Shared Psychotic Disorder (Folie À Deux): A Rare Case with Dissociative Trance Disorder That Can Be Induced.

BACKGROUND: Shared psychotic disorder was first introduced in the 19th century in France with the name Folie à deux. Since then, the concept of Folie à deux has been developed and produces several subtypes in France. In DSM, this disorder is called Shared Psychotic Disorder, and in ICD-10, it is called Induced Delusional Disorder. However, some of the classic subtypes of Folie à deux are not included in the above categories. CASE REPORT: We found a case of shared psychotic disorder between a 38-year-old male inducer, a Batak tribe with two female recipients, 34 and 36 years from the Batak tribe. They were found to share the same delusions and hallucinations, and inducers could make recipients into trance conditions. These three individuals did not get along with the surrounding community and often carried out activities and perform rituals together.
CONCLUSION: Overall, our case has some unique features of folie à deux. In this case, there is a trance condition that can be induced that have not been reported in the literature or case reports related to Folie à deux. Copyright:

Introduction

Shared psychotic disorder (SPD) is a psychiatric disorder that is very interesting and rare and not well understood. Because few individuals with this disorder seek medical help that causes individuals with shared psychotic disorder to be very rare in hospitals. Therefore the literature on this disorder consists mostly of case reports [1]. Shared psychotic disorder is characterized by the transfer of abnormalities and/or abnormal behaviour of someone who has suffered a psychiatric disorder (called Primary, Inducer or dominant partner) to one person or more (also called secondary, induced or recipient) who has close relationships and social isolation relative to the primary patient [2].

Another name for this disorder is Lasegue-Falret syndrome, or more commonly called Folie à deux, which was first introduced by French mental medicine specialist Charles Lasegue and Jean-Pierre Falret in 1877 [3], [4]. Lasegue and Falret explained in their paper entitled “la Folie à deux ou folie communique” regarding special conditions to enforce this disorder, in the form of [3], [5]: - Someone who acts as an active element is usually smarter than others; this individual has an understanding and gradually imposes it on the second person who is a passive element; - It involves two people who have the same life, in the same place, share the same way of life, the same feelings, the same interests, the same fears and the same hopes, and free from outside influences; and - The third condition for the transmission of this delusion is that this seems correct, and this is maintained by the possibility of actions in the past or maybe in the future.

In 1942, Gralnick published a research review entitled “Folie à deux-the psychosis of association”.He divided Folie à deux into four subtypes by adopting the concept of European history, the division of the four subtypes can be seen in Table 1 below [6], [7].

Table 1

Folie à deux subtypes according to Gralnick [6], [7], [8]

Subtype A- Folie imposée (Lasègue and Falret)	The symptom of delusion is transferred from psychotic individuals to healthy individuals psychiatrically	Healthy individuals usually provide little resistance in accepting these delusions and do not ask for much explanation, the separation from the inducer will cause the recipient to leave the delusion
Subtype B- Folie simultanée (Régis)	The same psychotic symptom is characterised by depression and persecutory delusions that co-occur in two individuals who tend to experience actual psychotic disease.	This subtype has no evidence of transmission from one individual to another, unlike other subtypes.
Subtype C- Folie communiquée (Marandon de Montyel)	The recipient experiences symptoms of delusion after holding or giving resistance for a long time	Symptoms persist even though the inducer is separated from the recipient.
Subtype D- Folie induite (Lehman)	New delusions are added to the delusions of pre-existing psychotic individuals under the influence of other patients	Inducers and recipients in this subtype both have their delusions.

Some scientists have questioned the usefulness and theoretical validity of the subclassifications mentioned by Gralnick above. However, this classification is at least relevant to describe the various patterns of clinical delusional communication between the subjects involved [7].

Folie à deux was first included in the third edition of the literature on the Diagnostic and Statistical Manual of Mental Disorders (DSM) with the name shared paranoid disorder, which later changed its name on DSM-IV into a shared psychotic disorder (SPD) [2], [9]. In the latest DSM-5, SPD has not considered a separate disorder but is included in the diagnosis of a delusional disorder or other specified schizophrenia spectrum and other psychotic disorder [10]. In Indonesia, national health insurance still uses coding from the International Classification of Diseases 10th Edition (ICD-10). In this ICD-10, folie à deux is called induced delusional disorder or induced psychotic disorder. This difference in naming is sometimes confusing in diagnosing, which depends on the literature used [11].

The incidence of shared psychotic disorder is reported to range between 1.7 and 2.6% inpatient admissions in mental hospitals; the original prevalence rate is still difficult to estimate due to the lack of reports and frequent underdiagnoses regarding this case. The aetiology of this disorder is still unclear, although much literature suggests a theory that there is a possible influence of genetic and environmental factors in the occurrence of this disorder, more research needs to be performed [2].

Case Report

A man Mr A, 38 years old, unmarried Batak tribe has a schizoid personality who has been living for ± 10 years, this delusion was initially in accordance with local culture but over time, the story of An increasingly absurd, Mr A claimed to be the husband of the ruler of the southern sea, namely Nyi Roro Kidul and he was married off by the Prophet Muhammad who had considered himself like his child, during the umrah several years ago, Mr A also claimed to have met Prophet Solomon and had been taken to the kingdom of Solomon near Borobudur temple. Mr A is also considered to be able to treat other people, and many patients come to him for treatment. Since the beginning of A experiencing this permanent delusion, A often experienced hallucinations and trances and often got ruqyah by his family. In this case, Mr A is a Primary or an inducer.

A woman Sg. 34 years old, a tribe of Batak, unmarried, has an anti-social personality who is often sick, is a patient who is considered cured, A appoints Sg to be a disciple and gives a title to Sg in his kingdom (Mr A is king because of Nyi Roro Kidul’s husband), A can share the visual and auditory hallucinations he experienced to Sg and slowly put his delusions into Sg so that Sg trusts and beliefs in these delusions.

Another woman Sn, 36 years old, Batak tribe, unmarried, Tomboy, having a sexual attraction to same-sex (Lesbians) experiencing depression due to family and business problems, going to A and also being appointed as a student by A and being knighted in his kingdom. A with this individual can also share the hallucinations they experience to Sn and slowly put the delusions they have into Sn so that Sn trusts and beliefs in the delusion.

Sg and Sn, in this case, are Secondary or recipient. Mr A besides being able to share hallucinations and delusions with Sg and Sn he also can induce Sg and Sn to experience Trance, Sg and Sn can be any individual according to A’s will in the trance condition. An Sg and Sn are often together in their daily lives and rarely get along with other people, they often hold regular meetings and rituals, and if A has called them whenever Sg and Sn will come. When all three are examined for mental status, they have attitudes and behaviour, orientation, power of concentration, memory, values, abstract thoughts and reasonable impulse control. From the explanation above, it was found that these three individuals had the same delusions of greatness, visual and auditory hallucinations that could be shared as well as inducers who at the time experienced delusions often experienced trance can also induce the trance in the recipient.

Discussion

In making a diagnosis of a disorder, it is necessary to pay attention to the diagnostic criteria of the disorder whether it meets the criteria or not, in this case, two diagnostic criteria are used, namely from DSM-IV and ICD-10 that use different terms to diagnose Folie à deux.

Based on the case report above, after a complete psychiatric medical history, clinical interview, psychological test and mental status examination were carried out and referred to the diagnostic criteria in Table 2, it was found that the three patients above met the diagnostic criteria of Folie à deux on the DSM-IV and ICD-10.

Table 2

Diagnostic Criteria for Folie à deux on DSM-IV and ICD-10 [7], [9], [11]

DSM-IV 297.3 Shared Psychotic Disorder (Folie à deux)

A. A delusion that arises in a person in the context of close relationships with other people, or some people, with pre-existing delusions

B. Similar delusions relate to their contents with people who already have this delusion

C. Disorders are not better calculated by other psychotic disorders (for example, schizophrenia) or mood disorders with psychotic features and not due to direct physiological effects of substances (for example, substance abuse and drugs) or general medical conditions

ICD-10 F.24. Induced Delusional Disorder (Folie à deux)

A. Two people share the same delusion or delusional system and support each other in this belief

B. They have a very close relationship

C. There is temporal or contextual evidence that delusion is induced in passive individuals through contact with active individuals

If classified according to the Gralnick classification in table 1 about Folie à deux, then this case report is consistent with the description of subtype A-Folie imposée (first described by Lasègue and Falret) where delusional symptoms are transferred from psychotic individuals to normal individuals and normal individuals do not give much resistance in accepting the delusion and not asking much for an explanation of the delusion. In relationships between individuals, the inducer usually has certain characteristics that place it in a dominant position. As reported in other case reports, inducers usually have an older age, higher intelligence with aggressive characters that are strong and highly suggestive while recipients are younger, dependent and lower intelligence inducers [1], [12].

Folie à deux which is accompanied by hallucinations that are shared quite frequently, while the presence of visual and auditory hallucinations may be transmitted by suggestions from inducers to recipients and in accordance with the theory that hallucinations can be caused by emotions, and the emotional process itself and the hallucinatory content is a reflection from emotional problems faced by individuals [13]. So that referring to this theory, it can be concluded that the appearance of hallucinations, in this case, is closely related to inducer suggestions to the recipient and emotional closeness of the three individuals so that all three are possible to share the same hallucinations. Also, social isolation plays an essential role in the emergence of these symptoms because the isolation of the recipient from the social environment will limit the information obtained by the recipient, which may conflict with the beliefs that are induced by the inducer. So in many cases, recipients often leave their delusions when separated from the inducer [12].

Trance condition that is shared or induced by an inducer is new in this disorder. As far as we know, there have been no case reports regarding Folie à deux accompanied by a trans-inducing condition. However, it can be possible that this condition is an abnormal behaviour that can be transmitted besides delusions in this case of Folie à deux. Folie à deux can develop in a cultural environment that is isolated from others, where the recipient responds to the abnormal behaviour of the inducer, which in this case is a trance condition. This disorder usually starts with a difference in strength and influence between the two, where recipients who experience symptoms of this disorder also play an active role in psychosis, they are involved in this condition because of personal interest, such as promising benefits, or the realisation of desire [14]. In this case, the trance condition is a condition found in the local culture called kesurupan. The isolation from the environment and the factors mentioned above and the feeling of being rewarded (in this case the inducer gave the title as a king) is a personal interest from the recipient so that the inducer can easily give his suggestion, in this case, he can induce the recipient to enter a trance.

Overall, our case has some unique features of Folie à deux. In this case, there was trans-inducing that have not been reported in the literature or case reports related to Folie à deux. In this case, we also found a link between environmental and cultural factors that affect the condition of the trance. Further research is needed to study and understand more about this disorder.