In this series, I dig a little deeper into the meaning of psychology-related terms. This week’s term is shared psychotic disorder, also known as folie à deux.
Folie à deux is the more commonly recognized name for what the DSM-5 calls shared psychotic disorder. It’s a rare condition that involves shared delusions between two or more people who are in a close relationship. The primary, or inducer, in the relationship holds the original delusional belief, and then the secondary, or induced, in the relationship comes to share the delusion.
How it develops
The disorder was first identified in the late 1800s. In 1942, psychiatrist Alexander Gralnick proposed four subtypes of folie à deux based on how the shared delusions came about:
- folie imposée (imposed psychosis): the primary imposes the delusional beliefs on the secondary
- folie simultanée (simultaneous): both people were psychotic to begin with, and came to share a delusion
- folie communiquée (communicated): the “normal” secondary maintains the delusion after separation
- folie induite (induced): a psychotic person adds new delusions to another psychotic person’s delusional system
Several risk factors contribute to the development of folie à deux, including:
- lengthy relationship with strong attachment, usually family members
- social isolation
- personality disorders: histrionic | dependent | schizoid, schizotypal
- personality traits: neurotic, emotionally immature, passivity, suggestibility, suspiciousness
- untreated mental illness in the primary in the relationship; most common diagnosis is delusional disorder
- cognitive impairment in the secondary
- stressful life events
- communication difficulties
- female gender
Cases of folie à deux
More than half of reported cases involve either mother-daughter or sister-sister pairs. The primary plays a dominant role, while the secondary plays a submissive role. In some cases, the entire family becomes involved, and an 11-member family suicide reported in India was suspected to be due to shared psychosis.
There was a fascinating case report in the Archives of Sexual Behaviour that described a married couple involving a female primary and male secondary. The shared delusional belief was that the husband was being financially exploited by a mistress (whom he worked with) and was being given drugs and forced to have sex with her. While he did not have memories of events his wife described, he was entirely certain that they occurred and didn’t question any of it.
In terms of treatment, perhaps the biggest challenge is getting the pair (or system) to accept the need for treatment. The atypical antipsychotics aripirprazole and quetiapine appear to be most effective for medication treatment. One would guess that a lifetime of therapy would probably need to be thrown into the mix as well.
This condition sounds like a bit of a Freudian wet dream. In psychoanalytic theory, unresolved Oedipus/Electra complex issues leading to jealousy or abnormal sexualization of the relationship are thought to contribute to the development of folie à deux.
I vaguely recall when I worked in inpatient psychiatry there was one patient that was part of a suspected folie à deux, but I’ve never encountered a clear-cut case.
It’s fascinating the things the mind can do.
You can find the rest of the what is… series in the Psychology Corner.
- Archives of Sexual Behaviour: Shared psychotic disorders with sexual delusions
- Journal of Research in Medical Sciences: Folie à deux and delusional disorder by proxy in a family
- Medscape: Shared psychotic disorder
- StatPearls: Shared psychotic disorder
- Wikipedia: Folie à deux