A case series of shared delusional infestation: folie à deux revisited.

Delusional infestation describes the unshakeable belief that one's skin is infected or infested with an external organism or inanimate material, in the absence of supportive medical evidence. It is one of the most challenging psychodermatological conditions to manage, given the rigidity of patients' physically focused health beliefs, and the competing need to introduce antipsychotic therapy to bring about resolution. This is rendered exponentially more complex when partners or family members are similarly afflicted. This situation is known as shared delusional infestation, shared psychotic disorder (SPD), or folie à deux. We present a series of three couples with SPD who were referred to our tertiary psychodermatology service during the same year. On examining the literature we were intrigued to discover that subtly different subtypes of SPD have been recognized since the late 1800s. These include folie simultanée, imposée, communiquée and induite. Our cases neatly demonstrate three of these variants, and highlight the difficulties in facilitating effective treatment.

Delusional sharing: a history focus-on and case report of folie à deux.

Folie à deux (FAD) is a clinical condition that was first described by Lasègue and Falret in 19th century. They reported a rare condition where two or more people shared delusional ideas from a person to another. Nowadays a trace of this historical diagnosis and its theoretical framework, could be found on ICD-10 where FAD is translated in "Shared Psychotic Disorder". Given the lack of literature and a well-defined set of symptoms it is hard to detect the clinical limits of FAD. Furthermore, the complex of comorbidities could lead to a misdiagnosis. In this paper we report a peculiar case of FAD with an historical focus trying to give a wider point of view and tools to recognize this unconventional psychiatric diagnosis.

The Psychotic Couple--Sharing Drugs or Delusions?

Mephedrone and methylenedioxypyrovalerone (MDPV) are common compounds found in "Bath Salts," a recreational drug which has skyrocketed in popularity, resulting in increasing annual emergency room visits across the country. As users are often young and without previous psychiatric history it is often difficult to discern if symptoms are substance induced or related to an organic disorder. Our patient was a 38-year-old woman with no history of psychosis who presented to the emergency room following two failed suicide attempts via overdose and self-mutilation. On initial examination, the patient was somnolent yet arousable and oriented. She endorsed auditory and visual hallucinations as well as paranoid delusions regarding being spied on by her son. Upon further questioning, patient admitted to use of bath salts one day prior to admission and urine toxicology was positive for phenycyclidine. She was admitted for stabilization but despite improvement in her hallucinations, her paranoia persisted. She was visited by her husband who also expressed similar paranoid delusions, raising the question as to whether her symptoms were truly substance induced or if the patient was experiencing a shared psychotic disorder with her spouse. Prior to discharge, her hallucinations and paranoia had improved with abstinence from bath salts and the initiation of olanzapine. She was able to gain some insight, recognizing the delusions were false yet her husband still continued to believe they were true. As such, we concluded that the couple's psychotic symptoms were more likely related to shared bath salts rather than shared delusions.

Comorbilidad entre folie à deux y trastorno del espectro del autismo de alto funcionamiento: a propósito de un caso / Comorbidity between folie à deux spectrum disorder and high functioning autism: report of a case

Los déficits persistentes en comunicación e interacción social y los patrones repetitivos y restringidos de conducta, actividades e intereses son las características clínicas que conforman los trastornos del espectro del autismo. En este contexto psicopatológico se describe el caso de un niño de 8 años que presenta una descompensación psicótica compatible con el diagnóstico de folie à deux, entidad psiquiátrica caracterizada por la transferencia de ideas delirantes y/o conductas extrañas de una persona a otra la cual ha mantenido una relación estrecha e íntima con el paciente afectado originalmente. En este caso, el sujeto afectado primariamente es la madre del paciente, como se evidencia tras las primeras exploraciones (AU)

Persistent deficits in social interaction and communication, and restricted, repetitive patterns of behavior, activities and interests are the clinical features that integrate the autism spectrum disorders. In this psychopathological context, is presented the case of an 8-year-old with a psychotic decompensation compatible with the diagnosis of folie à deux, a psychiatric disorder characterized by the transfer of delusional ideas and strange behavior from one person to other, both of them members of a close relationship. In this case, the "primary subject" is the mother of the child, as it is demonstrated in the first examinations (AU)

[Parental alienation syndrome (PAS): unknown in medical settings, endemic in courts]. / La sindrome di alienazione parentale: sconosciuta negli ospedali, endemica nei tribunali.

A purposed syndrome of so-called parental alienation (PAS), unsupported by any evidence-based data, unknown in medical settings, unquoted in medical books, absent in DSM and ICD, never demonstrated by controlled studies published in high scientific level journals, is rampant in Courts where it can lead to loose parental custody. During a divorce trial, almost always the mothers and the children, become joint in a sort of folie au deux, in a denigration campaign of ex-husband/father. From a review on this issue it seems evident its theoretical roots lie on a theory that justify gender violence and children sexual abuse. The bias that both of them are layers and that he children have not autonomy block their possibility of any defence in front of a Court. In severe cases, PAS becomes a new and efficient tool of intra-familiar violence. The treatment of severe cases is to stop any contact between mother and children. The resort to PAS in Courts must be strongly rejected.

Folie à deux: double case-report of shared delusions with a fatal outcome.

BACKGROUND: Treatment of shared delusional disorder (folie à deux) often involves separation and use of antipsychotic medication, with uncertain outcomes and potential risks. METHODS: We report on two highly interdependent and chronically psychotic sisters with shared systematic delusion, followed by psychiatrists over several years. RESULTS: The dominant patient was diagnosed with schizoaffective disorder and her non-dominant sister with paranoid schizophrenia. Both received antipsychotics and supportive therapy as outpatients and allowed to continue conjoint therapy with individual psychiatrists-therapists. They returned for follow-up visits for 20 months, when the dominant decided to continue treatment alone, as her sister gradually improved symptomatically and functionally. After separation, the dominant became increasingly anxious. She impulsively ingested an overdose of the non-dominant sister's medicines and died of cardiac arrest, despite her sister's efforts to seek medical assistance. The surviving non-dominant sister developed anxiety and increasing agitation requiring psychiatric hospitalization and increased pharmacotherapy. She improved gradually, but continued to be dysfunctional and required placement in a psychiatric inpatient unit for several months, eventually doing better in a community-based rehabilitative program with regular psychiatric follow-up. CONCLUSIONS: Combined treatment of patients with folie à deux may encourage continuous pathological interactions, but separation may increase risk of adverse outcomes.

["Folie à Famille", an interdisciplinary experience from a clinical and therapeutic stance]. / "Folie à Famille", una experiencia interdisciplinaria desde la clínica y la terapéutica.

UNLABELLED: Report of a learning process experience by Psychiatry residents in the Mental Health area of a public monovalent hospital of the province of Entre Ríos. This work is based on an analysis of roles played by interdisciplinary experiences such as Psychiatry, Psychology, Therapeutic Assistance, Social Work and Occupational Therapy as well as Clinical and Therapeutical perspectives (Psychosocial, Psychoeducational and Psycopharmacology), not only addressing the peculiarity of the "Folie à Famille" case but also the institutional, legal, locational and neighborhood level elements taking into account the development of the diagnostic and therapeutic strategies in the area of Mental Health. Clinical case report of the entire family from the legal admission to its final home and neighborhood reinsertion. Consisting of clinical diagnosis, legal, situational, social and therapeutic interventions during hospitalization, home and social networks restoring process, hospital release and support of outpatient treatment. A full review of the concept of "Folie à Famille" will be provided as described previously in the literature. METHOD: Observational analytic descriptive study.

[Shared psychotic disorder (Folie à deux) and Huntington's disease]. / "Induzierte wahnhafte Störung" (Folie à deux) bei Chorea Huntington.

INTRODUCTION: Folie à deux describes a rare psychiatric disorder of mostly closely related persons. The main feature of this disease is the unconditional adoption of the delusions of the primarily diseased person by the second person. This disturbance most frequently originates from a paranoid schizophrenia. METHOD: Our case is the first published description of a married couple with shared psychotic disorders which were caused by a genetically verified Chorea Huntington of the husband. RESULTS: The symptoms of the wife quickly declined after spatial separation from her primarily diseased husband. Thus, in her case it was assumed that she suffered from a Folie imposée which is a sub form of the Folie à deux. DISCUSSION: Our case report demonstrates that not only a paranoid schizophrenia but also an organic psychosis may cause this very interesting form of shared psychotic disorder.

[Folie à deux: update of an old concept regarding two cases]. / Folie à deux: actualités d'un concept ancien, à propos de deux cas.

INTRODUCTION: Folie à deux or induced delusional disorder is a rare mental disorder. It was initially described by the French Lasègue and Falret in 1877. Two subjects, who live in a close relationship, in isolation, share delusional ideas based on the same themes. Various classifications exist. Its epidemiology remains unclear, because most of the data have been extrapolated from case reports. CASE REPORTS: In this paper, we describe and comment two cases of shared paranoid disorder: in the first case report, a husband shares the paranoiac delusion of his wife; the second case report describes a shared paranoid disorder between a schizophrenic daughter and her mother. LITERATURE FINDINGS: A review of the existing literature is also presented. Some clinical characteristics arise, such as frequent mother-daughter associations and diagnosis of schizophrenia in inducing subject. Particular social and psychopathological conditions for the occurrence of a shared delusional disorder are described, such as personality traits and genetic influences. This article also reviews some forensic issues, which may be of importance, since this disorder is underdiagnosed. Data concerning the principles of its treatment are sparse, but most authors consider that the separation of the two subjects has to be the basis of any intervention. The inducing subject has to be treated with specific medical interventions, including the prescription of antipsychotics. Sometimes, the separation is enough to eliminate the delusional ideas from the induced subject, who, according to the ICD-10 and DSM-IV, is the only one to meet the criteria for shared delusional disorder. The case reports are discussed in light of the review, and some propositions for their treatment are made. CONCLUSION: As shared delusional disorder is a rare disease, only few data exist on its pathophysiology and mechanisms, and controlled studies are needed in order to understand its specific implications better and to define recommendations for its management.

Locura familiar: revisión clínica y a propósito de un caso / Folie a famille: clinical review and a case report

Introduction: Shared paranoia disorder, also known as folie à deux, is a fairly uncommon disturbance characterized by the presence of similar psychotic symptoms in two or more individuals. Most often the symptoms are delusional. The 'primary' case, the individual who first develops psychotic symptoms, can be distinguished from one or more 'secondary' cases, in whom the symptoms are induced. Usually two people are involved, although full family case reports are described. These cases are even more uncommon and more difficult to treat. Case report: We describe a case of folie a famille, this condition being a type of shared paranoia disorder. The case involves a father and his three sons and clinical picture appears after fourth son 's suicide The dead son is the primary' case, whilst his three brothers and his father are 'secondary' cases. The father was admitted to psychiatric unit for in-patient treatment. Conclusions: Treatment success was modérate in terms of improving the features of folie a famille in the four individuals involved. The first step for a right treatment is a right diagnosis. Social features and family relationships need to be consider.

Introducción: El trastorno psicótico compartido, también conocido como folie à deux, es un cuadro muy poco frecuente caracterizado por la presencia de síntomas psicóticos similares en dos o más individuos. Principalmente los síntomas son delirantes. El caso primario, el individuo que primero desarrolla los síntomas psicóticos se puede diferenciar de uno o más casos secundarios en los que los síntomas son inducidos. Lo más habitual es que participen dos individuos, aunque se han descrito casos que afectan a familias enteras, siendo estos cuadros muy poco frecuentes y con un abordaje más complicado. Caso clínico: Presentamos el caso de una locura familiar, un subtipo de trastorno psicótico compartido. El cuadro abarca a un padre y sus tres hijos y se desarrolla a partir del suicidio del cuarto hijo. El hijo fallecido constituye el caso primario mientras que sus tres hermanos y el padre son los casos secundarios. El padre es ingresado en la planta de psiquiatría. Conclusiones: El éxito del tratamiento fue moderado en el sentido de mejorar las características de la folie a famille en los cuatro sujetos implicados. El primer requisito para un tratamiento correcto es un diagnóstico correcto que tenga en cuenta aspectos sociales y la dinámica familiar.

[Folie à deux - mental infection or individual psychosis]. / Die Folie à deux - Psychische Ansteckung oder eigenständige Psychoseerkrankungen?

The phenomenon of folie à deux has been a topical issue in psychiatry for more than a century. Mainly, genetic and psychodynamic factors are discussed controversially in terms of their relevance to the etiology of folie à deux. In this paper, effort is taken to reconceive the topic applying the criteria of a differentiated psychopathological classification. Based on the literature and on two own cases, we try to elaborate characteristical psychopathological features of folie à deux patients. We hypothesize that at least a substantial fraction could be classified as "folie simultanée" when Leonhard's criteria of the affect-laden paraphrenia are considered.

Folie induite: relato de um caso à margem das classificações atuais / Folie induite: report of a case outside of the actual classifications

Na classificação de Gralnick, de 1942, a folie à deux é dividida em quatro subtipos básicos: folie imposée, folie communiquée, folie simultannée e folie induite. O último termo se refere à adição de novas idéias delirantes por paciente previamente psicótico sob influência de outro paciente. Relatamos um caso de folie induite ocorrido entre mãe e filho primariamente psicóticos (transtorno delirante e esquizofrenia, respectivamente), que passaram a compartilhar delírios de natureza persecutória e sexual. Casos de folie à deux geralmente correspondem ao transtorno psicótico induzido (DSM-IV-TR) ou transtorno delirante induzido (CID-10). No entanto, o paciente deste relato não pode receber tais diagnósticos, já que nos critérios validados atualmente percebe-se a exigência de que o parceiro induzido não possua um transtorno psicótico anterior ao início do compartilhamento do delírio. Consideramos que o presente relato exemplifica a insuficiência das modernas classificações nesta área. Casos de folie induite podem necessitar de manejo distinto dos demais casos de psicose compartilhada ou não compartilhada. Sugerimos que os critérios diagnósticos correntes poderiam ser revisados para incluir condições psiquiátricas como essa.

In the Gralnick classification of 1942 the term folie à deux is classically divided into four basic subtypes: folie imposée, folie communiquée, folie simultannée and folie induite. This last one refers to the addiction of new delusions in a previous psychotic patient, under the influence of another patient. We report a case of folie induite that occurred between mother and son, both diagnosed previously with psychotic disorders (delusional disorder and schizophrenia, respectively), who started to share persecutory and sexual delusions. Cases of folie à deux generally correspond to the induced psychotic disorder in the DSM-IV-TR or the induced delusional disorder in the ICD-10. However, our patient do not meet neither diagnosis, since, in both, it is necessary that the induced delusional patient do not have any previous psychotic disorder. We think that our report underscores the insufficiency of the modern classifications in this area. Cases of folie induite may require a management different from those used in other cases of shared or non-shared psychosis. We suggest that modern criteria should be revised to include cases such as the present one.

Shared obsessive-compulsive disorder.

BACKGROUND: Shared psychotic disorder (folie à deux) is an uncommon entity reported mainly in the context of delusions. Obsessions and compulsions occur very rarely as shared psychopathology. MATERIAL AND METHODS: We present two sisters who manifested shared obsessive-compulsive disorder. RESULTS: Both sisters were managed in keeping with their shared obsessive-compulsive disorder leading onto a similar pattern of response. CONCLUSIONS: Shared obsessions could represent the continuum concept of obsessions and delusions, and their relationship needs to be evaluated in greater detail.

Folie a trois in a multilevel security forensic treatment center: forensic and ethics-related implications.

Shared (Induced) Delusional Disorder commonly occurs in close relationships and involves a varying number of participants who may be nonconsanguineous. The disorder has been associated with forensic and fatal consequences. Its occurrence in three nonrelated, incarcerated individuals is described in this article. This case of folie à trois has forensic implications and raises several questions of ethics that relate to autonomy, confidentiality, safety, and risk estimation. The presentation, management, and outcome of the patients suggest that a high index of suspicion is needed to detect cases in similar settings. The report concludes that the rarity of the disorder in a forensic mental health population may be the result of underdetection, given that conditions are conducive to the development of the disorder. Telltale signs of its manifestation are hypothesized as being responsible for some events in incarcerated populations. Physical separation and antipsychotic medications remain the mainstay of treatment.

Folie à famille and separation-individuation.

The case history, treatment and follow-up of a family sharing the same delusion are presented in this article. The characteristics of separation-individuation of this pathological condition and its treatment are discussed.