Folie B Deux

Michael H. Sacks

A review of folie a deux or induced psychotic disorder (DSM-III-R) is provided. The author believes it
to be a more frequent phenomenon than usually thought, especially when hospitalized patients are
evaluated with their families. An argument is made for viewing it as a description of a relationship
and possible influence between individuals who may have very different disease processes. This
includes, in the secondary partner, a continuum from being very impressionable to having an
autonomous and independent delusional disorder. A case report and suggestions for treatment are
given.
e 1988, by Grune & Stratton, Inc.

F OLIE A DEUX or induced psychotic disorder is a psychiatric condition which

has fascinated psychiatrists since its description by Lasegue and Falret in
1877. It epitomizes the worst imaginable form of what may be a ubiquitious
concern, a pathological relationship in which one individual adversely affects
another; in this case, literally drives the other person crazy. Ingmar Bergmans film,
Cries and Whispers, is a popular dramatization of this theme. In it, a nurse is
inexorably drawn into the psychosis of her patient. Induced Psychotic Disorder is
the most recent in a long list of alternative names for this disease entity, again
emphasizing the concept of a mental disease being transmitted from one individual
to another. A brief list might include induced insanity, infectious insanity, conta-
gious insanity, reciprocal or double insanity, parasitic insanity, insanity by associa-
tion, conjugal insanity, symbiotic insanity, and induced schizophrenia.2*3
DSM-III emphasized the paranoid nature of the shared delusions and originally
classified it as a shared paranoid disorder in which there is a persecutory delusional
system that develops as a result of a close relationship with a person who already has
an established paranoid psychosis. This has been criticized for being too restrictive.4
Although persecutory delusions seemed to be the most common delusion in shared
psychotic disorders (70% in Gralnicks study), religious, grandiose and hypochon-
driacal delusions occur. Also, the primary diagnosis need not always be a paranoid
psychosis or paranoid schizophrenia. The newer DSM-III-R nomenclature has
omitted the criteria of an established paranoid psychosis.
The DSM-III-R criteria are:
A. A delusion(s) develops (in a secondary case), in the context of a close
relationship with another person, or persons, with an already established delusion(s)
(the primary case).
B. The delusion(s) of the secondary case are similar in content to the delusion(s)
of the primary case.
C. Immediately prior to the onset of the induced delusion the secondary case did
not have a psychotic disorder.

From the Payne Whitney Clinic, Cornell University Medical College, New York.
Address reprint requests to Michael H. Sacks, M.D.. Associate Professor of Psychiatry Cornell
University Medical College Payne Whitney Clinic 525 East 68th Street New York. NY 10021
8 I988 by Grune & Stratton, Inc.
OOIO-440X/88/2903-0006$03.00~0

270 Comprehensive Psychiatry, Vol. 29, No. 3 (May/June), 1988: pp 270-277

FOLIE A DEUX 271

CLINICAL SUBTYPES
Shortly after Lasegue and Falrets definition of Folie a deux four different
subgroups were described. These have been summarized by Gralnick and Gr0ver.j
1. Folie imposee; (Imposed psychosis). The delusions of a psychotic person are
transferred to a mentally sound person who offers little resistance to them. The
delusions of the recipient disappear after separation.
2. Folie simultanee (Simultaneous psychosis). In this subtype there is a simulta-
neous but independent appearance of an identical psychosis in two morbidly
predisposed individuals.
3. Folie communique. (Communicated psychosis). The recipient develops psy-
chotic symptoms after a variable period of resistance. After adopting the content of
the delusion, the recipient then goes on to develop delusions that are independent of
the first subject.
4. Folie induite (Induced psychosis). This subtype refers to an already psychotic
hospitalized individual who is influenced by another patient. He or she enriches his
[or her] delusions
The only systematic effort to study the frequency of the different types was
conducted by Gralnick2 who in an English language review was able to distinguish
61 cases of imposed psychoses, 24 of communicated psychoses, six of simultaneous
psychoses, and five of induced psychoses. This suggests that the distinction between
imposed and communicated psychoses is valid and that the stability of the
delusional system in the recipient once the subjects are separated is important.
Dewhurst and Todd6 dismiss stability of the delusion as an artifact of the duration of
the psychosis. Another explanation is that it reflects different degrees of pathology
in the secondary person(s). We will return to this below.
Another subdivision of shared delusional disorder refers to groups in which more
than two persons are involved. There are reports of folie a trois, folie a quatre,7 folie
a deuze,* folie a famille, and folie a pleusirs.3 The distinction between these groups
or collective psychoses and mass or epidemic hysteria is not always clearly defined.

EPIDEMIOLOGY
Shared psychotic disorder is usually considered a relatively uncommon syndrome.
One investigator reported a frequency of 29 individuals (1.7%) with folie a deux in
1700 consecutive admissions. Gralnick2 summarized 103 cases and reports of
additional cases have been added every year or so since then. Most hospital
clinicians have encountered at least one case. It is likely that many cases go
unnoticed in admission statistics because they are classified individually or because
only one member of the pair is admitted to the hospital and the diagnosis is not
made. The more a hospital is oriented toward careful family evaluation and
diagnosis, the more likely a partner in a shared psychotic disorder will be found. The
author sees one to two cases per year as director of an acute care inpatient unit that
averages 425 admissions per year.
Gralnick2 emphasizes the preponderance of induced psychotic disorders in
persons who live together intimately for a long time. He reports the following
combinations in 103 pairs: two sisters, 40; husband and wife, 26; mother and child,
24; two brothers, 11; brother and sister, six; father and child, two. The greater
272 MICHAEL H. SACKS

susceptibility of women to the disease is probably due to the more restricted and
submissive roles imposed upon them socially. To this might be added their greater
likelihood to seek help and be hospitalized.

THE ASSOCIATION BETWEEN THE SUBJECTS

The relationship between the partners in an induced psychotic disorder has been
studied from a variety of diagnostic, biological and psychodynamic perspectives.
Many of these studies are inadequate because of the exclusivity of their approach
and a failure to adequately define diagnostic criteria. In the following paragraphs
we will consider each of these perspectives.

Diagnosis of the Partners

The most complete diagnostic study of partners in induced psychotic disorders is
that of Soni and Rochley. They were able to find 109 cases in the English literature
with sufficient data to permit a diagnostic evaluation. In nearly all the reported
cases the diagnosis is schizophrenic (65) or paraphrenic (31) for the primary or
dominant partner. Paraphrenia is used in the European literature to describe a mild,
late onset paranoid schizophrenic condition. By DSM-III criteria it would likely
divide into a very mixed group of paranoid states, atypical bipolar disease,
schizophrenia, and perhaps paranoid/schizotypal personality disorders. Other
diagnoses found in the primary were affective psychosis (nine) and senile arterio-
pathic psychosis (four). More than one half of the secondary partners in the Soni
and Rochley review belong to a schizophrenic-paraphrenic group but a significant
number have either a personality disorder, a dementia, mental retardation, some
physical disability such as deafness or a stroke, or a language barrier.
This study, although limited by its dependence on reported literature and lack of
diagnostic criteria, does illuminate the controversy surrounding the usefulness of
the subtypes of imposed and communicated psychosis. In the communicated
psychosis the secondary develops a true delusional disease in which an underlying or
latent psychotic condition is shaped by the illness of the primary case. These
patients do not readily abandon their delusions on separation from the primary.
Those who have an imposed psychosis and do abandon their delusions on separation
may have a severe personality disorder or mental retardation and do not form a true
delusional disorder. Members of this group are highly impressionable rather than
deluded.* It is likely, then, that imposed psychosis and communicated psychosis
represent extremes found in shared psychotic disorders, and that there are grada-
tions from a partial compliance with the delusions in an impressionable partner to
influencing the content of a separate psychosis in a deluded partner. This would
account for the varying results regarding the efficacy of separation in the treatment
of the disease.
A frequent diagnostic distinction which occurs in the literature is that of one
partner being dominant and the other being submissive.13 The primary subject or
inducer is often found to be more dominant as well as intelligent, forceful,
autonomous, and imaginative. The secondary or induced partner is submissive and
less intelligent, highly suggestable, dependent, more passive, more prone to hysteria,
and more likely to be socially deprived, and disadvantaged physically. Although
Lesegue and Falret in their original communication emphasized the dominance of
the primary figure over the recipient they note that the recipient is not entirely a
FOLIE /i DEUX 273

submissive partner since in most of their cases he or she becomes delusional after
considerable resistance and then may impact on the primary sufficiently to modify
his/her delusions. It is sometimes difficult to determine which partner is dominant.
Both criminal acts14 and suicide pactsI have been described as occurring in
shared psychotic disorder. An example of the latter was a man with a severe
depressive illness with pronounced nihilistic and suicidal ideas who convinced his
wife to join him in a suicidal pact. She survived and although remaining depressed
was no longer suicidal or nihilistic.16

Genetic Studies
Biological investigators emphasize the fact that most shared disorders are
consanguinous, (91% by Gralnicks data) and that a similar genetic inheritance
forms the basis for the phenomenon. In cases of conjugal psychosis, in which a
similar genetic makeup could not be invoked, the effect of assortative mate selection
is a likely explanation.
Kallman and Mickey and others who have invoked the genetic argument fail,
however, to address the rarity with which consanguinous psychotic patients share
each others delusions under normal conditions. Jaspers,* in his discussion of the
phenomenology of schizophrenia, emphasizes that one never finds a community of
schizophrenics because the rigidity and the pervading egocentricity of their
delusions precludes any communal life. They are normally as uncommunicative and
unresponsive to each other as they are to the arguments of family and health
professionals. The significant discordance for the presence of schizophrenia in
monozygotic twins also supports the contention that sometime more than genetic
similarity is required to explain the contagion of insanity.
In an important neglected study, Scharfetter19 collected 2 15 reports of symbion-
tic psychoses (sic), 75 inducers and 140 induced, with sufficient information to
permit a study of the incidence of schizophrenia, affective disorder and schizoid
personality in the relatives of both partners. Using unspecified criteria he found the
incidence of schizophrenia among the relatives of the secondary partners who were
not consanguinous with the primary to be similar to that among the relatives of
secondary partners who did share a blood relationship with the primary. The morbid
risk in both cohorts was similar to the reported risk value expected for relatives of
schizophrenic probands. Scharfetter concluded that these findings support the view
that only persons with a genetically determined predisposition to schizophrenia are
likely to develop a schizophreniform psychosis under the influence of a schizo-
phrenic partner.

The Environment and Psychodynamics

Most reports of individuals with shared psychotic disorder note their isolation or
seclusiveness from the remainder of society. This sequestration, which may derive
from non-illness factors such as poverty, physical disability, language difficulties,
and geographic isolation, may contribute to the vulnerability of the secondary
because of an increased dependency on the primary. Additionally, a process
similar to brainwashing may occur. In most cases, however, the isolation from
friends and community in induced psychotic disorders is self-imposed and results
from the hostile and rejecting attitude that accompanies the delusions. Whatever
274 MICHAEL H. SACKS

the origin of the sequestration of the partners there is the loss of the possibility of
any balancing dialogue or self-correcting impact on the delusional formation.
A number of contributions have explored the psychodynamic mechanisms
involved in the sharing of the delusional content. Layman and Cohen believe that
similar underlying needs in the partners allow a delusion to be transmitted because
it is tailor made. It is not communicated, transmitted, or forcibly imposed but
~dopted.~ This is a shift from the common belief that the delusion is often imposed
by a persistent wearing away of the recipients resistance.
Early dynamic explanations of induced psychotic disorders sought to use hypno-
sis, transference, and identification as models to elucidate the illness. Pulver and
Brunt2 provide the most detailed dynamic analysis. They view the primary partner
in the pre-psychotic relationship as stressed (angered) by the dependent needs of the
secondary partner. Once he or she becomes psychotic the hostility toward the
secondary is projected into the outsider and continues toward the secondary in the
now persistent demand that the secondary partner accept his or her delusions. The
secondary partner, unable to either tolerate the aggressive behavior of the primary
partner or to free himself or herself by forming a relationship with another person,
resolves this conflict by identifying with the primary partners delusional aggres-
sion. A similar construction using this defense of identification with the aggressor
could be established for grandiose or religious delusions.
An alternative dynamic approach emphasizes the intense attachment of the
secondary partner. He or she seeks to preserve the relationship with the dominant
one by adopting his or her delusions because the threat of the loss is greater than the
fear of psychosis.
A family dynamic perspective of induced psychotic disorder has been largely
neglected in the literature. All families share a common reality and family myths
which help the family to maintain a stable cohesiveness or homeostasis in the midst
of internal and external threats.22 These threats may occur as a result of members
unresolved ambivalence, competition, dependency, etc. The shared psychosis of one
or more members can be viewed from this background.23
TREATMENT
The treatment of shared psychotic disorder is complicated by the absence of any
systematic treatment outcome studies and the fact that usually only one partner
presents for hospitalization. It is only during a family visit or family evaluation that
the induced psychotic disorder becomes evident. The most significant complication,
however, is that induced psychotic disorder is not a distinctive psychopathological
entity in itself, but a description of a relationship and possible influence between
individuals who may have very different disease processes.
In those instances where both partners are identified in the emergency room or
prior to hospitalization there is no consensus in the literature on how to proceed. The
traditional approach since Falret and Lestque is separation of the partners. If both
members require hospitalization then separate wards or even institutions might be
considered. This classic approach was first seriously questioned by Layman17 who
claimed to find only one case report of a successful treatment by separation. Other
recent reports have emphasized the traumatic impact on the partners that may
occur following separation. Rioux24 reported two paranoid schizophrenic sisters in
which the secondary began to severely deteriorate following separation from the
primary. He recommended that treatment be directed toward exploration of the
FOLIE A DEUX 275

association between the members. Potash and Brunell also recommend a conjoint
psychotherapy.
An advantage of hospitalizing both patients together or hospitalizing one and
permitting frequent contact is that it allows an evaluation of the interaction between
the two partners, as well as a careful diagnostic evaluation of the individual
pathologies. The diagnosis of induced psychotic disorder by itself is insufficient; the
diagnoses of the primary and secondary must be determined, and it must be
established whether the secondary has an imposed psychosis (is impression-
able) or an autonomous communicated psychosis (is delusional). Observing the
two together will often clarify this. An automatic quality to the recitation of the
delusions, or an absence of firm conviction in the secondary partner usually points to
an imposed psychosis with an underlying personality disorder. A mutually support-
ive and interactive elaboration and maintenance of the delusion will suggest that the
secondary has a primary autonomous disease (communicated psychosis) such as
schizophrenia, bipolor disease, etc. If there are doubts regarding the diagnosis then
temporary separation may be necessary to clarify the issue.
In a situation of an imposed psychosis separation and/or successful treatment of
the primary relieves the delusions in the secondary subject. Since separation is often
undesirable, e.g., a mother and child, or difficult, e.g., two sisters sharing an
apartment in a community in which they have lived their entire lives, successful
treatment of the primary is critical. This will be the same as the treatment usually
recommended for the core disease process of the primary. More specific interven-
tions are required when physical disabilities such as mental retardation, deafness,
drug dependence, dementia, etc. contribute to the secondarys dependency on the
primary. In children, foster care may need to be considered until the response of the
parent to treatment is evaluated. Relapse is always a danger in the secondary if the
primary relapses.26 In one instance, successful pharmacologial treatment of a major
depression in a woman with a dependent personality enabled her to resume a
relationship with a paranoid schizophrenic who had imposed on her the necessity
of suicide as the only way to obtain relief from her unhappiness which she had acted
on with his help. Once her depression was treated she no longer felt compelled to
follow his suggestion.
In the communicated psychoses both will require specific treatments for the
automonous psychotic process. This may be either neuroleptics, lithium, ECT, or
antidepressants depending 3n the primary diagnosis. Pimozide has been reported to
be highly successful in paranoid states but this waits confirmation by other
investigators in more controlled studies.*
Once the primary disease has been biologically treated it is important to treat the
relationship between the partners. How this is done will depend on the relationship.
In general, therapy needs to be directed toward increasing the autonomy of both the
primary and secondary by providing alternative supports, activities, and interests so
that there is a decrease in the pathological enmeshment with each other. In some
instances a psychotherapeutic approach aimed at insight into issues of aggression,
dependency, and separation may prove useful.

Case I.
A 43-year-old housewife-writer was admitted to the hospital in a severely agitated and confused state.
Her history revealed a delusional state of 10 years duration regarding a conspiracy in the literary world
which prevented her poems from being published. Her husband and three adolescent children shared
276 MICHAEL H. SACKS

these beliefs and confirmed her assertion that strange sounds on the telephone indicated it was tapped.
The husband was the only one to state unequivocally that he heard the sounds and to elaborate on the
techniques of the invasion of privacy that the establishment used to control artists. The patients
family were not hospitalized since they functioned well outside the home without any need to mention the
conspiracy. If they did, it was usually in generalized terms such as, the literary establishment has it in
for my mother. The patient herself had managed to function remarkably well during her marriage as a
housekeeper and mother by keeping the delusion within the family. Her primary diagnosis was paranoid
state with a schizophreniform psychosis. A diagnosis of induced psychotic disorder was made in the
husband and children. The patient responded quickly to neuroleptic medication. The children and
husband agreed after two visits that they had mistakenly gone along with the patients over intense
imagination although the treatment team was quite convinced that the husband was just being
compliant. He was an impassive college physics teacher who seemed to be an odd caricature of an absent
minded professor. Although attached to his family he expressed it by distant concerned observation
rather than by participation in family activities.
Follow-up over a 6-year period revealed the diagnosis in the primary to be a chronic paranoid state
with periodic affective disruptions usually related to some cumulative unexpressed anger at her husband
or apprehension about her children. These were easily controlled with medication and a supportive
therapy that encouraged the patient in her commitment to writing despite the chronic lack of success, and
sympathized with her immense efforts at maintaining the family with the husbands limited income,
severe passivity, and interpersonal distance. A decreased need to convince the family of her persistent
delusions was sufficient to permit the three children to begin to separate from the family and to enter
college without untoward incident, although one of the children showed tendencies toward being isolated
and without friends. They had an imposed psychosis. The husband continued to share his wifes
delusions regarding the establishment although he accepted his wifes need for treatment to prevent
her from getting too excited about things. He seemed to have a communicated psychosis.
Comment. Mild supportive intervention with the occasional use of medication had a dramatic effect
on this folie a famille. Over time it became clear that much of the wifes passionate and angry
involvement with the literary establishment was a displacement from the husband who supported it
because it enabled him to maintain a comfortable emotional distance in the relationship. Conjoint
therapy was not recommended in this case because of a tactical decision to enlist the husband as an ally
with the therapist in helping his wife with her over-reaction.

DISCUSSION
Although there are no outcome studies in the treatment of Folie a deux, the
literature seems to be oddly optimistic regarding the prognosis. The most that could
be said at this point is that it is no better than the prognosis for the treatment of the
core disease processes in the respective individuals, and perhaps worse because of
the complications secondary to the mechanisms sustaining the shared delusions.
Until more systematic epidemiological, phenomenological, diagnostic, treatment,
and outcome studies are available on induced psychotic disorder, this, as well as
other guidelines to the understanding and treatment of these fascinating disorders,
will have to rest on anecdotal reports and clinical judgment.
FOOTNOTE
An expanded version of this review will appear as a chapter entitled Induced Psychotic Disorder in
Report of the APAs Task Force on Treatment of Psychiatric Disorders, edited by T. Byrum Karasu,
APA Press (to be published).

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FOLIE A DEUX 277

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