How to diagnose folie a deux, a mental illness that affects two or more individuals

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Recent media reports have focused on the peculiar case of Purushottam Naidu and his spouse Padmaja, who murdered their daughters. This gory incident took place in Chittoor district of Andhra Pradesh. When police rushed to the scene, they found the bodies of the couple’s daughters, Alekhya, 27, and Sai Divya, 22. They were allegedly bludgeoned to death using dumbbells. The Naidus thought that ‘evil spirits’ had infested their younger daughter’s head, which is why they had to break open her skull to rid her of the ‘evil forces’. The couple was distressed that their ‘ritual’ was broken by the police while they tried to resurrect their dead daughters. The wife even instructed the police to come back the next day to witness a miracle, wherein the dead daughters would be brought back to life. Police found the couple to be in a state of complete denial, trance and disorientation, amid a pool of blood. The Naidus told the police, that they received signals from heaven and had a house of miracles.

The key treatment aspect involves physically separating the passive recipient/s of delusions from the more active primary member. This will automatically lead to the secondary family members ridding themselves of their delusional belief systems.
Folie a deux (‘madness for two’) is the French terminology for this disorder, which is characterised by the presence of similar psychotic symptoms (usually delusions) in two individuals.

Netflix is now streaming a three-part documentary series titled House of Secrets: The Burari Deaths. Apart from India, the series is also trending in Pakistan and most countries in south Asia. It details the suicide pact of ten members of a Delhi family. They were found hanging from the ceiling, blindfolded, gagged, and with their hands tied behind their back. The eleventh member—the oldest woman in the house—lay strangled in a corner of the room. The cops found diaries in the house written over 11 years. It had detailed instructions on how every single member of the family was supposed to go through life, where they are to invest money, and explicit instructions for ‘mass salvation’, including how the hangings should be conducted. The primary source of all these oddities is finally pointed to a relatively young family member with a history of unaddressed trauma.

In November 2019, Ellen Barry, a journalist with The New York Times, wrote a highly cited article titled ‘The Jungle Prince of Delhi’. In it, Barry chronicled the ‘royal family of Oudh’ that had been deposed, and had resigned to their fate of living in a ruined palace in Delhi.

The cases reflect an uncommon but intriguing psychiatric disorder, known by many names. Some of these names include double insanity, psychosis of association, shared psychotic disorder, and induced psychosis.

Folie a deux (‘madness for two’) is the French terminology for this disorder, which is characterised by the presence of similar psychotic symptoms (usually delusions) in two individuals. A delusion is defined as a fixed, false, unshakeable belief that is out of keeping with a person’s social and cultural background. The person who first develops the delusional symptoms is referred to as the ‘primary’ patient. He/she can be distinguished from one or more ‘secondary’ patients. In these secondary patients, the delusional symptoms are induced by the primary patient. This phenomenon of transmitting symptoms is not seen in any other psychiatric disorder, and this lends intrigue to this complex phenomenon.

The term folie a deux was coined in the 19th century by two French psychiatrists—Charles Lasegue and Jean-Pierre Falret. It is posited that transmission of psychiatric symptoms from one individual to another occurs under a special set of circumstances. A more active and intelligent person generates delusional themes and ideas, while a submissive person can act as a passive recipient of these ideas. It is in this context that assimilation of these delusional ideas occurs.

Covid-19 and the consequent global lockdown have served as a ground for social isolation and depravity. Under such unprecedented circumstances, having close physical and social ties becomes next to impossible. This facilitates the easy transmission of delusional ideas, in persons having close associations via common interests, opinions, values and emotions.

As with any other psychiatric disorder, genetic and environmental factors play a pivotal role in the genesis of this disorder. It is more common in families who have had members suffering from any other psychiatric disorder, particularly schizophrenia. The family climate serves as the environmental trigger in the pathogenesis of this disorder. The key factor in precipitating induced delusional disorder is disturbed interpersonal relationships.

An interesting offshoot of folie a deux is folie a famille. It is characterised by the presence of delusional ideas in more than two members of the same family. In most cases, individuals across several generations are affected such as grandparents, parents and children. Typically, these families shun treatment as they have little to no insight into their delusional belief systems. Folie a famille is a common occurrence in the context of socially isolated families, in closely enmeshed families wherein there is a high and abnormal degree of interdependence, in unstable families who have frequent crises, and in families having highly dominant personalities who serve to transmit these delusions.

The diagnosis is made on clinical grounds, and includes detailed assessments of all the affected family members. In some contexts, brain scans (MRI, CT) are ordered especially if the symptoms are secondary to organic brain conditions such as brain tumours, metastasis to the brain secondary to cancer, head injury and dementia. A panel of blood investigations to rule out thyroid abnormalities, vitamin B12 and vitamin D deficiencies are also commonly ordered.

A multi-component treatment approach is essential as for any other psychiatric disorder. The key treatment aspect involves physically separating the passive recipient/s of delusions from the more active primary member. This will automatically lead to the secondary family members ridding themselves of their delusional belief systems, as they are no longer controlled by a more dominant person. Treatment approaches include a specialised form of talk therapy called cognitive behavioural therapy (CBT), which encompasses two processes---the cognitive component and the behavioural aspect. The cognitive component will explore the way the affected family members think about themselves, the world, and other people including other family members. The behavioural component of CBT will examine how their actions further influence their thought processes and feelings. CBT adopts a ‘here and now’ approach to problem solving. CBT may involve anywhere from five to 20 sessions, and each talking session lasts between 30 to 60 minutes. Inputs are also given in the form of family therapy. This involves all the family members and tries to address the interpersonal conflicts that may be present within families. In some persons wherein the symptoms continue even after physical separation, low dose medications that block chemical messengers in the brain are given for a short period. The technical term for this class of medications is dopamine receptor blockers (DRBs), and these are commonly referred to as anti-psychotics. Careful consideration is given to personalising the right medication for each individual.

The prognosis for affected family members is good, and most members make a full functional recovery with the right support.

Dr Alok Kulkarni is a senior consultant psychiatrist at the Manas Institute of Mental Health, Hubli.

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