FOLIE A DEUX A Case of "Demonic Possession" Involving Mother and Daughter*
S. J.
This paper concerns a case of paranoid psychosis, which may be of interest in the light of the revival in occultism. The author attempts to relate the particular problems of his patient(s) to the major literature concerning paranoia and Folie aDeux.
Review of Literature Lasegue and Falret (7) first reported the syndrome in 1877, and believed this illness to be extremely rare. In the following century approximately 200 papers were written on the subject. Most of these were concerned with the method by which delusions were transferred from one person to another. Dewhurst (2) considered that subclinical forms were more prevalent, and that a normal variant could be found in isolated groups under faltering leadership. Using his definition this illness must meet the following criteria: • The presence of a high degree of similarity in the general motif and delusional content of the partners' psychosis. • The presence of positive evidence that the partners have been intimately associated. Gralnick (4) in 1942 renamed Folie a Deux' 'The Psychosis of Association". He stressed the prepsychotic association of the partners in the causation of the psychosis 'Manuscript received June, 1974. 'Clarke Institute of Psychiatry, Toronto, Ontario. Can. Psychlatr. Assoc. J. Vol. 20 (1975)
KIRALY,
M.D.1
and a logical extension of this was to be found in Folie a Trois, Folie a Quatre, Folie a Cinque and Folie a Beaucoup. As early as 1880, the syndrome was noted in noneonsanguinous groups such as husband and wife, and this surprised early clinicians who up to this point in history explained almost all mental illness on the basis of hereditary taint. Folie a Deux came to be called 'Morbid Interpsychology', a disorder previously unknown. Subsequently, terms such as 'mental contagion' were introduced, and within a decade the illness was divided into four categories: the Forme Imposee - cases in which delusions were transferred from a mentally ill person to a previously healthy person; Forme Simultanee - cases in which partners were predisposed together and became deluded together without either one initiating the process; Forme Communiquee referred to a situation in which the recipient of the delusion went on to elaborate on the delusions after separations from the inducer; Forme lnduite - cases of Folie a Deux occurring within insane asylums. Kallman and Mickey (6) in their paper 'Genetic Concepts and Folie a Deux' in 1946 reintroduced the role of heredity. In their own words, the concept of Folie a Deux was, " ... useful for the practice of counting in French but not for describing the occurrence of similar symptoms in twin pairs or units of blood relatives. " Deutsch (3) and Obendorf (10) took the opposite viewpoint - they conceived of Folie a
223
224
CANADIAN PSYCHIATRIC ASSOCIATION JOURNAL
Deux dynamically, and proposed that it was a result of unconscious identification aimed at rescue of the lost object, a type of identification with the aggressor. Pulver and Brunt (11) elaborated the dynamics in 1961. "In the prepsychotic relationship of a Folie ii Deux pair, the primary partner is strongly dependent on the secondary partner, and has few outside sources of gratification. This libidinal tie is oral in nature. In turn, the primary partner provides gratification for the secondary partner but this is usually of a less dependent type. At some point in the relationship the primary partner feels that the secondary partner is taking advantage of his dependent needs and becomes increasingly angry. The taking advantage may appear as excessive control, desertion, unacceptable sexual demands or any other behaviour. Because the primary partner is afraid of giving up the relationship, his emerging hostility must be defended against. The defence used is projection of hostility onto an outsider in the form of paranoid delusions. The result is a paranoid psychosis which does not differ in content or structure from any other paranoid psychosis. The primary partner needs the support of the secondary partner and demands that he accept a delusion. When the secondary partner refuses to do this, the projective defence weakens and the primary partner becomes more directly and overtly hostile. As the hostility becomes more and more direct, the secondary partner's anxiety and guilt increase proportionately. A point is reached where the tension becomes intolerable and the secondary partner accepts the delusions. By deflecting his partner's hostility away from himself and re-establishing the projective defence, the secondary partner can now maintain his source of gratification, ease his guilt and express his own anger at the primary partner in projected form. " This most recent viewpoint supports the idea that there is no difference between Folie a Deux in consanguinous partners or combinations of partners not blood related. Cases of Folie a Deux among identical twins were reported by Oatman (9) in 1947, and in these the dominant and submissive
Vol. 20, No.3
dynamic interpretation applied. Dewhurst asserted that the diagnostic criteria listed were too well met to allow confusion of these cases with ordinary hereditarily determined non-specific psychoses (2). . Case Presentation The case is that of an l8-year-old female high school student who presented at the Drop-In Service of the Clarke Institute of Psychiatry, accompanied by her mother. Their chief complaint was that they were hearing voices and they were controlled by an evil spirit. The patient's history revealed that she felt herself to be under great pressure from two sources: financial difficulties at home and exams in Grade XIII. A week prior to admission she and her mother started to perform experiments taken from a book of exercises related to occult phenomena. They involved a cross and a ring tied to a string dangling from the patient's finger. Both the patient and her mother felt they were gradually being 'taken over' by an archangel who later became a fallen angel or demon. Four days before admission they heard voices and the daughter experienced involuntary movement of her hand. The spirit started to give instructions to the daughter: specifically he wanted her to take over all the money in the world and bring it under his control, Three days prior to admission the daughter followed some of the instructions. For unknown reasons she dug a hole in their yard and beat her head against the side. She did not experience fear at the time but over the next few days both the daughter's and mother's anxiety mounted. On the day of admission they went to their family lawyer to obtain help in contacting the publisher of the book in order to gain more information on the subject of demonology. He referred them to a radio journalist who has given lectures on the subject, and he in turn sent them to the Clarke Institute. The daughter was admitted the same day and the mother was sent home accompanied by a public health nurse to assess her home situation. As she had no thought disorder and her anxiety settled with reassurance, she was treated as an outpatient by another psychiatrist. The daughter was short, red haired, and of average build. She looked younger than her age. She appeared exhausted. She also seemed to be vigilant, anxious and fidgety, and exhibited pressure of speech. Her orientation for time, place and person was not impaired but attention and concentration did show impairment. Except
April,1975
,
FOLIE A DEUX
for blocking, her memory for recent and long past events seemed unaffected. Her intelligence was estimated from her vocabulary and was judged to be average. She gave concrete interpretations of proverbs and her thought processes revealed out-of-context responses with loosening and fragmentation. The content of her communication was bizarre: she interrupted the interview, waved her arm and exclaimed " ... there he is, doing it again ... I do the opposite of what he wants ... can't you hear him". She could not explain what the 'demon" wanted her to do. She expressed ideas of influence and of being controlled: she felt the demon was not only moving her arm but guided her in other actions. Other delusions included fears that the demon would kill her if she did not comply. She was ambivalent and believed that if she did comply, some harm would come to her mother and brother. The patient also gave evidence of delusional perceptions in the past which were visual and she also reported having hallucinations which were auditory and to which she responded verbally. She was also observed to hallucinate in the office - site reported that she had been hearing voices at night for a week prior to admission and that these became noxious, mocking or demanding for three days prior to her admission. Her affect was abnormally flat and her mood was extremely fearful. She remained superficial, and in discussion her understanding of sexuality was mechanical, using the correct terminology but without accompanying emotion. On formal testing her judgement was not impaired. She believed her delusions completely. Her sleep pattern was totally disrupted. She slept only three hours during the threeand-a-half days before admission. The mother was interviewed by the admitting physician. When interviewed separately, the mother and daughter gave identical descriptions of the delusions. When interviewed together, they collaborated each others' stories and interupted one another. There was some evidence of a role reversal. The mother was a woman of short stature looking older than her stated age of 53. She was exhausted, anxious fearful and preoccupied. She was well oriented in all three spheres and showed no memory disturbance. Her thought process revealed no abnormality. She gave her history with a hysterical flavour. She was theatrical. She, like her daughter, was delusional and claimed that the demon constantly relayed messages to her. She gave a history of auditory hallucinations which were identical to those of her daughter. She was also afraid that she would
225
harm someone or that some harm would come to her. She was very reluctant to separate, even temporarily, from her daughter. Following admission the daughter's personal history was obtained with difficulty because she remained aloof and superficial and was coping with much anxiety. She was born in Toronto and moved to a small town at age two, where the family lived on a one-acre plot opposite a graveyard. Her early development was uneventful as recorded by the mother, but the patient vividly recalled some disturbing childhood memories: getting lost in a laneway; almost being run over by a car and being threatened by her brother. Her brother, who is eighteen months older, was a close playmate throughout her preschool years. The patient's early play tended to be masculine. She was very close to her mother who was overprotective, while the father was a distant person who, according to the patient, was wrapped up in his own problems. She began school at the age of six at a girls' school. Although there were schools in their community the mother chose to send the patient to one in Toronto which necessitated 400 miles of driving per week. The mother explained this arrangement on the grounds that the neighbourhood was full of drug addicts and bullies. The daughter remained at this school until her final year and there were no difficulties associated with school. However, during the patient's latency period there was much strife at home, revolving around her father's involvement with his parents. The family business was in bankruptcy and her father had to support his parents. The patient's further development was painfully lacking in peer relationships. Her mother was overly concerned about her daughter's social life and had many sexual fears. Remaining socially isolated, the patient took part in school sports in a half-hearted way and attended one dance throughout her high school career. She was not dating. Her involvements were more serious at home. Gradually, she assumed increasing responsibility in family matters regarding such decisions as vacation and financial planning. Her brother, on the other hand, from early adolescence was becoming more and more independent of the family. He studied forestry and had an evening job. One year prior to admission, on the daughter's decision, the family, excluding the brother, went on a holiday to New Mexico. While driving back the father suffered myocardial infarction and spent several weeks in a hospital in the United States. The patient and her mother were very involved in his convalescence and took turns in
226
CANADIAN PSYCHIATRIC ASSOCIATION JOURNAL
staying with him, acting as private nurses. As a result of this, the daughter missed much of her school year and almost failed Grade XII. The mother and daughter remained overly concerned about the father's health despite his protests. Before starting Grade XIII the patient saw an advertisement in a newspaper which offered a book on occult phenomena. She purchased this with the aim of gaining occult powers to solve her problems. It was not until two months later, one week prior to admission, that the mother, at the patient's invitation, also started to experiment with the occult. The patient's sexual history is remarkable in that she denied having any sexual experiences or even fantasies. She reached menarche at age nine. Two months before this she was advised by her mother that something wonderful would happen in the near future but at the time of menarche the subject was not discussed. Her sexual education took the form of health lectures at school. She was shy of males and never dated. The diagnosis on the basis of the history and mental status examination of both mother and daughter was Folie a Deux presenting as a paranoid psychosis. In the case of the mother there was a hysterical overlay. In the daughter, the diagnosis of a schizophrenic relation was made on the basis of both Bleulerian and Schneiderian criteria. She met these criteria because she had abnormality of association, affect, was autistic and ambivalent. She exhibited Schneider's first order symptoms of auditory and somatic hallucinations, delusions of thought control and of being controlled from the outside. The hospital management and rationale of the therapy was as follows: in Folie a Deux it is important to separate the partners (10) and this was effectively done by hospitalizing the delusion-inducing daughter. The mother was followed-up by another psychiatrist, and recovered in one week. Following admission, the daughter's anxiety and thought disorder were brought under control with phenothiazine medication. At first methotrimeprazinet and trifluoperazinett were used to obtain sedation and antipsychotic effect. She improved dramatically, and in ten days recalled her delusions as tricks of her mind. As her anxiety diminished, this medication was reduced to its final maintenance value. Four weeks after admission the patient was on 50 mgs chlortNozinan ttStelazine tttTrilafon
Vol. 20, No.3
promazine and 10 mgs trifluoperazine a day, and attending school. Chlorpromazine was substituted for methotrimeprazine as it was less sedating. While in school Parkinsonian side effects proved to be a problem. SUbstituting 8 mgs of perphenazinettt proved to be a better solution than treating the side effects with an antiParkinsonian drug which would have increased the anti-cholinergic side effects of the phenothiazines. The psychotherpaeutic management followed Modlin's model (8). In essence, the patient's delusions were accepted without argument and she was encouraged to suppress their expression (to dissimulate). As soon as she perceived them as ego-alien she was assisted with the reality testing. When the delusions became submerged the topic was avoided. In addition to this she was encouraged to concentrate on the here-and-now reality and to keep active. The team's involvement reached into the family. The family was assessed by the social worker who confirmed that the mother was dependent, easily swayed but verbally dominant over other members of the family. The father was extremely passive and would not speak at all as long as his wife was allowed to speak unchecked. Family therapy was offered and carried on past discharge with the following objectives: to encourage mother's acceptance of her daughter's involvement outside the home; to help the parents overcome their own social isolation; to assist the parents in setting realistic limits to their expectations of their daughter's performance at school; to encourage them to let their daughter make her own decisions regarding career and educational plans. Psychological testing elaborated the findings of the mental status examination and further revealed that the patient's verbal abstracting ability was unusually low for someone in Grade XIII. The school was contacted and the Principal complained that the patient had been working very hard but for the last two years it was obvious that she would not be able to function at a Grade XIII or university level. Therefore, her academic course had to be readjusted. She dropped two subjects and the parents accepted her decision to attend business school. Following this decision, the patient began attending school from hospital. She continued to do well on medication, her affect remained improved and there was no recurrence of delusions or thought disorder. She was discharged from hospital six weeks after admission and remained in followup with her own nurse and physician on the ward.
April,1975
,
Discussion The dynamics described by Pulver and Brunt apply to the mother-daughter dyad reported in this paper. There was an intimate prepsychotic relationship between them. The daughter, the primary partner, had no outside sources of gratification and was strongly dependent on her mother for oral gratification. The mother depended upon her daughter for making decisions and sharing the guilt of the possibility of having caused the father's illness. Two months prior to her admission the daughter felt she had too many demands placed upon her in the way of controls and decision-making. She dealt with hostility by projection and developed a paranoid psychosis; she then needed the support of her mother and invited her to accept the delusions by experimenting with her. The mother, identified with the daughter (the aggressor) in order to rescue the relationship. This is consistent with the mother's extreme reluctance to separate from the daughter at the time of hospitalization. By accepting the delusion, the secondary partner could use the same projective defence, and at the same time express her anger at the primary partner in projected form while maintaining her source of gratification. 1. 2. 3. 4. 5.
227
FOLIE A DEUX
6. 7. 8. 9. 10. 11. 12.
psychosis of association or folie Ii deux. Psychiatr. Q., 17: 294,1943. Kallman, F. and Mickey, J.: Genetic concepts and folie a deux. J. Hered., 37: 298, 1946. Lasegue, C. and Falret, J.: La folie a deux ou folie communiquee , Ann.' Med. Psychol., 5eserie, T. 18: 321,1877. Modlin, H. C.: Psychodynamics and management of paranoid states in women. Arch. Gen. Psychiatry, 8: 263-8, 1963. Oatman, J.: Folie Ii deux, report of a case in identical twins. Am. J. Psychiatry, 98: 842, 1947. Obendorff, C.: Folie Ii deux. Int. J. Psychoanal., 15: 14, 1934. Pulver, A. and Brunt, M.: Deflection of hostility in folie Ii deux. Arch. Gen. Psychiatry, 5: 257-65,1961. Rioux, B.: A review of folie Ii deux, the psychosis of association. Psychiatr. Q., 37: 405-28,1963.
Resume Cet article presente brievement les principales etudes sur la paranoia et la folie Ii' deux. Pour evaluer ce syndrome ainsi nomme, on remonte au premier rapport de Lasegue et Falret (7), en 1877, puis 11. la conceptualisation modeme de Pulver et Brunt (11). On tient compte egalement des presupposes genetiques de 1afolie a deux. Apres ce bref rappel, on decrit 1es cas d'une References jeune fille de 18 ans et de sa mere qui, l'une et l'autre, se croyaient possedees, Le diagDewald, P. A.: Folie Ii deux and the function of reality testing. Psychiatry, 33: nostic de psychose paranoide, 1a fille etant 390-5, 1970. 1a premiere partenaire, est examine de pres; Dewhurst, K. and Todd, J.: The psychosis c'est un cas d'identification avec I'aggresof association, folie a deux. J. Nerv. Ment. seur, accompagne de projection d'hostilite Dis., 124: 451,1956. sur une tierce personne pour defendre le Deutch, H.: Folie Ii deux, Psychoanal. Q., 7: moi. On note la facon de traiter les patientes 1938. I'hopital et les moyens psychotheraGralnick, A.: Folie Ii deux, the psychosis of peutiques, pharmacologiques et sociaux association. Psychiatr. Q., 16: 230, 491, employes. Ces methodes peuvent servir 1942. Gralnick, A.: The Carrington family, a d'exemple pour le traitement des etats psychiatric and social study illustrating the paranoiaques chez Ie femmes.
a
Demoniacfrenzy, moping melancholy And moon-struck madness. Paradise Lost John Milton 1608-1674
S. J.
This paper concerns a case of paranoid psychosis, which may be of interest in the light of the revival in occultism. The author attempts to relate the particular problems of his patient(s) to the major literature concerning paranoia and Folie aDeux.
Review of Literature Lasegue and Falret (7) first reported the syndrome in 1877, and believed this illness to be extremely rare. In the following century approximately 200 papers were written on the subject. Most of these were concerned with the method by which delusions were transferred from one person to another. Dewhurst (2) considered that subclinical forms were more prevalent, and that a normal variant could be found in isolated groups under faltering leadership. Using his definition this illness must meet the following criteria: • The presence of a high degree of similarity in the general motif and delusional content of the partners' psychosis. • The presence of positive evidence that the partners have been intimately associated. Gralnick (4) in 1942 renamed Folie a Deux' 'The Psychosis of Association". He stressed the prepsychotic association of the partners in the causation of the psychosis 'Manuscript received June, 1974. 'Clarke Institute of Psychiatry, Toronto, Ontario. Can. Psychlatr. Assoc. J. Vol. 20 (1975)
KIRALY,
M.D.1
and a logical extension of this was to be found in Folie a Trois, Folie a Quatre, Folie a Cinque and Folie a Beaucoup. As early as 1880, the syndrome was noted in noneonsanguinous groups such as husband and wife, and this surprised early clinicians who up to this point in history explained almost all mental illness on the basis of hereditary taint. Folie a Deux came to be called 'Morbid Interpsychology', a disorder previously unknown. Subsequently, terms such as 'mental contagion' were introduced, and within a decade the illness was divided into four categories: the Forme Imposee - cases in which delusions were transferred from a mentally ill person to a previously healthy person; Forme Simultanee - cases in which partners were predisposed together and became deluded together without either one initiating the process; Forme Communiquee referred to a situation in which the recipient of the delusion went on to elaborate on the delusions after separations from the inducer; Forme lnduite - cases of Folie a Deux occurring within insane asylums. Kallman and Mickey (6) in their paper 'Genetic Concepts and Folie a Deux' in 1946 reintroduced the role of heredity. In their own words, the concept of Folie a Deux was, " ... useful for the practice of counting in French but not for describing the occurrence of similar symptoms in twin pairs or units of blood relatives. " Deutsch (3) and Obendorf (10) took the opposite viewpoint - they conceived of Folie a
223
224
CANADIAN PSYCHIATRIC ASSOCIATION JOURNAL
Deux dynamically, and proposed that it was a result of unconscious identification aimed at rescue of the lost object, a type of identification with the aggressor. Pulver and Brunt (11) elaborated the dynamics in 1961. "In the prepsychotic relationship of a Folie ii Deux pair, the primary partner is strongly dependent on the secondary partner, and has few outside sources of gratification. This libidinal tie is oral in nature. In turn, the primary partner provides gratification for the secondary partner but this is usually of a less dependent type. At some point in the relationship the primary partner feels that the secondary partner is taking advantage of his dependent needs and becomes increasingly angry. The taking advantage may appear as excessive control, desertion, unacceptable sexual demands or any other behaviour. Because the primary partner is afraid of giving up the relationship, his emerging hostility must be defended against. The defence used is projection of hostility onto an outsider in the form of paranoid delusions. The result is a paranoid psychosis which does not differ in content or structure from any other paranoid psychosis. The primary partner needs the support of the secondary partner and demands that he accept a delusion. When the secondary partner refuses to do this, the projective defence weakens and the primary partner becomes more directly and overtly hostile. As the hostility becomes more and more direct, the secondary partner's anxiety and guilt increase proportionately. A point is reached where the tension becomes intolerable and the secondary partner accepts the delusions. By deflecting his partner's hostility away from himself and re-establishing the projective defence, the secondary partner can now maintain his source of gratification, ease his guilt and express his own anger at the primary partner in projected form. " This most recent viewpoint supports the idea that there is no difference between Folie a Deux in consanguinous partners or combinations of partners not blood related. Cases of Folie a Deux among identical twins were reported by Oatman (9) in 1947, and in these the dominant and submissive
Vol. 20, No.3
dynamic interpretation applied. Dewhurst asserted that the diagnostic criteria listed were too well met to allow confusion of these cases with ordinary hereditarily determined non-specific psychoses (2). . Case Presentation The case is that of an l8-year-old female high school student who presented at the Drop-In Service of the Clarke Institute of Psychiatry, accompanied by her mother. Their chief complaint was that they were hearing voices and they were controlled by an evil spirit. The patient's history revealed that she felt herself to be under great pressure from two sources: financial difficulties at home and exams in Grade XIII. A week prior to admission she and her mother started to perform experiments taken from a book of exercises related to occult phenomena. They involved a cross and a ring tied to a string dangling from the patient's finger. Both the patient and her mother felt they were gradually being 'taken over' by an archangel who later became a fallen angel or demon. Four days before admission they heard voices and the daughter experienced involuntary movement of her hand. The spirit started to give instructions to the daughter: specifically he wanted her to take over all the money in the world and bring it under his control, Three days prior to admission the daughter followed some of the instructions. For unknown reasons she dug a hole in their yard and beat her head against the side. She did not experience fear at the time but over the next few days both the daughter's and mother's anxiety mounted. On the day of admission they went to their family lawyer to obtain help in contacting the publisher of the book in order to gain more information on the subject of demonology. He referred them to a radio journalist who has given lectures on the subject, and he in turn sent them to the Clarke Institute. The daughter was admitted the same day and the mother was sent home accompanied by a public health nurse to assess her home situation. As she had no thought disorder and her anxiety settled with reassurance, she was treated as an outpatient by another psychiatrist. The daughter was short, red haired, and of average build. She looked younger than her age. She appeared exhausted. She also seemed to be vigilant, anxious and fidgety, and exhibited pressure of speech. Her orientation for time, place and person was not impaired but attention and concentration did show impairment. Except
April,1975
,
FOLIE A DEUX
for blocking, her memory for recent and long past events seemed unaffected. Her intelligence was estimated from her vocabulary and was judged to be average. She gave concrete interpretations of proverbs and her thought processes revealed out-of-context responses with loosening and fragmentation. The content of her communication was bizarre: she interrupted the interview, waved her arm and exclaimed " ... there he is, doing it again ... I do the opposite of what he wants ... can't you hear him". She could not explain what the 'demon" wanted her to do. She expressed ideas of influence and of being controlled: she felt the demon was not only moving her arm but guided her in other actions. Other delusions included fears that the demon would kill her if she did not comply. She was ambivalent and believed that if she did comply, some harm would come to her mother and brother. The patient also gave evidence of delusional perceptions in the past which were visual and she also reported having hallucinations which were auditory and to which she responded verbally. She was also observed to hallucinate in the office - site reported that she had been hearing voices at night for a week prior to admission and that these became noxious, mocking or demanding for three days prior to her admission. Her affect was abnormally flat and her mood was extremely fearful. She remained superficial, and in discussion her understanding of sexuality was mechanical, using the correct terminology but without accompanying emotion. On formal testing her judgement was not impaired. She believed her delusions completely. Her sleep pattern was totally disrupted. She slept only three hours during the threeand-a-half days before admission. The mother was interviewed by the admitting physician. When interviewed separately, the mother and daughter gave identical descriptions of the delusions. When interviewed together, they collaborated each others' stories and interupted one another. There was some evidence of a role reversal. The mother was a woman of short stature looking older than her stated age of 53. She was exhausted, anxious fearful and preoccupied. She was well oriented in all three spheres and showed no memory disturbance. Her thought process revealed no abnormality. She gave her history with a hysterical flavour. She was theatrical. She, like her daughter, was delusional and claimed that the demon constantly relayed messages to her. She gave a history of auditory hallucinations which were identical to those of her daughter. She was also afraid that she would
225
harm someone or that some harm would come to her. She was very reluctant to separate, even temporarily, from her daughter. Following admission the daughter's personal history was obtained with difficulty because she remained aloof and superficial and was coping with much anxiety. She was born in Toronto and moved to a small town at age two, where the family lived on a one-acre plot opposite a graveyard. Her early development was uneventful as recorded by the mother, but the patient vividly recalled some disturbing childhood memories: getting lost in a laneway; almost being run over by a car and being threatened by her brother. Her brother, who is eighteen months older, was a close playmate throughout her preschool years. The patient's early play tended to be masculine. She was very close to her mother who was overprotective, while the father was a distant person who, according to the patient, was wrapped up in his own problems. She began school at the age of six at a girls' school. Although there were schools in their community the mother chose to send the patient to one in Toronto which necessitated 400 miles of driving per week. The mother explained this arrangement on the grounds that the neighbourhood was full of drug addicts and bullies. The daughter remained at this school until her final year and there were no difficulties associated with school. However, during the patient's latency period there was much strife at home, revolving around her father's involvement with his parents. The family business was in bankruptcy and her father had to support his parents. The patient's further development was painfully lacking in peer relationships. Her mother was overly concerned about her daughter's social life and had many sexual fears. Remaining socially isolated, the patient took part in school sports in a half-hearted way and attended one dance throughout her high school career. She was not dating. Her involvements were more serious at home. Gradually, she assumed increasing responsibility in family matters regarding such decisions as vacation and financial planning. Her brother, on the other hand, from early adolescence was becoming more and more independent of the family. He studied forestry and had an evening job. One year prior to admission, on the daughter's decision, the family, excluding the brother, went on a holiday to New Mexico. While driving back the father suffered myocardial infarction and spent several weeks in a hospital in the United States. The patient and her mother were very involved in his convalescence and took turns in
226
CANADIAN PSYCHIATRIC ASSOCIATION JOURNAL
staying with him, acting as private nurses. As a result of this, the daughter missed much of her school year and almost failed Grade XII. The mother and daughter remained overly concerned about the father's health despite his protests. Before starting Grade XIII the patient saw an advertisement in a newspaper which offered a book on occult phenomena. She purchased this with the aim of gaining occult powers to solve her problems. It was not until two months later, one week prior to admission, that the mother, at the patient's invitation, also started to experiment with the occult. The patient's sexual history is remarkable in that she denied having any sexual experiences or even fantasies. She reached menarche at age nine. Two months before this she was advised by her mother that something wonderful would happen in the near future but at the time of menarche the subject was not discussed. Her sexual education took the form of health lectures at school. She was shy of males and never dated. The diagnosis on the basis of the history and mental status examination of both mother and daughter was Folie a Deux presenting as a paranoid psychosis. In the case of the mother there was a hysterical overlay. In the daughter, the diagnosis of a schizophrenic relation was made on the basis of both Bleulerian and Schneiderian criteria. She met these criteria because she had abnormality of association, affect, was autistic and ambivalent. She exhibited Schneider's first order symptoms of auditory and somatic hallucinations, delusions of thought control and of being controlled from the outside. The hospital management and rationale of the therapy was as follows: in Folie a Deux it is important to separate the partners (10) and this was effectively done by hospitalizing the delusion-inducing daughter. The mother was followed-up by another psychiatrist, and recovered in one week. Following admission, the daughter's anxiety and thought disorder were brought under control with phenothiazine medication. At first methotrimeprazinet and trifluoperazinett were used to obtain sedation and antipsychotic effect. She improved dramatically, and in ten days recalled her delusions as tricks of her mind. As her anxiety diminished, this medication was reduced to its final maintenance value. Four weeks after admission the patient was on 50 mgs chlortNozinan ttStelazine tttTrilafon
Vol. 20, No.3
promazine and 10 mgs trifluoperazine a day, and attending school. Chlorpromazine was substituted for methotrimeprazine as it was less sedating. While in school Parkinsonian side effects proved to be a problem. SUbstituting 8 mgs of perphenazinettt proved to be a better solution than treating the side effects with an antiParkinsonian drug which would have increased the anti-cholinergic side effects of the phenothiazines. The psychotherpaeutic management followed Modlin's model (8). In essence, the patient's delusions were accepted without argument and she was encouraged to suppress their expression (to dissimulate). As soon as she perceived them as ego-alien she was assisted with the reality testing. When the delusions became submerged the topic was avoided. In addition to this she was encouraged to concentrate on the here-and-now reality and to keep active. The team's involvement reached into the family. The family was assessed by the social worker who confirmed that the mother was dependent, easily swayed but verbally dominant over other members of the family. The father was extremely passive and would not speak at all as long as his wife was allowed to speak unchecked. Family therapy was offered and carried on past discharge with the following objectives: to encourage mother's acceptance of her daughter's involvement outside the home; to help the parents overcome their own social isolation; to assist the parents in setting realistic limits to their expectations of their daughter's performance at school; to encourage them to let their daughter make her own decisions regarding career and educational plans. Psychological testing elaborated the findings of the mental status examination and further revealed that the patient's verbal abstracting ability was unusually low for someone in Grade XIII. The school was contacted and the Principal complained that the patient had been working very hard but for the last two years it was obvious that she would not be able to function at a Grade XIII or university level. Therefore, her academic course had to be readjusted. She dropped two subjects and the parents accepted her decision to attend business school. Following this decision, the patient began attending school from hospital. She continued to do well on medication, her affect remained improved and there was no recurrence of delusions or thought disorder. She was discharged from hospital six weeks after admission and remained in followup with her own nurse and physician on the ward.
April,1975
,
Discussion The dynamics described by Pulver and Brunt apply to the mother-daughter dyad reported in this paper. There was an intimate prepsychotic relationship between them. The daughter, the primary partner, had no outside sources of gratification and was strongly dependent on her mother for oral gratification. The mother depended upon her daughter for making decisions and sharing the guilt of the possibility of having caused the father's illness. Two months prior to her admission the daughter felt she had too many demands placed upon her in the way of controls and decision-making. She dealt with hostility by projection and developed a paranoid psychosis; she then needed the support of her mother and invited her to accept the delusions by experimenting with her. The mother, identified with the daughter (the aggressor) in order to rescue the relationship. This is consistent with the mother's extreme reluctance to separate from the daughter at the time of hospitalization. By accepting the delusion, the secondary partner could use the same projective defence, and at the same time express her anger at the primary partner in projected form while maintaining her source of gratification. 1. 2. 3. 4. 5.
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6. 7. 8. 9. 10. 11. 12.
psychosis of association or folie Ii deux. Psychiatr. Q., 17: 294,1943. Kallman, F. and Mickey, J.: Genetic concepts and folie a deux. J. Hered., 37: 298, 1946. Lasegue, C. and Falret, J.: La folie a deux ou folie communiquee , Ann.' Med. Psychol., 5eserie, T. 18: 321,1877. Modlin, H. C.: Psychodynamics and management of paranoid states in women. Arch. Gen. Psychiatry, 8: 263-8, 1963. Oatman, J.: Folie Ii deux, report of a case in identical twins. Am. J. Psychiatry, 98: 842, 1947. Obendorff, C.: Folie Ii deux. Int. J. Psychoanal., 15: 14, 1934. Pulver, A. and Brunt, M.: Deflection of hostility in folie Ii deux. Arch. Gen. Psychiatry, 5: 257-65,1961. Rioux, B.: A review of folie Ii deux, the psychosis of association. Psychiatr. Q., 37: 405-28,1963.
Resume Cet article presente brievement les principales etudes sur la paranoia et la folie Ii' deux. Pour evaluer ce syndrome ainsi nomme, on remonte au premier rapport de Lasegue et Falret (7), en 1877, puis 11. la conceptualisation modeme de Pulver et Brunt (11). On tient compte egalement des presupposes genetiques de 1afolie a deux. Apres ce bref rappel, on decrit 1es cas d'une References jeune fille de 18 ans et de sa mere qui, l'une et l'autre, se croyaient possedees, Le diagDewald, P. A.: Folie Ii deux and the function of reality testing. Psychiatry, 33: nostic de psychose paranoide, 1a fille etant 390-5, 1970. 1a premiere partenaire, est examine de pres; Dewhurst, K. and Todd, J.: The psychosis c'est un cas d'identification avec I'aggresof association, folie a deux. J. Nerv. Ment. seur, accompagne de projection d'hostilite Dis., 124: 451,1956. sur une tierce personne pour defendre le Deutch, H.: Folie Ii deux, Psychoanal. Q., 7: moi. On note la facon de traiter les patientes 1938. I'hopital et les moyens psychotheraGralnick, A.: Folie Ii deux, the psychosis of peutiques, pharmacologiques et sociaux association. Psychiatr. Q., 16: 230, 491, employes. Ces methodes peuvent servir 1942. Gralnick, A.: The Carrington family, a d'exemple pour le traitement des etats psychiatric and social study illustrating the paranoiaques chez Ie femmes.
a
Demoniacfrenzy, moping melancholy And moon-struck madness. Paradise Lost John Milton 1608-1674
