European Review for Medical and Pharmacological Sciences 2022; 26: 5362-5366

Shared psychotic disorder – a case study

of folie à famille
S. IVANOVIC KOVACEVIC1,3, V. SOBOT2,3, A.M. VEJNOVIC1,3, V. KNEZEVIC1,3

1
Department of Psychiatry and Psychological Medicine, 2Department of Psychology, Faculty of
Medicine Novi Sad, University of Novi Sad, Novi Sad, Serbia
3
University Clinical Center of Vojvodina, Clinic of Psychiatry, Novi Sad, Serbia

Abstract. – BACKGROUND: Folie à famille is portant to separate persons who share this disorder
a rare form of shared psychotic disorder. It is de- within the treatment. This psychiatric phenome-
fined as the transfer of delusions from one per- non can also occur in a larger number of people
son to another.
CASE REPORT: This paper presents a case
when they belong to isolated groups. There are no
of shared psychotic disorder in two brothers, controlled studies on induced psychosis because
aged 16 and 17 and their mother who were ad- the involvement of multiple family members in
mitted on the same day at the Clinic for psychi- the disease reduces the possibility of a critical
atry. The inducer was a mother, suffering from family member initiating a visit to a psychiatrist.
schizophrenia. She transferred her delusions to This disorder often goes undiagnosed because it
her sons. Both boys produced mostly the same involves persons who generally don’t have in-
paranoid delusions, that the others have been
recording and monitoring them since their fa- sight into their mental illness. Therefore, it is not
ther died. After few days, the older boy, who had uncommon for people with induced psychosis to
more severe psychotic symptoms, was treated be discovered by accident, when seeking other
with aripiprazole, while both received anxiolyt- medical care, in a lawsuit or by engaging the local
ics in low dosage. community. We lack data on the real frequency
RESULTS: We observed a withdrawal of psy- of this disorder. Although the overall disorder is
chotic psychopathology in both kids. Genetic
burden, social isolation and strong emotional
evenly distributed between male and female pa-
connection of family members are factors that tients, sisters are more prone to shared psychotic
have contributed to the development of shared disorders than other siblings1.
psychotic disorder in this case. In 1877, the term folie à deux was first intro-
CONCLUSIONS: The new approach of treat- duced by Lasègue and Falret. In 1942, Gralnick
ment for induced psychosis includes not only announced four subtypes of this disorder: subtype
separation from the primary case, but also spe- A - folie imposée; subtype B - folie simultanée;
cific pharmacotherapy. It is necessary to think
about this clinical entity, because this delusion- subtype C - folie communiquée; and subtype D -
al disorder needs specific treatment, with better folie induite2,3.
prognostic outcomes. The transfer of delusional ideas from one per-
son to another is a characteristic of this disorder.
Key Words: The most common disorder in the primary patient
Folie à deux, Induced psychosis, Paranoid delusions, is a psychotic disorder (e.g., schizophrenia), but
Psychopharmacotherapy. other diagnoses such as delusional disorder or
mood disorder with psychotic symptoms have
also been described4. The affected individuals
have an unconventionally close relationship. This
Introduction could be an explanation of a high incidence of in-
duced psychosis in twins (more often in sisters)
Induced psychoses belong to the group of de- due to shared biological factors4-6.
lusional disorders with specific characteristics, Previously, clinicians noticed that induced
although they are a rare psychiatric phenomenon. delusions disappeared in a secondary after sep-
They occur in closely emotionally connected per- aration from the psychotic person. However, it
sons, most often family members. It is very im- proved insufficient by few authors in the analyzed

5362 Corresponding Author: Ana-Marija Vejnovic, MD; e-mail: [email protected]

 Shared psychotic disorder – a case study of folie à famille

studies. Usually, separation from the primary is not want to let her in, while later she changed her
followed by recovery of the secondary with the decision. The social worker saw the mother was
use of antipsychotic drugs3,7,8. sitting in the dark room, with heavy curtains on
In the current revision of DSM-5 (Diagnostic the windows. Older son’s room was also in the
and Statistical Manual of Mental Disorders), in- heavy dark as well. He refused any sort of com-
duced psychosis is singled out as a separate entity, munication. The younger son spoke with her for
and it is included in the section “other specified a while and claimed that the unknown people
schizophrenic spectrum and other psychotic dis- were recording and monitoring him. Both boys
orders”9. International classification of diseases produced mostly the same psychotic delusions,
(ICD-11) classifies this illness as a delusional dis- such as impressions that the others have recording
order instead of a separate category in ICD-1010 and monitoring them since their father died (he
(Table I). committed suicide by hanging seven years ago).
They made these conclusions because they felt
that classmates were ironic and segregated them.
Case Report Brothers had strong beliefs that they saw each of
them often on the TV and that there were a lot of
The case study is based on an insight into the TV shows about them.
medical records of family members during their They believed that other kids could get un-
treatment at the Clinic for psychiatry. Insight and der control of their behaviors, communicate their
analysis of reports of prescribing psychiatrists proper thoughts, and know exactly what they think
during their post-hospital treatment were per- at each moment. The only difference between the
formed for one year. Informed consent was ob- kids was that the younger boy still attended the
tained from the mother for this case study, at the school, while the older abandoned it (because of
time of her post-hospital treatment, when remis- these psychotic delusions).
sion and critical insight into her own disorder was At the beginning, after their admission to the
achieved. All information about family members hospital, both produced psychotic psychopathol-
is presented in a way that preserves their anonym- ogies, with paranoic delusions. The older one
ity, in order to ensure the confidentiality of the in- produced hallucinatory behavior. The PANSS
formation. The Ethics Commission of the Clinic score was 92 for older boy (Positive scale 16,
for Psychiatry obtained the consent for the case Negative scale 16, General psychopathology
study and publication of this manuscript. scale 36). The older boy was treated with aripip-
Two brothers, aged 16 and 17, were admitted razole in a dose of 5 mg, both received anxiolyt-
to the Department of Child and Adolescent Psy- ics in low dosage, and in both kids was a with-
chiatry on the same day as their mother, who was drawal of psychotic psychopathology. During
hospitalized at the Clinic for Adult psychiatry. the hospitalization, they did not have any com-
They arrived in an ambulance car followed by a munication with their mother.
doctor and a specialized consultant social work- Analyzing their genogram, a distinct hered-
er, who provided the information that the mother itary psychiatric burden is visible. Their father
had sent a letter to the Governments with high and suffered from paranoid psychosis, and he com-
main authorities, in which she claimed that there mitted suicide, while his maternal aunt suffered
were plenty of unknown people in her street, who from schizophrenic psychosis, and she tried to
followed and observed her, as well as recorded commit suicide. Her mother suffered from schizo-
her communication with other people. She asked phrenic psychosis as well. The psychological tests
the protection from the High Government author- showed that the older boy had a very vulnerable
ities on the basis of her basic human rights. The personality and the possibility to react with psy-
High government office sent a letter to the region- chotic disorganization, with actual impaired im-
al Center for social work to investigate what was pulse control. The psychological tests showed no
really happening. Social worker, based on this subclinical psychopathology for the younger boy.
letter, went to the school, where she found out Both could not elaborate on their own psy-
that both boys were very good students until two- chotic delusions, and they made the distance from
three months ago. Meanwhile, the older brother them. It was very notable that they were so ig-
stopped going to school, while the younger one norant because of hospitalization. After the ther-
stopped learning. After that, the social worker vis- apeutic suggestions, they accepted the possibility
ited the children’s house. Firstly, the mother did that psychotic delusions were induced by their

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 S. Ivanovic Kovacevic, V. Sobot, A.M. Vejnovic, V. Knezevic

Table I. Traditional and recent views on shared psychotic disorder3,4,11.

Traditional Views Recent Views
Females are more likely to be affected Equal distribution between sexes
Younger individuals are more likely to be affected Equal age distribution
Vulnerable relationships are between two sisters, spouses, mother Equal incidence in married/common-law
and child, two brothers, brother and sister, pairs of friends, whole families couples and siblings
Lower intelligence level in the secondary in comparison with the primary No differences in the level of intelligence
Similar delusions between primary and secondary Different delusions might be experienced
Separation from the primary is sufficient treatment Separation from the primary is insufficient.
Separation from the primary and
antipsychotics administration are required

mother. They went home for a weekend with their experience of shame in siblings due to the suicide
grandmother, and everything went well. After a of the father contributes to their increased social
few days we contacted their mother with a strong withdrawal, hypersensitivity, and anticipation of
support of our colleagues at the Clinic for Adult the hostile attitude by other people from the im-
Psychiatry. She showed a good recovery at anti- mediate social environment. The suggestive and
psychotic therapy. After a few weeks, all the fam- dominant influence of the mother, as the only
ily went home. They were monitored by region- parent figure, who has been treated for paranoid
al Center for social work. Both boys returned to schizophrenia for many years, culminates in chil-
school and finished the year with excellent marks. dren in a particularly sensitive adolescent phase
They also referred us to relative familiar harmony. of development, when uncritical adoption of the
The older boy was treated with aripiprazole for mother’s delusional ideas occurs16. Very similar
one year and after that the pharmacotherapy was clinical picture was developed in both brothers.
discontinued. After this period, we have no data All family members have the experience of being
on further psychiatric treatment and the course of monitored, observed, and persecuted by people in
the disease. their social environment. The older brother was
completely isolated from the social environment,
by dropping out of school.
Discussion Genetic burden and the existence of a pre-ex-
isting psychotic disorder in inducers, in accor-
Shared psychotic disorder is usually shared by dance with the data from the literature, proved
two people, while very rarely involves three or to be important in this case as well6,15. The older
more people (as in the case shown)5,11-14. A strong brother was found to have an introverted, sensi-
emotional connection between inducer and in- tive and vulnerable personality, predisposed to
duced person(s) is observed, as well as the time the possible development of psychotic disorders,
alignment of the occurrence of symptoms and in- which resulted in somewhat more diverse psy-
creased suggestibility of the induced patient8. chotic symptoms and complete social withdrawal
The described case of induced disorder cor- compared to the younger brother, more extrovert-
responds to type A, folie imposée. The primary ed in structure, and with no subclinical psycho-
person is the mother, and she imposes her delu- pathology continued to attend school and had no
sions on her sons. According to the data from the hallucinatory experiences. Due to the predisposi-
literature, in the described case of a single-parent tion of the personality, the older brother is at risk
family, with two siblings in adolescence, it is also of possible development of a psychotic disorder in
a more socially withdrawn family, with a weak the later stages of the life cycle.
social support network and more rigid borders The new approach to treatment for induced psy-
towards a narrower social environment15. Fami- chosis is the same as the treatment of other psychotic
ly members are emotionally close to each other. disorders4,8. The drugs of choice are atypical anti-
The traumatic event of the loss of the father, who psychotics. Aripiprazole, olanzapine and quetiapine
committed suicide seven years ago, affected the showed to be effective in these cases3,17,18. It should
increase in the cohesion of family members and be borne in mind that the response to therapy may
the orientation of the two brothers only to the be related to genetics. As there is a transmission of
mother in satisfying emotional needs. Also, the the disorder among relatives, there may be a genet-

5364
 Shared psychotic disorder – a case study of folie à famille

ic predisposition to respond to therapy, which some remission and critical insight into her own disorder was
research confirms19. According to recent treatment achieved. All information about family members is present-
ed in a way that preserves their anonymity, in order to en-
guidelines for induced disorder, a combination of sure the confidentiality of the information.
inducer separation and pharmacotherapy has been
implemented in the treatment protocol of the broth-
ers. The brothers were physically separated from Ethics Approval
their mother, after which there was an increase in The Ethics Commission of the Clinic for Psychiatry ob-
criticism and insight into their own symptoms. The tained the consent for the case study and publication of this
contact of the brothers with the mother was renewed manuscript.
only when there was a significant withdrawal of psy-
chotic symptoms in the mother as well.
As family members continue to live together,
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