o substance abuse, any physical illness or past h/o psychiatric illness in any one of the three. All were subjected for physical investigations like hemogram, ECG, and EEG. These were non-contributory.

They were started on mild dose of risperidone and clonozepam. During their stay, they had supportive psychotherapeutic sessions. After three days of separation from each other and other management, the acute symptoms subsided. Later, all three were allowed to interact with each other and to be in the same room. Most of the symptoms were controlled by the seventh day. However, the delusions of foul play persisted in all the three. They were discharged to attend the eleventh day ritual ceremony of their deceased mother. They reported for follow-up treatment after a week. All three felt relaxed; they did not manifest any of the earlier symptoms like impending fear and apprehension of danger to their life. However, the delusion in the primary persisted.

DISCUSSION

Dewhurst and Todd described Folie a deux consisting of definite evidence that the partners are in intimate associations. There is high degree of commonality in the content of delusions, although the formal psychosis may differ. There is unequivocal evidence that the partners share support and accept each other's delusion.[7]

Folie a deux may be a way of coping with hostility and aggression. Western studies emphasize social isolation, especially in women, and this is conducive to the development of psychosis of paranoid kind. The role of imitation and sympathy also contribute to Folie a deux. The dominant partner uses the powers of suggestion to convey his/her delusions to the weaker partner. Exposure to the primary partner acts as a psychological trigger for a transient psychotic phenomenon; several other factors like superiority in age, intelligence, education, and aggressive drive may contribute the development of induced delusional disorder. These factors manifest in the present case study.

Case studies of Folie a deux in different clinical settings and with different clinical profiles have been reported by various Indian authors.[89101112]

The present case report illustrates the occurrence of Folie a trio in a bereavement situation in a brother and two sisters who were closely and emotionally knit together, and all three have extreme affection and dependency on their mother. The death of their mother due to febrile illness is a marked stressor to induce a bizarre disorganized behavior. Suggestibility and close association of the primary and persons resulted in sharing of the delusion by the two younger sisters of the elder brother. All the three manifested grossly disorganized behavior, speech, hallucinations, and tendency to run from pulled up forced to escape from fancied impending fear. These symptoms are acute and abrupt in onset. The clinical presentation of the illness in all three was one of acute transient psychotic episode. With therapeutic measures, the symptoms psychotic phenomena abated. The ritual ceremonies on the eleventh day of their deceased mother helped for further improvement and recovery from the illness.

Bizarre and disorganized psychotic behavior occurs commonly in a bereavement setting. Somatic distress, preoccupied image of the deceased, guilt feelings, hostile reaction, and loss of previous pattern of conduct were reported to be common symptoms in bereavement.[13] Marris (1958) recorded five reactions that occurred following bereavement — lasting deterioration in health, difficulty in sleeping, loss of contact in reality, withdrawal, and hostility.[14] The present case reported meets the criteria of acute transient psychotic episode with a disorganized bizarre psychotic behavior and the delusions of foul play being shared by three of the family members, one elder brother and two younger sisters.

The occurrence of the phenomenon of Folie à Deux should alert the clinician to investigate the presence or monitor the development of psychiatric illness in the secondary. Separation is often the treatment option most advocated, but it may be inadequate or insufficient. Patel et al. have reported that separation of the dyad or more does not always result in disappearance of psychopathology.[15] To conclude, Folie à Deux can occur in many situations outside the confines of current diagnostic classification systems, and is perhaps not as rare as is believed.