Folie deux a phenomenon which may accompany illnesses with delusionl9798 and

This phenomenon is listed as a psychiatric disorder in DSM-IV (Shared Psychotic Disorder, 297.3) and in ICD-10 (Induced Delusional Disorder, F24) but there is a conceptual difficulty in regarding it as a psychotic illness in its own right, as will be discussed shortly.

Folie à deux is a venerable term used to describe a situation in which mental symptoms, usually but not invariably delusions, are communicated from a psychiatrically ill individual (the 'primary patient') to another individual (the 'secondary patient') who accepts them as truth. As noted, DSM-IV and ICD-10 refer to this by different names and there have been several confusing changes of official terminology in recent years. The older name, which is used as an alternative by DSM-IV, is well known to most psychiatrists and is used here by preference. However, à deux may sometimes be a misnomer since several people can be involved, and then we read of folie à trois, folie à plusieurs, folie à ménage, etc.

Taking the dyad as the classical situation, the two people are usually closely associated or related, especially husband-wife, siblings, or parent-child, and usually live in social isolation. The content of the shared belief depends on the predominant delusion(s) of the primary patient and can include convictions of persecution, delusional parasitosis, belief in having a child who does not exist, misidentification delusions, and many others. There have been descriptions of shared persecutory and apocalyptic beliefs in quasi-religions and cults apparently originating with a charismatic leader and coming to be shared by gullible followers. In many shared delusional constellations there is a sense of antagonism by 'them' who may be defined or who may be what Cameron (100) referred to as the 'paranoid pseudocommunity', the hovering 'they' who carry out persecution which is evident to the sufferers but not to others.

Once thought rare, folie à deux has been increasingly described in the literature. Milder cases may not be recognized and, also, many delusional people strive to avoid psychiatric referral; collusion between primary and secondary patient in this has been noted. The physician should be aware of the phenomenon and not overlook it.

The current official names (above) are open to semantic criticism since 'shared psychotic' and 'induced delusional' disorder imply that both members of the dyad are psychotic. In delusional disorder this is certainly true of the primary patient, but the recipient of the beliefs does not usually have a psychotic illness. Most often, he or she is highly impressionable and perhaps highly dependent and adopts the untrue beliefs because of their prolonged and extraordinarily intense transmission by the primary patient. Social isolation, accentuated by induced mistrust of 'them', prevents adequate reality testing from occurring. Thus one might say that the content of the secondary patient's false belief derives from psychotic thinking, but he or she is not usually psychotic.

Nearly all cases of folie à deux are reported in association with schizophrenia, delusional disorder, severe depressive illness with delusions, or early dementia, but it is probable that the condition also sometimes coexists with non-psychotic illnesses such as obsessive- compulsive disorder, somatoform disorder, and histrionic-dissociative personality disorder, in which the beliefs are intensely held and communicated but are not delusional. This makes the DSM-IV and ICD-10 names even less appropriate.

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