Course and prognosis

This depends on the outcome of treatment (see below). Treatment

In folie imposée the logical approach is to identify the primary patient and treat his or her mental disorder adequately. It may also be helpful to separate the two individuals for a time, for example by admitting the primary patient to hospital. With both people, every attempt must be made to reduce social isolation and to reintroduce them to reality. If the primary patient's delusions improve with treatment, the secondary patient's beliefs usually also improve. It is rarely appropriate to treat the secondary patient with antipsychotic medication, although this is sometimes mistakenly done.

In folie simultanée, both patients require neuroleptic or other active treatment.

Theoretically, treatment is straightforward but in practice it can be problematic. For example, in delusional disorder the primary patient often resists psychiatric help, and subterfuge and resistance by both individuals is common. In group situations, for example a cult, this resistance is likely to be widespread and intense, and will be justified by the participants in terms of religious and social beliefs which they claim are being suppressed and persecuted. The propagators should be separated from the recipients as much as possible, and the treatment team has to expend much time and diplomacy in gaining some confidence and a degree of co-operation. Direct challenge of the beliefs in any shared delusional situation is usually totally counterproductive.

Mass suicide is a reported outcome of shared delusions in some cult situations and any danger of this must be countered with great urgency. (1°1)

Case Study Folie a deux A highly intelligent man in his early fifties had had a brief sexual affair with a woman in his workplace some years before. He felt rather guilty although the liaison ended amicably and his wife did not know about it. About 3 years later he gradually became convinced that the woman involved had generated a plot against him amongst his fellow workers. He became totally preoccupied with this and eventually publicly accused her. She totally denied his charges, but in the next few months he harassed her and fellow employees incessantly, demanding 'proof and a 'confession'. He was eventually dismissed and it was made clear to him by the company that they found no basis for his suspicion. For the next 2 years he spent all his time at home, endlessly retailing his constantly elaborating beliefs to his wife and neglecting all his normal routines. His equally intelligent wife had become totally convinced by him and was running a campaign with him to force the woman to admit to her alleged provocations. This had resulted in several legal actions against both of them which proved no deterrent. They reluctantly agreed to a psychiatric examination which indicated that he had a delusional disorder of the persecutory subtype and that she suffered from folie a deux. Neither accepted the need for treatment.

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